ON COMMERCIAL AVIATION SAFETY SPRING 2007

ISSUE 66 THE OFFICIAL PUBLICATION OF THE ISSN 1355-1523 FLIGHT1 SAFETY COMMITTEE

The Official Publication of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE

ISSN: 1355-1523 SPRING 2007 ON COMMERCIAL AVIATION SAFETY

FOCUS is a quarterly subscription journal devoted to the promotion of best practises in contents aviation safety. It includes articles, either original or reprinted from other sources, related Editorial 2 to safety issues throughout all areas of air transport operations. Besides providing information on safety related matters, FOCUS aims to promote debate and improve Chairman’s Column 3 networking within the industry. It must be emphasised that FOCUS is not intended as a substitute for regulatory information or company publications and procedures. Bond Offshore Helicopters 4 Editorial Office: Ed Paintin The Graham Suite Conditional ILS Clearance phraseology within the Fairoaks Airport, Chobham, Woking, Surrey. GU24 8HX Terminal Manoevering Area 7 Tel: 01276-855193 Fax: 01276-855195 by Stuart Lindsey e-mail: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900 - 1630 Monday - Friday To Err is Human, Or So They Say, But Why? 8 Advertisement Sales Office: UKFSC by Group Captain Andy Ebdon The Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey GU24 8HX Tel: 01276-855193 Fax: 01276-855195 Improving our understanding of Vortex Wake 10 email: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900 - 1630 Monday - Friday London TMA Speed Restriction Trial 13 Printed by: Woking Print & Publicity Ltd by Capt. Jim Snee & Capt. Ian Mattimoe The Print Works, St. Johns Lye, St. Johns, Woking, Surrey GU21 1RS Tel: 01483-884884 Fax: 01483-884880 ISDN: 01483-598501 UKFSC Members List 14 e-mail: [email protected] Web: www.wokingprint.com

FOCUS is produced solely for the purpose of Letters 16 improving flight safety and, unless copyright is indicated, articles may be reproduced providing that the source of material is acknowledged. Tail Strikes: Prevention 18 Opinions expressed by individual authors or in by Capt. Dave Carbaugh advertisements appearing in FOCUS are those of the author or advertiser and do not necessarily reflect the views and endorsements of this journal, the editor or the UK Flight Safety Committee. EU Air Carrier Blacklist Update 24

While every effort is made to ensure the accuracy of the information contained herein, FOCUS accepts no responsibility for any UKFSC Seminar 25 errors or omissions in the information, or its consequences. Specialist advice should always be sought in relation to any particular circumstances. Front Cover Picture: Eurocopter AS 332L2 operating in Marseilles

1 Editorial

Communication Error

During 2006 Communication Error was everyone involved in the working group Currently the standard of use of the RT is identified as one of the major threats to were anxious to try to assist in improving not very good at all. We all need to be aviation safety. communication. making an effort to improve the performance of ourselves and of those An industry working group made up of The differences between the ICAO RTF we fly with. Only if we all make an effort is pilots and air traffic controllers was set up terminology and the terminology used in the situation likely to improve. to try to find ways of tackling this the United Kingdom are covered in detail problem. The group included participants and the reasons for the differences clearly For those pilots who’s first language is from NATS, British Pilots explained. Pilots that fly internationally not English we appreciate that it may be Association, The UK Civil Aviation need to be able to understand both sets more difficult for you. However, it is not Authority, UK Airprox Board, CHIRP, The of terminology. possible to make exceptions based on Guild of Air Traffic Control Officers and whether or not you are proficient in the UK Flight Safety Committee. The Call-sign confusion is illustrated in a English if you fly in domestic international output of this working group has been the number of incidents and it is important for airspace that you share with other users production of a DVD that can be used by pilots to make sure that they do not act then you must make an even greater pilots to improve both their radio on an ATC instruction that is not intended effort to improve your RT performance. phraseology and methodology. The DVD for them because they were not paying is easy to use and is put together in enough attention to the RT. The old Lastly, we should be grateful to NATS and modular form so that it may be used as adage “if in doubt ask” certainly applied other air traffic service providers for and when pilots have time available. here. The Flight Operations Departments monitoring the situation and bringing also need to ensure that they do not these shortcomings to our notice. We The DVD is divided into five modules: compound the issue when planning their should also join together in asking them The Introduction gives an overview of the call-signs. to continue to monitor the situation so problem, Aerodrome, Approach, En that we may see the overall improvement Route and a Summary of the key learning So what can the industry do to improve as we all make an effort to hone our points. the situation? personal performance.

Humour is used to illustrate just how big Firstly, the air operators should the problem of communication is. encourage, if not insist, their pilots use However the overall message is very the Communications Error training disk. serious indeed. If this can in some way be built into the recurrent training programme so much Included in some of the modules are the better. questions with multiple choice answers. If you are not sure of the answer the Secondly, simulator and line training available choices really make you think. instructors could tighten up on the way By the end of these questions you should the RT is used both in the simulator and have a much better understanding of the during line training. answers. Thirdly, all pilots, assuming that they value Actual case studies of incidents with their status as professionals, could make commentary illustrate each of the points a real effort to use the training disk (not very clearly and it soon becomes once but several times) to get their radio apparent that poor communication leads telephony (RT) performance up to to most of the difficulties and subsequent standard. incidents. Fourthly, aircraft Captains could insist that An examination of 700 communication each and every aircrew member that they events recorded, revealed that 105 fly with makes a concerted effort to use resulted in a level bust, 40 in runway the correct terminology and methodology incursions and 73 in loss of separation to improve their RT. between aircraft. It is no wonder that

2 Chairman’s Column

What Lies Beneath by Ian Crowe, Willis Ltd

Firstly, may I wish everyone a very happy much for granted and this is of course Looking at systems it is easy for us to and safe new year. Part of my role at rightly so. However, the work both in hand over safety to aircraft and system Willis is to provide an international terms of systems and procedural designers. Arguably, we could say that the aviation insurance training course. development is unknown much like the improvement in operational safety is a delegates when seeing the inner workings function of modern engines and to a lesser With the exception of one individual, a of an aircraft. extent system reliability coupled with lawyer, all of the 22 speakers are Willis improvements in air traffic management. employees. Each course attracts over 20 Aircraft operate in a very hostile different nationalities, a truly multi role environment flying 6 miles high at 500 Commercial pressure continues to drive operation! In addition to risk, safety and mph with an outside air temperature of – our industry but it’s true we need to make insurance related topics the 2 week course 50 Celsius, and doing this 20 hours a day money so we can spend it on safety, includes a section on aircraft and how they for at least 25 years; well, its no wonder training, retention and retaining of fly. During this phase we review the we all take safety for granted. valuable staff. multitude of aircraft systems explaining how these have developed in sophistication and In my very first column for FOCUS, I Data indicates, however, that in the majority reliability over the last hundred years of touched on the topic of complacency and I of cases accidents say 90%, are due to powered flight. To complete the training still feel this is one of the biggest risks that human error with this figure on the rise. session we visit the RAF Museum at we face in our business of safety. Records Hendon and there we see some of the show that in 2006 there were some 96 Data collection, therefore, seems to be our systems “in the flesh” as it were. Seeing accidents killing over 1200 people at a next challenge, for without data we cannot aircraft and engines exposed displaying cost of many millions of dollars. It’s true manage the risk. This data is in many their internal workings is always a complete that in the majority of these cases the respects “invisible”. The complexities of surprise to the course delegates. Many of accidents were low profile, involving older human nature do not allow us to them have no concept or understanding of aircraft in remote locations. challenge every report to find out the true what lies beneath the fabric, skin or casings nature of the incident or accident. This is of an aircraft and its engine. The current start for 2007 in respect of where a fully functioning and experienced accidents has not been particularly good to safety department is so valuable. Having It struck me how we often view safety in say the least. In January alone there have the ability to ask questions that a reporting much the same way. We do take it for been some 9 accidents killing 134 people form cannot cover is a skill that is in granted forgetting all the hard lesson that at a cost in the region of USD 300 million. danger of being lost. life in the aviation business can throw at us. To us, the safety professionals, we Looking at these figures it seems we are Just below the surface there is always an know that aircraft and supporting systems headed for a similar statistic as we had in accident waiting to happen, the old including, operations, air traffic control, 2006. expression there are no new accidents engineering and maintenance develop only new people is as true as ever. procedures to control, maintain and As much as the course delegates do not operate extremely complicated and see the systems that lie beneath the So let’s make sure for 2007 safety is not sophisticated systems at times under aircraft exterior, we too must not be just skin deep. difficult circumstances. The traveling lapsed into a false sense of security public sees safety and safe operation in a believing our own statistics and industry completely benign way, taking it all very propaganda that all is well.

UKUK FLIGHTFLIGHT SAFETYSAFETY COMMITTEECOMMITTEE OBJECTIVESOBJECTIVES

■ To pursue the highest standards of aviation safety. ■ To constitute a body of experienced aviation flight safety personnel available for consultation. ■ To facilitate the free exchange of aviation safety data. ■ To maintain an appropriate liaison with other bodies concerned with aviation safety. ■ To provide assistance to operators establishing and maintaining a flight safety organisation.

3 Bond Offshore Helicopters

Bond Offshore Helicopters (Bond) was established by brothers Stephen and Peter Bond in the autumn of 2002 in response to approaches from the major Oil companies in the North Sea. It was well known that many oil companies were concerned at the limited number of helicopter operators in the UK sector.

In December 2002, BP awarded Bond a 10 year contract with a five year option, to provide crew change services from to its Central and Northern After 10 months of planning, selection of Crewchange North Sea and West of Shetland staff and writing the various manuals installations. To facilitate this Bond required to gain an AOC the company The five aircraft utilised on crew change invested £55 million in five Eurocopter took delivery of the first aircraft in May of (the movement of BP and contract AS332L2 aircraft. A further £2 million was 2004. All Engineers, licenced and personnel to and from BP platforms) to invested in upgrading an existing unlicenced, attended factory type courses December 2006 have flown 19,984 flying engineering building on the east side of and aircrew were trained on the simulator hours. This equates to 6498 flights . Benefiting from at Marignane in . Immediately on (16,314 sectors), with an on time previous experience, the layout of the delivery flying training on the actual departure rate of 98.3%, transporting building was carefully planned to both aircraft was undertaken. 214,752 passengers to platforms, rigs adhere to regulatory requirements and and vessels in the North Sea. allow the smooth flow of passengers from The original plan was to commence check-in to the departing aircraft. In operations for BP on 1 August 2004, The AS332L2 can carry 19 passengers addition, this provides a well organised however due to the early arrival of the first and two crew, with an all up mass of base for the Bond staff to carry out their aircraft in May the company was able to 9300KG. Capable of cruising at 145 kts, various functions with the best equipment bring this forward to the beginning of the L2 is equipped with a fully coupled available. June. The second aircraft arrived in June four axis auto pilot with a glass cockpit. followed by two more in July with the final The management team recruited were aircraft arriving in August. By that time Crew change pilots have recently chosen from various fields for their Bond had 30 pilots and 25 engineers as adopted a new fixed roster which entails knowledge and experience and set about well as support staff working in Aberdeen. working 5 days on, followed by 2 days off, laying the foundations of the Company. 7 days on and 7 days off. This equates The benefits of starting with a “blank Additionally, in May of 2004, BP to 191 working days a year, including sheet of paper” were quickly realised and announced that the Jigsaw SAR contract leave. best practice could be readily adopted (valued at £100 million) had also been into the formation of the Company policy. awarded to Bond for 10 years, again with a The typical flying day starts with the early For example the Safety Management five year option. This heralded the arrival crews coming on shift at 0600 for a 0700 System (SMS) was specifically built of two further AS332L2 aircraft, this time in take off, and the late crews often working around CAP 712 with an electronic ‘Alert’ a Search and Rescue (SAR) configuration. to 2200-2230. Crews will arrive one hour database implemented to track and The recruitment of SAR crews and further before the scheduled take off time, to control all documents within the company. engineers commenced, followed by a enable them to plan the flight and provide In addition all engineering tools are rigorous training programme. payload details for check-in staff. supplied by the Company and placed on purpose built shadow boards to effect Presently the company has 52 pilots, 18 Passengers arrive at Check-in and are tool control. aircrewmen, 33 engineers and 43 support weighed along with their baggage. All staff. details are logged and recorded through the Vantage POB System which is used

4 to a VCR, Autohover (also controllable, with limited authority, from the Winch Operators position) , Spectrolab SX16 Nightsun, Dual Hydraulic and electric hoist installation with a hoist line video camera linked to VCR and vertical light to aid hoist operations, HF, Homer, Skyshout, Medical Storage, Iridium Sat Phone, additional despatcher harness points and a steerable scanner light.

One aircraft is based offshore on a BP Platform and the other in a purpose built hanger at Sumburgh in the Shetland Islands. The aircraft are rotated between the bases on a weekly basis to facilitate maintenance and in order to carefully monitor for corrosion due to exposure to the salt laden environment of the platform.

The crew on the platform have to carefully BP installations Serviced by Bond monitor weather conditions and will relocate the aircraft to Aberdeen if the by the majority of oil companies to track using the Norwegian landing limits, using wind speed offshore is forecast to be all UKOOA (United Kingdom Offshore Rate of Heave as opposed to Amplitude excessive and out of limits i.a.w. the Operators Association) passengers. The as a limiting factor for landing. manufacturers specifications for starting system prints off the manifest which is rotors. When at Aberdeen they remain on handed to the crew. Current practice within the UK sector is to standby and available for SAR operations. use a 5 metre heave (with a max of 3° Once checked-in, passengers await their Pitch and Roll) as the limit for landing. flight in the lounge and approximately 30 The trial involves using the same pitch minutes prior to take off are called and roll limits but using a 1.3 m/s (day) forward through security to a briefing 1.0 m/s (night) rate of heave. This has lounge. Here they are issued with seen an increase in the number of survival suits, Personal Locator Beacon landings carried out to the vessel with (PLB) watches and then view a safety one landing at 6.9 metres. The trial has video. Having started the aircraft, one of increased landings on this vessel by in the pilots will then personally brief the excess of 20 in the last 12 month period. passengers on flight times, weather and Passenger Lounge routing (often flights can go to more than one destination) in the Departure Gate. SAR

The average round trip flight time is 3:30 Deemed to be among the worlds most with the longest scheduled flight being sophisticated Civilian SAR aircraft, two approximately 4:25. AS332L2 aircraft are utilised as part of JIGSAW, a BP initiative integrating marine One location to the West of Shetland is and aviation assets in an innovative the Schiehallion FPSO, where Bond are programme. The aircraft are substantially currently conducting a trial based on modified with FLIR (Ultra Force 2) linked Check-In Desk

5 The aircraft are utilised only in the Offshore SAR role and are regularly called out by the Coastguard, with the one on the Platform supplying coverage to other platforms in the Norwegian sector and carrying out inter-field Civil Air Transport (CAT) flights when possible. The Sumburgh aircraft is also utilised to provide Inter Island Patient transfer around the Shetland Isles.

The crews have a rigorous and carefully monitored training programme and carry out day and night training sorties on a daily basis when possible. Their roster is two weeks on, two weeks off, (one week Some of the weather problems on the platform on days the other on nights) alternating between Sumburgh and the Miller. three month rotation which enables them are seriously considering abnitio pilot to maintain experience in all aspects of training. Between going live in February 2006 up Engineering Maintenance. The roster is 6 to the end of December 2006 36 callouts days on and 3 days off. have been undertaken by the two SAR Support Staff helicopters. Early shift Engineers work from 0630 to 1530 and carry out pre-flight inspections, As in any company, the support staff, turn-rounds and manage any defects that often behind the scenes, are vital to the Engineering occur through the day-to day flying business. The movement of aircraft, programme. baggage and passengers is well The Engineers working on Crew Change orchestrated with Security Staff, Accounts, aircraft have a three shift pattern on a The Team Leader will also plan the Tech records, HSE and Quality, Check-in, scheduled maintenance for the late shift. Ramp, Ops and Management all contributing to the smooth and safe Late shift Engineers work from 1500 to operation of the daily functions of the 2400 and rectify any deferred defects as Company. well as carrying out after flight inspections and routine scheduled maintenance The Company has two Eurocopter EC225 planned by the early shift. They also aircraft on order with delivery expected ensure that the aircraft scheduled for a T June 2008. Options on a further three check is available for the night shift. EC225’s are available to Bond. Miller Platform Running from 2100 to 0600 night shift Engineers carry out the T checks on the A conscious decision has been made by aircraft without any distractions. the Bond Senior Management to grow at a pace which enables the core structure The SAR bases always have an to sustain the high standard of all aspects airframe/engine and an avionic engineer of the operation that the Company available at all times. aspires to.

Looking to the future Bond currently have four engineering apprentices going Schiehallion FPSO through a four year training course and

6 Conditional ILS Clearance phraseology within the London Terminal Manoeuvring Area by Stuart Lindsey, Head of TC Operations, London Terminal Control Centre, West Drayton

Within the UK Air Traffic Control do not but omitting the QNH and aerodrome Heathrow, Gatwick, Stansted and Luton use the phraseology “(callsign) Cleared elevation. The justification for omitting airports in the autumn of 2006. It is now ILS” due to implications of using this these is based on the fact that the QNH possible for London TMA Approach phraseology and aircraft descending will already have been passed on descent Controllers to use either form of the before becoming localiser established. to an altitude, and a mandatory read back phraseology for establishing / descending This is of particular concern for the will have been received. The aerodrome aircraft on the ILS at Heathrow, Gatwick, London airports within the London elevation is omitted on the basis that Stansted or Luton. Terminal Manoeuvring Area (TMA) pilots have this information available on because of the number of routes, mainly the approach charts, and that it is not During periods of high frequency helicopter routes that pass close to or passed currently. occupancy especially when controllers under final approach tracks. anticipate that pilots will intercept the ILS glide path before being able to report to The standard phraseology used by ATC that they are established on the approach controllers is “(callsign) turn localiser they can use the conditional left/right heading (3 digits) report clearance. However its use has been established on the localiser”. Once the slightly undermined by pilots still reporting pilot reports established the controller will established even though they have been then give the clearance “(callsign) given the conditional clearance. This has descend on the ILS”. led to controllers using the conditional clearance less than they otherwise would During periods of high frequency loading because they are still having to make two – especially within the London TMA - it transmissions! can often difficult for a pilot to get back on the frequency in a timely manner to We have managed to move some way to report established. This can have the reducing frequency occupancy levels undesirable effect of the aircraft been left within the London TMA during the high and potentially leading to a rushed approach; pilots can help ATC make approach or go-around. Being able to a better use of this change by not reporting give a conditional clearance to establish established when they have been issued then descend in a single transmission with the conditional establish then would help alleviate this problem. descend clearance.

Within the current Civil Aviation Authority [email protected] Manual of Air Traffic Services Part 1 Controllers could then use the following phraseology does exist which allows phraseology: “(callsign) turn left/right conditional ILS descent clearances to be heading (3 digits), when established given. It is not, however, widely utilised on the localiser, descend on the ILS”. within the London TMA because this This helps to ensure that during periods existing phraseology requires the of high frequency occupancy, pilots are inclusion of QNH and aerodrome able to start the descent without having to elevation. actually report established. This abbreviated phraseology is only approved After consultation with the Civil Aviation for use by Heathrow, Gatwick, Stansted Authority Safety Regulation Group a trial and Luton approach controllers. was undertaken within the London TMA (at Heathrow, Gatwick, Stansted and After six months of monitoring, by both Luton airports only) to promote the use of NATS and CAA SRG, the trial of the this conditional ILS descent phraseology, phraseology became permanent for

7 To Err is Human, Or So They Say, But Why? by Group Captain Andy Ebdon, Programme Manager for the MOD’s Harrier GR9 Upgrade and Chairman of the Engineering and Maintenance Standing Group (EMSG) within the Royal Aeronautical Society’s Human Factors Group.

require decoding and interpretation. Here the brain can be its own worst enemy because we often see or hear what we expect or want to, rather than what is actually there. Any number of illusions or party tricks prove this and if you put this into a maintenance context then add physical problems that can further degrade performance, such as poor lighting, tiredness, cramped conditions or poor tooling and it is not to difficult to understand why mistakes can happen. Complacency can be induced, especially Whenever anything goes wrong these ultimately lead to a reverse in human in the more experienced personnel, but days the first question that always seems factors behaviour. the ‘can do’ attitude that we all know is to be raised by the media is ‘Whose fault vital when the pressure is on can be was it?’, followed rapidly by ‘and when When human activity leads to the wrong equally vulnerable in such circumstances. can we expect them to lose their job/go outcome, be it an accident, a delay, or Fatigue is a particular worry with very clear to court/or generally be subjected to some expensive rework, there is almost research to show the degradation of some form of retribution’. In many always a significant chain of events performance that can be expected when aspects of society the ‘me culture’ is leading to the final failing. Frequently people get tired. Shift working, particularly becoming more and more predominant there is more than one person involved long periods of night work, can be and I find it increasingly disappointing and there is usually a mixture of cumulative and there seems to be a that the desire for instant gratification is conscious and unconscious acts. growing culture of long hours in the finding its way into the analysis of human Discounting the terrorist condition, it is maintenance arena. Furthermore, many failing, at least as far as the populist very rare indeed to encounter someone live long distances from work and have media is concerned. As all those who deliberately wants to cause harm. stressful commutes, which only involved will know, progress with human In my experience the vast majority of exacerbate the situation. The greater the factors understanding in the aviation people come to work intent on doing a fatigue, the less an individual is able to industry has been a long and hard fought good job. It is certainly far too easy to interpret a problem and the more easily road, but the long-term evidence of label individuals involved in an incident as they can be distracted. Distraction at a accident reduction is a very clear sign of negligent without fully understanding the crucial moment can mean a vital step in a success. Open and honest reporting of circumstances. That does, of course, process is missed, or a fault is not seen. issues and incidents in an environment take time to find out, which gets us back In terms of an individual’s capability it is where a Just Culture is demonstrated by to instant media gratification and a not unreasonable to expect a technician actions rather than merely words in a commercial reluctance to commit hard or mechanic to be adequately trained to ‘Mission Statement’ has paved the way pressed funds. With this in mind, it carry out the tasks given, but this is not for improvements across the board. seemed like a reasonable time to refresh always the case. Training is expensive Unfortunately, in a highly competitive some of the ‘whys’ of human error and, and may often be a distant memory for a market in which security, cost of travel given my background, I hope you will long serving individual. Refresher courses and punctuality are more to the front of forgive me for doing so from an are vital, but not just in strictly technical the customer’s mind it is easy to believe engineering and maintenance activity. Human factors training is now we are safe enough and the balance of perspective. also mandated and should not be taken investment should swing elsewhere. lightly or as a one off. While I would hesitate to suggest there is The Human Machine is immensely any growing complacency over accidents impressive and well beyond anything Man generated through human error, I am has yet been able to devise. While it is convinced that the combination of media adaptable, flexible and resilient it is also and commercial pressures has the vulnerable to misinterpretation of data. potential to not only stifle further progress, Human physiology is such that sensory but to harden attitudes, which could inputs to the brain are not absolute, but

8 the body works on autopilot with little and trust. People are not going to talk attention being paid to sensory input. about personal issues in an adversarial, blame-seeking environment and yet it It is almost always the case that in the may well be personal issues that have analysis of any human error incident the been at the heart of the problem. individual concerned has been in 2 or Unfortunately, dealing with this and more of the conditions described above. setting the right tone takes time, which Maybe they were not trained for the task, means money, and leadership. But it is so why were they doing it? Pressure to the right thing to do. get the job done – why? No one else available – why? Perhaps they just I hope that this has given you some food missed something, but why? Tired – for thought. Next time you see someone why? Distracted – why? on the ‘who is to blame’ bandwagon try getting them to ask why someone might If there is a genuine desire to prevent the have done something first before passing repeat of an incident the full depth of the judgement. After all, one day it might be circumstances have to be understood them in the spotlight for an unintentional As well as physiological impacts, humans and this cannot be achieved by a cursory mistake. are similarly vulnerable psychologically. It examination. Asking ‘Why?’ 5 times is requires a particularly strong character to likely to get you somewhere near to the resist the norms of an environment, even root cause, but it requires persistence though he or she may be particularly uncomfortable with a given situation where they are expected to follow the unwritten rules and behaviour of the majority of their in association with group. Even in less overtly pressured Nigel Bauer & Associates areas, a lack of individual assertiveness in putting forward doubts, opinions or beliefs QUALITY MANAGEMENT FOR OPERATORS has the potential for disaster. JAR-OPS Quality Systems, documentation & auditing 5 days - LGW - 14 May, 03 Sep, 19 Nov 07 Management pressure to cut corners and Now in its 11th year, this course is still about using quality for safety get the aircraft back into service may not and business enhancement, with regulatory compliance as routine. be that overt, but it takes very little for an Nigel Bauer’s IRCA certificated Internal Auditor Training course is incorporated in the 5 days, set in an airline environment. individual to feel they are being pressured. May be economically presented ‘in-company.’ Indeed, many pressurise themselves because they think that is what is SAFETY MANAGEMENT SYSTEMS required, even if it is not supervisory or SMS training for air & ground operators management intent. Such pressure leads 3 days - LGW - 21 May 07 to rushed thinking and ‘bending’ of the A starter level course on Safety Management Systems from regulatory requirements through planning and implementation of risk management, rules. How often is the threat of ‘working ERPs and the Safety case. Also available in-company to rule’ seen as a potentially business Also available on demand: crippling threat and the perception of rules Auditing in an Operational Environment (3 days) (and procedures?) is that they are for the Audit Improvement Workshop (2 days) guidance of wise men rather than Quality for Senior Management (2 days) adherence by rote? Difficult and complex For further details including tasks can illicit good concentration for In-Company courses and consultancy or auditing services please contact: long periods, even when someone is Shape Aviation Ltd: Tel +44 (0) 1780 721223 Fax +44 (0) 1780 720032 fatigued, because of the stimulation of the e-mail: [email protected] url: www.shape.aero challenge. It is often the mundane, simple Nigel Bauer & Associates: tasks where things can go wrong because Tel +44 (0) 1243 778121 Fax +44 (0) 1243 789121 of boredom and low arousal. The mind e-mail: [email protected] url: www.nigelbauer.co.uk wanders onto more interesting topics and

9 Improving our understanding of Vortex Wake

Introduction questionnaire was the desire to better after B757-type aircraft. The extra understand under which circumstances a separation was, in most cases, restricted Wake vortices are the tightly spinning pilot will report an encounter. It would to the approach phase of flight. tornadoes of air that are generated at an also provide us with information on pilots’ aircraft’s wing tip. Wind speeds in the perceptions of the risks posed by wake Recently, it has become apparent that core of the vortex can reach over vortices, thus allowing us to more there is some concern amongst the pilot 300km/h and, if a strong vortex is accurately assess the reports that we community over whether or not there is a encountered, the vortices can have a receive. requirement for extra separation for dramatic affect on a following aircraft. aircraft departing after B757 aircraft. Wake vortices are an unavoidable by- Research suggests that the B757 should product of the generation of lift; hence, Results not generate vortices inconsistent with the potential danger of wake vortex aircraft of its weight on departure and turbulence is currently one of the most The questionnaire was distributed through therefore should not be treated differently limiting factors for the take-off and UKFSC on 1st November 2006 and the to other Medium category aircraft. Briefly, landing frequencies at airports. deadline for returning completed the reason for the increased propensity questionnaires was 6th December. Over for B757’s to cause hazardous wake Monitoring and analysis of reported wake 100 replies were received in this time vortex encounters is thought to be a vortex encounters is one of the most period, and this is a summary of the combination of the characteristic wing important tasks of the NATS Wake Vortex feedback. design (in particular, the continuous Team, within the Operational Analysis trailing edge) and the fact that they are Department The analysis performed on There were several issues raised by the relatively slow over the last stage of the the data aims to identify any trends, in analysis of the questionnaire. These approach path, meaning that following particular any increase, in the underlying included concerns over the current wake aircraft are more likely to catch them up. risk of a wake vortex encounter. The vortex separation minima behind a B757, Neither of these factors are particularly majority of reported encounters (63% over the action that pilots are taking to avoid relevant to the departure phase of flight the past ten years) occur at Heathrow encountering wake vortices and the (the wing design is most influential when leading to the bulk of our analysis being phase of flight on which encounters are the B757 is in it’s landing configuration) – focused on this airport. Daily runway logs most common. The remainder of this hence the lack of extra separation on for the airport also allow us to take into article deals with these subjects in more departure. account any changes in traffic levels. In detail. addition to monitoring the number of To support this theory, the reported reported wake vortex encounters, other encounter rate of aircraft following B757s aspects of the encounters are collected B757 on departure was analysed and and analysed, for example, the height at compared to aircraft of a similar size. The which the encounter occurred, the When asked if they felt that there was a NATS Wake Vortex Database, where all separation between the affected aircraft particular aircraft which caused wake received reports are stored, was queried and generating aircraft, and the aircraft vortex encounters, 30% of pilots to determine the number of encounters pair that was involved. This provides an highlighted their concern over the B757 where the leader was a B757 on invaluable data set which is used to family. The B757 has been synonymous departure from Heathrow. The data was support theoretical hypotheses on wake with wake vortex encounters ever since normalised to give a rate of encounter – vortex behaviour and ensures that any the late 1980s and early 1990s when this is the number of encounters per changes to airspace or procedures does there were a series of wake related 100,000 queued departures (a queued not increase the risk posed by wake accidents in the US. All of the accidents departure is where the separation is less vortices. occurred to aircraft following B757-type than 150 seconds). This was then aircraft on approach whilst under visual compared to data for the A321 (a similar In November 2006, the NATS Wake Vortex separations. The accidents prompted medium aircraft), and for encounters Team produced a questionnaire to be many states (including the UK), but not involving Medium-Medium and Heavy- completed by pilots concerning aspects ICAO, to revisit their wake vortex Heavy pairs. The data was taken over the of wake vortex encounters. The separations and led many to introduce seven year period 1999-2005. motivation behind the Wake Vortex increased separations for aircraft landing

10 ■ The rate of encounter for a B757 Avoidance Action to ‘catch up’ and can lead to the following leading on departure was aircraft having to undertake a go-around, approximately 40 encounters per It has become apparent from the analysis resulting in increased delays. In the en- 100,000 queued pairs of responses to the questionnaire, that route arena, pilots choosing to climb or pilots are regularly taking action, ranging descend, or fly off-sets (in domestic ■ The rate for an A321 leading on from increasing separations and staying airspace) without permission from ATC, departure was approximately 25 high of the glide path, to increasing risk coming into conflict with other aircraft. encounters per 100,000 queued pairs departure spacing and flying offset en- route, to avoid wake vortices. In response What action do you take to avoid WV? ■ The rate for Medium-Medium pairs on to the question of whether or not pilots None departure was approximately 20 take action to avoid encountering wake Stay above glide encounters per 100,000 queued pairs vortices only 17% of pilots reported that path they do not take any action. This is Increase spacing ■ The rate for Heavy-Heavy pairs on potentially concerning as any action that

departure was approximately 90 an aircraft takes to avoid vortices can Climb/descent encounters per 100,000 queued pairs have knock-on effects for successive Stay upwind

Offset Increasing 120 departure spacing

100 Figure 2: Questionnaire results to the question: What action do you take, if any, to avoid wake vortices? 80 757 as leader Heavy-Heavy 60 Medium-Medium En-Route Encounters A321 as leader 40 The questionnaire revealed an approximately equal split between the 20 likelihood of a wake vortex encounter on approach, departure and en-route phases of flight. However, only 11% of our 0 1999 2000 2001 2002 2003 2004 2005 received wake vortex reports took place Year en-route compared to 63% inbound and 26% outbound. This discrepancy is likely Figure 1: Rate of encounter for various aircraft pair combinations on departure from to be due to the fact that wake vortex Heathrow encounters in en-route carry less risk than those closer to the ground where the pilot This shows that although the rate of aircraft. Flying high on the glide path, has less recovery time. As a result of this encounter for a B757-Medium is higher flying upwind of the previous aircraft and we are only receiving the more severe than average, it is not as high as the rate reducing speed on approach can all have encounters occurring in en-route airspace. of encounter for Heavy-Heavy pairs, and consequences as following traffic With the introduction of the A380 on the is not significantly outside the typical becomes more susceptible to encounter horizon, and in the light of recent incidents rates seen for other aircraft pair the vortices of the aircraft performing the that have resulted in significant rolls in en- combinations. It should be remembered avoidance action. There have been a route airspace, NATS are keen to receive that these results are based on the rate of number of encounters reported that have as much information as possible about en- reported encounter and as such is been the direct result of the previous route encounters. If there is anything that subject to fluctuations in reporting rates. aircraft taking avoidance action. The un- could make it more convenient for pilots to instructed reduction of speed on record and report en-route encounters we approach can cause subsequent aircraft would be happy to hear about it.

11 The flight phase on which WV are occuring However, the form can currently be found The Wake Vortex Operational from the database on the www.customer.nats.co.uk site or Monitoring Team obtained by emailing Email: [email protected] [email protected]. NATC CTC Arrival 4000 Parkway Departure Summary Whiteley En-Route Fareham Thank you to all those pilots that took the HANTS PO15 7FL time to complete the questionnaire. The impressive response to the questionnaire has enabled us to improve our The percentage of pilots that reported a WV understanding of pilot’s perception of encounter occuring every 20 flights wake vortex encounters. It has alerted us to issues that we were unaware of, such as the scale of the perceived problem with the B757 and the action regularly Arrival undertaken by pilots to avoid Departure encountering wake vortices. The low En-Route reporting rate for en-route encounters has also been brought to our attention as an issue that needs to be addressed, especially with the imminent introduction of the A380. The fact that we received so Figure 3: Questionnaire answers many completed questionnaires shows compared to information from the Wake that pilots consider wake vortices to be Vortex Database an important safety issue that concerns them.

Encounter Report Forms

The issue of the time consuming nature of the reporting process was also drawn to our attention. Several pilots expressed concern at the high volumes of paper work already involved with flying and felt that they would not report a wake vortex encounter unless absolutely necessary. The lack of awareness of the NATS Wake Vortex Report Form (previously named CA1695) was highlighted with only 1% of questioned pilots employing this method of reporting. This has prompted the redesign of the NATS Wake Vortex report form and alerted us to the need for its promotion. The Wake Vortex team are currently investigating ways in which to better publicise and promulgate the NATS Wake Vortex Encounter form.

12 London TMA Speed Restriction Trial by Capt. Jim Snee & Capt. Ian Mattimoe - bmi

(Max speed 250kts below FL100 on ■ Although it is very difficult to make a constraint when, in their view, the traffic departure – NOTAM XXXX refers) direct link with safety, there are some pattern has warranted it. positive indicators such as a reduction You will be aware that a departure speed of the number and severity of loss of One of the conditions of the trial – for limit of 250kts below FL100 has been separation incidents reported and level obvious reasons – is that controllers are trialled since April this year within the busts in TC allowed to remove the speed restriction London TMA (AIC 39/2006). This trial has only for over-riding safety reasons, or now been extended until January 2007, ■ Overall, the TMA has been ‘slowed when the pilot requests it due to aircraft with the probability of making it a down’ and this has achieved the configuration and the request can be permanent feature thereafter. systemised flows required although accommodated. The key elements of this This notice is intended to explain the sector occupancy times have alleviation are ‘when the pilot requests it’ rationale behind the trial, to give you some increased slightly. which should be ‘due to aircraft feedback on results to date and to exhort configuration’, and then only if the request you to ensure compliance from here on in. ■ The slowing of traffic has improved the ‘can be accommodated’. This caveat has effectiveness of avoiding action when perhaps been too liberally applied. it has been required and there have One of the consequences of the The Rationale been no loss of separation incidents alleviation of the speed control limitation below FL100 where aircraft have been has undoubtedly been confusion, with The trial was initiated as a consequence of complying with the restriction. several receiving queries from their the growing volume of traffic within the pilots as to whether or not the trial was still London TMA and the complexities that this ■ The systemisation has reduced r/t in place. increase has generated, not least the wide clutter. variation in climb speeds used (210kts – 355kts) which gave controllers an ■ There are some indications that a Conclusion additional - and unpredictable - challenge further benefit has been a reduction in that they didn’t want. Whilst the aim of the the number of sector regulations ■ The trial has now been extended until trial is obviously to ‘smooth’ the traffic applied. January 2007 in order to confirm that flows, maintain separations, and take the the initial positive indications of unpredictability out of the process for ■ There has been a reduction in noise success are maintained and verified. It controllers, there is also an additional from aircraft accelerating on SIDs. is anticipated that the trial will then dimension. The continued growth in traffic translate to a permanent feature within volumes requires evolution in the the London TMA. controlling process also. We are moving Compliance toward a more strategically managed ■ There have been some very positive process and need to develop procedures As mentioned above, a compliance rate of safety benefit trends during the trial as that encompass P-RNAV to handle the 65% has so far been achieved, with some well as ATC handling benefits. increasing number of movements. Greater airlines performing better than others in predictability in traffic flow will also help this respect. The question here is what ■ The remaining challenge is to now reduce r/t congestion and should maintain about the remaining 35%, why not those ensure that all pilots – and all a smooth handover of traffic from the TMA pilots too? controllers – apply the speed control to En-Route Control. This consistent speed process for the rest of the duration of flow is the first move toward the more There are essentially two answers to this the trial. strategic management process that ATC question; the first is lack of knowledge. need to cater for future demand. The crews haven’t read the AIC/Notam, or ■ Remember, if you need more than have ignored it, and/or have not been 250kts to optimise climb and minimise advised by their management that the trial drag you can ask. For the rest, 250kts Feedback is in place. clean below FL100 is the way to go.

■ The trial to date has produced some The second is that some controllers have good results with a 65% compliance been over keen to ‘be kind to pilots’ and rate (of which more later). have released aircraft from the speed

13 Members of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE

Full members Air Seychelles CargoLux Airlines Ben L’Esperance Mattias Pak Chairman Willis Ltd ALAE Cathay Pacific Airways Ian Crowe Dave Morrison Rick Howell

Vice-Chairman Astraeus Ltd CHC Scotia John Denman Mike Whitcombe Treasurer Air Contractors BA Connect CityJet Capt. Anthony Barrett-Jolley Capt. Ed Pooley Capt. Tom Murphy

Non Executive Board Member BAE SYSTEMS Reg. A/C Club328 RAeS Alistair Scott Capt. Derek Murphy Peter Richards BALPA Cranfield Safety & Aegean Airlines Carolyn Evans Accident Investigation Centre Capt. Dimitris Giannoulatos Graham Braithwaite Belfast Intl. Airport Aer Arann Alan Whiteside CTC Aviation Services Ltd Capt. Paddy Callahan Robin Berry BMED Aer Lingus Nicholas Young CTC Service Aviation (LAD) Tom Curran Andrew Cripps bmi regional AIG Aviation Peter Cork DARA Jonathan Woodrow Richard Allen Airclaims Steve Hull DHL Air Paul Clark Peter Naz British International Air Contractors Capt. Terry Green UK Ltd Capt. Anthony Barrett-Jolley Capt. Jacqueline Mills CAA Air Mauritius Dave Lewis - MRPS easyJet Capt. Francois Marion Sarah Doherty - Safety Data Dept. Capt. Lance Jordan Ed Bewley - Flight Operations European Air Transport NV/SA Vincent Lambotte

European Aviation Air Charter ADVERTISING IN THIS MAGAZINE Ron Hendrick

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Jet2.com Singapore Airlines flybe. Aviation Services Rob Trayhurn Capt. Patrick Lee Steve McNair

Libyan Airways Smiths Aerospace MOD Engr. Tarek Derbassi Nigel Moody DASC Capt. Michael Evans DASC Eng. Wg Cdr Ian Woodhouse Limit Aviation SR Technics Ltd Jerry Flaxman Frank Buggie QinetiQ Maj. Mark Chivers Superstructure Group Capt. Sarah Hendry Eddie Rogan QinetiQ Eng. Keith Wigmore TAG Aviation (UK) Ltd Gary Hodgetts Tony Bisson RAeS Peter Richards Lufthansa Consulting GmbH TAM Brazilian Airlines Capt. Marco Castro RAeS Eng. Malaysia Airlines Jim Rainbow Capt. Ahmed Zuraidi Thomas Cook Airlines Capt. Roger Chandler Manchester Airport plc Co-opted Advisers Simon Butterworth Thomsonfly Ltd Jez Last AAIB Monarch Airlines Capt. Margaret Dean Capt. Tony Wride Airways Gavin Staines CHIRP MyTravel Peter Tait Chris King Willis Ltd Ian Crowe GASCo NATS John Thorpe Richard Schofield Group members Legal Advisor Penauille Servisair Edward Spencer Mike Cooper bmi Barlow Lyde & Gilbert David Barry NetJets Royal Met. Society Capt. Catherine Thompson bmi Eng. Dr John Stewart Willam Taylor

15 Letters

2 January 2007 unless the AIP has been amended In the boxed guidance notes for BCN 1 recently, I notice that they do not appear X/RWY 27 and BCN 1Z /RWY 09 it clearly Dear Sir, on the chart. Perhaps AC&D and AIS will states 'cross BCN 15 at 6000 to BCN not countenance such vulgarity! However, VOR'. Nothing about levelling off, although The first point to make is that Focus on the Brecon SID, placing the current the annotated altitude indicates 'not above' appears not to have a ‘Letters’ section; I 'warning' box nearer to the point of and ‘not below'. One might infer (and wonder if such a facility might elicit some application might help. clearly some do) that as long as one is good ideas. So, let me start the ball rolling - over D15 at 6000 it is OK. It also refers - I'm not so sure about the 'good ideas' bit! What did I find misleading or confusing? one to Note 6: 'Pilots of aircraft which are Select any from the following! The word unable to maintain (keep going) climb BRISTOL. SIDS –'LEVEL BUSTS' 'maintain' (in the General Information gradients to achieve FL 80 by BCN D10 notes) implies that you keep doing etc, etc'. which again implies that it is OK Your ‘Winter 2006’ FOCUS back page, something that you are already doing to keep climbing. which highlights ‘level busts' on departures (dictionary: 'keep going'). In the Brecon from Bristol, captured my attention. As a case one needs to determine whether one Human (pilot) nature tells one that seeking humble - but reasonably experienced - ex- can maintain a climb gradient to achieve 'alternative clearance' from ATC (Note 6) RAF pilot and (probably more important in FL 80 by BCN DI0. One had been will be tedious to say the least, and who this instance) ex-staff officer - the little bells climbing but was directed (by implication wants to go via some circuitous route started ringing. When a number of people on the SID chart) to level at 6000 ft at BCN when a straight line is easier and more get something wrong, overlook something Dl5. Could one maintain the climb gradient efficient. So, one makes the assumption - or don't understand fully what they are and achieve FL 80 by DI0? Yes, if one based on performance data - that one can supposed to do, it is often because of a 'kept going'. Is one permitted to do so? make FL 80 by D I0, and the mind is set. failure in communication. The instruction No, not without ATC clearance. When will The over-riding aim is FL 80 by DI0 or guidance may be poorly worded, clearance be given? Don't know. Will one because (presumably) it has something to contradictory or just wrong, and there are still be able to make FL 80 when cleared do with safety. A not unreasonable thought of course shades of grey caused by other to climb? Don't know. How much further process! factors such as – in this case – pilot along track will one be when cleared? Is discipline. airmanship, or a reluctance to the QNH against one – altitude v FL – The solution would appear to be a deviate into the 'too difficult', 'unknown' or does one have more than 2000ft to climb? combination of two actions. The first is to 'inconvenient' categories. As a typical 'ex- What is one's TAS? Does one have a review the written guidance and pert' I couldn't resist the temptation to try significant head/tail wind? What is one's instructions on the SID Chart with the aim to figure out what was wrong and propose G/S? I could go on. of eliminating any possible anomalies, a solution. confusion and inconsistencies. The It seems to me (a mere spectator) that the second, I assume pilots and ATC do FOCUS seems to have an answer the red 'Warning' box contradicts the procedure actually speak to each other during the warning boxes are 'eye-catching'; however. that is laid down in the SID. departure procedure; therefore, the suggestion is for ATC to instruct the pilot what to do when he gets to D15. I would be surprised if this does not already happen, but perhaps a review of what is said and when might be timely. If communication is to be effective it must be clear, concise and accurate. It would appear that the Bristol SID does not satisfy those criteria. This letter probably doesn't either - but I've tried!

Yours Sincerely, Martyn Redmore

16 Dear Editor, supporting text explaining the vertical controlled airspace and have been doing profile so the crews has to rely on the this successfully since the routes were LEVEL BUSTS ON DEPARTURE FROM information provided on the plan view introduced. The note about the minimum BRISTOL AIRPORT although the warning about not climbing climb gradient was added at the request above 6000 feet was included. In the of the Directorate of Airspace Policy to Thank you for forwarding me the letter circumstances it was not surprising that ensure that every possible mitigation was addressed to you from Martyn Redmore some crews misinterpreted the final SID put in place to cover worst case which was prompted by the poster on the level and climbed to FL80. scenarios; RTF failure, the ATCO final page of the winter 2006 edition of the forgetting to climb the aircraft or a very UKFSC magazine FOCUS. I think it would As soon as we became aware of the heavy aircraft which struggles to make the be useful to provide some background to situation we wrote to the chart producer appropriate levels. the publication of the poster. highlighting the number of level busts on the SIDs, that all of the crews had been We are in discussion with the Directorate Standard instrument departures (SIDs) using charts produced by this one of Airspace Policy to determine if, in the were introduced from Bristol on the 31st manufacturer and illustrating the incorrect light of operational experience and of the of August following airspace changes. interpretation of the information from the number of level busts on the routes, it is The new SIDs were published in the UK AIP. We requested that the manufacturer still appropriate to have the potentially AIP with a plan view of the route and with acknowledge the errors, warn its confusing warning included about the explanatory text which includes customers about the errors and publish minimum climb gradient. We are also information on the vertical profile. All of new charts. All of the requested actions still in discussion with the chart producer the SIDs have a final altitude of 6000 feet were carried out but we didn’t know how who did correct the original incorrect chart and some have a warning in the notes in long they would take so we took the but we still have some concerns about the the UK AIP that the aircraft must achieve decision to publish a poster, based on the style and content of their chart. FL80 by a specified DME range, this is to AIP SID plates, to warn operators and ensure that the aircraft remain inside pilots about the problem. This poster was Richard Schofield controlled airspace. The chart also produced and disseminated by the 28th Division of Safety - NATS includes a warning that crews should not of September. We took the decision to climb above 6000 feet until instructed by add the red warning box to the UK AIP ATC, by implication climb above 6000 feet SID plates in the poster to highlight the can only be after an ATC instruction. existing warning box and that the note Commercial third party companies take about the minimum climb gradient did not this information from the AIP and produce constitute clearance to climb. In the charts to their own design and warning box which we added we use the specification. phrase ‘You MUST maintain 6000’ until cleared by ATC.’ We used the word In the two week period immediately after maintain in the context explained by the introduction of the SIDs there were a CAP413 Radiotelephony Manual ‘continue number of actual level busts on the BCN, in accordance with the condition(s) BADIM and WOTAM SIDs and a number specified’. of occasions when ATC intervened to prevent level busts. On all of these Martyn believes that the AIP SID chart occasions the crews involved climbed to used in the poster is potentially confusing. FL80 rather than the correct SID level of There have been no level busts by crews 6000 feet. When these events were using the chart from the UK AIP or any of investigated by NATS we discovered that the other third party manufacturers but all of the crews involved in the events this does not mean that Martyn is were using the same chart which had incorrect. The source of the potential been produced by the same third party. confusion appears to be the inclusion of These charts had included the warning the note about the minimum climb about the minimum climb gradient on the gradient to reach FL80. In the operational plan view of the route which gave the environment controllers know that they impression, incorrectly, that the final level must climb aircraft above the SID level to of the SID was FL80. There was no ensure that aircraft remain inside

17 Tail Strikes: Prevention By Capt. Dave Carbaugh, Chief Pilot, Flight Operations Safety

Tail strikes can cause significant damage a catastrophic event if the flight continues In addition, some 777 models incorporate and cost operators millions of dollars in while pressurised. a tail strike protection system that uses a repairs and lost revenue. In the most combination of software and hardware to extreme scenario, a tail strike can cause Tail strikes are expensive, too. During a protect the airplane. And some models of pressure bulkhead failure, which can safety investigation, one airline reported the 737,767, and 777 have a tail skid that ultimately lead to structural failure; however, that a single tail strike cost its company prevents damage from most takeoff tail long shallow scratches that are not repaired $12 million in repair cost and loss of strikes. However, these devices do not correctly can also result in increased risks. revenue during the repair. guarantee protection for landing tail Yet tail strikes can be prevented when flight strikes and some takeoff tail strikes. They crews understand their causes and follow Boeing has done design work to reduce also reduce tail clearance distances. certain standard procedures. tail strikes, including implementing an Many of the longer-bodied Boeing improved elevator feel system in some airplanes use relatively higher speeds Two vital keys to prevention are raising airplanes. For example, the 747-100/- than their shorter-bodied major models awareness of tail strikes among flight 200/-300 has varied feel (column forces) (e.g., the 757-300 versus the 757-200). crews and including tail strike prevention throughout the center of gravity (CG) and The subsequent higher V1, Vr and in standard training procedures. It's also weight envelope. The newer 747-400's V2 speeds, or approach speeds, are important to promote discussion about elevator feel system design provides a designed to improve the tail clearance. tail strikes among members of the flight constant feel elevator pressure, which has Higher speeds make the tail clearance crew as part of takeoff and landing reduced the potential of varied feel equivalent to the shorter-bodied briefings, particularly when strong wind pressure on the yoke contributing to a tail equipment of the same model. conditions are present. strike. The 747-400 has a lower rate of tail strikes than the 747-100/-200/-300. This article: Regardless of airplane model, tail strikes can have a number of

■ Provides an overview of tail strikes causes including gustywinds and strong crosswinds. But and how Boeing is addressing them. environmental factors such as these can often be overcome by a well-trained and knowledgeable flight crew following prescribed ■ Examines tail strike causes and procedures. Boeing conducts extensive research into the causes of prevention. tail strikes and continually looks for design solutions to prevent them, such as an improved elevator feel system. Enhanced ■ Discusses operations in strong gusty winds. preventive measures, such as the tail strike protection feature in some Boeing 777 models, further reduce the probability of incidents. ■ Reviews training recommendations and preventive measures.

Tail Strikes: An Overview

A tail strike occurs when the tail of an airplane strikes the ground during takeoff or landing. Although many tail strikes occur on takeoff, most occur on landing. Tail strikes are often due to human error.

Tail strikes can cause significant damage to the pressure bulkhead. Failure of the Most tailstrikes occur when the tail of an airplane strikes the ground during landing and pressure bulkhead during flight can cause are preventable. In this incident, the crew made an error and calculated takeoff data incorrectly. This resulted in an early rotation.

18 Typical Tail Clearance for Takeoff

Model Flap Liftoff Minimum Tail Tail Strike Attitude (deg) Clearance [inches (cm)] Pitch Attitude (deg)

747-400 10 10.1 39 (99) 12.5 747-400 20 10.0 40 (102) 12.5

Figure 1. This diagram indicates the effect of flap position on liftoff pitch attitude as well as minimum tail clearance during takeoff. The minimum tail clearance depicted is predicted on a no-wind, no-crosswind control, and constant rate of 2 to 3 degrees per second rate of rotation.

Typical Tail Clearance for Engines-Out Takeoff

Model Flap Liftoff Minimum Tail Tail Strike Attitude (deg) Clearance [inches (cm)] Pitch Attitude (deg)

747-400 10, 20 10.6 34 (86) 12.5

Figure 2.

When an operating engine failed at V1 with only 75 percent of thrust available for a four-engine airplane or 50 percent of thrust available for a two engine airplane, minimum tail clearance is reduced. If there is a crosswind, the aileron/spoiler displacement will further reduce minimum tail clearance. In all cases, whether operating in one-engine or two-engine configuration during the rotation, a high average rate of rotation above what is recommended will further reduce minimum tail clearance.

19 Boeing also works to reduce tail strikes These factors can be mitigated by using ■ Overrotation during go-around. through exhaustive takeoff testing, which proper takeoff techniques (refer to your is a part of certification for any new operations manual for specific model Techniques that can reduce the chance of airplane program. During flight testing, information), including: a tail strike during landing include: takeoff test conditions are specifically designed to investigate the impact of ■ Normal takeoff rotation technique. For ■ Maintain an airspeed of Vref + 5 knot early rotation, rapid rotation, no flare current production airplanes, the feel minimum to start of flare and fly the during landing, and long flare. During this pressure should be the same as long approach at the "specified target testing, an acceptable margin per as the CG/weight and balance are airspeed." certification criteria is established for the done correctly. For most cases, there design operational use of the airplane. In is no reason to be aggressive during ■ The airplane should be in trim at start all cases, Boeing commercial airplanes rotation. of flare; do not trim in the flare or after meet or exceed the design certification touchdown. criteria for takeoffs and landings, as well ■ Rotating at the appropriate time. as for crosswind takeoffs and landings Rotating early means less lift and less ■ Do not "hold the airplane off" in an (see fig.1). Criteria for engine-out takeoffs aft tail clearance. attempt to make an excessively and landings are also evaluated (see smooth landing. fig.2). ■ Rotating at the proper rate. Do not rotate at an excessive rate or to an ■ Use only the appropriate amount of excessive attitude. rudder/aileron during crosswind Causes and Prevention approaches and landing. ■ Using correct takeoff V speeds. Be Takeoffs. A number of factors increase sure to adjust for actual thrust used ■ Immediately after main landing gear the chance of a tail strike during takeoff, and be familiar with quick reference touchdown, release the back pressure including: handbook and airplane operations on the control wheel and fly the nose manual procedures for takeoff speed wheel onto the runway. ■ Mistrimmed stabilizer. calculations. ■ Do not allow pitch attitude to increase ■ Improper rotation techniques. ■ Consider use of greater flap setting to after touchdown. provide additional tail clearance on ■ Improper use of the flight director. some models. ■ Do not attempt to use aerodynamic braking by holding the nose off the ■ Rotation prior to Vr: ■ Use the proper amount of aileron to ground. • Early rotation: Too aggressive, maintain wings level on takeoff roll. misinterpretion. Sometimes the best option for the • Early rotation: Incorrect takeoff Landings. Tail strikes on landing approach is a go-around. It is important speeds. generally cause more damage than that the culture within the airline promote • Early rotations: Especially when takeoff tail strikes because the tail may go-arounds when needed without punitive there is a significant difference strike the runway before the main gear, measures.

between the V1 and Vr. damaging the aft pressure bulkhead. These factors increase the chance of a ■ Excessive initial pitch attitude. tail strike during landing: Operations in Strong, Gusty Winds

■ Strong gusty winds and/or strong ■ Unstabilized approach. Tail clearance is reduced during takeoffs crosswinds may cause loss of performed in strong gusty winds and airspeed and/or a requirement for ■ Holding airplane off the runway in the crosswinds because of the lift loss lateral flight control inputs that can flare. incurred by flight control inputs, primarily deploy some flight spoilers, reducing spoilers. With very large inputs, this loss the amount of lift on the airplane. ■ Mishandling of crosswinds. can be significant (see figs. 3 and 4).

20 Approximately two years ago, Boeing airplane is slow to liftoff due to cross control and reduced tail revised wording in all production model airspeed stagnation. clearance margins. When safely flight crew training manuals (FCTM) to airborne, smoothly transition from the incorporate input from industry and safety ■ Limiting wheel input to that necessary slip by slowly releasing the rudder professionals regarding tail strikes during to maintain wings level. Pre-setting while maintaining desired track. strong and gusty winds. The Boeing too much aileron increases drag and FCTM recommends that crews use thrust reduces lift with higher probability of ■ Avoiding the tendency to quickly settings higher than the minimum required. The use of a higher takeoff thrust setting reduces the required runway length and minimizes the airplane exposure to gusty conditions during takeoff roll, rotation, liftoff, and initial climb.

Pilots can take a number of steps to reduce the possibility of tail strikes during takeoff in gusty winds or strong crosswinds, including:

■ Momentarily delaying rotation during the gust. As airspeed fluctuates back and forth (what is sometimes referred to as "bounce"), ensure that the airplane starts rotation at a speed that averages above rotate speed.

■ Using a normal rate of rotation, but not a greater rate Tailstrike Comparison. Figure 3. of rotation than This is a comparison of a normal takeoff and a tail strike takeoff in gusty wind conditions. Note that takeoff normal. This faster #2 suffers a 9- to 10-knot airspeed loss during the rotation. The pitch attitude increases at an increasingly rate may be a at an increasing rate until the tail strike. This is primarily due to the continued elevator increased deflection tendency if the during rotation.

21 Aft Body Clearance Breakdown. Figure 4. Guidelines that relate to Boeing airplanes show that airspeed loss, lateral control deflection, a greater than average pitch rate, and a maximum pitch rate in excess of 4 degrees per second all contribute to reduced tail clearance margins. The numbers change, but the concepts hold true for other models.

Factor Incremental Difference From Nominal Reduction in Aft Body Clearance

Airspeed loss Each 1 knot below the nominal liftoff speed =2.8 inches†

-∆ CL from lateral controls Each 0.1 of (-∆ CL) from lateral controls =14 inches

Pitch rate* Average pitch rate to Each 0.1 deg/sec in the average 10 degrees pitch pitch rate above 2.5 deg/sec =2.8 inches† attitude Either/Or Maximum pitch rate Each 0.1 deg/sec above 4.0 deg/sec =1.3 inches

* If the maximum pitch rate up to the point of contact was less than 4.0 deg/sec, the average pitch rate corrections are used. If the maximum pitch rate up to the point of contact was above 4.0 deg/sec, then the maximum pitch rate correction should be used. In all cases, only one method or the other is employed.

† For these increments, the relationship holds for both positive and negative contributions, i.e., an increase in lift off speed by 1 knot would increase the aft body clearance by 2.8 inches, and each 0.1 deg/sec of average pitch rate below 2.5 deg/sec would increase the aft body clearance by 2.8 inches.

rotate the airplane off the ground during program that reinforces proper takeoff and ■ Use a self-measuring tail strike rotation in these wind conditions. Gusts landing procedures. There are a number operational tool in the airline's fleet up to 20 knots have been noted in the of steps both management and flight (see "Crew" section). review of tail strike incidents. crews can take to help prevent tail strikes. ■ Ensure that flight operational quality ■ Rotating on the conservative side of Management: assurance programs are not used as gusts. Use normal rate of rotation a bit a punitive device. on the side of a slower versus faster ■ Ensure instructors and evaluators rotation, similar to the engine-out case stress proper landing and takeoff Crew: noted earlier. techniques during all training and evaluations. ■ Adhere to proper takeoff and landing If, after reaching the normal takeoff attitude, techniques the airplane is not airborne, avoid the ■ Make "tail strike prevention" part of the tendency to increase rotation rate. Either safety program through posters, ■ Never assume—double-check the slow or momentarily stop rotation rate. briefings, videos, computer-based takeoff data, especially if something Many tail strikes on takeoff occur when or training, and other elements which are doesn't look right. Coordinate insertion just after the main gear is airborne. available from Boeing Field Service of the zero fuel weight (ZFW) in the representatives. Flight Management Computer with another crew member. Double-check Training Recommendations and ■ Make tail clearance measuring tools data with the load sheet. Inaccurate Preventive Measures available in the simulator for all (low) ZFW entries have caused takeoffs and landings during simulator significant tail strikes. Tail strikes can be prevented. The most training and evaluations and provide effective means of prevention is a training feedback to crews.

22 ■ Know your airplane—have an idea Other approaches include a self limited to commanding nose down about the approximate takeoff and monitoring tail strike analysis tool that increments only. Tailskid height and rate approach speeds. provides a pitch report for every takeoff are computed from radio altimeter and landing. If the tail gets within 2 signals, pitch attitude, pitch rate, vertical ■ When setting airspeed bugs, always degrees of a potential tail strike, an auto speed, and the length between the radio do a "reasonable check." printout is provided to the crew after the altimeter location and the tailskid location. respective takeoff or landing. Airlines that A complementary filter is used to provide ■ Be aware of the differences between have adopted this program have had acceptably smooth rate and height models and types, especially when significant drops in tail strike rates. signals. Provisions are included to transitioning from other equipment. account for the bending of the forward Preventative measures. Boeing is fuselage when the nose wheel gear lifts ■ If a tail strike occurs, follow the actively developing tail strike preventive off the ground. checklist. measures. Some 777s have two additional features that help prevent tail ■ Crew resource management should strikes: the semi-levered main gear and Summary be an integral part of training. Crews tail strike protection. can get complacent during routine Tail strikes are preventable. If standard operations, yet a real threat exists Boeing 777 semi-levered main gear. recommendations are followed for all during operations in strong gusty Because the vast majority of the weight of Boeing models, the chance of tail strikes crosswinds. How the crew plans for the airplane is borne by the lift of the is greatly reduced. There are additional and mitigates the threat can make the wings at the time of rotation, the semi- challenges and solutions when operating difference between a safe takeoff or levered gear acts as if it were "pushing" during strong crosswinds and gusty landing and one that results in a tail down like a longer gear. This allows winds. Training is the key to preventing strike. Every crew should have a plan a higher pitch attitude for the same tail tail strikes. Technology enhancements for identifying and discussing the clearance or more clearance for the same can also contribute to solutions for threat. For example: pitch attitude. A hydraulic strut provides Boeing production airplanes. the energy to provide this increased • The entire crew should review takeoff performance. Although designed For more information, contact appropriate crosswind takeoff to increase takeoff capability, the system Capt. Dave Carbaugh at procedures and techniques for provides increased tail clearance for the [email protected]. operating in strong gusty winds. same weight and thrust as nonequipped airplanes. Reprinted with kind permission of Boeing • The pilot flying (PF) should review AERO Magazine. threat strategy for the takeoff or Boeing 777 tail strike protection. landing with the pilot monitoring Timely elevator input can help avoid tail (PM). strikes on both takeoff and landing. The tail strike protection command (TSP • The PM should monitor airspeed CMD) is summed with the pilot's input to versus rotation callout to the PF and form a total elevator command. The TSP identify airspeed stagnation during CMD is limited in size to 10 degrees, the rotation phase to takeoff target which allows the pilot to overcome its pitch attitude. effects, if desired, by pulling the column farther aft. The size of the TSP CMD is • If the first officer is making the controlled by excessive tailskid rate takeoff, the captain should monitor relative to a nominal threshold of tailskid pitch rate and attitude and call out rate, and by excessive nearness of the any deviations and be prepared to skid to the runway, relative to a nearness intervene. threshold. Different thresholds are used for takeoff and landing. The TSP CMD is

23 EU Air Carrier Blacklist Update By Keith Richardson, Barlow Lyde & Gilbert

Bulgarian carriers are under threat of recognition of certificates and approvals carrier knew of the situation was the being added to the latest blacklist of issued by the Bulgarian CAA is perhaps grounding of its aircraft upon arrival in the carriers banned from operating in the EU more likely. However, the EC has been EU. Of course, the list is only updated at when the updated list is published shortly. adamant in the past that its decisions are approximately three month intervals In the meantime, the experience of at motivated by concern for the safety of the which, in the case of the carrier least one carrier suggests some potential travelling EU public which may override concerned, was enough to bring it to the flaws in the Commission’s decision- political or economic considerations. brink of insolvency. making processes for adding carriers to the blacklist and in its notification process A further issue which has been expressed Certain stories emerging suggests that to carriers who are being considered for by one of the carriers which has already the manner in which some SAFA inclusion on the list. been subject to a ban, is the process by inspections are conducted, as well as the which carriers might be added to the qualifications of the personnel conducting In February of this year the European blacklist. The criteria for addition focus those inspections within some EU Commission (“EC”) will publish the latest on the use of antiquated, poorly Member States, would benefit from review version of the list of carriers which are maintained or obsolete aircraft; the results given the potentially serious financial banned from operating within the EU or of ramp inspections carried out at EU consequences for carriers. As from 1 are subject to operating restrictions - airports; and the ability of an airline to January this year responsibility for the otherwise known as the EU Aviation rectify shortcomings identified during coordination of the SAFA programme Blacklist. such inspections. passes to EASA. Whilst the maintenance of the highest aviation safety standards Whilst the publication of this list will be In practice, there appear to be some must remain the overriding objective for keenly awaited by those operators who significant flaws in the system. EASA, the use of EU-wide bans is a are either seeking to challenge existing Blacklisting decisions can be made on draconian sanction and, therefore, bans or which have been subject to the basis of Safety of Foreign Aircraft should be applied following a balanced investigation by the EC, the latest version Assessment (“SAFA”) reports prepared and informed assessment of all of the will be of particular interest as there is the following ramp inspections. However, it evidence available. possibility that, for the first time, an EU has been reported that the carrier’s state could see its carriers added to the response to an adverse ramp inspection blacklist. is not passed on automatically to the EC, so the risk is that the EC may only see Bulgaria, one of the two countries which one side of the story when assessing the became EU member states as from 1 SAFA reports. This can mean that a January 2007, potentially faces a ban carrier is at the whim of the competence following European Aviation Safety and/or qualifications of the relevant SAFA Agency (“EASA”) reviews of the Bulgarian inspectors. One carrier who has CAA conducted in 2005 and 2006. EASA expressed concerns was effectively reported serious deficiencies in the powerless to correct the inappropriate administrative capacity of the Bulgarian categorisation of defects in a series of CAA but, as at January 2007, no detailed SAFA reports which ultimately led to that corrective plan had been received by carrier’s addition to the blacklist. That EASA. carrier’s situation was made even worse by the lack of notice provided by the EC. Political embarrassment as well as the EU legislation requires carriers to be economic implications for Bulgarian notified if they are being considered for carriers may mitigate against an outright inclusion on the blacklist and given the ban (which would effectively ground all opportunity to make representations. Bulgarian carriers) and so some Nevertheless, in this case, no such notice restriction on their operations and/or non- was received either by the carrier or its regulatory authority and the first that the

24 UK FLIGHT SAFETY COMMITTEE

TECHNICAL INNOVATION AND HUMAN ERROR REDUCTION Annual Seminar 2007

1st/2nd October 2007 The Radisson Edwardian Hotel Heathrow

SEMINAR OBJECTIVE The continuing growth in technical innovation has without doubt helped to reduce the number of accidents. However, some of these developments have introduced unexpected challenges for the operators. The formulation of good procedures helps to mitigate these challenges, but there is a consensus within the industry that major difficulties still exist. This Seminar will highlight the problems encountered and propose strategies for the future.

PROVISIONAL PROGRAMME

1st October 2007 2000hrs Seminar Dinner After Dinner Speaker - TBA

2nd October 2007

0800 - 0900 Registration Session Chairman - TBA 0900 - 0910 Welcoming Introduction - Chairman – UKFSC 0910 - 0945 Keynote Speech - Dr Kathy Abbott - FAA 0945 - 1020 Future ATM/Single European Sky - Mark Green - IFATCO 1020 - 1040 Refreshment Break 1040 - 1115 R-NAV, B-RNAV, P-RNAV - Andy Shand – British Airways 1115 - 1150 Passenger Entertainment in the 21st Century - Panasonic Avionics Corp - T B A 1150 - 1225 Flying the Emb195 - Capt. Bob Horton – Emb195 Fleet General Manager – flybe. 1225 - 1255 Questions 1255 - 1400 Lunch 1400 - 1435 The Complexity of Unmanned Aerial Vehicles (UAVs) - Cdr Paul Brundle, RN Defence Aviation Safety Centre 1435 - 1450 Comfort Break 1450 - 1525 Airbus - The Way Forward- TBA 1525 - 1600 Maintenance Human Factors - Howard Leach - RAeS 1600 - 1630 Questions 1630 - 1645 Closing Speech - Chairman - UKFSC

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