AeroSafety world
FIGHTING FATIGUE Strategies for staying sharp EXCURSION IN ICELAND Fatigued crew lands poorly BIRD RADAR Feathered hazard warning BIZJET ENGINE MONITORING Maintenance input from afar
SAVING THE RESCUERS SAFER HEMS OPERATIONS
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uring the last few weeks, I have been asked life, but it will never be without risk — and that countless times to comment on what has is OK. That seems to make their heads hurt, but been known as the “Miracle on the Hud- it needs to be said. son,” the immediately famous ditching Finally, I was surprised at how emotional it Dof US Airways Flight 1549, an Airbus A320, in was for me to listen to recordings of air traffic New York City’s frigid Hudson River. After being control (ATC) communications with Flight 1549. quoted on this event in a few hundred news outlets In less than a minute, the flight crew and ATC around the world, I want to say just three things dealt with a normal departure, an emergency about this accident. return, four runway options at two different First, I find it amazing that the ditching is the airports and a ditching, handling the situation fourth in a series of major airline accidents where in a crisp and professional manner. The public the aircraft was destroyed but everyone escaped seems amazed, but those of us who have dealt with relatively minor injuries. I am thinking of with emergencies in the cockpit and in ATC the Air France Airbus A340 at Toronto, the Brit- heard exactly what we expected to hear. That is ish Airways Boeing 777 at Heathrow, and the just what we do. Continental Boeing 737NG at Denver. At first We all grew up thinking about how we would everyone talked about how “luck” got everyone handle a crisis like that, hoping that if the time off the Air France aircraft, but now that there came we would get it right. The thought of living have been three more major nonfatal accidents, up to that expectation is what made most of us people are realizing, I think, that there is more fall in love with this business and stay with it. The to it than luck. Clearly, manufacturers are doing desire to perform brilliantly at a critical moment something right regarding the crashworthiness of is something that we all have in common. the airframes, and the airlines have to take some So, take a second. Put aside the data, the crew credit for the extraordinary performance of the schedules and the reporting systems, and have cabin crews. a quick listen to those ATC recordings on your Second, the US Airways accident is important computer. You undoubtedly will smile, remember- because it reminds us that despite our best efforts, ing for a second how good it feels to be part of an there will always be some residual risk. According industry where such high performance standards to Bird Strike Committee USA, “a 12-lb Canada are just the way we do things. goose struck by a 150-mph aircraft at lift-off generates the force of a 1,000-lb [454 kg] weight dropped from a height of 10 ft. [3 m].” There is nothing we are ever going to do that will make it easy at 300 mph to avoid, or to safely fly through, a flock of geese. I have been trying to explain to William R. Voss the public that flying in a commercial airliner is President and CEO one of the safest things they will ever do in their Flight Safety Foundation www.flightsafety.org | AeroSafetyWorld | March 2009 | 1 AeroSafetyWorld
contents March2009 Vol 4 Issue 3 features
14 CoverStory | HEMS: Closing the Loop
19 InSight | Wake Me When My Shift Is Over
14 22 HumanFactors | Easing Fatigue
28 CausalFactors | Too Long at the Wheel
32 CausalFactors | Left Behind
38 ThreatAnalysis | Bird Detection Radar
44 MaintenanceMatters | Remote Engine Diagnostics
19 departments
1 President’sMessage | High Expectations
5 EditorialPage | Fighting Fatigue
6 AirMail | Letters From Our Readers
7 SafetyCalendar | Industry Events 22 9 InBrief | Safety News
2 | flight safety foundation | AeroSafetyWorld | March 2009 38 44
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AeroSafetyWORLD telephone: +1 703.739.6700 13 FoundationFocus | Flight Safety Foundation and Me William R. Voss, publisher, FSF president and CEO [email protected] 49 | Speaking of Clearances DataLink J.A. Donoghue, editor-in-chief, FSF director of publications 53 InfoScan | We Still Need Exceptional People [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 57 OnRecord | Roller Coaster Ride Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Karen K. Ehrlich, web and print production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer [email protected], ext. 120 Susan D. Reed, production specialist [email protected], ext. 123 About the Cover Patricia Setze, librarian Report from NTSB’s hearing on HEMS safety. © Chris Sorensen Photography [email protected], ext. 103 Editorial Advisory Board We Encourage Reprints (For permissions, go to
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v i s i t o u r w e b s i t e fo r a f r e e a u t o m a t e d d e m o c a l l fo r a f r e e l i v e d e m o n s t r a t i o n w w w. e t q . c o m / a i r s a f e t y Editorialpage Fighting Fatigue
he growing body of evidence that responsible to some degree for the de- Both sides of the labor-management we in the aviation industry are velopment and persistence of poor prac- divide must surrender ground to solve this not defending adequately against tices. Labor, in the cases of controller problem. However, that doesn’t mean that the dangerous consequences of schedules and other shift practices, solutions must come with a high cost. Tfatigue is reaching, from my point of view, seeks to maximize blocks of time off at Several years ago at Flight Safety Foun- critical mass. I have been of this opinion the expense of rational work routines, dation’s International Air Safety Seminar in before (ASW, 11/06), but I have been and management tries to minimize staff Paris, I was struck by the presentation of an wrong in assuming that changes would sizes and travel expenses by condensing innovative program launched by easyJet, be made to adjust current practices to flight sequences into neat little packets with the approval of the U. K. Civil Avia- take into account the new information. that meet the letter of the rule but do tion Authority, to experiment with different Maybe this is the time. violence to its spirit and ignore what we pilot scheduling sequences. The degree In this edition of AeroSafety World, have learned about fatigue since those of a schedule’s success was judged not by we have stories on several fatigue studies rules were established. survey (“How do you feel?”), but by flight and a first-person description of air traf- The insidious nature of how fatigue data analysis, closely tracking exactly how fic controller shift scheduling, all calling debilitates personal performance is an- crews performed. Improved schedules, it into question the way we do things. And other part of the problem. Despite the turned out, were not hugely expensive to the way we do things is to largely ignore fact that fatigue repeatedly is cited as a management or invasive of crew time. what we know very well about fatigue, causal factor in reports of accident inves- The good science on this matter choosing for the most part to stick with tigations — as it is in the report in this must no longer be ignored, and further strategies that date to the 1930s or, be- issue of ASW on the landing incident in science must be developed, if new rules yond that, to simply ignore it, pretend- Reykjavik International Airport, Kefla- are to be effective. Hopefully, the Euro- ing, for example, that flying late into the vík, Iceland — it is easy to dismiss this pean Aviation Safety Agency’s ongoing night is no different than ending a flight and other more serious events as simply effort to update its pilot fatigue rules sequence in mid-afternoon. poor piloting. But science shows that will establish an enlightened benchmark To say that this is a complicated matter the problem with fatigue is not simply that others will follow. with roots entwined deep in the history of that someone is on the verge of sleep. aviation labor-management relationships Rather, it also manifests in a wakeful state and leave it at that is simply irresponsible, in which performance is unknowingly yet that is how the issue has been handled degraded to a level equal to what is pro- — or not handled — for decades. duced by drinking alcoholic beverages for J.A. Donoghue At the heart of this failure is the quite a while, accompanied by an inability Editor-in-Chief unfortunate fact that both sides are to detect that degradation. AeroSafety World www.flightsafety.org | AeroSafetyWorld | March 2009 | 5 AirMail
Talking senses about cockpit alerts input ability — the aural he many issues raised in “Autoflight and tactile inputs. In high-workload Audit” (ASW, 6/08, p. 30), related flight phases, the use of cues other Tto the pilot-automation interface, than visual optimizes the human reminded me of one thing I’ve lost interface. The click announcing a transitioning from the old “mechanical” flight mode change is an extra that can cockpit to the “glass” version, and that capture a pilot’s attention at the right was the click. moment, gaining seconds compared to Although not contemplated in the the routine visual scan. AeroSafety World encourages flight manuals, old cockpits actually A moving throttle lever informs the comments from readers, and will signaled the flight mode annunciator pilot of the autothrottle system perfor- assume that letters and e-mails changes with the audible click of a flip- mance via his hand, while a static lever are meant for publication unless ping flag, which caught a pilot’s attention. may require a visual confirmation of otherwise stated. Correspondence Glass cockpits, friendly though they the commanded thrust indexes in the is subject to editing for length are, have grown silent; audible cues are center panel at a critical heads-up mo- and clarity. categorized as cautions and warnings; ment. I believe modern cockpit design Write to J.A. Donoghue, director and awareness has come to rely entirely should try to use all available physi- of publications, Flight Safety on visual monitoring. The sole remaining ological capability as well as it uses all Foundation, 601 Madison St., discrete aural cue is the triple-click warn- available technology. Suite 300, Alexandria, VA ing for landing capability degradation. 22314-1756 USA, or e-mail I think that modern cockpit design Manuel Chagas
FSFSeminars 2009 Exhibit and Sponsorship Opportunities Available CASS 2009 April 21–23, 2009 Flight Safety Foundation and National Business Aviation Association 54th annual Corporate Aviation Safety Seminar Hilton Walt Disney World, Orlando, Florida IASS 2009 November 2–5, 2009 A Joint Meeting of the FSF 62nd annual International Air Safety Seminar, iStockphoto.; iStockphotoiStockphoto.; / IFA 39th International Conference, and IATA Tom Kelly Tom
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6 | flight safety foundation | AerosafetyWorld | March 2009 ➤ safetycalendar
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www.flightsafety.org | AeroSafetyWorld | March 2009 | 7 Serving Aviation Safety Interests for More Than 60 Years
Officers and Staff light Safety Foundation is an international membership organization dedicated to Chairman, the continuous improvement of aviation safety. Nonprofit and independent, the Board of Governors Amb. Edward W. Stimpson Foundation was launched officially in 1947 in response to the aviation industry’s need President and CEO William R. Voss F 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 1,170 individuals and member organizations in 142 countries.
Manager, Support Services Linda Crowley Horger MemberGuide Flight Safety Foundation Financial 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 www.flightsafety.org Accountant Feda Jamous
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flight safety foundation | AeroSafetyWorld | March 2009 Safety News inBrief Communications Cleanup
elicopter operators in the Gulf of The report said that the pilots had Mexico should be evaluated after not contacted base operations when they Hhurricanes and other events that departed on the accident flight, or when might disrupt communications to ensure they departed and arrived on the previous that the operators remain in compliance flight, as required by HHI’s FAA-approved with their own communication contin- operations specification. The pilots said gency plans, the U.S. National Transpor- that, before Hurricane Katrina in August tation Safety Board (NTSB) says. 2005, they had been able to make most U.S. National Oceanic and Atmospheric Administration The NTSB issued the recommenda- of their calls on the company’s commu- “Each pilot reported in post-accident tion to the U.S. Federal Aviation Admin- nications network. When the accident interviews that he assumed the other pi- istration (FAA), citing the Sept. 6, 2005, occurred, the company’s network and lot made efforts to contact the company,” forced landing of a Houston Helicopters cellular towers in the area were still out of the report said. Inc. (HHI) Sikorsky S-76A in Gulf waters operation because of storm damage. The NTSB said that search and after both engines lost power about 24 mi “Although other Gulf offshore helicop- rescue operations were delayed because (44 km) southeast of Sabine Pass, Texas. ter operators secured alternate means for of “the pilots’ incomplete mayday call, All 10 passengers and both pilots exited their pilots to communicate with their base the pilots’ and HHI’s noncompliance the helicopter before it sank; the pilots operations … HHI did not take similar ac- with company and FAA flight-following and three passengers had serious injuries, tion,” the report said. “Rather than provide requirements and HHI’s inadequate and the seven remaining passengers a formal communications plan, HHI man- communications contingencies and pro- received minor injuries. All were rescued agement suggested that its pilots use their cedures for reporting overdue flights.” after about 7 ½ hours in the water. own cellular phones or request assistance The NTSB also cited the FAA’s “inad- The NTSB’s final report on the from oil platform personnel to relay flight equate surveillance of previously identi- accident said the probable cause was departure information to base operations.” fied company deficiencies, including “the pilots’ delayed response to the no. The report said that the accident HHI’s lack of adequate flight-following 1 engine fire warning and the loss of pilots did not ask platform personnel procedures,” and said that the lack of sur- power to both engines, which occurred to relay messages and did not contact a veillance “allowed HHI’s corporate culture for undetermined reasons.” flight service station for assistance. to remain lax with regard to safety.”
Australia Increases Safety Oversight
ustralian transportation officials have asked lawmakers to agencies and operators within the aviation industry to respond to consider new legislation aimed at strengthening two avia- its formal recommendations within 90 days” — a provision that Ation safety agencies and their oversight of airlines. Albanese said would increase public confidence “that the lessons One proposal before the Australian Parliament calls for from past accidents will be acted upon in a timely manner.” creation of a five-member board within the Civil Aviation He added that additional measures to strengthen aviation Safety Authority (CASA) to “provide high-level direction to the safety would be outlined in an aviation white paper expected to organization’s regulatory and safety oversight role,” said An- be finalized later this year. thony Albanese, minister for infrastructure, transport, regional development and local government. The measure also would improve CASA’s ability to oversee foreign carriers operating in Australia, strengthen provisions for “preventing operators from continuing to operate services where CASA considers it unsafe for them to continue,” and make it an offense to negligently carry dangerous goods on an airplane, Albanese said. The second proposal would re-establish the Australian Transport Safety Bureau (ATSB) as an independent statutory agency outside the government’s Infrastructure Department. The measure also would give the ATSB new authority to “compel © Qantas
www.flightsafety.org | AeroSafetyWorld | March 2009 | 9 inBrief
Charges Filed in Teterboro Crash
ive officials of the company that injuries in the crash, operated the Bombardier Challenger which destroyed the F600 that crashed on takeoff from airplane. Teterboro Airport in New Jersey, U.S., on The U.S. At- Feb. 2, 2005, and a company pilot — who torney’s Office said was not one of the crewmembers on the that the airplane had accident flight — have been charged in a been “over-fueled in a 23-count indictment in connection with manner that caused the the crash (ASW, 3/07, p. 30). plane’s center of gravity The U.S. Attorney’s Office in New Jer- to exceed its forward sey said that the charges against the offi- weight limit for takeoff,
cials of Platinum Jet Management of Fort contributing to the U.S. National Transportation Safety Board Lauderdale, Florida, included conspiracy crash.” The office said to commit continuous willful violations of that the over-fueling attitude by the defendants to get their regulatory requirements for the operation practice was commonly used by Platinum planes in the air and maximize profits of commercial charter aircraft. Jet to increase company profits. without regard to passenger safety or The indictment accused the men of Acting U.S. Attorney Ralph J. Marra compliance with basic regulations.” “routinely undertaking and concealing Jr. added, “The fuel loading was the Marra’s office said that the six men dangerous fueling and weight distribution primary contributing factor in the crash. “joined a conspiracy to defraud charter practices” on the airplane, which overran It is astounding — and criminal — that flight customers, jet charter brokers and a runway, crashed through an airport pe- owners and operators of jet aircraft would the Federal Aviation Administration rimeter fence and onto a six-lane highway repeatedly engage in such a dangerous (FAA) through interstate wire communi- and struck a warehouse before coming game with passengers and airplanes cations, and to defraud the United States to a stop. Nine people in the airplane and loaded to the brim with jet fuel. What this by impeding and obstructing the FAA’s one person in the building received minor indictment alleges is an anything-goes regulation of commercial aircraft.”
Next Phase for NextGen Laser Warnings
ilots are being warned of increasingly common incidents aircraft with the intent of doing harm,” IFALPA says in a Medi- involving laser illumination of aircraft, which — especially cal Briefing Leaflet for pilots. “The problem has become more Pat low altitudes — can cause glare, flash blindness and pronounced with the easy availability of powerful lasers, often other visual disturbances. purchased via the Internet.” The International Federation of Air Line Pilots’ Associa- As an example of recent incidents, IFALPA cites the laser tions (IFALPA) says that although laser illuminations can illuminations of at least four aircraft on approach to Sydney result from outdoor laser light shows, most recent incidents Airport in Australia in March 2008. The green laser beams have resulted from deliberate action by a person with a hand- came from four locations, IFALPA says, noting that in response held laser pointer. to the illuminations, air traffic control (ATC) changed the “This is either because the perpetrator has a lack of runways in use. understanding of the consequences or, of more concern, the Exposure to laser beams has resulted in burning of the cor- perpetrator understands the hazards of lasers and illuminates nea, the surface layer of the eye — a temporary condition made worse by rubbing the eye — but has rarely been associated with more serious, lasting damage. IFALPA advises pilots, in the event of laser illumination, to look away from the laser, shield their eyes, engage the autopilot and, if possible, turn over control of the aircraft to a crew- member who was not exposed. Turning up cockpit lights can minimize the effects of further illuminations. The crew should inform ATC and later file a more detailed report with authori- ties, IFALPA said.
Wikimedia.org
10 | flight safety foundation | AeroSafetyWorld | March 2009 inBrief
Airport Turf Infrastructure Upgrade Urged
ynthetic turf designed to improve he aviation infrastructure in the Middle East is not keeping pace with the airport safety has been installed at industry’s growth and must be upgraded to improve efficiency and capacity, an Sthe edges of one runway at Paris Tofficial of the International Air Transport Association (IATA) says. Charles de Gaulle International Airport. Majdi Sabri, IATA regional vice president for the Middle East and North Africa, FieldTurf Tarkett, the turf manufac- told a Civil Air Navigation Services Organisation conference in January that govern- turer, says the synthetic turf is designed ments, air navigation service providers and other aviation groups must address the to improve visibility by creating a visual inefficiencies in air traffic that are threatening expansion of the industry. contrast that makes the edge of the run- “That means looking way more conspicuous; reduce dust and beyond national borders debris on the runway; eliminate sources to the regionwide imple- of food, water and shelter for wildlife in mentation of en route the area; and improve drainage. airspace and terminal Similar airport synthetic turf control areas based on systems are in place at several other air- performance-based ports, including those in Boston, Hong navigation,” Sabri said. Kong, New York and San Francisco, the “It calls for investment manufacturer said. in improved aeronautical Wikimedia.org information management and communications infrastructure. And it means making better use of aircraft and air traffic manage- ment technology to achieve an airspace structure that is based on user-preferred flight paths.” Air travel in the Middle East makes up 10 percent of international traffic, up from 5 percent seven years ago, IATA said. U.S. Federal Aviation Administration Aviation Federal U.S.
Next Phase for NextGen
he U.S. Federal Aviation Administration (FAA) is ready for a new phase of its Next Generation Air Transporta- Ttion System (NextGen) — the plan to transform the national airspace system with an infusion of advanced tech- nologies to meet future safety, capacity and environmental needs. The next phase of the program focuses on the avionics that will support NextGen operational capabilities expected to be in place by 2018. “NextGen investment requires more than FAA investment, it requires industry investment,” said Michael Romanowski, FAA director of NextGen integration and implementation, add- ing that the agency needs more input to determine exactly how
NextGen will develop in the next few years and how aircraft U.S. Federal Aviation Administration should be equipped. “The FAA cannot completely answer these questions on our has established a task force to develop recommendations on own,” he said. “We can’t gain the traction we need to move for- “how to get the most benefits from the NextGen mid-term ward unless we have the guidance, support and cooperation of operational capabilities,” the FAA said. the aviation community as full partners in this area, particularly RTCA said its task force will “recommend when, where in the area of equipage.” and how the FAA and operators should implement the needed To provide this guidance, RTCA, an industry association infrastructure, aircraft equipage, policies, procedures, training that functions as an advisory committee to the government, and other actions” for NextGen operations.
www.flightsafety.org | AeroSafetyWorld | March 2009 | 11 inBrief
NVG Training Single Sky
17-month trial of urocontrol says it has taken a big night vision goggles step toward integrating all major A(NVGs) has ended Egroups involved in air traffic in Australia, and ap- management with the first meeting proved operators are con- of the Air Navigation Services Board, tinuing to use the devices a 15-member panel designed to help in designated operations shape Eurocontrol’s work in support and in training. of the Single European Sky. The Australian Civil The new board represents air Aviation Safety Authority navigation services providers, air- (CASA) has approved the space users, airports and the military. U.S. Air Force use of NVGs for opera- Board Chairman Dieter Kaden tors conducting flights said after the February meeting that for emergency medical services, law enforcement, search and rescue, marine pilot the board’s primary objective is to transfer, aerial fire fighting and NVG training. Their use has not been approved in develop a consensus on priorities private flight operations, except for training. and “enhance the efficiency of the CASA plans to evaluate applications for NVG operations throughout 2009, and overall [air traffic management] to oversee the safety of NVG use in operations that already have been approved. supply chain.”
In Other News …
he ANA Group plans to extend the line operations safety au- Tdit (LOSA) — in which trained observers record flight crew actions during a flight — to all six member airlines. In 2006, ANA became the first Japanese airline to implement LOSA. … A new surface surveil- lance system to improve visibility from aircraft and ground vehicles on runways and the apron (ramp) is being installed at Montreal-Pierre Elliott Trudeau International Airport. Sensis Corp.’s Multistatic Dependent Surveillance technology uses airport sensors and aircraft transponder signals to triangulate aircraft loca- tions and provide the information to air traffic controllers. … For the first time, the European Aviation Safety © Dave Sherman/Associated Press Agency has granted a type certifi- cate to a transport aircraft from the Fire fighters look at the wreckage of a Colgan Air turboprop that crashed into a Commonwealth of Independent home in suburban Buffalo, New York, U.S., on Feb. 12, during an approach to States. The certificate was issued for Buffalo Niagara International Airport. The crash killed all 49 people in the the Tupolev Tu 204-120CE, a cargo Bombardier Q400 and one on the ground; the airplane was destroyed. The U.S version of the Tu 204. National Transportation Safety Board is investigating.
Compiled and edited by Linda Werfelman.
12 | flight safety foundation | AeroSafetyWorld | March 2009 FoundationFocus
Flight Safety Foundation and Me By Sid Baker
The sudden death of Sid Baker, vice chairman of Flight Safety Foundation’s Corporate Advisory Committee, just a few days after he sent us the following column, was a sad shock to everyone who knew Sid. Recently retired as head of Kodak’s flight department, Sid, 63, was already eager to take on new challenges. He will be missed by all who knew him and worked with him.
ince you are reading this maga- also operating safely and securely into government agencies around the world. zine, you and I have something in many varied locations not served by The Foundation represents you and me common — a passion for safety, our airline counterparts. on safety matters in venues we cannot particularly aviation safety. I was We eventually realized that we are access, and that absolutely affect how Sbitten by the safety “bug” not long after part of a system larger than our individ- we do our jobs and how we can con- I started flying. I can still remember ual companies, and that we can impact tribute to the success of our companies. the importance placed on maintaining that system either positively or nega- The Foundation has taken the leading a safe environment and the expecta- tively. Flight Safety Foundation helps to role in dealing with fatigue issues, pre- tion that all of us would operate safely. make that impact favorable. venting approach and landing accidents Granted, that was in a military flight No other organization views avia- and controlled flight into terrain acci- school, but the same principles and tion as a global operation involving dents, checklist construction, corporate consequences apply to every situation manufacturing, operations, mainte- flight operational quality assurance we encounter today. Those who are nance, air traffic control and regulation programs, explaining the advantages corporate aviation safety managers all with a regional — as well as a universal of safety management systems, and have the same purpose — to achieve — outlook on safety. The Foundation petitioning governments to prevent predictable outcomes based on proven recognizes that not all aviation efforts the criminalization of the accident procedures and practices that enhance are equal, with vast differences among investigation process. The Foundation the opportunity for our companies to regions, among operators and among likely will lead future projects that will become more successful. controlling agencies. The Foundation identify risks and formulate responses Most of us began our careers think- offers a forum to address these varied to enhance safety, which facilitates our ing we were the center of the operation. safety issues in a nonpartisan manner, companies’ drive to succeed. As we matured, we realized that the appealing to government agencies in The Foundation is important to me reason there is an aviation department all countries and offering suggestions, and to you. It is important to our compa- is to facilitate the success of the com- support and advice to those concerned nies, it is important to our nations, and it pany — not so we could fly airplanes! with maintaining a safe air transporta- is important to our global economy. We cannot guarantee the company’s tion system. We are the Foundation; it works success, but we can certainly enhance The Foundation offers a venue to through us and for us. I am proud to the chances of success by providing a meet and trade information with other be associated with the Foundation and rapid response to travel needs with the aviation professionals. The Founda- look forward to all we can accomplish flexibility to modify schedules while tion represents our safety interests to in the future. www.flightsafety.org | AeroSafetyWorld | March 2009 | 13 Coverstory
elicopter emergency medical with 13 crashes, nine of them fatal, and The motivation for the hearing, services (HEMS) missions in the 29 fatalities — the fatal accident rate was Sumwalt said, was “to find innovative United States have among the 2 per 100,000 flight hours, he said (Figure ways to improve HEMS safety.” He said highest fatal accident rates in the 1, p. 17, and Figure 2, p.17). In 2007, the hearing might lead to an updated Haviation industry, and their pilots and according to calculations based on a 10- study of HEMS operations, issuance medical crews are more likely to be killed year average, the fatality rate was 113 per of new safety recommendations or in crashes, a medical data specialist has 100,000 HEMS crewmembers. In com- development of a “white paper” that told a federal panel probing the recent parison, according to U.S. government addresses HEMS safety issues and pro- surge in HEMS accidents. data for 2007, workers in what typically vides guidelines for resolving them. “You can’t manage what you can’t is the highest-risk occupation in govern- In recent years, the NTSB has measure,” Dr. Ira Blumen, program and ment statistics — fishing — were killed issued numerous recommendations medical director of the University of at a rate of 111.8 per 100,000. A study of aimed at improving HEMS safety, Chicago Aeromedical Network, said, data from 1980 through 2008 showed many of them calling for regulatory telling a U.S. National Transportation that HEMS patients died at a rate of 0.76 action by the U.S. Federal Aviation Safety Board (NTSB) public hearing per 100,000 patients flown, Blumen said. Administration (FAA). Several of on HEMS safety issues that efforts to “We’ve crunched a lot of numbers,” those recommendations currently are prevent HEMS accidents have suffered he added. “I truly believe that we have included in the NTSB’s list of “Most because of incomplete accident data. the ability to save lives, but unfortunate- Wanted” safety improvements: Blumen said that a detailed analysis ly, we also have the ability to take them.” found that 146 HEMS accidents, in- NTSB member Robert Sumwalt, who • Conduct all flights in which med- cluding 50 fatal accidents, occurred headed the four-day hearing in early Feb- ical personnel are on board in between 1998 and 2008. Of the 430 ruary, called the recent accident record accordance with Federal Aviation people in the accident helicopters, 131 “alarming and unacceptable,” and added, Regulations Part 135, which gov- were killed, including 111 crewmem- “The safety board is concerned that these erns charter aircraft operations — bers, 16 patients and four others. types of accidents will continue if a con- not general aviation operations, In 2008 — the most deadly year on certed effort is not made to improve the which are subject to more lenient record for HEMS in the United States, safety of emergency medical flights.” weather and visibility restrictions;
Closing the BY LINDA WERFELMAN Loop
Alarmed by a surge in fatal accidents in 2008, the NTSB is spearheading an effort to identify new safety measures for helicopter EMS operations.
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report analyzed the crashes of 55 EMS aircraft, concluding that 29 of the 55 could have been prevented if the four safety actions recommended had already been in place. Nineteen other recommendations were issued in 1988, after a safety study that evaluated 59 earlier HEMS crashes.2 John Allen, direc- tor of the FAA Flight Standards Service, said that the FAA is “working with the NTSB to close the loop on an industry that is safe but not as safe as it could be.” Al- len noted that most of the nation’s more than 830 EMS helicopters have flown for years without a fatal crash — and many have never experienced any type of accident. Nevertheless, he cited accident statis- tics — especially the
© Chris Photography Sorensen increases recorded in 2008 in HEMS • Develop and implement programs to accidents and fatalities — as proof that intensi- evaluate the safety risks of each flight; fied safety efforts are needed. Allen credited an • Require formalized procedures for dis- earlier round of safety initiatives with a reduc- patch and flight-following, including the tion in HEMS accidents in the years preceding use of current weather information; and, 2008 and said that, because of the decrease, the FAA had not implemented new regulations. • Install terrain awareness and warning “We believe the existing regulatory struc- systems (TAWS) on all EMS aircraft. ture is safe; the numbers prove it,” Allen said. These recommendations were issued previously, “However, the upward trend in 2008 has in a 2006 special investigation report by the NTSB prompted a more aggressive response to this on airplane and helicopter EMS operations.1 The problem.”
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practice in which one HEMS operator FSF Endowment Will Aid HEMS Research after another is contacted — typically in instrument meteorological conditions (IMC) — until one accepts a mission. light Safety Foundation has received a $1 million gift, part of which will be used to develop ways to improve the safety of helicopter emergency The associations said that a recent Fmedical services (HEMS) operations, and the remainder to endow the AMOA survey found that eight Part 135 Foundation’s new Manuel S. Maciel Chair for Aviation Safety Research. operators, whose 700 helicopters account The gift was from the estate of Maciel, the founder of Manny’s Sonoma Aviation, a full-service fixed base operator at the Charles M. Schulz Sonoma for more than 90 percent of those in- County Airport in Santa Rosa, California, U.S. Maciel died in 2005. volved in HEMS operations nationwide, “The research he has funded will drive safety improvements in HEMS for years have equipped 35 percent of their aircraft to come,” said Foundation President and CEO William R. Voss. with NVGs. The survey also found that — LW operators planned to equip 90 percent of their aircraft with NVGs by 2011. The FAA’s efforts have included not “We must establish effective safety so- A separate survey submitted to the only regulations but also the establish- lutions that allow for the continuance of NTSB by the National EMS Pilots Asso- ment of a task force responsible for this necessary service — a service that has ciation (NEMSPA) showed that of 380 implementing safety initiatives, revised become an integral part of the health care HEMS pilots questioned, 334 (88 per- operations specifications for increased system,” they said, asking the NTSB to cent) said they agreed with a statement weather minimums and the develop- consider a series of recommendations, in- that the use of NVGs “has improved the ment of incentives for operators to cluding a requirement that all night EMS safety of HEMS night operations.” equip their EMS helicopters with night flights be conducted either with NVGs or NEMSPA President Gary Sizemore vision goggles (NVGs) and helicopter- another form of enhanced vision system, said that the survey respondents did TAWS (H-TAWS), designed especially or under instrument flight rules (IFR). not recommend H-TAWS as a viable for the low-altitude flight paths typi- Other recommendations called for alternative to NVGs, noting, “Although cally flown by helicopters, Allen said. use of automated weather observation these systems may well have a role in “Technology alone does not and systems and instrument approaches at improving the safety of HEMS night cannot solve the problem,” he said. “We hospital helipads and airports used for operations, they only warn the pilot of routinely seek voluntary compliance on air medical transport, establishment of a hazards that he cannot see. With NVGs, safety advances while we are consider- “dedicated low-altitude helicopter IFR in- the pilot can see, identify and avoid ing rule making as a dual-prong ap- frastructure,” accelerated implementation hazards in much the same manner that proach to safety enhancement.” of automatic dependent surveillance– he does during daylight flight.” broadcast infrastructure in HEMS op- T.K. Kallenback, vice president of ‘Zero Tolerance’ erating environments, a study of fatigue marketing and product management In a joint statement delivered to the in HEMS operations and establishment at Honeywell Aerospace, said that the NTSB hearing, three industry associa- of flight operational quality assurance Helicopter-Enhanced Ground Proxim- tions —the Association of Air Medical programs for HEMS operators. ity Warning System (H-EGPWS) — one Services (AAMS), Helicopter Associa- In addition, the associations en- of Honeywell’s TAWS products — was tion International (HAI) and the Air dorsed recommendations to apply the developed from the EGPWS used for Medical Operators Association (AMOA) same federal safety standards and over- several years in airplanes and designed — said that they “maintain a position of sight provisions to commercial HEMS specifically for helicopters operating zero tolerance for accidents.” Neverthe- operators and government, or public- very near terrain and obstacles. less, the associations said, a review of use, operators; to eliminate response FAA documents presented to the HEMS accidents during 2007 and 2008 time requirements, which promise a NTSB panel said that because H-TAWS showed that “no service model, category response to calls within a prescribed is sensitive not only to the proximity of of operator (for-profit, not-for-profit, time period; to increase management terrain but also to excessive sink rate, civilian or government) or geographic oversight of crew performance; and it is especially effective against con- area is immune to accidents. to address “helicopter shopping,” the trolled flight into terrain and against
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some approach and landing accidents. safe flight,” Bonham said, adding that More, and Better, Training “Because the accident scenarios against Air Evac EMS operates under Part 135, Several of the 40 witnesses testifying which H-TAWS would be effective equips all helicopters for recovery from before the NTSB panel identified crew tend to have severe outcomes, it would inadvertent entry into IMC and plans to training — including crew resource reduce the risk of fatal accident by 20 install NVGs in helicopters at all its bases. management (CRM) training for pilots percent,” the FAA said. Matthew Zuccaro, president of HAI U.S. Aviation Accident Rates, 1982–2008 and co-chairman of the International 25 Helicopter Safety Team, told the NTSB HEMS General aviation panel that his organization promotes Helicopter 20 135 scheduled not only the use of NVGs but also 135 nonscheduled 121 scheduled H-TAWS, and other technological 121 nonscheduled advances, as well as development of a 15 strong safety culture and other related human factors advances. 10 “But there is no magic bullet,” he said, noting that previous HEMS fatal 5
accidents have involved helicopters hours per 100,000 ight rate Accident with advanced cockpits and two-pilot, 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 IFR-qualified crews, and have occurred Year during visual flight rules (VFR) opera- HEMS = helicopter emergency medical services tions as well as in IMC. Part 121 = U.S. Federal Aviation Regulations Part 121, “Air Carriers and Commercial Operators” Part 135 = U.S. Federal Aviation Regulations Part 135, “Commuter and On-Demand Operations” VFR vs. IFR Source: Ira Blumen, M.D. Larry Buehler, an aviation safety inspector in the FAA Flight Standards Figure 1 Service, said that night flights and inadvertent entry into IMC are among U.S. Aviation Fatal Accident Rates , 1982–2008 the greatest challenges facing HEMS 9 pilots and that conducting a flight in HEMS General aviation accordance with instrument flight rules 8 Helicopter 135 scheduled is the best countermeasure for the risk 7 135 nonscheduled 121 scheduled of controlled flight into terrain. 6 121 nonscheduled
One-third of HEMS operators are 5 authorized to conduct IFR flights, he 4 said; for those that must fly under 3 VFR, compliance with regulations and proper preflight planning — with 2 1 special attention to establishing a hours per 100,000 ight rate Accident minimum safe altitude — are crucial, 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 he added. Year Tony Bonham, chief pilot for Air HEMS = helicopter emergency medical services Evac EMS, which conducts VFR flights Part 121 = U.S. Federal Aviation Regulations Part 121, “Air Carriers and Commercial Operators” from 84 bases in 14 states, said that VFR Part 135 = U.S. Federal Aviation Regulations Part 135, “Commuter and On-Demand Operations” and IFR flight are both safe for HEMS. Source: Ira Blumen, M.D. “Our first mission is to follow the rules and regulations and procedures for Figure 2 www.flightsafety.org | AeroSafetyWorld | March 2009 | 17 Coverstory
and medical crewmembers — as crucial Paramedics (IAFP), said that many med- some areas, with more aircraft than are in improving HEMS safety. ical crewmembers are reluctant to be the needed to transport patients. The states Bruce A. Webb, Eurocopter’s chief sole crewmember to suggest refusing a should work with the federal govern- flight instructor, described himself as mission because of safety concerns. ment to coordinate oversight of EMS “certainly an advocate of technology” Riley also voiced concern that, in a operations, NASEMSO said. but added that technology alone is not July 2008 survey of IAFP membership, Dr. David Thompson of AAMS, the solution to the problem. “That’s 30 percent of respondents reported that who also is the national medical training,” Webb said. pilots were well aware of the nature of adviser for PHI Air Medical, said that Training requirements vary, the request for each flight. HEMS operations often function as depending in part on the complexity “This opens the door for human backup medical care in small com- of the helicopter and the operator’s factors to be taken into account when munities that lack hospital services, weather minimums, Webb said, adding deciding whether it is safe to fly,” he said, medical specialists or ambulances that an annual training session prob- noting that pilots who are told about the to provide ground transportation to ably is adequate for pilots of basic VFR critical condition of a patient may feel distant medical facilities. helicopters who comply with conser- pressure to accept a flight in bad weather. He denounced the concept of vative weather minimums. “But twice “We can try not to consider that the helicopter shopping, suggesting that a year is better,” he said. For pilots of patient is a sick child or we are the last patients and operators alike would technologically advanced helicopters, chance for the survival for the patient,” benefit from increased cooperation; for he recommended quarterly training. Riley said. “However, with over 70 example, a VFR operator that rejected “Scenario-based training is where percent of the air medical crashes being a flight because visibility was below we must go to stop accidents from human-factor related, the IAFP is not minimums might refer the job to an occurring,” Webb said. “Most people comfortable with this process of inform- IFR operator. think their IFR recovery skills are better ing the pilot of patient information.” than they really are.” Indispensable Terry Palmer, an instructor and ‘Helicopter Shopping’ Regardless of what other steps are manager of rotorcraft programs for Dan Manz of the National Association implemented, a number of participants FlightSafety International, agreed that of State EMS Officials (NASEMSO) told the NTSB panel, establishment of a “training is key. These are perishable and state director of EMS in Vermont, strong safety culture within each opera- skills that need to be reinforced. The described “slow but steady growth” tion is crucial. best way to do that is with scenario- in HEMS operations from the 1970s, “A safety culture is the indispens- based training in a simulator.” when operations began, until 2000, able context for enabling technology,” Kevin High, a registered nurse and when the Centers for Medicare and said the FAA’s Allen. “When a manage- president of the Air/Surface Transport Medicaid Services developed a new ment team establishes a corporate cul- Nurses Association, cited mandatory formula to reimburse operators. The ture that supports the decision-making CRM training as one of the HEMS growth period that followed the cen- skills of the pilots and treats each flight community’s most pressing needs. ters’ action resulted in a doubling of as safe passenger transportation and “The culture has improved a lot” the number of EMS helicopters from not as an emergency evacuation mis- in recent years, with the advent of the fewer than 400 in 2000 to about 830 sion, the risk of an accident is reduced notion that there must be agreement today. Many of the new programs are dramatically.” among the pilot, flight nurse and flight private, for-profit operations, instead paramedic that conditions are right for of the non-profit hospital-based pro- Notes any particular flight, High said, noting grams that predominated before 2000, 1. NTSB. Special Investigation Report: the popularization of the phrase “three Manz said. Emergency Medical Services (EMS) to go, one to say no.” His organization told the NTSB Operations, SIR-06/01. Jan. 25, 2006. Nevertheless, High and James P. panel that the influx of helicopter and 2. NTSB. Commercial Emergency Medical Riley, a paramedic and president of airplane EMS programs has resulted in Service Helicopter Operations, SS—88-01. the International Association of Flight “coordination and confusion issues” in Jan. 28, 1988.
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By Thomas Anthony
Wake Me On the “rattler” shift, it’s a toss-up who will crash first. When My Shift Is Over
he rattler” is the nickname for a My first reaction to learning about the rattler work schedule used in U.S. air traffic shift was, “Does anybody know we are doing control (ATC) facilities. I used to this?” I figured the answer had to be “no,” since work the rattler shift as a controller no one would intentionally schedule a controller in“ theT 1980s. I learned that this shift earned its to work live traffic with only three or four hours reputation for doubling back and biting those of sleep. I found out I was wrong. Not only was who worked it. it done intentionally, but it occurred regularly in © Chris Photography Sorensen
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facilities around the Federal Aviation Adminis- between a day shift and a midnight shift (mid). tration (FAA) ATC system. Imagine my reac- Two hours of sleep is not an anomaly when tion after reading about the Comair Flight 5191 working the mid; it is a normal fact of life. The accident at Lexington, Kentucky — they’re still media failed to ask why the controller only got working the rattler. two hours. The idea behind the rattler is to compress At the University of Southern California Avia- your five eight-hour shifts closely together to tion Safety and Security Program, among the top- maximize the time in your days off. Here is how ics we cover is human factors that contribute to it works: The first day of your workweek — we’ll aircraft accidents. In one course, Flight Surgeon Gregg Bendrick of the U.S. National Aeronautics Alcohol Intoxication vs. Sleep Loss and Space Administration (NASA) Dryden Flight Research Center presents the science behind the 20 decrease in function associated with sleep loss and fatigue. This includes loss of focus, attention 10 and ability to perform complex tasks. Bendrick teaches that there are three aspects 0 0.05% BAC to fatigue: circadian rhythm, acute sleep loss and chronic sleep loss. Circadian rhythm means that –10 0.10% BAC people have “low points” in their day in terms of –20 alertness and functionality. A mild low point is Mean relative performance Mean relative normally in the mid- to late afternoon, whereas
–30 the other, more significant major low point is .000 .10 +.085.065.045.025 3 7 11 15 19 23 27 in the early morning — when one normally is Blood alcohol concentration (percent) Hours of wakefulness sleeping. Moreover, circadian rhythm physiology
Source: Accident Investigation Board of Norway/Susan Reed makes it easier for humans to lengthen their day rather than to shorten it. Indeed, personal Figure 1 experience tells us it is easier to fly from the East call it Monday, but it could be any day — you Coast to the West Coast of the United States, start work at 4 p.m. and are off at midnight. rather than vice versa. But with the rattler, one is Your second day, you work from 2 p.m. to 10 trying to force the body to do just the opposite p.m. Your third day, Wednesday, is from 8 a.m. — shorten the physiological day. to 4 p.m. Your fourth day, Thursday, is from 6 Acute sleep loss refers to how many hours a.m. to 2 p.m. For your fifth day, you begin at one has been continuously awake. The real either 10 p.m. or midnight on your fourth day, problem comes in when the acute sleep loss late Thursday night. You are off at either 6 a.m. overlaps the major low point in the circadian or 8 a.m. Friday. Then you have until 4 p.m. rhythm. At that point, performance deterio- on Monday before you have to come back. For rates to the point of being identical to someone someone wanting to maximize time away from who is legally drunk. Admittedly, some of work, this is an ideal shift. From the perspective this effect can be counteracted with caffeine, of a responsible individual wanting to ensure air cold air and auditory stimulation. However, safety, it is irresponsible. chronic sleep loss — the difference between In the days following the Comair accident, the number of hours slept and the number of the news media made a big deal of the fact that hours of sleep required — over the preced- the controller only had two hours of sleep. My ing two weeks lessens the effects of the usual thought at the time was that the controller was countermeasures. Hence, the triple whammy of fortunate that he had gotten that much sleep circadian rhythm, plus acute and chronic sleep
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loss leads to a several-hour “valley of fatigue” that I got into only one wreck coming home during which one’s performance is really poor, from a rattler shift; the car was a total loss. At whether or not the person realizes it. As the in- the time, I made no connection between the dividual climbs out of the valley with the pro- wreck and coming off a rattler shift. gression of the circadian rhythm, he or she may So what is the answer? Air traffic managers actually feel pretty good, as if having caught a must staff the midnight shift. Controllers can- “second wind.” It is possible to be lulled into a not work a permanent midnight shift because false sense of security. their skills would erode. The U.S. Air Force The effects of fatigue are shown in two in Vietnam was faced with a similar challenge graphs that compare performance degradation of scheduling crews that would fly missions from hours of wakefulness and performance during the hours around midnight. They did degradation associated with blood alcohol so by scheduling three straight midnight shifts concentration (Figure 1). The two curves are separated by days off on either side. This kind strikingly similar.1 of schedule avoids the “double back” feature My perspective on workplace fatigue is of the rattler shift. Alternatively, a schedule entirely more personal. It comes from years of employing a week of straight mids every two working the rattler shift. I can remember lying months would be an option. The options may in bed in the summer at 5 p.m. with all the shut- not be popular with the unions because they ters closed, trying my hardest to get some sleep result in less regular time off between shifts. Ei- before I had to get up and go to work at 9 p.m. ther option would, however, be the responsible Several of the neighbors had gathered on the choice. sidewalk outside my bedroom window to talk, The science is clear. As Bendrick demon- and their kids played up and down the sidewalk. strates in his course, one cannot change human It was not an environment conducive to sleep. physiology. When one tries, the result is truly InSight is a forum for If I got an hour’s real sleep I felt lucky. And the impaired performance and myriad excuses to expressing personal urgency of knowing that I had to get some sleep, justify the current practice, with a search for opinions about issues of importance to aviation but not being able to sleep, is something I will a target of blame when something bad hap- safety and for stimulating never forget. Of course, the harder I tried to pens. But for me, it goes beyond science. It is a constructive discussion, sleep, the more difficult it became. memory of being so sleep-impaired that at times pro and con, about the There is a flip side to the phenomenon. it verged on pain. This is not a safety mindset, expressed opinions. Amazingly, with an hour or two of quasi-sleep and it is not a characteristic of a safety culture. Send your comments to you feel pretty good and alert for the first two or I must ask again: Isn’t it time to get rid of the J.A. Donoghue, director of publications, Flight three hours of your shift. Then there is about a rattler? Safety Foundation, 601 three- to four-hour period when the air traffic Madison St., Suite 300, demands are low, and you get into a “low and Note Alexandria VA 22314- slow cruise” mode. You are able to handle about 1756 USA or donoghue@ 1. Dawson, D.; Reid, K. “Fatigue, Alcohol and flightsafety.org. an hour of increased activity from 5 a.m. to 6 Performance Impairment.” Nature Volume 388, a.m. — or at least you think you can — but the July–August 1997. last two hours of the shift are very hard. You hope there is enough staffing so that the super- Acknowledgment visor can “bury” you on a low-activity position. Special thanks to Gregg A. Bendrick, M.D., M.P.H., chief Even at that, I remember that the effort to stay medical officer and flight surgeon at the NASA Dryden awake sometimes bordered on pain. Flight Research Center for his contributions to this The drive home after the last day of a rat- article. tler shift was no better. I would drive with the Thomas Anthony is director, Aviation Safety and Security windows down, blasting the radio and biting my Program, Viterbi School of Engineering, University of tongue to stay awake. I consider myself lucky Southern California. www.flightsafety.org | AeroSafetyWorld | March 2009 | 21 humanfactors
Aeromedical experts expect fatigue-related problems to worsen with the advent of more ULR flights, unless reliable countermeasures are implemented.
Easing FatigueBY LINDA WERFELMAN he aviation industry generally In a position paper adopted by of duty and rest scheduling guidelines has failed to incorporate new the Aerospace Medical Association for corporate and business operators.2 knowledge of fatigue-fighting (AsMA),1 the organization’s fatigue “Although the scientific understand- techniques into flight crew countermeasures subcommittee wrote ing of fatigue, sleep, shift work and schedulingT provisions and flight and that few changes have been made in circadian3 physiology has advanced sig- duty time limitations, according to flight time limitations and flight crew nificantly over the past several decades, sleep experts who recommend end- scheduling since the first limits were current regulations and industry practic- ing prohibitions on cockpit naps and adopted in the 1930s, despite numerous es have in large part failed to adequately authorizing the use of certain sleep- recommendations, including the 1997 incorporate the new knowledge,” the inducing medications. publication by Flight Safety Foundation fatigue panel said. “Thus the problem
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of pilot fatigue has steadily increased along with of flight marked by low workloads, and that pilots fatigue-related concerns over air safety.” are especially susceptible to microsleeps — periods A separate fatigue study conducted for the of sleep that last only several seconds and often go European Aviation Safety Agency (EASA) con- unrecognized — in the middle-to-late segments of cluded with a call for new limits on duty time cruise flight during long-haul operations. (See “Study: EASA Needs Stricter Limits on The fatigue panel cited a survey by the U.S. Fatigue,” p. 24). National Aeronautics and Space Administration The AsMA position paper said that accident in which 80 percent of 1,424 flight crewmembers statistics, pilot reports and operational flight from regional airlines said they had “nodded off” studies all indicate that aviation operators are during a flight. A survey of 1,488 corporate/ex- increasingly concerned about fatigue. ecutive flight crewmembers found that 71 percent “Long-haul pilots frequently attribute their had fallen asleep during flight. fatigue to sleep deprivation and circadian dis- “Fatigue in aviation is a risk factor for oc- turbances associated with time zone transitions,” cupational safety, performance effectiveness and the fatigue panel wrote. “Short-haul (domestic) personal well being,” the panel said. “Humans pilots most frequently blame their fatigue on simply were not equipped (or did not evolve) to sleep deprivation and high workload. Both long- operate effectively on the pressured 24-7 sched- and short-haul pilots commonly associate their ules that often define today’s flight operations, fatigue with night flights, jet lag, early wakeups, whether these consist of short-haul commercial time pressure, multiple flight legs and consecu- flights, long-range transoceanic operations or tive duty periods without sufficient recovery around-the-clock military missions. Because breaks. Corporate/executive pilots experience of this, well-planned, science-based fatigue fatigue-related problems similar to those re- management strategies are crucial for managing ported by their commercial counterparts.” sleep loss/sleep debt, sustained periods of wake- Concerns about fatigue are likely to increase fulness and circadian factors that are primary as ultra-long-range (ULR) flights — those of 16 contributors to fatigue-related flight mishaps.” hours or more — increase, the panel said. “An important question for ULR operations Current Practices is whether the strains imposed by the extension The AsMA fatigue panel rejected the rule- of flight duty hours beyond the limits com- making approach typically used by the U.S. monly flown will effectively be mitigated by the Federal Aviation Administration (FAA) and standard fatigue countermeasures, which in part other regulatory agencies to prescribe the limits have been responsible for the acceptable safety on flight, duty and rest times (Table 1, p. 24). record of existing flight operations,” the panel Such limits should be developed from scientific said. “Without proper management, ULR opera- research on the effects of sleep and circadian tions may exacerbate the fatigue levels that have rhythms on job performance, the panel said. already been shown to impair safety, alertness “The risks associated with non-science-based and performance in existing flight operations.” regulatory approaches may have been unknown in the 1930s, when flight and duty time limits Causes and Effects were first addressed,” the panel said. “At the time, Research has found that the causes of fatigue are research documenting the performance and alert- similar in all types of aviation operations, as are ness decrements associated with sleep loss and the effects. circadian disruption was limited, and it seemed Studies conducted during flight and in simula- sufficient to ensure safety via agreements between tors have found that fatigue interferes with the flight crew and management. However, with the functions of the central nervous system, that pilots demands of 24-7 aviation operations, it has be-
© Brand X Pictures may experience “vigilance lapses” during periods come increasingly apparent that such prescriptive
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Study: EASA Needs Stricter Stand on Fatigue
uropean Aviation Safety Agency The researchers said they were es- The European Cockpit Association (EASA) rules do too little to pecially concerned with provisions that welcomed the researchers’ findings, Emitigate the effects of fatigue on allow “a large number of duty hours in a noting that fatigue has been cited as a pilots, according to a report by human short time. … The permissible max- contributing factor in 15 to 20 percent factors researchers that was applauded imum of 180 duty hours in three consec- of fatal aviation accidents associated by pilot organizations and faulted by utive weeks allows for a high density of with pilot error. airlines as “seriously lacking.” work hours in a short period of time and The results of the study were not The report, made public in January should be limited through an additional included in a proposed revision of after it was submitted to EASA by provision for a maximum of 100 duty regulations governing air operations Moebus Aviation and the European hours in 14 consecutive days.” that were published in late January, Committee for Aircrew Scheduling and Their report also said that the EASA said. Instead, the study will be Safety (ECASS), said that a number of maximum daily flight duty time of 13 the subject of a regulatory impact existing EASA rules and proposed rules to 14 hours “exceeds reasonable limits, assessment to consider the potential changes conflict with scientifically devel- especially under exacerbating circum- safety benefits of its recommendations, oped principles of fatigue prevention. stances (e.g., high workload, night as well as their social, economic and “Our responses are based on the flying … ) and should be reduced.” environmental aspects, EASA said. available scientific knowledge which, The Association of European —LW briefly, finds that fatigue is increased Airlines denounced the report as “seri- Note by extended time awake, reduced prior ously lacking in substantive scientific 1. Moebus Aviation and ECASS. “Consensus sleep, the window of circadian low and and medical content” and said it “ar- Report Prepared by ECASS: Scientific task load, and that these effects are rives at conclusions which are oblivi- and Medical Evaluation of Flight Time Limitations,” TS.EASA.207.OP.08. 2008.
FAA Rest, Flight and Duty Time Limits For example, the panel said, current FAA reg- ulations do not recognize any difference between 1 2 Type of Limit Non-Augmented Crew Augmented Crew eight hours of duty time during the day and eight Minimum pre-duty rest period 10 hours 10 hours hours at night. A “scientifically informed” regula- Minimum post-duty rest period 10 hours 12 hours tion would acknowledge a difference, based on 18 hours for time of day and circadian rhythms, the panel said. multiple time zones Maximum flight time 10 hours 12 hours In-Flight Strategies Maximum duty time 14 hours 16 hours The fatigue panel reviewed several in-flight Maximum duty time per week 30 hours 30 hours fatigue countermeasures: napping on the flight Maximum duty time per month 100 hours 100 hours deck, activity breaks, bunk sleep on long-haul Maximum duty time per year 1,400 hours 1,400 hours and ULR flights, in-flight rostering — schedul- FAA = U.S. Federal Aviation Administration ing some flight crewmembers to assigned posi- 1. A non-augmented crew includes the minimum flight crew required to conduct a flight. tions on the flight deck while freeing others for 2. An augmented crew includes more than the minimum number of crewmembers to conduct a flight. in-flight rest — on long-haul and ULR flights,
Source: Aviation, Space and Environmental Medicine and increased exposure to flight-deck lighting. “All of [these] in-flight countermeasures … Table 1 clearly have a place in sustaining the alertness and approaches do not address inherent sleep and performance of aviation personnel,” the panel said. circadian challenges, nor do they provide opera- “However, the manner in which these strategies tional flexibility.” are employed should be based on the currently
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available scientific knowledge and should be Strategies for Better Sleep implemented only after thoughtful consideration.” Members of the panel said they “take excep- Recommendations to optimize sleep opportunities tion to the current prohibition on in-seat cockpit • Wake up and go to bed about the same time every day. napping in civil aviation,” and described in-seat napping of up to 40 or 45 minutes as a “safe and • Use the sleep area only for sleep — not for chores. effective” risk-management tool that could “sig- • Establish a consistent bedtime routine — for example, read and take a hot nificantly improve alertness … and help sustain shower, then go to bed. aircrew performance during situations in which • Perform aerobic exercises every day but not within two hours of bedtime. unexpected delays require the postponement of • Keep the sleep area dark, quiet, comfortable and relatively cool. the next consolidated sleep opportunity.” • Move the alarm clock out of sight. In-seat naps should not, however, be used to replace in-flight bunk sleep during long-haul and • Avoid caffeine in the afternoon and evening. ULR flights, the panel said, adding that bunk sleep • Avoid using alcohol to promote sleep. — used along with in-flight rostering — should be • Avoid cigarettes, especially before bedtime. considered a primary method of fatigue mitiga- tion. Additional research is needed to determine • If you can’t sleep, leave the sleep area and do something relaxing. When you become sleepy, go back to bed. the best timing for sleep to help crewmembers maintain maximum performance, AsMA said. Recommendations for rotating shift schedules
Research also has found that alertness is • When rotating onto night duty, avoid morning sunlight. improved with breaks for mild physical activity • To promote daytime sleep, keep the sleep area dark and cool; use eye and increased social interaction “or even just masks and either earplugs or a “masking noise” to limit interference from temporary disengagement from monotonous light and noise. tasks,” the panel said, recommending breaks of • Comply with the “Recommendations to optimize sleep opportunities,” about 10 minutes each hour. above, with adjustments for daytime sleep. In addition, laboratory studies have shown that • Before night duty, take a short nap. increasing the light level on the flight deck, espe- • After waking from daytime sleep, expose yourself to at least two hours of cially at night, can temporarily improve alertness sunlight or artificial bright light in the late afternoon or early evening. and performance, the panel said. This technique should be used only with an understanding of how Recommendations for time zone adjustments light can affect circadian rhythms, however. • Quickly switch to the new time zone schedule for sleep, meals and Off-duty naps that are intended to promote activities. on-duty alertness should be “as long as possible, • Maximize sunlight exposure during mornings. and whenever feasible, they should occur at the • Minimize sunlight exposure during afternoons. circadian time most conducive to natural sleep (i.e., early afternoon or early predawn hours, • Avoid heavy meals at night. according to the body clock),” the panel said. • Comply with the “Recommendations to optimize sleep opportunities,” above.
“The principles outlined for good sleep hygiene • Use relaxation techniques to promote sleep at night. should be followed to promote optimal nap • If possible, take a hot bath before bed. Cooling off after the bath “may quality and duration (Table 2). mimic the circadian-related temperature reduction that normally occurs “Upon awakening from a nap, there should during sleep.” be a wake-up period of at least 30 minutes prior • During the first few days of adjustment, use sleep medications, if au- to the performance of any safety-sensitive tasks.” thorized, to promote nighttime sleep and caffeine to promote daytime alertness. Sleep-Inducing Medications Source: Aviation, Space and Environmental Medicine Because sleep often is difficult to obtain — if the environment is noisy, hot, uncomfortable, Table 2 www.flightsafety.org | AeroSafetyWorld | March 2009 | 25 humanfactors
or otherwise not conducive to sleep; if such as valerian and kava and the syn- Caffeine Content of Common the individual is excited or anxious; or thetic hormone melatonin that some- Drinks and Over-The-Counter if the sleep opportunity occurs at a time times are used to promote sleep. Medicines not biologically conducive to sleep — Because the U.S. Food and Drug the fatigue panel recommended allow- Administration does not regulate Average Caffeine ing the off-duty use of one specific type these substances, the quality of com- Substance Content of sleep medication. pounds that contain them is left up to 1 cup Maxwell House coffee 100 mg The panel said that zolpidem — individual manufacturers and cannot 1 Starbucks short coffee 250 mg sold under the brand names of Ambien, be assured, the panel said. Melatonin 1 Starbucks tall coffee 375 mg Myslee and Stilnox — should be au- probably is the most frequently used of 1 Starbucks grande coffee 550 mg thorized for use by civilian pilots up to these substances, and studies indicate 1 Coke 50 mg four times a week, “in situations where that it may be useful in some aspects of 1 Mountain Dew 55 mg natural sleep is difficult or impossible sleep-promotion, especially when it is 1 cup tea 50 mg due to circadian or other reasons.” The taken outside the usual sleep period. In 2 Anacin 65 mg FAA currently allows its use no more some countries other than the United 2 Extra Strength Excedrin 130 mg than twice a week, and requires 24- States, melatonin is regulated, and labo- 1 No Doz Maximum Strength 200 mg hour grounding for any pilot who takes ratory tests have found pharmaceutical- Source: Aviation, Space and Environmental Medicine it (Table 2, page 25). grade melatonin effective. The panel outlined three conditions Table 3 for use of zolpidem: The pilot must first ‘Tactical Caffeine Use’ determine, while off duty, that he or she Crewmembers also should understand The panel endorsed the continued has no unusual reactions to the medica- how their intake of caffeine — in coffee, use of caffeine as a fatigue countermea- tion; the dose must not exceed 10 mg in tea, soft drinks and some pain relievers sure and recommended that crew- a 24-hour period; and at least 12 hours — will affect their alertness, the panel members avoid taking more then 1,000 must pass between the time the pilot said (Table 3). mg of caffeine in any 24-hour period, takes the medication and the time he or “Numerous studies have shown that take it only “when it is truly needed to she returns to duty. caffeine increases vigilance and im- reduce the impact of fatigue” and avoid “Zolpidem should not be taken to proves performance in sleep-deprived it within four hours of bedtime. promote any type of in-flight sleep,” the individuals, especially those who do “Here are some situations where us- panel said. “It should be noted that facili- not consume high doses,” the panel ing caffeine makes sense: leading into the tating quality sleep with the use of a well- said. “Caffeine … is already used as predawn hours, mid-afternoon when the tested, safe pharmacological compound an alertness-enhancing substance in a alertness dip is greater because of inade- is far better than having pilots return to variety of civilian and military flight quate nocturnal sleep and prior to driving duty when sleep-deprived or having then operations, and it has proven safe and after night duty, but not within four hours return to duty following a sleep episode effective.” of going to sleep,” the panel said. that has been induced with alcohol.” Most people feel the effects of caf- The panel’s recommendation did feine — including increased alertness, New Technologies not extend to other types of sleep- decreased sleepiness and a more rapid The panel cautioned against any over- inducing medications. heartbeat — within 15 to 20 minutes, reliance on fatigue-detection technolo- Other sleep medications not yet and these effects typically last four or gies and scheduling tools that rely on on the market are likely to be more five hours, longer in people who are biomathematical models of alertness effective — and may improve sleep ef- especially sensitive. — such as monitoring an individual’s ficiency so much that fewer than eight Crewmembers who use caffeine for brain waves, eye gaze, muscle tone or hours of sleep a day will be required for alertness should consume it in small other characteristics. “effective wakefulness,” the panel said. quantities, “and save the arousal effect Nevertheless, some of these tools Like the FAA, AsMA’s fatigue panel until they really need it,” the panel said. can be incorporated into overall safety discourages the use of herbal substances “This is called ‘tactical caffeine use.’” management, and some have great
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potential but have not yet been shown day-to-day sleep is the best possible safety levels are not compromised by to meet practical, scientific and ethical protection against on-the-job fatigue,” offering an interactive way to safely standards, the panel said. the panel said. “Recent studies have schedule and conduct flight operations “None of the real-time fatigue- made it clear that as little as one to two on a case-by-case basis,” the panel said. detection technologies have been hours of sleep restriction almost imme- The development of fatigue sufficiently proven in an aviation envi- diately degrades vigilance and perfor- countermeasures requires increased ronment (with the possible exception mance in subsequent duty periods.” attention to individual differences in of the wrist-worn alertness device that Educational efforts should empha- responding to sleep loss, sleep disrup- triggers an alarm sound when wrist size five points, the panel said: tion and time zone transitions, the inactivity occurs for a preset amount of panel said. • “Fatigue is a physiological prob- time) to warrant widespread implemen- “Many issues associated with flight lem that cannot be overcome by tation,” the panel said. operations remain unanswered and can motivation, training or willpower; The panel said that some crew only be answered by collecting data scheduling tools based on fatigue- • “People cannot reliably self-judge during carefully scientifically designed prediction models have proved “to a their own level of fatigue-related research,” the panel said. “While fatigue limited extent” worthwhile, especially impairment; represents a significant risk in avia- those that are used to evaluate the • “There are wide individual differ- tion when left unaddressed, there are fatigue associated with different sched- ences in fatigue susceptibility that currently numerous countermeasures ules and design alternatives. must be taken into account but and strategies that can be employed “Refinement of both the new fatigue which presently cannot be reliably to increase safety. Furthermore, new monitoring technologies and scientifi- predicted; technologies and countermeasures are cally based scheduling software must being developed that hold great prom- • “There is no one-size-fits-all ‘magic continue, and once they are validated ise for the future.” bullet’ (other than adequate sleep) for specific types of operations, they that can counter fatigue for every should be incorporated as part of an Notes person in every situation; but, overall safety management approach 1. Caldwell, John A.; Mallis, Melissa M.; supplementing regulatory duty limita- • “There are valid counter-fatigue Caldwell, J. Lynn; Paul, Michel A.; tions,” the panel said. strategies that will enhance safety Miller, James C.; Neri, David F.; AsMA and productivity, but only when Aerospace Fatigue Countermeasures No ‘One-Size-Fits-All’ Cure they are correctly applied.” Subcommittee of the Human Factors Committee. “Fatigue Countermeasures To discourage overreliance on sleep Along with educational efforts, op- in Aviation.” Aviation, Space, and medications, the panel said, “crew- erators should implement a fatigue Environmental Medicine Volume 80 members should be educated about risk management system (FRMS) to (January 2009): 29–39. proper sleep hygiene, the benefits of develop flight and duty schedules based 2. Flight Safety Foundation Fatigue aerobic exercise for promoting quality on physiological and operational needs Countermeasures Task Force. “Principles sleep and natural strategies designed to rather than prescriptive hours-of- and Guidelines for Duty and Rest promote circadian readjustment.” service limitations that do not take into Scheduling in Corporate and Business Aviation.” Flight Safety Digest Volume 16 Education must lead to an under- consideration the effects of circadian (February 1997). standing of the dangers of fatigue, the rhythms, the panel said. causes of sleepiness and proper sleep The panel characterized an FRMS as 3. A circadian rhythm is the human body’s natural internal cycle — approximately habits, which can help ensure that crew- an “evidence-based system for the mea- 24 hours long — of periods of sleep and members obtain about eight hours of surement, mitigation and management wakefulness. sleep every night, the fatigue panel said. of fatigue risk” that often exists within “Ultimately, the individual pilot, an operator’s safety management system. Further Reading From FSF Publications schedulers and management must be “A multi-component FRMS pro- FSF Editorial Staff. “Lessons From the Dawn of convinced that sleep and circadian gram, with a scientific foundation, Ultra-Long-Range Flight.” Flight Safety Digest rhythms are important and that quality helps ensure that performance and Volume 24 (August–September 2005). www.flightsafety.org | AeroSafetyWorld | March 2009 | 27 causalfactors
he augmented flight crew elected to take their rest breaks in the Ke avik, cockpit of the Boeing 737-800 rather than in the on-board rest Iceland facility that had been provided for the round-trip flight between Iceland and Turkey — a journey that was prolonged by delays Tand the unexpected need for an en route fuel stop. The cockpit pro- vided an unsuitable environment for rest, and the pilots likely were tired when they conducted the last approach and landing of the long day, according to the Aircraft Accident Investigation Board (AAIB) of Iceland. The board’s final report on the incident said that fatigue was reflected in the crew’s performance during the approach and landing at Keflavik. With little or no flare, the aircraft bounced on touch- down. The wheel brakes were applied late, and reverse thrust was not used to its full effectiveness. The surface conditions at the end of the
Edinburgh, Scotland
BY MARK LACAGNINA Too Long
Fatigue factors in a runway excursion. Antalya, at the Wheel Turkey Susan Reed
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Ke avik, Iceland
© Viktor Gadestedt/Airliners.net
Edinburgh, Scotland Nearing Keflavik, runway were worse than expected, and the crew The pilots reported for duty at 0905. They re- the pilots of this turned the 737 onto the final taxiway to avoid ceived a message from a duty officer for ScanOps, 737 commented on an overrun. the contracted flight-planning service for JetX, that how long the day “The aircraft skidded off the taxiway and 189 passengers were expected for the 2,616-nm had been and how came to rest parallel to the taxiway with the (4,845-km) flight from Antalya to Keflavik. “Due tired they were. nose landing gear and the right main landing to strong headwinds, the duty officer advised that gear off the paved surface,” the report said. No carrying all the luggage could pose a problem,” the one was hurt, and damage was minor. report said. “If so, and if flight and duty time limi- Pointing to the fatigue-related errors identi- tations allowed, he suggested that a fuel stop would fied during the investigation, the board called be preferable to offloading luggage.” on authorities to ensure that operators provide The JetX flight operations manual set a adequate crew rest facilities when required and 16-hour duty limit for an augmented flight to develop guidance for implementing fatigue crew. Two landings were allowed during the management systems. duty period; a third landing could be conducted The incident flight was conducted on Oct. 28, only with permission by the Icelandic Civil 2007, by JetX under a wet-lease agreement with Aviation Administration (CAA). Among the Astraeus. The flight plan called for the 737 to de- requirements for permitting a third landing was Too Long part from Keflavik at 1005 coordinated universal the availability of approved crew rest facilities time (1005 local time) for the positioning flight aboard the aircraft. to Antalya, arriving at 1600 (1800 local time) and At the crew’s request, ScanOps developed departing at 1700 for a 2320 arrival in Keflavik. another flight plan for the return flight, with a The estimated duty period was 14 hours and 15 fuel stop in Edinburgh, Scotland, and obtained Antalya, minutes, which necessitated the augmented flight permission from the CAA for the third landing. Turkey at the Wheel crew. The commander, 39, had 6,132 flight hours, including 976 hours in type. The “augmented” (re- Behind Schedule lief) commander, 41, had 5,850 flight hours, with The 737 departed from Keflavik at 1056 — 51 1,590 hours in type. The first officer, 28, had 2,949 minutes late. “During preparations for departure, flight hours, including 365 hours in type. the crew was delayed because the auxiliary power
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passengers by a door rather than a simple curtain.”
© Google Earth About 40 minutes from Keflavik, the senior cabin crewmember entered the cockpit and asked the pilots how they were doing. “The flight crew answered that they were really tired and comment- ed on how long the day had been and how tired they were,” the report said. The commander listened to the Keflavik automatic terminal informa- tion service broadcast, which said that weather conditions at 0100 included surface winds from 270 degrees at 5 kt, visibility greater than 10 km (6 mi), a few clouds at 4,000 ft, temperature 0° C (32° F) and dew point minus 3° C (27° F). The following information was Groundspeed was 35 kt when the pilots turned left off of Runway 02 onto the final taxiway. provided for Runway 11/29: “Braking action good, occasional ice patches. unit was inoperative and they had to have commander made the decision to carry Braking action taxiways and apron the engines airstarted,” the report said. the extra passenger and made a note medium/poor, sanded.” “During startup an igniter failed, causing that the passenger would have to sit in The pilots discussed the surface further delays.” a cabin crew seat during cruise,” the winds, and the PF said that they would The designated crew rest facility report said. “In fact, the passenger sat request Runway 02 if the wind veloc- comprised a row of three adjacent seats in the crew rest area from Antalya to ity remained less than 10 kt. The report at the rear of the cabin, partitioned by a Keflavik.” noted that Runway 11/29 and Runway curtain. The relief commander did not The aircraft departed from Antalya 02/20 are more than 3,000 m (9,843 ft) use the facility while the commander at 1810 — one hour and 10 minutes late. long but provided no information about and first officer conducted the posi- The relief commander and the first officer the runway safety areas. tioning flight to Antalya. He remained were at the controls. The commander When the commander requested, and in the cockpit and participated in plan- took his rest break in the cockpit. received, radar vectors from Reykjavik ning the return flight. The 737 arrived at Edinburgh at 2313 Control toward Runway 02, he did not The 737 arrived in Antalya at 1634 — and departed for the final leg to Keflavik ask for a braking action report for that 34 minutes later than planned. The crew at 2345. The standby commander was runway. Keflavik Approach cleared the was informed that filing the new flight the pilot flying (PF), and the command- crew to conduct the instrument landing plan with Turkish authorities might er was the pilot monitoring. The first system (ILS) approach to Runway 02. take up to four hours. “Upon consulta- officer remained in the cockpit. “During the briefing for the approach, the tion with a duty officer at ScanOps, the PF mentioned that the taxiways to the flight crew decided to take off with their Inadequate Facility terminal would be slippery but the run- original flight plan and, once en route, The pilots told investigators that they way would be good,” the report said. divert to Edinburgh to make a fuel stop, considered the crew rest facility to to avoid further delays,” the report said. be inadequate. “The crew felt that Callouts Omitted The actual passenger count was 187 the cockpit provided a more suitable The pilots omitted several required plus one infant — or one passenger resting environment,” the report said. calls during the descent, including the more than can be accommodated with “The crew could recline in their seats, callout at Flight Level 100. The PF did three seats reserved for crew rest. “The stretch out and were separated from not respond to the commander’s callout
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at 2,500 ft radio altitude and did not About 18 minutes before the 737 said. “Thrust reversers remained de- identify the radio frequency set for the was landed, the airport surface condi- ployed and at idle power [until the 737 ILS. “The reason for the missed callouts tion analyzer generated a frost pave- neared the end of the runway].” remains unexplained and could possibly ment condition warning because the The wheel brakes initially were ap- be attributed to fatigue,” the report said. dew point had increased above the run- plied about 46 seconds after the second Noting that a cabin crewmember way surface temperature. “At the time touchdown, when the aircraft was occupied a cockpit jump seat during of the frost warning, all the airfield about 1,500 ft (457 m) from the end of the descent and approach, the report services staff were outside the office the runway with a groundspeed of 72 kt. said that “there were distractions in the working on runway maintenance, and Groundspeed was 35 kt when the cockpit, and the mood was relaxed.” the system was not being monitored,” crew began to steer the aircraft left onto The crew flew the approach with the report said. Taxiway N-4. They increased reverse the autopilot, autothrottles and auto The crew omitted the required call- thrust to 80 percent N1 to help slow speed brakes (ground spoilers) engaged, out when the aircraft crossed the outer the 737. “The aircraft came to rest on but they did not engage the autobrakes. marker. They disengaged the autopilot a final heading of 288 degrees with the Landing reference speed (Vref) was and autothrottles while descending right main landing gear and nosewheel 148 kt. through 575 ft above ground level. “On off the paved surface of Taxiway N-4,” The last friction measurement short final, the crew used the precision the report said. on Runway 02 was made at 2312. A approach path indicator (PAPI) lights as The nosewheel had been slightly SNOWTAM (snow warning to airmen) a visual approach slope indicator as well damaged during the excursion. The issued shortly thereafter indicated that as the runway lighting,” the report said. crew kept the left engine running until the runway was contaminated with ice Surface winds were from 318 de- a ground power unit was connected. and that the measured friction values grees at 7 to 10 kt at 0155 when the 737 “There was no need to evacuate the were 69 for the first third of the runway, touched down on Runway 02 at 150 kt. aircraft immediately, and the passen- 71 for the second third and 45 for the “The aircraft contacted the runway and gers stayed on board until buses were final third. (Lower values are associated then bounced up into the air again before brought by the airport authority to with less effective braking action.) full runway contact was made with the bring them to the terminal building,” When a Keflavik Tower controller main landing gear tires followed by the the report said. cleared the crew to land on Runway 02, nose landing gear tire,” the report said. The pilots were on duty for 17 he said that the winds were from 320 Recorded vertical accelerations hours and 20 minutes — more than degrees at 5 kt and that braking action were 2.13 g — that is, 2.13 times stan- three hours beyond the expected duty was “good-good with the occasional ice dard gravitational acceleration — on period. The report said that although patches.” The controller told investi- the first touchdown and 2.01 g on the current regulations allow an aug- gators that he had no explanation for second touchdown. The report said mented flight crew to be on duty for using the term “good-good”; he said that the flight crew “channelized into as many as 19 hours under unforeseen that he normally reports braking ac- analyzing the reason behind the hard circumstances, they “do not restrict tion using measured friction values, as landing instead of focusing on the the number of hours of wakefulness or required by the airport authority. deceleration of the aircraft.” prescribe a minimum number of hours The ground spoilers had deployed of restorative sleep.” No Extra Precautions after the first touchdown, and the crew Based on the findings of the inci- “The information on the runway and engaged the thrust reversers after the dent investigation, the AAIB called on taxiway conditions that the PF received second touchdown. “Reverse thrust was the European Aviation Safety Agency led him to expect that no extra precau- initially increased to 73 percent N1 [en- to modify the flight and duty time tions would be necessary during the gine fan speed] for approximately seven regulations. landing,” the report said. The crew also seconds, then reduced to idle thrust This article is based on AAIB Iceland “Report had no indication that the surface con- decelerating through a groundspeed on Serious Incident, Runway Excursion, ditions on the last third of the runway of 110 kt and approximately 4,000 ft M-03707/AIG-19: JetX; Boeing 737-800, TF- were deteriorating. [1,219 m] down the runway,” the report JXF; Keflavik, Iceland; October 28, 2007.” www.flightsafety.org | AeroSafetyWorld | March 2009 | 31 causalfactors Left Behind BY MARK LACAGNINA
The ATR 42 pilots were unaware of current procedures for recovering from an ice-induced upset.
he airline’s failure to promptly update its In its final report on the serious incident, the standard operating procedures (SOPs) board said that the airline, Coast Air, had only was among organizational deficiencies recently distributed revisions to severe-icing emer- that contributed to the loss of control gency procedures that had been issued two years Tof an ATR 42-320 during an encounter with earlier by the aircraft manufacturer. “The pilots re- severe icing conditions the morning of Sept. 14, ceived this [information] close to the time at which 2005, said the Accident Investigation Board of the incident occurred and had not had time to
Norway (AIBN). become familiar with its content,” the report said. Hjelmen/Airliners.net Andre Thomas ©
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Coast Air operated two ATR 42s and six Brit- Moreover, the OPS INFO document did ish Aerospace Jetstream 31s and 32s on sched- not include the following notice that the uled flights between nine airports in Norway. manufacturer had added to the “Severe Icing” The airline issued SOPs for the ATR 42 when it emergency checklist: received its air operator certificate early in 2000; Severe icing may result from environmental the last revision was dated Sept. 13, 2002. conditions outside of those for which the In October 2003, the manufacturer revised airplane is certificated. Flight in freez- the ATR 42 airplane flight manual to require ing rain, freezing drizzle or mixed icing pilots to memorize the following six actions on conditions (supercooled liquid water and the “Severe Icing” emergency checklist: ice crystals) may result in ice buildup on unprotected surfaces exceeding the capabil- • Increase the “red bug” minimum icing ity of the ice protection system or may speed by 10 kt1; result in ice forming aft on the protected • Apply maximum continuous torque; surfaces. This ice may not be shed using the ice protection systems and may seriously • Disengage the autopilot while firmly hold- degrade the performance and controllabil- ing the control wheel; ity of the airplane. • Escape from the severe icing conditions; and, “In severe icing, therefore, it is necessary to change • Notify air traffic control (ATC). course and/or altitude instantaneously since the aircraft’s anti-ice and deice systems cannot A notation following these memory items says handle these conditions,” the report said. “A char- that if any unusual roll response or uncom- acteristic of severe icing is said to be ice forma- manded roll control movement occurs, the con- tion on the side windows and/or an unexpected trol wheel must be pushed firmly forward and decrease in speed and climb rate. Water which the flaps extended to 15 degrees. These actions, splatters and streams on the front windshield and however, are not designated as memory items. ice buildup at the back of the spinner and on the ATR told investigators that roll excursions will airframe in places where ice does not normally not occur if the actions that are designated as collect are given as secondary indications. In memory items are completed correctly upon addition, it is stated that visible rain and large encountering severe icing conditions. droplets with an outside temperature of around 0° The report said that shortly before the inci- C [32° F] could lead to severe icing.” dent, a newly hired flight operations manager “discovered by coincidence” the two-year-old Strong Cold Front revisions and told the chief pilot to distribute The aircraft was being operated as Flight 602 the information. An “OPS INFO” document from Stord, an island off the southwestern coast outlining the revised procedures was issued to of Norway, to Oslo, about 170 nm (315 km) east. the company’s ATR 42 pilots the day before the The pilots and the flight attendant reported for incident. The airline did not have a system to duty at 0615 local time. The flight crew monitor the receipt and review of OPS INFO Noting that a strong cold front had passed struggled to regain documents. The pilots told investigators that through the area overnight, the report said, control of this ATR 42 they remembered retrieving the documents “The weather was the subject of conversation after an ice-induced from their mailboxes either the day before, that morning. There had been a landslide in stall.. the same day or the day after the incident. Bergen [north of Stord] during the night, and “However, they had not picked up particularly precipitation records had been set at several on details of the content or reflected in any locations in the western part of Norway.” concrete way on what the changes meant,” the The three crewmembers visited the airport’s report said. flight information service facility to gather
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weather information and notices to airmen. “The cause the autopilot to automatically disengage — at weather forecast was a moderate risk of local a lower-than-normal angle-of-attack: 11 degrees icing in the western part of Norway up to Flight instead of 18 degrees with flaps retracted. Level (FL) 180 (approximately 18,000 ft), which is The flight proceeded east, toward the cold normal for this time of year,” the report said. front and rising terrain. The crew did not use Before departing with 24 passengers at 0710, the weather radar system during the climb. the flight crew activated the anti-ice systems for “This may indicate that the crew had a low level the probes and windshields (Figure 1). The first of awareness of the importance of using the officer, 29, was the pilot flying. He had been em- weather radar as an aid for avoiding severe icing,” ployed by Coast Air in 2003 and earned an ATR the report said, noting that the airline did not 42 type rating the same year. He had 2,980 flight have a written policy about using the equipment. hours, including 1,350 hours in type. “Information from the weather radar could have The commander, 39, had been employed by made it possible for the crew to plan their route Coast Air as a Jetstream pilot in 1999. He earned outside the cells with the heaviest precipitation an ATR 42 type rating in 2000 and upgraded to at greatest hazard of severe icing.” commander in type the next year. He had 7,850 flight hours, including 2,800 hours in type. ‘Impression of Complacency’ The flight attendant, 29, had been employed The aircraft was climbing through FL 100 when by the company in 2001. the “ICING” warning light illuminated. This The aircraft entered icing conditions shortly indicated that the electronic ice detector sensed after takeoff, and the crew activated the anti-icing that ice was accumulating on the wing and that systems for the aileron, elevator and rudder horns, the appropriate ice protection systems had not propellers and side windows. Activation of the been activated. In response, the crew activated horn ice protection system also armed the stick the deicing systems for the wing and horizontal shaker (stall warning) system to activate — and stabilizer leading edges, and the engine nacelles. “The crew is certain that the systems were functioning as intended,” the report said. How- ATR 42 Ice Protection Systems ever, ice continued to accumulate rapidly. Nei- Electrical anti-icing Pneumatic deicing ther pilot realized that the aircraft had entered Probes severe icing conditions. Ice evidence probe Gas path deicer “The commander has stated that they gradu- Windshields ally went into heavy rain, with large drops that Engine air intakes Propellers splattered on the front windshield while the out- Electronic ice detector side temperature (static air temperature, SAT) Wing leading edges was minus 10° C [14° F],” the report said. “He saw significant ice formation on the evidence probe outside his window and assessed the icing as more or less the same as the worst case he had experienced during the course of his six Aileron, years of flying this aircraft type.” elevator and That “worst case” had been resolved when the rudder Horizontal stabilizer aircraft exited the icing conditions. “It may ap- horns leading edges pear that the flight crew also anticipated that the problems here would resolve themselves by their
Source: Accident Investigation Board of Norway/Susan Reed exiting the icing area in time, which is something that gives the impression of complacency,” the re- Figure 1 port said. “Both pilots were experienced and had
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flown the route between Stord and Oslo in icing conditions countless times with no problems. ATR 42-320 The pilots were used to the aircraft’s systems handling moderate icing conditions. … Another important element is that the hazard of icing was not given particular emphasis in the company’s program for training and flight safety.” Ice covered the cockpit side windows, but the pneumatic deice boots on the wings ap- peared to be shedding ice from the leading edges. “From the cockpit, it was not possible to see whether there was ice further back on the upper and lower sides of the wings,” the report said. “Neither the commander nor the first of- ficer remembered afterwards whether they saw ice on the propeller spinners.” The crew said that the aircraft climbed normally until reaching FL 120. Climb perfor- © Hans Olav Nyborg/Airliners.net mance then decreased significantly. “When they approached FL 140, the climb was marginal,” he Avions de Transport Régional (ATR) program was launched the report said. The first officer, who was flying in 1981 when Aérospatiale and Alenia agreed to combine their the aircraft with the autopilot engaged in the Tefforts to design a twin-turboprop regional airplane. Deliveries airspeed-hold mode, adjusted the commanded of the first model, the ATR 42-300, began in 1985. The airplane has 1,342-kw (1,800-shp) Pratt & Whitney Canada PW120 engines. The ATR airspeed from 160 kt to between 150 and 155 kt 42-320, introduced in 1987, has 1,566-kw (2,100-shp) PW121 engines, in an attempt to increase the climb rate. which improve performance at high altitude and with high ambient The crew had set the red speed bugs on their temperature. airspeed indicators to 143 kt, the minimum Basic seating capacity is for 42 passengers. Maximum takeoff airspeed specified for flight in “standard” icing weight is 16,700 kg (36,817 lb). Maximum operating altitude is 25,000 conditions. “Both the commander and the ft. At a maximum cruising speed of 267 kt at 17,000 ft, range with re- serves is 4,481 km (2,420 nm). Stall speeds are 104 kt with flaps up and first officer were of the opinion that they had 81 kt with flaps extended 30 degrees. sufficient margins when they were at least 7 kt Production of the ATR 42-300 and -320 was phased out in 1996. above [minimum] icing speed,” the report said. ATR became a corporate entity in 2001 and currently produces the ATR According to the emergency checklist, however, 42-500 and the ATR 72-500. the correct speed bug setting for severe icing Source: Jane’s All the World’s Aircraft conditions was 153 kt. “The crew therefore did not have the safety margin they assumed since they had allowed the speed to drop to 150–155 kt,” the report said. Struggle for Control The pilots discussed the possibility that the The aircraft stopped climbing at 14,400 ft. The aircraft’s performance was being affected by first officer placed his hand on the control column mountain wave activity, which indicates that and felt the stick shaker activate. He was about to they did not associate the performance deficien- disengage the autopilot when it disengaged auto- cy with severe icing. The airspeed reduction did matically. “A second or two after this, the aircraft not result in the anticipated climb rate improve- suddenly rolled, uncommanded, approximately ment; instead, it resulted in the contaminated 45 degrees to the right at the same time the nose wing nearing the critical — stall — angle-of- dropped to approximately 7–8 degrees below the attack, the report said. horizon,” the report said (Figure 2, p. 36). www.flightsafety.org | AeroSafetyWorld | March 2009 | 35 causalfactors
of approximately Flight Profile 3,200 fpm for the 28
15,000 seconds that passed before the aircraft First wing drop again commenced 14,500 14,400 climbing,” the report Second said. “At its steep- 14,000 wing drop est, the descent was around 5,000 fpm.” 13,800 Terrain clearance, 13,500 however, was not a Altitude (ft)Altitude factor. The aircraft was 13,000 over a glacier about 12,900 35 nm (65 km) east
12,500 of Stord, where the minimum safe altitude was 7,000 ft. With 12,000 the wings leveled and
0522:20 0522:25 0522:30 0522:34 0522:39 0522:44 0522:49 0522:53 0522:58 0523:03 0523:08 0523:12 0523:17 0523:22 0523:27 0523:32 0523:36 0523:41 0523:46 0523:51 0523:55 0524:00 0524:05 0524:10 0524:15 0524:19 0524:24 0524:29 0524:34 0524:38 0524:43 0524:48 0524:53 0524:58 0525:02 0525:07 0525:12 airspeed increasing to Time (UTC) about 175 kt, the first UTC = coordinated universal time officer pulled the con-
Source: Accident Investigation Board of Norway trol column back to stop the descent. The Figure 2 aircraft then entered The first officer said that he pushed the con- a relatively steep climb. “According to the radar trol column forward to keep the nose down while readings, it climbed 700 ft in the first 15 seconds, setting the engine controls to achieve maximum which corresponds to 2,800 fpm,” the report continuous torque. He did not extend the flaps said. “The fact that the crew did not register that 15 degrees. “He struggled to regain control of the the pull-out from the dive was excessive can be aircraft and tried to rectify the bank angle,” the explained by the fact that they were shaken by the report said. “The bank angle moved from the experience in addition to the fact that they were in right straight over to the left before it gradually cloud and had to correct a most abnormal aircraft allowed itself to be straightened up.” attitude based on information from the aircraft’s The commander’s decision not to take instruments,” the report said. control when the upset occurred was not faulted. Angle-of-attack again exceeded the criti- “The best the commander could have contrib- cal value, and the aircraft stalled and rolled uted in the critical situation … would probably left. “This wing drop was almost as powerful as have been to extend the flaps in time,” the report the first, and the first officer has stated that he said. “Control would have been regained more used the same procedure to regain control,” the quickly. By only pushing the stick forward, the report said. During this time, the aircraft had speed would have to increase more before the exited from the clouds. angle-of-attack dropped below the critical value.” After the first upset, the commander had set Recorded ATC radar data indicated that the the red airspeed bug at 160 kt and told ATC that upset had begun at 0723 (0523 coordinated uni- they were having icing problems and were request- versal time) and that the aircraft had descended ing FL 150 as their final cruising altitude. After the 1,500 ft before the first officer regained control. second upset, he told ATC that they were unable “It is equivalent to an average descent speed to maintain FL 150 and requested, and received,
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clearance to fly within an altitude block that they were corrected. Chief among The report also said that the stall- between FL 130 and FL 150. the persistent deficiencies were an recovery training in the flight simula- All the passengers had been seated unsatisfactory document-management tor was not related to icing conditions. during the upsets. The flight attendant, system and inadequate collection and The airline’s training manager was not who was placing empty bottles in the dissemination of information about aware that the flight simulator was cargo compartment at the rear of the hazards and preventive measures. programmed to provide four icing aircraft, lost her balance and fell into Among deficiencies that related scenarios — two related to inadequate the cargo compartment. Uninjured, she directly to what the report character- preflight deicing, and two related to en- returned to the galley and held onto an ized as an “organizational incident” was counters with standard icing conditions unsecured service cart until the aircraft inadequate pilot training for flight in and severe icing conditions without the was returned to controlled flight. icing conditions. “Pressure to keep appropriate ice protection systems ac- The flight attendant then entered down cost levels within the company tivated. “Coast Air first became aware the cabin and found the passengers sit- may have contributed to reducing the of the opportunity to train on realistic ting still; none had been injured. “She quality of flight crew training,” the icing scenarios in the simulator as a spoke for a little while with a woman report said. result of this incident,” the report said. who, before takeoff, had told her she The airline had contracted with The incident aircraft was not was afraid of flying,” the report said. Finnair to use its ATR 42 flight simula- equipped with an aircraft performance “The commander gave a passenger tor to train Coast Air pilots for type monitoring (APM) system, which ATR announcement, [stating] that they had ratings and to conduct six-month introduced as an option in 2005. The moved into some bad weather involv- proficiency checks. The training was system monitors icing intensity and its ing turbulence and icing, but that performed by Coast Air instructors. effect on aircraft performance, and gen- this was now over, so the flight would The proficiency checks comprised four erates several different visual and aural continue to Oslo as normal.” hours in the simulator. Among the advisories and warnings. For example, The ATR 42 was flown between procedures reviewed was stall recovery an “INCREASE SPEED” warning light cloud layers and out of icing condi- in various aircraft configurations. illuminates and a chime sounds if tions, and was landed without further “The first items in the procedure airspeed decreases below red bug speed incident in Oslo at 0804. when the stick shaker actuated in a plus 10 kt. The AIBN recommended Although AIBN requires prompt clean configuration (gear up, flaps that the APM system be required notification of a severe icing encounter zero degrees) was that the person fly- aboard all ATR 42s and 72s. involving a loss of altitude, Coast Air’s ing should say, ‘Stalling,’ immediately This article is based on AIBN Report SL 2009/02, manuals contained “extremely old” in- advance power, level the aircraft’s nose “Report on the Serious Incident Over Glacier formation about reporting requirements. 2–3 degrees above the horizon and say, Folgefonna, Norway, on 14 September 2005 with The airline reported the incident to the ‘Set max power, flap 15,’” the report said. ATR 42-320, LN-FAO, Operated by Coast Air AS.” Civil Aviation Authority of Norway “The second pilot should do the manual Notes (CAA) almost two weeks after it oc- actions and respond, ‘Max power set, curred. The CAA forwarded the report flaps 15 selected.’ … The training man- 1. The “red bug” is an adjustable marking on to the AIBN. By then, voice and flight ager has stated that it was common for the airspeed indicator. data recorded in the aircraft during the the pilots to forget to extend the flaps in 2. Coast Air filed for bankruptcy in January incident no longer were available. conjunction with this exercise.” 2008. Noting that the French accident- ‘Organizational Incident’ investigation bureau also has found Further Reading Coast Air had experienced major that ATR 42 pilots generally are not Rosenkrans, Wayne. “Surveillance Without changes in its ownership, key personnel familiar with the requirement to extend Surprises.” ASW Volume 2 (April 2007): 42–46. and route structure.2 The report said flaps to 15 degrees, the AIBN recom- Dow, John P. Sr. “Understanding the Stall- that the CAA had found deficiencies mended that the action be designated Recovery Procedure for Turboprop Airplanes in the airline’s quality system and flight as a memory item on the emergency in Icing Conditions.” Flight Safety Digest safety program but had not ensured checklist. Volume 24 (April 2005): 1–17. www.flightsafety.org | AeroSafetyWorld | March 2009 | 37 ThreatAnalysis
hen the U.S. National System: Strategic Plan (NABSAS) pre- investigation. But the plan may have Transportation Safety Board pared by the U.S. Federal Aviation been most prescient in expecting miti- (NTSB) convenes a public Administration (FAA), the U.S. Air gation of bird strike risk to be impeded hearing in mid-2009 on a Force and Transport Canada1— was primarily by human, not avian, factors. Wfew aspects of the Jan. 15, 2009, ditch- shelved, and the FAA decided to limit Preliminary NTSB factual informa- ing of a US Airways Airbus A320 into most subsequent avian radar research tion said that Flight 1549 was “ditched the Hudson River, attention to digital to performance assessments. into the Hudson River shortly after the avian radar likely will be more intense Aspiring to deploy a network of aircraft struck Canada geese, resulting than at any time since 2006. That year, airport avian radars and real-time in an immediate loss of thrust in both a proposal for civilian-military and bird hazard alerting within 10 years, engines.” Two people were seriously public-private collaboration — the the NABSAS addressed issues that injured among the 155 passengers and North American Bird Strike Advisory may resurface in the current NTSB crew. One of four focus areas planned
Paradigm By Wayne Rosenkrans After the recent A320 bird strike and ditching, expectations soared for avian radar to warn airline pilots of real-time hazards. Shift © Mark Kryst/Airliners.net
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In The Spotlight The avian radar systems intended for civil or military airport use typically are designed from commercial off-the-shelf marine X-band, S- band or combined radar sensors; advanced digi-
© Accipiter Radar Technologies Radar © Accipiter tal radar signal processors; personal computers programmed with proprietary bird-tracking algorithms that process target data; geographi- cal information system (GIS) mapping software; and network communication. Some are on mobile platforms, others have been installed in airport buildings with roof-mounted antennas. In the wake of the Flight 1549 accident, some have asked the FAA and its Center of Excellence for Airport Technology (CEAT) at the University of Illinois–Urbana Champaign to explain what has impeded the development of Paradigm real-time alerting for air traffic control (ATC) Avian radar captures a near-miss event at Naval Air and pilots (see “Other Countermeasures,” p. 40). Station Whidbey Island, Washington, U.S. The possible timing and relative safety of envi- sioned alerts to pilots have yet to be determined, for the hearing is “new and developing technol- however, in the context of the maneuverability ogies for detection of large groups of birds and limitations of transport jets, visibility restric- procedures to avoid conflicts with birds in the tions from the flight deck and air traffic con- general vicinity of airports,” the NTSB said. flicts. Nevertheless, Edwin Herricks, a professor Shift NTSB member Robert Sumwalt on Feb. 24 at the university and principal investigator on told a congressional committee hearing that the avian radar use at civil airports for CEAT, says first officer, the pilot flying, “spotted a group that because of this accident “the paradigm has of dark birds slightly to the right of the flight shifted — we are no longer working in obscu- path” and an instant later, about 1.5 minutes rity” given new public expectations. after takeoff, the flock filled the windscreen and “Now that we have radars deployed and multiple bird strikes occurred at an altitude of collecting data, the CEAT team is working on a about 2,750 ft. The captain took control of the group of reports,” Herricks said. “One report on airplane, and the aircraft touched down about the deployment of avian radars hopefully will 3.5 minutes after the bird strikes. help people who are contemplating using them Margaret Gilligan, FAA associate adminis- to have a realistic sense of what an avian radar trator for aviation safety, characterized avian can do. We then will produce a shorter technical radar at the hearing as a limited technologi- publication on mapping clutter — the electronic cal solution so far. “Bird detection radar may background noise and the radar returns from have the most promise as tools to help air- buildings, trees, etc. Our third report will talk port operators manage their wildlife control about our nearly two years of experience with programs,” Gilligan said. “However, as many three radar systems at Seattle-Tacoma [Interna- airports routinely have birds in the area, we do tional Airport, Washington, U.S.] and discuss not yet know if this system would be capable the operational applications and their utility of providing alerts that would be operationally from the perspective of a user … to promote suitable for making specific time-critical deci- realistic expectations rather than unrealistic sions on landing or takeoff.” ones.” During the deployment phase, the FAA
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Sidelined Strategy Other Countermeasures The NABSAS aimed to overcome problems in developing avian he Air Line Pilots Association, International lowing a bird strike, but ALPA is unaware of any (ALPA) in February expressed optimism airline that provides wildlife-avoidance train- radar in 2000–2005. Tabout the safety contributions of digital ing,” Prater said. “We would suggest that wild- “The purpose of this avian radar and published a white paper titled life-avoidance techniques and guidance, such strategic planning “Wildlife Hazard Mitigation Strategies for as that included in the [U.S. Federal Aviation document is to fully Pilots.“ Administration] Aeronautical Information integrate all the dispa- “Being able to find birds, track them and Manual, be provided in airline flight operations rate systems currently project their position with quality radar is of manuals, training materials and other company great interest to us,” said Rory Kay, a captain guidance for flight crews. … On arrivals and under deployment, and ALPA’s executive air safety chairman. “Pilots departures, [airline pilots] are held sometimes development or pro- not only have to know the projected direction for hundreds of miles at low level because of posal,” the plan said. of flight but know at what altitude the birds are the inadequacy of the ATC system. So NextGen “Many have argued flying. If [the birds] are at 1,000 ft and 5 nm [9 is about capacity at airports, keeping us higher that further and much km] from the airport, the birds are not an issue. longer, saving fuel, reducing carbon emissions greater advancement If I can be made aware [of birds] I can pick a dif- and certainly keeping us and the birds out of ferent runway to use for departure or arrival, or each other’s path.” could be made if the I can simply delay my departure or arrival while The ALPA white paper calls for high alert- current fragmented a clearly visible, large flight of birds transits the ness to bird and mammal activity reports and competitive area. That would not always work, so ongoing while taxiing; a final check of the runway for efforts could be con- wildlife hazard mitigation programs at each wildlife before commencing takeoff; waiting solidated in a single airport are important.” for wildlife hazard managers to clear birds from cooperative venture.” John Prater, a captain and president of the runway environment; advance preparation ALPA, added, “What we are really looking for is to adjust an aircraft’s vertical path to avoid One phase of separate air traffic control displays so they have birds; best rate of climb through any altitude the plan would have a radar that is specifically tuned and pointing band where birds have been anticipated; using integrated “small- at the local area, a small radius for tracking and extreme caution if accelerating above 250 kt scale mobile radars … … a sophisticated communication system … below 10,000 ft; monitoring airport and en available to monitor so that if birds are being tracked, that informa- route radio frequencies for intelligence about local bird movements tion can be passed via radio to the pilots.” bird activity; using higher rates of descent Airline training on flight deck countermea- — without increasing speed — to descend in real time at select sures, and quickly funding and implementing through altitude bands where birds have been locations,” the plan the next generation air transportation system, anticipated; and considering a go-around if said, building on NextGen, also were cited as important ways to an encounter with birds occurs on approach, similar Canadian ef- reduce bird strike accident risk. “Some airlines subject to other precautions. forts to upgrade com- provide a checklist that covers what to do fol- — WR mercial airports. “At the airport or airfield has required only letter reports and updates on level, dedicated radars must be able to detect progress, he said. birds in the critical airspace, defined as three-di- The current situation of inadequate valida- mensional coverage out to 5 nm [9 km] and up tion of avian radar performance and little to 3,000 feet above ground level,” the plan said. peer-reviewed literature on avian radar ap- “The goal is to provide effective bird strike warn- plications in airport settings will be rectified by ings to pilots flying from one location to another. studies that both CEAT and the U.S. Depart- … Automated warnings [would] be issued when ment of Defense have under way, Herricks the system has identified potentially hazardous said. Another issue has been inadequate basic concentrations of birds. One example is heavy engineering research that could lead to new migration of large birds in critical airspace.” bird-specific radar sensors to supersede today’s The decision was made around 2002 by marine sensors. the U.S. Air Force and the FAA to look at
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commercially available avian radar technolo- the critical data that would be important to air gies, Herricks said. “Since these were untried traffic controllers and to pilots?’ Or long term, Top: Performance of and unproven in civil airport environments, this how could airports better understand the dynam- roof-mounted avian meant deploying these technologies to airports ics of the bird populations around the airport and radar currently is and conducting performance assessments so what we can do about them?” being assessed by that the FAA could obtain technical information The safety factor of providing timely avian CEAT for the FAA at that would allow it to identify standards and radar data to an airport wildlife hazard manager Seattle-Tacoma. requirements that could be used in an advisory cannot be underestimated. “We are learning Bottom: Durban circular,” he said. “The advisory circular will be about bird population habits beyond what we International Airport, critical because it basically will define charac- already knew,” Reis said. “We are learning them South Africa, plans teristics that technologies must meet to allow with greater accuracy, and we can learn 24 to install displays in reimbursement from the FAA Airport Improve- hours a day, 365 days a year as opposed to when its air traffic control ment Program for avian radar funding.” people are able to observe [bird activity].” FAA tower linked to In 2006, the FAA shifted the focus of its air- and airline flight safety specialists will have to mobile avian radar. port-related avian radar research, as noted in the FAA 2008 National Aviation Research Plan. “The vision of the original [NABSAS] draft focused on providing near-real-time hazard advisory infor- mation to a variety of end users such as pilots, air traffic controllers, airport operators and wildlife control personnel. While that long-term objective is still viable, recent lessons learned and advances in technology have shifted the approach toward initially validating current avian radar capabili- ties, and providing risk assessments for key flight operational zones in the airport environment.”2 In 2009, avian radar assessments by CEAT sup- port the wildlife hazard manager’s work at Seattle- Tacoma. The FAA’s schedule calls for additional testing at Chicago O’Hare International Airport, © Accipiter Radar Technologies Dallas/Fort Worth International Airport (DFW) and John F. Kennedy International Airport (JFK).
Seattle-Tacoma Experience Assessment work at Seattle-Tacoma illustrates how details of avian radar can differ from avia- tion industry assumptions and public expecta- tions. “In cooperation with researchers at [CEAT], we are exploring enhanced wildlife monitoring through the use of an avian radar system that was installed in August of 2007,” said Mark Reis, the managing director of Seattle-Tacoma, in testi- mony at the hearing. “Are we able to accurately track the birds? Absolutely. … The question is, ‘What can we do with that data?’ At this point, we probably have too much data. The key thing for © DeTect [future] operations is, ‘How do we filter down to www.flightsafety.org | AeroSafetyWorld | March 2009 | 41 ThreatAnalysis
determine how real-time tactical use of discovered at Seattle-Tacoma that if we return on investment is further demon- the data by ATC and pilots would occur put the radar in a ground depression, strated, and the additional cost for the later, he said. this actually improves the performance system can be justified.” Herricks remains resolute that of the radar by a significant amount.” DeTect’s tactical concepts of opera- © Matt Klope/Accipter avian radar validation at large civilian tion vary by site but generally include airports and resultant requirements and Outspoken Critic a specialized display — called Merlin standards have to precede any real-time DeTect, a U.S. manufacturer of avian ATC, designed with input from air applications. “I don’t believe at this point radar systems, disputes the basis of the traffic controllers and pilots in 2003 that any avian radar is capable of operat- policy position at the FAA and CEAT. and 2004 — that provides “continuous, ing within the complex environment of “Advanced bird radars from several real-time display and monitoring of civil airport operations at even moder- manufacturers are in operational use bird activity in the runway approach ately busy commercial airports,” he said. by the U.S. Air Force, U.S. National and departure corridors with the cur- “It is not a turnkey situation where we Aeronautics and Space Administration rent ‘bird strike’ risk level displayed in turn these radars on and automatically (NASA), the U.K. Royal Air Force and color-coded text above each corridor we prevent bird strikes. I agree with the several U.S. and foreign airports, air- with low risk as green, moderate risk as FAA that these systems are not ready for fields and ranges,” said Gary Andrews, yellow and severe risk as red,” he said. prime time. … All of the data that we general manager and CEO. Unlike “Merlin ATC is currently used in the have to date — including lots of experi- systems assessed by CEAT at Seattle- control tower only at military instal- ence at Seattle-Tacoma — indicate that Tacoma and elsewhere, “the DeTect lations,” Andrews said. “The Durban we have still got a ways to go. But that Merlin avian radar system has been International Airport in South Africa doesn’t mean that we can’t provide qual- and is being used tactically by the U.S. will be the first use of Merlin ATC in ity information to the airport system to Air Force at five U.S. locations since the tower [of a civilian airport].” make things safer now.” 2003 and by NASA launch controllers The system is fully automated and Part of the reasoning behind this at Kennedy Space Center since 2006 does not require full-time monitoring policy position is that avian radar is not with real-time bird radar displays in the because when the bird hazard risk level just a matter of technology issues but control towers/launch control center increases, an audible alert directs the concepts of operations, achieving buy- and data used to make tactical deci- controller’s attention to the risk condi- in of stakeholders, developing commu- sions,” he said. tion, risk location and precise altitude nications systems and deciding how to Most avian radars used at U.S. sites on the display, he said. Risk thresholds safely and reliably communicate alerts in this decade have been made by Ac- are defined and set in the software so to ATC and pilots in time for them to cipiter Radar Technologies, DeTect that insects do not contaminate the take action, he said. and Geo-Marine. “Much of the current data, and only birds that pose a risk One example of a recurrent glitch level of technology is limited by what to specific airframes are factored into seen in CEAT assessments is occasional users will currently pay for a bird radar the ATC displays and alerting. Military disappearance of some bird targets system,” Andrews said. “In March 2009, wildlife personnel also have real-time on avian radar. “We see a big bird that DeTect will announce its next-gener- radar displays on mobile wireless shows up very well on the radar,” Her- ation bird radar, which will be a solid devices to help them respond more ricks said. “We see it flying, and then state, all-weather system that will detect quickly to hazardous bird activity. all of a sudden, that track disappears. It and alert bird strike risk in wet fog and CEAT has received funding to lease may be that we can pick up that track a moderate rain.” Merlin is not “blinded” the DeTect Merlin system for assess- little later. If the clutter environment is by light rain or wet fog, he said. “We ment at DFW, Herricks said. The FAA relatively intense, the signal associated are also ‘Dopplerizing’ [adding Doppler hopes to broaden its knowledge from with the bird will be lost in that back- marine radar sensors to] our first sys- working with the Merlin system, he ground noise. … We are now mapping tem and expect to introduce it in late added. “We have been working madly the clutter environments at O’Hare, JFK 2009 or 2010. True three-dimensional for six to nine months to try to get the and DFW from multiple locations; we systems will likely become available as money out the door to go to DeTect,” have done 23 sites at O’Hare. We also the technology gains greater acceptance, Herricks said.
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CEAT and FAA recognize the need political support for federal fund- Nohara said. “Multi-sensor integration to use all available expertise, he said. ing — but I believe the more important in the past year has included integra- “I don’t think there is any company application in improving flight safety tion [of marine radar] with a number of that has thought more about how to is providing airport wildlife control cameras. … Having the radar automati- get information into the ATC-pilot personnel a greatly improved bird situ- cally classify birds into different species decision-making framework than De- ational awareness.” or groups is still in the research and Tect,” Herricks said. “I also want DeTect Two of the CEAT research sites development domain.” in our performance assessment because — Naval Air Station Whidbey Island, nobody has the experience that they Washington; and Marine Corps Air Staying The Course have with vertically spinning radars. Station Cherry Point in North Carolina Misunderstandings of what avian radar They can provide information about — each have generated a year’s worth of can do have the potential to set back altitude — the missing feature in virtu- avian radar data, enabling for the first CEAT’s process of moving avian radar ally all our radar work to date. We get time retrospective overlays of bird tracks toward acceptance and utilization, Her- some altitude discrimination with dual and aircraft flight paths on the same GIS ricks fears. “We can’t afford to have a four-degree radars — parabolic dish map. “We are taking one month’s data tool that provides so much potential types — but it would be nicer to have at both sites and refining the process of fall prey to that, so we have to have greater discrimination.” identifying/extracting near-miss events expectations that are realistic,” he said. Responding to Andrews’ criticisms (NMEs),” Nohara said. “Once we’ve Realism about avian radar also means of assessment time spent by CEAT refined the procedure, we will apply it understanding policies and procedures compared with military and NASA to the year’s data sets. We will analyze required for safe insertion of this tech- programs, Herricks said that these NME patterns over time, compare them nology into the ATC decision-making comparisons are not valid. CEAT’s with reported bird strikes over the same framework, he added. position is that avian radar research for time and confirm correlation,” i.e., that The Flight 1549 accident report and civilian commercial hub airport envi- they follow the same trend. “We are the forthcoming reports by CEAT on ronments is significantly different in getting a measure of how tightly the air- its avian radar assessments may quell character, scope and complexity from space is packed with birds in the vicinity the current controversy about avian these military and NASA contracts. of an aircraft, rather than counting birds radar by clarifying logical next steps. alone, or counting bird strikes alone, to Better information about detectable Accipiter Perspective provide a more sensitive indicator to a bird hazards — possibly including real- Seattle-Tacoma and the other U.S. change in safety,” he said. time alerts to ATC and pilots — will civilian airports deploying avian radar Manufacturers typically enhance require better collaboration among through CEAT — except DFW — use performance with their own system all stakeholders willing to take time systems from Accipiter. Beyond the design innovations or by adopting newly to understand the complexity of avian three mentioned, Accipiter’s current invented radar sensors, antennas or other radar systems, the civil airport environ- military installations include Naval components. “We have developed the ment and the ATC implications while Base Ventura County in California and first dual-beam, height-finding avian assessing risk under safety management Elmendorf Air Force Base in Alaska. radar prototype — with patents pending systems.
“Eventually, bird advisories gen- — and it is ready to undergo three-dimen- To read an enhanced version of this story, go to erated in real time in response to sional tests against remote-controlled the FSF Web site
By Wayne Rosenkrans
ngine condition monitoring and maintenance recommendations to to manually upload data from a laptop (ECM) like that required for ex- operators and flight crews. computer to a remote database, uninten- tended range operations (ETOPS) They take advantage of digital tionally using outdated analysis models has begun to interest non-ETOPS electronic engine controllers, advanced or losing critical engine data without businessE airplane operators.1 Risk reduc- sensors, telematics2 and remote diagnos- backup copies off the aircraft. tion, however, may not be what appeals tics technology, analytical software that The technology reflected, for most when they consider subscribing to compares measured parameters to those example, in the Honeywell Aerospace several new services tailored for them. of a master model, secure global network Zing remote diagnostics service for These services equip engine systems communications and handheld comput- TFE731 engines on the Hawker 750, with wireless data-downloading capa- ers or mobile telephones with computer 800, 800XP, 850XP and 900XP and the bilities used on the ground, remotely functions. Logically, the services could programs of Pratt & Whitney Engine acquire the data, conduct in-depth help reduce human factors errors such Services–Advanced Diagnostics, a unit analysis at a central facility and rapidly as failing to remember to manually of Pratt & Whitney Canada (PWC), communicate safety-critical information download data from the aircraft, failing for the Dassault Falcon 2000EX and
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7X have been embraced by a growing number forwarding to Jet-Care and an Internet Web in- of business jet operators. Honeywell this year terface where remote diagnostics link directly to has been expanding its service to the Falcon 50, suggested tests, repairs and original equipment Falcon 900 and Learjet 40/45 fleets. manufacturer manuals, she said. In 2008, Honeywell published several early Subscriber flight crews typically shut down operator experiences. In one report, the flight the engines after each landing, engage the digital crew of a Hawker observed an “ENGINE FAIL” electronic engine controllers and press a green light during descent, and one engine changed to button on the Zing control panel. This action manual mode. The crew landed in northern Min- downloads data stored by the engine controllers, nesota, U.S., on a Saturday and called the director encrypts the data and sends it over a Global Sys- of maintenance, who instructed them to initiate tem for Mobile Communications (GSM) digital a wireless data download from the engines to the mobile phone network in about five minutes. Zing service. The director of maintenance then Nine Hawker operators performed more than contacted the engine manufacturer’s technical 500 downloads of engine data with the service representative, who reviewed the data on a mo- at U.S. and international airports while logging bile phone. The review was completed in 15 min- 3,500 flight hours in 2008. utes, and the director of maintenance grounded Some safety specialists see growing accep- the aircraft. Within 30 minutes of the download, tance of this technology by operators but have The Internet brings however, the correct parts had been shipped to yet to decide how it will influence their own engine data history the remote airport. Maintenance technicians were programs. “We do not have a formal policy or po- and remote analysis able to install them and release the airplane to sition on this technology,” said Eli Cotti, director, within reach. service the following day. Maintenance, repair and overhaul (MRO) paradigms are undergoing a significant shift as a result of the application of this new technology compared with relying on maintenance techni- cians at one shop acquiring knowledge of an engine through first-hand experience, said Ma- ria Mandato, senior advisor–communications of PWC. “Today, any technician who has access to the Internet — from a remote location anywhere, anytime — can have 24x7 access to engine data, including both reports and alerts. They also can have access to watch lists for a visual summary of engine status.” When combined with the TFE731 engine trend monitoring services provided by partner Jet-Care International,3 “Zing eliminates manual engine data downloads, improves proactive trend monitoring and reduces downtime during unscheduled engine events,” said Donna Chase, vice president of Honeywell Business and Gen- eral Aviation Customer and Product Support. Operators annually save hundreds of hours of downloading time with the wireless engine data download service, which provides fault code, event/exception alerting, automated trend data © Pratt & Whitney Canada www.flightsafety.org | AeroSafetyWorld | March 2009 | 45 MaintenanceMatters
technical operations, of the National Business “An example of a typical unscheduled engine Aviation Association. “Many operators are taking event would be intermediate turbine tempera- advantage of this service because of the real-time ture (ITT) indication shifts,” Cotti said. “This response and logistic support it provides almost could be as a result of combustion chamber immediately upon landing. transition ducts or seal misalignment. Another “Once a discrepancy is noted in the aircraft example would be that, if and when exceedance records, the aircraft is out of service. The only events are recorded, they are typically accom- way to continue operating is to perform cor- panied by a [digital] date-time ‘stamp’ of all rective action. One of the underlying reasons running parameters. for Zing, for example, is to allow operators to “Exceedances often have a cycle/limitation send their maintenance and support personnel penalty — a reduction of total operating hours [timely] information about events. Without Zing, or a cycle limitation, useful hours or cycles for the operator requires maintenance personnel an hour-limited or life-limited component. Ex- attention to accomplish the task of engine data ceedances that go beyond the exceedance record download, usually once every 50 flights.” — that is, a limit in the event-recording process More than targeting anomalies such as in- — would be followed by an auto-commanded flight engine shutdowns or rejected takeoffs, to- engine shutdown to automatically resolve the day’s ECM services focus on subtle combinations problem. For example, if overspeed is the type of of engine parameter exceedances and events, fault exceedance, overspeed beyond a certain RPM or codes, trends and associated flight conditions. time frame would be followed by an overspeed Services provide detailed guidance so that opera- shutdown.” Consistent, frequent tors and pilots can respond appropriately before Actions to be taken — including whether to data downloads an issue affects any aspect of flight operations, notify the operator or await results from sub- accelerate work including airworthiness. Some deviations from sequent downloads — vary according to the at MRO centers. normal limits are safety critical. engine parameter exceedance involved and the context of other parameters. “For example, if an over-temperature exceedance is detected, the temperature attained and the duration of the over-temperature condition will determine if im- mediate action is required,” PWC’s Mandato said. “Likewise, fault codes can have different levels of required actions depending on the nature of the code. A trend shift … still within the recom- mended operating parameters of the engine … may merit further monitoring but may not require immediate action if still within limits.” Sometimes, reported events lead the des- ignated analysis center, third-party specialist or the engine manufacturer’s representative to give advice to the operator and flight crew that will disrupt the flight schedule. “If sufficiently severe, the recommendation may be to not operate the aircraft until the recommended [maintenance] actions have been undertaken,” Mandato said. “This is the extreme-case sce- nario, but may be the most prudent course of action, depending on the circumstance.” © Honeywell Aerospace
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Stress Reduction operator’s support organization know Minimizing cockpit disruptions and dis- [about issues] well in advance reduces tractions related to engine anomalies and the amount of time the aircraft is going relieving pilots of routine engine-data to be in maintenance or out of service.” documentation tasks — especially free- ing up crew time for other operational, Blurred Distinctions safety and mission responsibilities — Boundaries between what is feasible have been cited as risk-reduction factors. in the airline environment versus the “In the old days, the crew was business aircraft environment are obliged to record on paper the parame- blurring, PWC’s Mandato said. “Signifi- ters of an event or warning signal,” Cotti cant inroads have been made to assist said. “Parameters changed frequently, operators in determining whether an however, and the crew may not have aircraft is ‘safe’ to fly,” she said. “By fully written down the correct parameters. capitalizing on the systems offered, These new systems capture the informa- the operator [obtains] invaluable and tion instantaneously so that potential er- actionable information for mainte- © G. Schläger/Lufthansa Technik ror in engine instrument interpretation nance planning that will assist them in Devices that add wireless connectivity is eliminated. This leaves the flight crews validating their own [aircraft safety] to engine computers mitigate free to focus on flying the aircraft rather experience and judgment. Operators human factors errors. than troubleshooting.” Even when busi- get immediate confirmation that the ness aircraft crews using these systems engines have been operated within the and presents trend data for ground- receive an in-flight alert, they feel more established limits. based analysis that would normally take at ease knowing that recently down- “Visibility of engine events and hours to process and tabulate.” loaded engine data give maintenance exceedances also encourages pilots to Advantages of the services include specialists a head start on diagnosis, and fly within the specified parameters. The consistent data collection after each quick problem resolution often awaits more operators know about their air- flight; no need for the flight crew or them upon arrival, he said. craft, the better their decisions. Options maintenance technician to carry aboard Virtual “built-in support” has been available — such as instant-alert noti- a laptop computer with engine controller touted as one of the real-world benefits fications in the cockpit and automatic cable harness or to handle engine data of remote engine diagnostics, particu- data transfer from the aircraft [engines] storage media; and capability of engine larly by enhancing the operator’s confi- to monitoring systems on the ground troubleshooting from a remote location. dence about continuing to fly missions. once a flight segment has been com- Airplane operators considering a Although equipment aboard the busi- pleted — maximize effectiveness.” subscription to remote ECM also have ness aircraft subscribed to these services Illumination of PWC’s optional to decide whether they will rely on in- wirelessly download data to a diagnostic alert light, supplementing engine house technical expertise to interpret center only after landing — unlike com- instruments on the flight deck, tells the the new data available on a Web site mercial jets performing in-flight down- pilots to seek immediate maintenance or contract for external expertise. “By loads — this capability still contributes assistance for a serious engine problem. having direct access, operators can see to in-flight situational awareness. Services that integrate analysis of [for themselves] how their engines are “From a safety perspective, having engine data and flight data also help performing … with data in easy-to- in-flight knowledge of an event could operators to make data-driven deci- understand format for ground-based help the crew decide if the mission is sions. “Advanced diagnostics add analysis,” Mandato said. The PWC soft- safe to continue or if an unscheduled objective operational, trending and ware suite on the operator’s side com- landing is needed,” Cotti said. “The exceedance data to the [operator’s] de- prises engineering algorithms, analysis crew also can plan ahead to meet cision-making process,” she said. “The enhancement tools, fleet management needs of the unscheduled landing and Internet-based data management sys- information, automatic alerts, data ware- proceed to a repair facility. Letting the tem … automatically accepts, organizes housing and data-graphing capability. www.flightsafety.org | AeroSafetyWorld | March 2009 | 47 MaintenanceMatters
If the operator does not want to available to the commercial jet’s flight Even when the engine maintenance rely on in-house expertise, the external crew. “In case of exceedance of a pa- is performed at the home base or a service will provide required engine rameter over a certain level, the crew preferred major maintenance station, information and make decisions. “Data will get an alert via several displays and knowledge gained from continuous review by our designated analysis center acoustic indications,” Reinert said. “It engine analysis often eliminates some assists in the detection of trend shifts, is not very difficult for the flight crew steps otherwise required to return the exceedances and events [with] expert to interpret their ECM data — the im- airplane to service. “Inspections and analysis of trend data, watch lists, alerts portant parameters such as exhaust gas smaller repairs normally do not require and regular updates on the status of the temperature, fuel flow, N1, N2 — and an engine run-up,” Reinert said. “A aircraft engines,” Mandato said. “The on Rolls-Royce engines, N3 — oil pres- run-up is always a consequence due to determination as to whether an alert … sure and temperature, and vibrations.” a part or engine change. Our ECM sys- necessitates the removal of the aircraft Many air carriers routinely generate tem does not eliminate these run-ups, from service would only be made once and transmit during every flight several but due to early failure detection, we the aircraft has landed and the data have types of engine condition data. “Our can conduct inspections before we have been downloaded into the Turbine ECM uses takeoff, cruise and exceedance to change special engine parts.” Tracker data repository for analysis.” reports to detect engine problems,” Rein- Practically all decisions about ert said. “These reports are generated at maintenance action for an engine Airline Precedents specific altitudes, speeds, etc. Takeoff and involve a degree of risk, requiring Lufthansa Technik, which provides ser- cruise reports are just snapshots trans- high quality of both data and data vices covering about 1,450 engines for mitted by VHF radio. An exceedance analysis. “We try to minimize this risk more than 50 operators, says that the report, however, will be forwarded im- by analyzing the data very carefully,” basic objective of ECM is early failure mediately via satellite communication.” Reinert said. ECM engineers will not detection that avoids a severe engine As a rule, timely rectification averts hesitate to advise changing an aircraft, failure during flight. When the compa- further problems that could affect airwor- if a spare is available to the operator, ny’s Frankfurt diagnostic center detects thiness. “It is better to have a small delay or a flight delay for maintenance to a deviation in engine data compared than an engine failure during flight,” he ensure that “everything is fine with the with preset threshold/limit values, an said. “The best examples are trouble with engines,” he said. ECM engineer automatically receives the bleed system, fuel metering, sensor Notes an alert on a computer display. and probe failures and engine-control “At first, we receive an alert e-mail [anomalies] like variable bleed valve or 1. Before 2007, ETOPS referred only to from our system,” said Wolfgang Rein- variable stator vane trouble.” extended-range operation with two-engine ert, an international media relations Air carriers and business operators airplanes. representative for the company. “An alike look to the services to reduce the 2. Telematics in this context refers to inte- ECM engineer then analyzes the trend probability of an aircraft on ground at grating telecommunication, information systems and autonomous, self-contained data and the raw data to find the cause a remote site because of engine issues. electromechanical sensors in vehicles, for the alert. If a severe engine failure This situation can be extremely costly including aircraft. is detected, the engineer informs the because of the logistical complexity and 3. Jet-Care International. A Guide to Gas customer via e-mail or phone call and additional work, and may entail more Path Analysis. November 2008. The recommends a maintenance action risk than engine work performed at company monitors the condition of according to the aircraft maintenance major maintenance stations. “Engine more than 12,000 engines worldwide, manual or troubleshooting manual. The removals at stations other than the home including identification of problems next action — from a visual inspection base are expensive because the operator with main engine instrumentation that up to an engine change — depends on has to bring the maintenance staff, tools can cause flight crews to inadvertently operate at off-design conditions that the findings.” and the spare engine to the [remote] reduce engine component life. Analysis From a safety standpoint, an ECM station,” Reinert said. “Special tooling or also gives operators advance warning of engineer usually plays a backup role to even a hangar is required for an engine engines likely to be restricted for power the real-time engine status information change.” on hot-day operations, Jet-Care said.
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Speaking of Clearances U.S. pilots preferred speaking to writing when responding to non-U.S. controllers, but were divided about speech versus datalink in receiving ATC messages.
BY RICK DARBY
oncern about substandard In the first of several reports on their experiences. These pilots had an English language use in aviation pilots’ non-U.S. flying experience and average of 15 years of international flight is often raised in terms of pilots practices by the U.S. Federal Aviation experience, with an average of five inter- whose native language is other Administration,1 researchers found national flights in the 30 days before the Cthan English. That was, for example, that, based on small-group inter- interviews. All listed English as their first a critical factor in the 1990 accident views with U.S. pilots experienced on language. About 60 percent of the pilots Raymond/iStockphoto © Alejandro involving Avianca Flight 52, which international routes, “English language said that they knew no languages other crashed because of fuel exhaustion on proficiency is often deficient in non- than English, and among the others, the its third approach to New York’s John native-English countries and hampers majority spoke and understood some F. Kennedy International Airport after effective communication. English French and Spanish. being placed in a holding pattern for language deficiency below a certain Responses were categorized into more than an hour. The pilots had been level hampers air traffic control [ATC] 10 sections. This report concerns their unable to make clear to controllers the communication. Language proficiency responses to the first two sections, nature of their emergency. includes pronunciation, structure, vo- “Background Information” and “Preflight But U.S. pilots who have a na- cabulary, fluency, comprehension and Preparation.” The pilots’ answers to ques- tive’s command of English encounter interaction.” The researchers also asked tions and discussions during the inter- problems at non-U.S. locations where general questions about ATC differ- views “provide a wealth of ideas related they must communicate with control- ences in international operations and to the international flight experiences,” as lers whose English is limited. Also, in how they affected the pilots’ procedures well as “their perception of the situations some cases, being unable to understand and performance. they encountered,” the report says. non-English communication on the ra- Twelve airline transport pilots from Although the pilots’ responses were dio frequency reduces their situational each of four major U.S. air carriers, for partly anecdotal, they answered ques- awareness. a total of 48, were interviewed about tionnaires that enabled the researchers www.flightsafety.org | AeroSafetyWorld | March 2009 | 49 DataLink
preferred to hear ATC communications, 54 per- Countries Flown Through by U.S. Pilots cent preferred to read them and 13 percent had In the Three Months Preceding the Interview no preference (Figure 1). Number One comment explaining a preference for of Pilots Countries hearing ATC messages was: “Information is 1–5 Argentina, Aruba, Antilles, Belgium, Belize, Bermuda, Bolivia, Cambodia, Chile, Colombia, Costa Rica, Crete, Cypress, Denmark, rapidly conveyed; it can be questioned and clari- Ecuador, El Salvador, Fiji, Grand Cayman, Greece, Greenland, fied quickly.” Another was: “Reading messages Guatemala, Haiti, Honduras, Iceland, Iraq, Israel, Jamaica, Kuwait, is a ‘heads down’ activity not suitable for many Laos, Luxembourg, Mongolia, The Netherlands, New Zealand, Nicaragua, Panama, Peru, Poland, Puerto Rico, Republic of the phases of flight.” Philippines, Scotland, South Korea, Spain, St. Martin, Switzerland, The opposite viewpoint was expressed as: Tahiti, Thailand, Trinidad, Turkey, Vietnam, United Arab Emirates “When talking to some foreign controllers, their 6–10 Brazil, China, Dominican Republic, Ireland, Italy, Japan, Russia, Venezuela English is so bad, or radios are so scratchy, that 11–15 Cuba, France, Germany you are simply listening for what you think they 16–24 Canada, England, Mexico are going to tell you.” When responding to ATC, the majority Source: U.S. Federal Aviation Administration preferred speech to typing (Figure 2). This Table 1 was elaborated as: “Speaking … is less time- consuming and it takes less effort. It is easier to quantify the results. to correct a misunderstanding. It is also easy to U.S. Pilot Preferences for Modality of The report includes make non-standard requests. Speaking is faster, Receiving ATC Messages quotes, which amal- and I can listen to the inflection and cadence in Strongly gamated the words speech.” prefer to hear 6 (12.5%) of various pilots for Pilots who preferred to type their mes- the sake of creating a sages to ATC believe “it minimizes hearback/ single coherent narra- readback problems significantly. Written com- Strongly prefer tive for each topic. munication greatly reduces confusion. For non- to read The 48 U.S. pilots English[‑speaking] controllers, datalink would 11 (22.9%) Prefer to hear listed 64 geographical be easier for them to understand.” 10 (20.8%) areas they had flown The next section of the questionnaire and Prefer through in the three interview concerned preparation for interna- to read No months preceding the tional flights. 15 (31.3%) preference 6 (12.5%) interviews (Table 1). Pilots were asked what language problems Canada, England and they expect, or have experienced, when flying in Mexico were transited non-U.S. airspace. They listed 109 examples of by at least 33 percent language-based difficulties, which the research- ATC = air traffic control of the pilots. “They ers categorized into themes (Table 2). “English Source: U.S. Federal Aviation Administration landed their aircraft language comprehension and production” plus Figure 1 in 47 different coun- “controllers’ inability to communicate in plain tries or regions during language” accounted for 56 percent of antici- that time period,” the report says. “Within the pated problems. 30 days preceding the interviews, 83 percent of “At times, when you ask a basic question the pilots flew an average of five international dealing with weather, runway conditions or flights, including multiple flights to Costa Rica, something that is not standard, the controllers Guatemala and Venezuela.” cannot answer that question if it’s not something Pilots were asked if they would prefer writ- that they would expect to parrot back,” was one ten communications, such as datalink, to voice example given of the “controllers’ inability to communications from ATC. About 33 percent communicate in plain language” category.
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Another pilot said, “Sometimes there’s dif- Pilots were asked how much differences in ficulty conveying our wishes due to a control- ATC “procedural complexities” had influenced ler’s comprehension skills. When there is a large their flight experiences. About 54 percent thunderstorm between my airplane and the air- reported either a moderate or considerable port … and I want to get across to the control- influence, and the remainder reported a limited ler that I cannot do what was just asked of me, influence (Table 3, p. 52). I’ll say, ‘Unable’ and you can see a big question A comment from a pilot who answered “to mark out there over his head. It is as though he a considerable extent” was: “One of the biggest is thinking, ‘What do you mean, unable? I gave problems is transition levels. There are some you a command.’ Well, it’s not the way we oper- places we fly into where we don’t know the tran- ate at our company. He can arrest me when we sition level until it’s land if he wants.” reported on the ATIS U.S. Pilot Preferences for Modality of Controllers’ pronunciation of fixes, intersec- [automatic terminal Responding to ATC Messages tions, waypoints and numbers was accounted a information service]. Strongly prefer major problem. When we get close No preference to type “Due to the accents and the speed that enough to where we 2 (4.2%) 3 (6.3%) they’re speaking, I personally have to ask them can hear the ATIS, it sometimes to repeat themselves more slowly will tell us — if we can or spell fixes phonetically to get the under- understand it — what Strongly prefer standing correct,” was one comment. “I have to the transition level is. Prefer to type to speak 9 (18.8%) make sure all of us are hearing the same thing. It may vary by 1,000 15 (31.3%) I’ve had it happen where we’re all listening, ft. One day it might but can’t decide what fix he’s trying to give us. be 6,000, one day it We’ve been up for 18 hours, so give us a break might be 7,000.” Prefer to speak 19 (39.6%) and spell it for us because we can’t understand A pilot said, “I the pronunciation.” feel that we should Another comment was: “Again, because of have standardization the accent, we never really did come up with anywhere we fly. I ATC = air traffic control exactly what he was saying. We came up with a should expect that Note: Percentages do not add to 100 because of rounding. pretty good consensus of what we thought he service, and pilots Source: U.S. Federal Aviation Administration meant, but I don’t think any one of us was 100 from other countries percent certain what the clearance was.” flying here [in the Figure 2 During the small group interviews, “oral responses were embellished and discussions Anticipated Language Problems for International Flights expanded to include cultural differences [in Survey Pilots’ Response Frequency Percent various countries],” the report said. Controllers’ inability to communicate in plain language 27 24.8 Asked about the effect of the difference in Controller voice quality and speech rate 10 9.2 ATC “procedural complexities” from country to country on the pilots’ flight experiences, about English language comprehension and production 34 31.2 10 percent reported a positive effect, about 40 Frequency congestion* 3 1.8 percent said it was neutral, and half said it was Multiple languages on frequency 18 16.5 negative. Among the choices offered, none said Non-standard terms for standard questions 14 12.8 the effect was “very positive” or “very negative.” Poor radio equipment, coverage, quality 3 2.7 Those who found the experience positive said * Frequency congestion was mentioned only in connection with “multiple languages on frequency.” it kept them on their toes, improved situational Source: U.S. Federal Aviation Administration awareness and encouraged flexibility — “Avia- tion is a dynamic environment.” Table 2 www.flightsafety.org | AeroSafetyWorld | March 2009 | 51 DataLink
U.S.] should expect vectoring in other places, you’ll either continue Influence of Differences in ATC Procedural that same service. In on your route, or if they need to adjust your Complexities on Pilot Flight Experiences other words, we are all position in line they’ll say, ‘After this point, Number best served by a single instead of going to Lucia, you’re now going to go Survey Pilots’ Response of Pilots Percent global standard.” straight to Mateo.’ But once you get onto the ap- To a great extent 0 0.00 The issue of proach, the routing leads you into the airport in- To a considerable extent 7 14.58 cultural norms was stead of the controller vectoring you all the way To a moderate extent 19 39.58 mentioned under the in, and the altitude restrictions have to be kept To a limited extent 22 45.84 subject of procedural up with all the way around. The difference is, in Not at all 0 0.00 complexities. A pilot the U.S., it’s radar vectors and with controllers in ATC = air traffic control said, “In South Amer- other countries, you fly the complete approach.” Source: U.S. Federal Aviation Administration ica, a lot of controllers The interviewed pilots were asked, “Is there have the opinion that any incongruence between what you would Table 3 ‘el capitán’ is always normally understand is written on a procedure Extent to Which Pilot Performance Is right. There is the and what the controller instructs or expects you Affected by Different ATC Procedures hierarchy where the to do during a flight?” Comments were received pilot knows what he is from 42 pilots, with the rest either seeing no Number Survey Pilots’ Response of Pilots Percent asking, and the con- examples of incongruities between written pro- To a great extent 1 2.08 troller should not try cedures and controller instructions or expecta- To a considerable extent 2 4.16 to interpret anything tions, or providing no examples. To a moderate extent 15 31.25 other than what he’s “I have had several occasions of being To a limited extent 25 52.08 asking. If a pilot asks cleared for a standard terminal arrival, and it To a very limited extent 1 2.08 to do something, they becomes ambiguous whether you are cleared to It depends 1 2.08 approve it because the descend via the arrival altitude restrictions or pilot knows what he not,” a pilot said. “Foreign controllers — espe- Not at all 3 6.25 wants to ask, even if cially non-native English-speaking controllers ATC = air traffic control it’s dangerous. So if ‘el — are unsure how to differentiate that specific Note: Percentages do not add to 100 because of rounding. capitán’ says he wants thing. On the standard departure, you’ll have an Source: U.S. Federal Aviation Administration to go down to 6,000 ft altitude restriction and they’ll clear you directly Table 4 and there is a 12,000-ft to an altitude; they don’t always mean that you mountain in front of are cleared to disregard the crossing restriction the aircraft, ‘el capitán’ will get permission to go on the climb. So, I’ve made it a habit when this down to 6,000 ft.” happens to read back and make sure I under- Forty of the 48 pilots reported that different stand the clearance is to climb unrestricted to ATC procedures affected their performance to a this altitude. A good percentage of the time, moderate or to a limited extent (Table 4). they’ll come back and say, ‘No, cross at the alti- “In Japan’s, China’s and Russia’s airspace, tude that’s listed’ or ‘comply with the restriction,’ ATC doesn’t have the ability to cope with fast- even though the altitude assignment should moving situations like weather deviations or have removed the restrictions.” turbulence, and I think they have to stop and Note think of how to talk to us in English,” said a pilot. “Things start falling apart and the com- 1. Prinzo, O. Veronika; Campbell, Alan. U.S. Airline munication stops.” Transport Pilot International Flight Language Experiences, Report 1: Background Information Another comment was: “In the U.S., there and General/Pre-Flight Preparation. Report DOT/ are a lot more approaches or arrival routes, FAA/AM-08/19. September 2008. Available via the followed by a radar vector into the pattern Internet at
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We Still Need Exceptional People James Reason, analyst of organizational precursors in accidents, returns the focus to the individual.
BOOKS He leads off with “A Mind User’s Guide,” a chapter about how the mind receives, interprets, Personal Qualities Make the ‘System’ Work stores and retrieves information. That might The Human Contribution: Unsafe Acts, seem peripheral to heroic recoveries, but hero- Accidents and Heroic Recoveries ism usually must be allied with good decision Reason, James. Farnham, Surrey, England, and making to be successful. Reason says, “Knowing Burlington, Vermont, U.S.: Ashgate. 310 pp. Figures, tables. something about how your mind works is often ames Reason has been among the most very helpful when making decisions in high-risk prominent advocates of a “systems” approach situations. Our heads are richly stocked with Jto understanding accident causation. He knowledge structures that are called to mind by is most closely associated with what has been similarity matching [observing common charac- called the “Swiss cheese” model — not his own teristics between a new situation and previously term — in its successive versions. His model experienced ones] and frequency gambling suggests that various latent failures sometimes [recalling the most frequently encountered combine with active failures, aligning organiza- information]. Sometimes … these unconscious tional and individual factors, to create a tempo- search processes can lead us into error. But it is rary window of opportunity for an accident to more likely that what is called to mind in this break through defenses. way is going to be an appropriate response.” In The Human Contribution, Reason asks He next considers “The Nature and Varieties us to consider whether we have so absorbed his of Human Error,” classifying types of errors. For and others’ system models that the balance has example, omissions, “a necessary or planned-for tilted too far from trying to understand the hu- step is not done at the intended time.” Any pilot man side of accident scenarios. In particular, he who has made a gear-up landing understands this wants to remind us that humans are not merely type of error. Omissions are likely to be the single risk factors around whom safeguards need to be most frequent type, he says, because they can designed. They are also capable of creative and occur at any stage of an activity. Another type is heroic actions on behalf of safety that no system wrong objects, when “the right actions are carried design can accomplish. out, but in relation to the wrong objects.” A doctor As a prelude to discussing what he calls “heroic who removes a kidney with impeccable skill from recoveries” that can be credited in large part to the wrong patient has committed this type of error. front-line individuals or small groups, Reason “Errors cannot be eradicated, but they can leads the reader step by step through the world of be anticipated and managed accordingly,” Rea- human factors in accidents and potential accidents. son says. “We can’t fundamentally change the www.flightsafety.org | AEROSafetyWorld | March 2009 | 53 InfoScan
human condition, but we can change the condi- What could be wrong with the pursuit of tions under which people work in order to make excellence? It depends, Reason says, on the real errors less likely and more easily recoverable.” — as opposed to the official or “correct” — defi- Reason continues by surveying the main nition of excellence that prevails, and whether it explanatory theories, or “models,” of unsafe acts. is understood in terms of overall results rather He first considers the “person model,” in than limited, sequestered successes. “When which “unsafe acts are thought of as arising dealing with complex systems, people think in An overemphasis mainly from wayward mental processes: for- linear sequences,” he says. “They are sensitive getfulness, inattention, distraction, preoccupa- to the main effects of their actions upon their on systems that tion, carelessness, poor motivation, inadequate progress towards an immediate (often numeri- knowledge, skills and experience, and on occa- cal) goal, but frequently remain ignorant of their virtually ignores sions culpable negligence or even recklessness.” side effects upon the rest of the system.” the human Safety management based on this model spawns In contrast to the person model, “a system countermeasures aimed at influencing cognitive perspective is any accident explanation that goes contribution risks processes — posters, rewards and punishments, beyond the local events to find contributory audits, “writing another procedure to proscribe factors in the workplace, the organization and instilling “learned the specific unsafe acts implicated in the last the system as a whole.” He describes a number helplessness” adverse event,” retraining, and blaming. of such accident models, in addition to his own Reason acknowledges that the person model “Swiss cheese” versions. in personnel. is intuitively appealing, not to mention attractive “Although the system models seem, on the to management that would like to ascribe bad face of it, to be far more appropriate ways of outcomes to wrongful acts by individuals. But, considering accident causation, both in terms of he says, “The shortcomings of the person model understanding the contributing factors and in greatly outweigh its advantages,” because as an their remedial implications, they too have their explanatory framework it is “inextricably linked limitations when taken to extremes,” Reason to a blame culture.” He says the culture involves says. People on the “sharp end” generally have a set of pathologies called the “vulnerable sys- little direct opportunity to bring about rapid tem syndrome.” Its three components are blame, system improvements and global changes. An denial and “the single-minded and blinkered overemphasis on systems that virtually ignores pursuit of the wrong kind of excellence.” the human contribution risks instilling “learned Blame is discussed at considerable length. helplessness” in personnel. Among its drawbacks, Reason says, is that it But personal attitudes are still important for sabotages any attempt to create a reporting cul- safety, whether the system is benign or other- ture in which front-line operators report errors wise. “Personal qualities do matter,” he says. or even by-the-book acts that might have, but Reason concludes that the person and did not, result in accidents. “Closely investigated system models are inadequate in isolation: “We accidents are relatively infrequent; only through need to find a balance between the two that the analysis and dissemination of these ‘free les- continues to promote systemic improvements sons’ can the organizational managers learn how while, at the same time, giving those who have close their operations come to the ‘edge.’” little chance of changing the system some men- Denial is the attitude that accidents happen tal skills … that will help them to avoid error to someone else who is less conscientious. “No traps and recurrent accident patterns tomor- statement from the managers of a hazardous row rather than at some undetermined time in system could chill me more than ‘it couldn’t the future.” happen here’ — although the claim that ‘we have In the culminating chapters on heroic an excellent safety culture’ comes very close,” recovery, Reason looks at the needed personal Reason says. characteristics under the headings of “training,
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discipline and leadership,” “sheer unadulter- with unlikely but possible hazards; and generic ated professionalism,” “skill and luck,” “inspired qualities “that could contribute to successful improvisations” and “the ingredients of he- recoveries in any emergency.” roic recovery.” To illustrate his points, he cites Expected hazards are not necessarily likely, numerous examples, not only from aviation but but rather ones that have occurred in the past from military, naval, space flight and medical and sooner or later will arise again. The human history. Reason’s earliest example of discipline is factors that improve the odds of a successful drawn from an 1811 battle in Spain during the response, Reason says, are these: “Identification Napoleonic wars. and assessment … ; the development, testing and Several famous incidents in aviation are training of a set of countermeasures designed to discussed in terms of the human qualities neutralize the threat (established long before it that enabled them to be ended successfully or was called upon); and an effective and timely way partially successfully. The chapter on “sheer of deploying these countermeasures, a process re- unadulterated professionalism” describes British lying critically on situational awareness. The latter Airways Flight 09 in 1982, when all four engines has three components: perceiving the critical of the Boeing 747 failed after ingesting volcanic elements in the current situation; understanding ash, and it looked like the airplane would have the significance of these elements; and making to glide to a water landing, which no one had projections as to their future status.” ever tried in a 747. The captain’s announcement For avoiding probable disaster in unlikely to the passengers while the crew was working situations — fuel exhaustion in the 767 and the out emergency landing procedures was calm- loss of normal control mechanisms in the DC- ness itself: “Ladies and gentlemen, this is your 10, for instance — Reason believes one key ele- captain speaking. We have a small problem. ment is “irreplaceable people.” In the case of the All four engines have stopped. We are doing 767, “the odds of having a skilled glider pilot as our damnedest to get them going again. I trust the captain and someone who had flown out of you’re not in too much distress.” The engines Gimli [the disused military airfield] as the copi- were eventually restarted and the crew made an lot, the two things necessary to save the stricken emergency landing at Jakarta, Indonesia. aircraft, are almost infinitesimally small.” The Other incidents include the British Airways saving of the lives of many passengers and BAC 1-11 flight in which an explosive decom- crewmembers on the United DC-10 was “a team pression blew the pilots’ windscreen out of the effort, but I believe it was [Capt.] Al Haynes’s aircraft; the Air Canada Boeing 767 that ran personality and his cockpit management skills Different styles of out of fuel because of a loading miscalculation that were the key elements in bringing that decision making are and was glided to a landing at a disused military about. And it was his inspirational use of the airstrip; the United Airlines McDonnell Doug- one and three engines that prevented the aircraft needed in different las DC-10 in which the flight crew maintained from turning onto its back and falling out of the controlled flight using thrust after an uncon- sky at a very early stage of the emergency.” kinds of situations. tained failure of the no. 2 tail-mounted engine Decision-making styles are another im- resulted in the failure of all three hydraulic portant factor, Reason says, although different control systems; and the ingenious improvised styles of decision making are needed in different procedures by which the captain of an Air New kinds of situations. “There are four principal Zealand DC-10 was able to guide to safety the types of decision making: intuitive (recognition- pilot of a Cessna 188 whose automatic direction primed), rule-based (where rules are available finder had failed. from remembered experience or from proce- Reason analyzes the human qualities that dures), analytical (choice through comparison underlie heroic recovery under three head- of options) and creative thinking (coming up ings: coping with expected hazards; dealing with something entirely new to solve a novel www.flightsafety.org | AEROSafetyWorld | March 2009 | 55 InfoScan
problem). Selection recommendations, plus guidance materials and of a decision-making best practices to support actions. Guidelines are mode depends cru- offered to assist local safety teams at airports in cially on assessing the initiating runway safety programs. Local safety situation.” teams are a key component of the larger action “Realistic opti- plan. mism” is one of the Presentations and accompanying materials most important ge- from runway safety workshops held in various neric qualities, Reason European locations between 2002 and 2008 can believes: “It is high on be found in the “Airport Safety Archives” section. the list of necessary Implementation products — posters, fact attributes for aspiring sheets and documents such as “Five Studies heroic recoverers, and Relating to Different Runway Management it is particularly im- Techniques” and “Air Traffic Control Situational portant when there is a succession of problems, Awareness Occupied Runways,” ICAO’s “Manual as was the case in many of these emergencies. for Preventing Runway Incursions,” and ARIA, an What wins out is the stubborn belief that it will Aerodrome Runway Incursion Assessment tool be all right in the end.” — are available online for downloading. Most are Reason sums up: “Many if not most recover- in Adobe portable document format (PDF). ies were achieved as the result of a providential Eurocontrol says ARIA is a computer-based awareness, personality, professionalism, team- assessment methodology that can help identify work and, in certain circumstances, some unex- specific airport locations where runway incur- pected skills. …But these individual ingredients sions could occur and remedial actions that did not appear altogether out of the blue. They might help reduce the odds of occurrences. had to be selected for and then trained, nurtured ARIA software, user guide and methodology and supported by the organizations that the documents may be downloaded at no cost. heroic recoverers served.” A link from Eurocontrol Airport Safety leads to a portal called “Preventing Runway Incur- WEB SITES sions.” Clicking on the link opens a new Web site,
56 | flight safety foundation | AEROSafetyWorld | March 2009 OnRecord Roller Coaster Ride Ice buildup on pitot probes caused erroneous airspeed indications.
BY MARK LACAGNINA
The following information provides an aware- the air data system, degrading its ability to reli- ness of problems in the hope that they can be ably determine the airplane’s airspeed,” the re- avoided in the future. The information is based port said. The captain was about to ask the first on final reports by official investigative authori- officer to retrieve the quick reference handbook ties on aircraft accidents and incidents. when the autopilot disengaged and the airplane, which had been climbing through 19,300 ft, JETS pitched down and entered a steep dive. During the recovery, the first officer assisted Flight Crew’s Response Was Uncoordinated the captain on the flight controls. Both pilots Boeing 717-200. No damage. No injuries. told investigators that the controls felt heavy and hile departing from Kansas City, Mis- that the airplane did not respond to their control souri, U.S., for a scheduled flight to inputs. “The flight crew initially applied uncoor- WWashington the night of May 12, 2005, dinated control inputs, in the process reaching the 717 encountered weather conditions “favor- nearly 100 lb [45 kg] of differential force on the able for the accumulation of structural icing,” pitch-control column, while attempting to re- said the report by the U.S. National Transpor- cover the airplane,” the report said. “During this tation Safety Board (NTSB). “At some point, period … pitch continued to oscillate through the pitot-static system began accumulating ice five cycles, for a duration of eight minutes, because the air data heat system had not been reaching altitudes as low as 10,600 ft and as high activated.” as 23,300 ft.” The captain, who was flying the airplane on The pilots observed erroneous airspeed autopilot, maintained airspeed between 280 and indications that varied between 54 kt and 460 kt. 300 kt during the climb to cruise altitude. “The “The captain stated that while he was trying to crew felt they did not need to utilize airplane recover the airplane, he attempted to maintain anti-icing because the outside temperature was a level pitch attitude by placing the pitch of the still too warm to require it,” the report said. airplane in a fixed position and tried to level the “The first indication of something abnormal was wings of the airplane,” the report said. “The first when the captain noticed the master caution officer stated that, during the recovery, he was light was illuminated.” trying to keep the airspeed away from the stall The “RUDDER LIMIT FAULT” warning speed and away from the overspeed red zone.” light also illuminated because ice had accumu- The crew eventually regained control of the lated on the pitot probe for the rudder limiting airplane, declared an emergency and landed system, which reduces maximum allowable rud- without further incident at Kirksville (Missouri) der deflection as airspeed increases. “The icing Regional Airport. None of the 80 people aboard continued to accumulate on the other probes of the 717 was injured. www.flightsafety.org | AEROSafetyWorld | March 2009 | 57 OnRecord
“Post-incident testing of the airplane’s an AAIB accident report, in which he “acknowl- mechanical and electronic systems revealed edged that the aircraft bounced on landing but no abnormalities that would have accounted stated that at all times he had control of the for the unreliable airspeed indications or the aircraft and maintained the runway centerline,” loss of control reported by the flight crew,” the the incident report said. The first officer filed a report said. “Post-incident computer modeling mandatory occurrence report with the U.K. Civil also confirmed that the airplane performed in a Aviation Authority, saying that the aircraft had manner consistent with all deviations from nor- reached heights of 10 to 15 ft during the bounces. mal flight having been initiated or exacerbated Noting that the difference between the by the control inputs of the flight crew.” indicated wind velocity at 2,000 ft and the reported surface wind velocity provided warn- Commander Overrules Go-Around Call ing that the pilots could expect significant wind Cessna Citation 550. No damage. No injuries. shear, the report said, “The selection of a speed nbound from Nice, France, the commander greater than minimum approach speed may was flying an autopilot-coupled instrument have provided a greater margin for wind shear.” Ilanding system (ILS) approach to Runway 21 at The report also said that a go-around conducted Biggin Hill Airport in Kent, England, the evening after the stall recovery “may have prevented the of Feb. 5, 2008. Night visual meteorological con- subsequent bounced landing.” ditions (VMC) prevailed, and surface winds were from 230 degrees at 15 kt. The pilots observed a Reversed Anti-Skid Wiring Leads to Excursion wind velocity indication of 54 kt on the electronic Airbus A320-200. Minor damage. Two minor injuries. flight instrument system (EFIS) as the Citation urface winds were from 330 degrees at 17 descended through 2,000 ft, said the report by the kt, gusting to 23 kt, when the A320 was U.K. Air Accidents Investigation Branch (AAIB). Slanded on Runway 22R at Chicago O’Hare After the autopilot captured the glideslope, International Airport the night of Oct. 9, 2007. the commander reduced airspeed to 115 kt, Perceiving no deceleration by the autobrakes, which he described as the “minimum approach the captain applied manual wheel braking when speed” — reference landing speed (Vref) plus airspeed decreased below 100 kt. 10 kt. “At two miles from the runway threshold, “The aircraft immediately swerved hard [the Citation] encountered severe wind shear, right,” the captain told NTSB investigators. “I After the second and the EFIS speed tape showed the speed corrected with full left rudder and brake, but trending to below 100 kt,” the report said. “The the aircraft continued to the right. I then used bounce, the first autopilot pitched up to maintain the glideslope, nosewheel steering to attempt to straighten the and the aircraft appeared to stall with a right- aircraft, but it was ineffective.” officer called for wing drop. The [commander] recovered from The nosewheel and right main landing gear
a go-around. the stall by lowering the nose and increasing ran off the right side of the runway. The captain power, and decided to continue the approach.” was able to steer the aircraft back onto the runway The commander The pitch attitude was described as “flat” on and bring it to a stop. A flight attendant and a pas- touchdown, and the aircraft began to “porpoise,” senger received minor injuries during the excur- responded, “Why?” bouncing off the runway an unspecified number sion; the other 125 occupants were not injured. of times. After the second bounce, the first of- “Although I knew there was some aircraft ficer called for a go-around. The commander damage, there was no indication of fire,” the cap- responded, “Why?” tain said. “Since the aircraft taxied normally, I The Citation was brought to a stop on the run- taxied … and parked at the gate.” After shutting way and taxied to its parking position. There was down the engines, the captain observed that the no damage, and none of the four people aboard indicated temperature of the brakes on the left was injured. Nevertheless, the commander filed main landing gear was about 60˚ C (140˚ F), and
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that the indicated temperature of the brakes on forecast severe turbulence in the area. Neverthe- the right main gear was about 375˚ C (707˚ F). less, wind shear data included in the preflight He then was informed by maintenance person- paperwork had caused the captain to anticipate nel that the left inboard tire had burst and that turbulence. Although the ride had been smooth the engine nacelles had been damaged. during descent, the captain said that the DC-9 The captain Examination of the A320 revealed that the was descending through 13,000 ft when he described the wiring for the anti-skid braking system tachom- “chimed the flight attendants early,” indicating eters on the inboard and outboard wheels on the that they were to prepare the cabin for landing turbulence encounter left main landing gear had been misrouted and and then be seated. The captain described the reversed during replacement of the tachometers turbulence encounter as a “violent jolt” that oc- as a “violent jolt” by a maintenance contractor the day before the curred with no warning. accident. This resulted in a high level of brak- that occurred with ing on the inboard wheel but no braking of the Pallet Loader Catches Fire no warning. outboard wheel. Airbus A320-200. No damage. No injuries. “The operator reported that the reference he A320 was being readied for departure documentation associated with the scheduled from Melbourne (Australia) Airport on maintenance involving both of the left main TDec. 31, 2007. “The flight crew was in the landing gear tachometers was unclear and that cockpit preparing the aircraft for the flight, the the procedure for that maintenance was revised,” passengers were boarding the aircraft through the report said. the left-forward door via the airbridge, and the ground handlers were loading and unloading Turbulence Warning Not Passed to Crew baggage and other items,” said the report by the McDonnell Douglas DC-9-83. No damage. Two serious injuries. Australian Transport Safety Bureau (ATSB). he DC-9 was descending through 8,300 ft The operator of a pallet loader on the right during an approach in VMC to Ontario side of the aircraft detected the odor of an T(California, U.S.) International Airport when electrical fire while restarting the engine, which it encountered severe turbulence the morning of had stalled. About the same time, the loading Dec. 25, 2007. Two flight attendants who were supervisor noticed a fire in the pallet loader’s completing final cabin duties in preparation for engine compartment and warned the operator, landing were thrown to the floor. “One of the who used a fire extinguisher attached to the pal- flight attendants sustained multiple fractures to let loader to put out the fire. The pallet loader one ankle, and the other flight attendant suffered was about 10 m (33 ft) from a fueler who was a head injury with loss of consciousness and refueling the aircraft under the left wing. concussion,” the NTSB report said. The other 112 “The ignition source for the fire was most people aboard the airplane were not hurt. probably intense electrical arcing within the “The turbulence was likely the result of pallet loader engine’s starter motor solenoid,” strong easterly winds interacting with the rough the report said, noting that after a similar terrain in the area (mechanical turbulence),” the incident on May 27, 2008, the operator retrofit- report said. The U.S. National Weather Service ted all of its pallet loaders with “a replacement had issued a significant meteorological advisory starter motor that significantly reduces the risk (SIGMET) for occasional severe turbulence of electrical arcing.” below 12,000 ft in the area. “The content of [the SIGMET] was available to the flight’s dispatch- Roll Excursions Spoil Landing er,” the report said. “However, this information Learjet 35A. Substantial damage. No injuries. was not provided to the flight crew.” eather conditions at Goodland (Kansas, The report said the company that supplies U.S.) Municipal Airport the morning weather information to the operator had not Wof Oct. 17, 2007, included winds from www.flightsafety.org | AEROSafetyWorld | March 2009 | 59 OnRecord
330 degrees at 9 kt, 1 1/4 mi (2,000 m) visibility spoileron circuit breakers were in the closed in mist and a 200-ft overcast ceiling. During the position.” briefing for the ILS approach to Runway 30, the The pilot said that he had closed the pilot told the copilot to fly the approach and that spoileron circuit breaker for a short time during he (the pilot) would take the controls for landing cruise flight while attempting to reset the sys- if he acquired visual contact with the runway. tem. “He stated that the system would not reset, The copilot told investigators that the ap- so he pulled the circuit breaker, and it remained proach was stabilized. As the Learjet neared in that position for the remainder of the flight,” decision height, he was preparing to go around the report said. “It was also stated that all cabin when the pilot announced that he had the run- circuit breakers were reset [closed] following the way environment in sight and took control of accident.” the airplane. The report said that examination and test- The pilot said that the airplane was slightly ing of the yaw damper and spoileron computer left of the extended runway centerline when it revealed “anomalies,” but the manufacturer said exited instrument meteorological conditions 250 that the anomalies would not prevent control of ft above ground level (AGL). He said that when the airplane. “Greater control wheel displace- he made a “slight correction to the right,” the ment and force to achieve a desired roll rate Learjet “rolled excessively to the right”; he then when compared with an operative spoileron corrected to the left, at which time the airplane system would be required,” the report said. “The “rolled excessively to the left.” result would be a slightly higher workload for The right wing tip fuel tank and then the the pilot, particularly in turbulence or crosswind left tip tank struck the runway before the conditions.” airplane ran off the left side of the runway The report concluded that the probable and came to a stop between the runway and cause of the accident was “the pilot’s failure to a taxiway. Damage included separation of the maintain aircraft control during the landing.” left outboard wing about 3 ft (1 m) from the tip tank. The pilots, who were alone in the TURBOPROPS airplane, escaped injury. The report said that maintenance had been Snow Melts, Refreezes on Parked Airplane initiated 15 days before the accident to correct Beech Super King Air 200. Destroyed. Two fatalities. a fault in the Learjet’s spoileron system, which he pilot removed the King Air from a heated uses the ground spoilers to augment the ailerons hangar and left it on the ramp at Salmon, at low airspeeds; the system is armed when the TIdaho, U.S., while having breakfast with a flaps are extended beyond 25 degrees for ap- passenger and waiting for two more passengers to proach. Maintenance records indicated that the arrive the morning of Dec. 10, 2007. “The outside system was “not working properly.” temperature was below freezing, and a steady Technicians at the maintenance facility were light-to-moderate snow was falling,” the NTSB troubleshooting the problem when the opera- report said. “The airplane sat in the aforemen- tor recalled the airplane. “They deactivated the tioned ambient conditions for at least 45 minutes spoileron system in accordance with the Learjet before the initiation of the takeoff roll.” minimum equipment list procedure,” the report The pilot did not remove snow that had said. “The [spoileron] circuit breaker was pulled accumulated on the airplane or ice that had and secured with a tie wrap, and a decal was formed when snow melted on contact with the installed indicating the system was deactivated. warm airframe and then refroze. Heavy snow “Neither the tie wrap nor decal were noted was falling, with 2 in (5 cm) of wet snow on the during the [post-accident] examination of the runway, and the temperature was about 10˚ F cabin of the airplane, and both the spoiler and (minus 12˚ C) when the takeoff was initiated.
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After lifting off the runway, the King Air fresh cold air,” the report said. “He also noticed an bounced once and banked steeply left and right almost immediate improvement in his condition.” several times. Passengers said that the airplane The check captain transferred aircraft was shuddering. The pilot discontinued the control back to the pilot, transmitted a “pan The check captain climb and turned to a left downwind. “During pan” urgency call to air traffic control and this turn, the airplane reportedly again rolled to requested clearance to descend to the minimum again said that he a steeper-than-normal bank angle, but the pilot safe altitude. The crew initially was cleared to was becoming light- successfully recovered,” the report said. “While descend to 9,000 ft. “The crew considered that on the downwind, the airplane reportedly continuing to Christchurch was preferable as headed and that his stabilized in a wings-level [attitude] without any they were about midway between [Westport and significant rolling or shuddering.” Christchurch] and the terrain allowed for an vision was blurring. However, when the pilot initiated a left turn to- earlier descent,” the report said. VMC prevailed ward the approach end of the runway, the airplane at Christchurch, which also had longer runways began to shudder, yaw and rapidly lose altitude, and full aircraft rescue and fire fighting service. the report said. The pilot applied full power, but When the pilot removed his hand from the the King Air continued to descend and struck a storm window, the check captain again said hangar about 1,300 ft (396 m) from the runway that he was becoming light-headed and that his threshold. The pilot and front-seat passenger were vision was blurring. “The check captain alerted killed; the other two passengers escaped injury the pilot to again start directing fresh air into the and were able to open the cabin door and exit the cockpit and noted an immediate improvement airplane before it was engulfed in flames. in his condition,” the report said. “The pilot continued to fly with his right hand, keeping his No Cause Found for ‘Partial Incapacitation’ left hand at the storm window, which required Dornier 228-200. No damage. No injuries. the check captain to manage the power levers fter several route-familiarization and pro- and radio.” motional flights, the pilots were conduct- The pilots acquired visual contact with the Aing a positioning flight from Westport, airport after descending to 6,500 ft and landed New Zealand, to Christchurch the night of the Dornier without further incident. Although March 20, 2007, when they began to feel dizzy they felt better, the pilots went to a local hospital while cruising at 10,000 ft. “The pilot flying told for a medical examination. “Blood samples the check captain that he ‘didn’t feel very well’ were taken … and the pilots put on oxygen,” the and thought he might ‘faint or pass out,’” said report said. “Displaying no ill effects, the pilots the report by the New Zealand Transport Ac- were released after about an hour.” Toxicologi- cident Investigation Commission. cal tests of the blood samples showed slightly Soon after taking control, the check captain elevated levels of carbon monoxide. also began to feel faint. He told the pilot that he The operator had recently purchased the air- felt light-headed and perceived a blurring of his craft, which had been in open storage for seven peripheral vision. “The check captain turned years, but had not yet placed it into service after off the air conditioning bleed air supplying the refurbishment. The investigation focused on the [flight deck] heating, selected external ram air heating and air conditioning system. “An initial and instructed the pilot to open the storm win- examination of the engines, associated bleed-air dow,” the report said. “The aircraft was not fitted systems and aircraft air conditioning identi- with portable oxygen or side air vents [and did fied no unusual smells and nothing that might not have a cabin pressurization system].” have caused contamination of the flight deck The pilot felt better after using a cupped air,” the report said, noting that a subsequent hand to direct fresh air onto his face. “The check examination and test flight also found “nothing captain leaned across and breathed in some of the untoward.” www.flightsafety.org | AEROSafetyWorld | March 2009 | 61 OnRecord
Concluding that the incident was an “iso- higher than 75 ft AGL and was in a nose-high lated occurrence,” the report said, “The reason attitude with the landing gear extended when it the pilots became partially incapacitated could stalled, rolled left and descended to the ground, not be determined but was most likely from the NTSB report said. some form of air contamination, because the Investigators found both fuel selectors po- symptoms disappeared when fresh air was intro- sitioned to the auxiliary tanks, a configuration duced into the cockpit.” As of December 2008, that is prohibited for takeoff. There was 1/4 the aircraft had been flown more than 500 hours gal (1 L) of fuel remaining in the left auxiliary since the incident “with no reported problems, tank and 9 gal (34 L) in the right auxiliary unexplained fumes or cases of ill health,” the tank. report said. NTSB said that the probable cause of the accident was “the pilot’s failure to maintain Pilots Did Not Notice Cargo Door Light airspeed during initial climb” and a contribut- Raytheon 1900D. Minor damage. No injuries. ing factor was “the pilot’s improper positioning ockpit voice recorder data indicated that, of the left fuel selector, which resulted in fuel contrary to standard operating procedures starvation to the left engine.” C(SOPs), the pilots discussed personal mat- ters while the first officer conducted challenge- Spatial Disorientation Leads to Crash at Sea and-response checklist procedures by himself Cessna C337G Skymaster. Destroyed. Four fatalities. and taxied the airplane for departure from Page, efore departing from Moorabbin, Victoria, Arizona, U.S., on March 26, 2008. Australia, the pilot indicated that he would “Due to the flight crew’s lack of professional- Bfollow the coastline during the visual flight ism and deviation from [SOPs], they most likely rules flight to Merimbula, New South Wales, on did not see that the [aft cargo door warning Nov. 17, 2007. Witnesses on a beach near Venus light] was illuminated prior to departure,” the Bay, Victoria, saw the Skymaster emerge from NTSB report said. The cargo door opened soon fog, flying low over the water. after liftoff. The captain took control, turned “Within seconds, it turned right to head out back to the airport and landed the 1900 without to sea,” said the ATSB report. “It turned through further incident. None of the 13 people aboard about 90 degrees at a steep angle of bank while the airplane was injured. maintaining height before disappearing from The pilots told investigators that the aft car- sight into the fog.” The witnesses then heard a go door light, which warns that the door is not bang. closed and locked, was not illuminated before Aircraft wreckage and the bodies of the three takeoff. The captain said that he saw the light passengers were found washed up on the beach shortly before the door opened. “Following the two days later. The pilot’s body was not found. accident, operation of the door and functional- The report said that the pilot, who was not ity of the cockpit indicator light were verified,” instrument-rated, likely had become spatially the report said. “No anomalies were noted.” disoriented and had inadvertently descended into the water. PISTON AIRPLANES Improper Gear Adjustment Causes Collapse Fuel Selector Set on Empty Tank Cessna 402B. Substantial damage. No injuries. Beech C55 Baron. Destroyed. One fatality. hile preparing to land at Fort Lauder- itnesses heard the left engine sputter dale (Florida, U.S.) Executive Airport and surge, and saw the Baron yaw left Won March 15, 2008, the pilot observed Won takeoff from Port Orange, Florida, indications that the right main gear was not U.S., on March 4, 2007. The airplane climbed no down and locked. He recycled the landing gear
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and used the backup extension system, but “Examination of the wreckage did not indicate saw green lights only for the left main gear and any mechanical defects that would have affected nosegear, the NTSB report said. the safe operation of the helicopter,” the ATSB The pilot flew the 402 near the airport report said. traffic control tower, and a controller radioed The report noted that flight below 500 ft that all three gear appeared to be extended. AGL is prohibited in Australia. It said that However, on landing, the right main gear during the steep turn, main rotor blade inertia collapsed. The pilot and the three passengers and rotor rpm would have decreased. “If the escaped injury. pilot did not react rapidly to this condition, Investigators found that several days before or if the front-seat passenger had pushed the the accident, the right main landing gear down collective control down, the result would be a lock had been improperly adjusted by mainte- loss of altitude,” the report said. “Regardless, in nance technicians. The report concluded that the either circumstance, the helicopter was being improper maintenance likely caused the accident. operated at a height from which recovery was not possible.” HELICOPTERS Loose Fastener Causes Control Disconnect Windshield Shattered by Eagle Aerospatiale AS 350BA. Substantial damage. Four fatalities, three Eurocopter EC 130B4. Substantial damage. Three minor injuries. serious injuries. he air tour helicopter was cruising at 100 to he helicopter was returning from a sightsee- 120 kt at 500 ft AGL near Meadview, Ari- ing flight on March 8, 2007, when the pilot Tzona, U.S., the afternoon of Sept. 27, 2007, Treported hydraulic system problems (ASW, when the pilot saw a bird pass below and to the 11/08, p. 30) and that he would perform a run- left. “Another large bird, tentatively believed to on landing at the Princeville (Hawaii, U.S.) Air- be a golden eagle with an 8-ft [2-m] wingspan, port. As the helicopter neared the runway, the suddenly appeared directly ahead of the helicop- pilot radioed, “Okay, we’re done.” The sound of ter,” the NTSB report said. the rotors changed, and the helicopter descend- The bird shattered the left windshield. The ed into a grassy area next to the runway. The pilot and two passengers were struck by debris; pilot and three passengers were killed, and three the other five passengers escaped injury. The other passengers sustained serious injuries. helicopter was landed without further incident “Postaccident examination of the helicopter at a local airport. revealed that the left lateral flight control servo became disconnected in flight at the transmis- No Room to Recover sion,” the report said. The disconnection was Bell 206B JetRanger. Destroyed. Five serious injuries. traced to maintenance personnel who, while he pilot had rented the JetRanger to pro- replacing the servo about a month before the vide short flights at a friend’s party near accident, had installed a “severely worn” lock THornsby, New South Wales, Australia, washer and had tightened the jam nut on the on March 1, 2008. Witnesses saw the helicop- lower clevis — a U-shaped attachment fitting ter making low passes over the party area at — to the lower torque value specified for the about 100 ft AGL. After one pass, it entered a upper clevis. steep left bank, rolled out and then descended “Examination of the company’s main- into trees. tenance program revealed that none of the The pilot told investigators that the front- mechanics at the helicopter’s base had received seat passenger might have pushed the collec- factory training and that the maintenance tive control forward. The passenger, however, manuals they used were three revisions out of could not recall what happened before the crash. date,” the report said. www.flightsafety.org | AEROSafetyWorld | March 2009 | 63 OnRecord
Preliminary Reports Date Location Aircraft Type Aircraft Damage Injuries Jan. 3, 2009 Telluride, Colorado, U.S. Learjet 45 substantial 2 minor Light snow was falling when the Learjet overran the runway on landing. Jan. 4, 2009 Morgan City, Louisiana, U.S. Sikorsky S-76C destroyed 8 fatal, 1 serious The helicopter crashed in a marsh shortly after departing from Amelia, Louisiana, in visual meteorological conditions to transport workers to an offshore oil rig. Jan. 5, 2009 Antarctica Basler BT-67 destroyed 4 NA The turboprop-converted Douglas DC-3 struck a mountain in an area of reduced visibility during a cargo flight. All four occupants reportedly survived. Jan. 11, 2009 Caticlan, Philippines Xian MA60 substantial 25 NA The twin-turboprop touched down short of the runway while landing in strong winds and struck a concrete fence. Three airport workers and at least two passengers reportedly were seriously injured. Jan. 11, 2009 Hayden, Colorado, U.S. Pilatus PC-12/45 destroyed 2 fatal Heavy snow was falling, and two line service workers saw wet snow on the airplane’s wings before it crashed shortly after takeoff in a steep nose-down and inverted attitude. Jan. 12, 2009 East Anglia, England Boeing 737-700 none 4 none The 737 was on a positioning flight when it pitched down violently and exceeded maximum operating airspeed by 100 kt while losing 10,000 ft of altitude before the flight crew recovered control. Jan. 15, 2009 Makhachkala, Russia Ilyushin 76MD destroyed 3 fatal, 4 NA The military transport was being taxied onto the runway when its forward fuselage was struck by the wing of another Il-76MD that was landing. The landing airplane was substantially damaged, but none of the 31 occupants was injured. The collision occurred at night and with visibility reduced by fog. Jan. 15, 2009 Wray, Colorado, U.S. Gulfstream Commander 690C destroyed 3 fatal Witness reports indicate that the airplane stalled and spun to the ground during an instrument approach in night instrument meteorological conditions (IMC). Jan. 15, 2009 New York Airbus A320 destroyed 1 serious, 154 none The A320 was ditched in the Hudson River after it struck a flock of birds and lost power from both engines while departing from La Guardia Airport. Jan. 16, 2009 Oradea, Romania Gulfstream G200 substantial 12 none The airplane overran the runway while landing in adverse weather conditions. Jan. 19, 2009 Falkenstein, Germany Piper Cheyenne IIIA destroyed 1 fatal The Cheyenne crashed in mountainous terrain shortly after departing from Frankfurt Main Airport in IMC. Jan. 19, 2009 Tehran, Iran Fokker 100 substantial 114 NA The Fokker veered off the runway after the right main gear collapsed on landing. No fatalities were reported. Jan. 20, 2009 Wichita, Kansas, U.S. Bombardier Global 5000 substantial none Static engine tests were being conducted when the airplane struck a blast fence. Jan. 22, 2009 Midway Islands Airbus A330-300 none 1 serious, 3 minor, 281 none A flight attendant suffered head and neck injuries, and three passengers received minor injuries when the A330 encountered severe turbulence during a flight from Tokyo to Honolulu. Jan. 22, 2009 Naples, Florida, U.S. Cessna 402C none 7 none The pilot landed the 402 at the Naples airport after both engines lost power during a charter flight from Key West to Fort Myers, both in Florida. Jan. 27, 2009 Lubbock, Texas, U.S. ATR 42-320 substantial 1 serious, 1 minor Night IMC prevailed, with light freezing drizzle and surface winds from 350 degrees at 10 kt, when the cargo airplane touched down short of Runway 17R and struck approach lights. Jan. 30, 2009 Huntington, West Virginia, U.S. Piper Seneca II destroyed 6 fatal The pilot reported a low fuel state before the Seneca crashed in a wooded area while being vectored for an airport surveillance radar approach in IMC. Jan. 31, 2009 Mudurnu, Turkey Eurocopter EC 135PC destroyed 2 fatal The helicopter crashed after the pilots reported adverse weather conditions during a ferry flight from Warsaw, Poland, to Ankara, Turkey. 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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