AeroSafety WORLD
LOOSE END Nut disconnection downs AS350 SPEAKING OF AVIATION Brazil upgrades aviation English DECISION TIME Choosing to go around … or not
GEOGRAPHIC INFORMATION SYSTEMS LOCATION, LOCATION, LOCATION
THE JOURNAL OF FLIGHT SAFETY FOUNDATION APRIL 2013 e Foundation would like to give special recognition to our BARS Benefactors, Benefactor and Patron members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible.
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LITHIUM-ION Batteries
ithium-ion batteries commonly used in a necessary step to ensure there were no oversights portable electronic devices, like cell phones, in making sure the aircraft design and operation laptops and cameras, have commanded their are safe. However, this is not the only step the FAA share of attention in air transport, but it is needs to take. What also needs to be accomplished Lthe application of this technology in the Boeing is an evaluation of FAA airworthin ess-certification 787 that has dominated aviation safety news for processes to make sure they are keeping up with two months. As this issue of AeroSafety World is modern-technology aircraft. going to press, the U.S. National Transportation During the certification process, the FAA Safety Board and Japan Transport Safety Board are doesn’t have enough organic resources to moni- continuing to investigate the two battery-related tor and approve the building of the aircraft. In incidents that occurred on 787s operated by Japan order to move the process along, the FAA uses Airlines (JAL) and All Nippon Airways (ANA) in “designees.” These are individuals who work for January. On March 12, the U.S. Federal Aviation the manufacturer but wear two hats. One is for the Administration (FAA) approved Boeing’s certifica- company function they perform, the other is for tion plan for a redesigned 787 battery system and the FAA, to certify that what has been done by the the OEM started testing the system. company will be certified. This system works well According to U.S. Transportation Secretary and is used in other areas such as pilot training. Ray LaHood: “This comprehensive series of My concern is about the standards the designees tests will show us whether the proposed battery are required to meet. Have the standards been up- improvements will work as described. We won’t graded to reflect that designees must not only have allow the plane to return to service unless we’re the knowledge, but the experience, to do the job? satisfied that the new design ensures the safety of The FAA has a good system and reviewing this the aircraft and its passengers.” certification process will be another step toward I’m not going to wade into the pool of specula- taking the best and doing better. tion about what happened on board the JAL and ANA flights in question. Nor am I going to venture a guess on how long testing of the redesigned bat- tery system may take or when FAA is going to lift its grounding of the 787. What I do want to address is the promise from Secretary LaHood and FAA Administrator Mi- Capt. Kevin L. Hiatt chael Huerta that FAA would review the 787 certi- President and CEO fication process. The Foundation agrees that this is Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 1 AeroSafetyWORLD
contents April 2013 Vol 8 Issue 3 features
FIRs Tra c 2010 14 CoverStory | Geographic Information Systems Flights 0–72,028 72,029–154,629 154,630–252,658 252,659–436,587 436,588–647,628 20 | Misuse of AS350 Connection Hardware 647,629–1,033,497 Causal Factors 1,033,498–1,676,958 1,676,959–3,277,175 14 24 FlightOps | Why Do We Forgo the Go-Around?
20 34 StrategicIssues | Brazil’s Leadership in Aviation English
40 ThreatAnalysis | Sharing ASIAS Techniques
departments
1 President’sMessage | Lithium-ion Batteries
24 5 LeadersLog | Safety Information Protection
6 EditorialPage | The New Normal
8 SafetyCalendar | Industry Events
9 AirMail | Letters From Our Readers
10 InBrief | Safety News
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 34
40
AeroSafetyWORLD telephone: +1 703.739.6700 47 DataLink | Flight Risk Assessment Tools Capt. Kevin L. Hiatt, publisher, FSF president and CEO 51 InfoScan | Error Tolerance, Error Containment [email protected] Frank Jackman, editor-in-chief, FSF director of publications 56 OnRecord | ‘Mission Pressure’ Cited in Overrun [email protected], ext. 116
Wayne Rosenkrans, senior editor [email protected], ext. 115
Linda Werfelman, senior editor [email protected], ext. 122
Rick Darby, associate editor [email protected], ext. 113
Jennifer Moore, art director [email protected]
About the Cover Susan D. Reed, production specialist A GIS-based map depicts features at [email protected], ext. 123 Beijing Capital International Airport. © GeoEye Editorial Advisory Board
David North, EAB chairman, consultant
We Encourage Reprints (For permissions, go to
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 3 Serving Aviation Safety Interests for More Than 60 Years OFFICERS AND STAFF light Safety Foundation is an international membership organization dedicated to Chairman Board of Governors David McMillan the continuous improvement of aviation safety. Nonprofit and independent, the President and CEO Capt. Kevin L. Hiatt FFoundation was launched officially in 1947 in response to the aviation industry’s need General Counsel for a neutral clearinghouse to disseminate objective safety information, and for a credible and Secretary Kenneth P. Quinn, Esq. and knowledgeable body that would identify threats to safety, analyze the problems and Treasurer David J. Barger recommend practical solutions to them. Since its beginning, the Foundation has acted in the
ADMINISTRATIVE public interest to produce positive influence on aviation safety. Today, the Foundation provides Manager of leadership to more than 1,000 individuals and member organizations in 150 countries. Support Services and Executive Assistant Stephanie Mack MemberGuide FINANCIAL Flight Safety Foundation Financial Operations 801 N. Fairfax St., Suite 400, Alexandria VA 22314-1774 USA Manager Jaime Northington tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org Member enrollment ext. 102 MEMBERSHIP AND BUSINESS DEVELOPMENT Ahlam Wahdan, membership services coordinator [email protected] Senior Director of Seminar registration ext. 101 Membership and Namratha Apparao, seminar and exhibit coordinator [email protected] Business Development Susan M. Lausch Seminar sponsorships/Exhibitor opportunities ext. 105 Director of Events Kelcey Mitchell, director of events and seminars [email protected] and Seminars Kelcey Mitchell Donations/Endowments ext. 112 Seminar and Susan M. Lausch, senior director of membership and development [email protected] Exhibit Coordinator Namratha Apparao FSF awards programs ext. 105 Membership Kelcey Mitchell, director of events and seminars [email protected] Services Coordinator Ahlam Wahdan Technical product orders ext. 101 Consultant, Student Namratha Apparao, seminar and exhibit coordinator [email protected] Chapters and Projects Caren Waddell Seminar proceedings ext. 101 Namratha Apparao, seminar and exhibit coordinator [email protected] COMMUNICATIONS Website ext. 126 Director of Emily McGee, director of communications [email protected] Communications Emily McGee Basic Aviation Risk Standard Greg Marshall, BARS managing director [email protected] GLOBAL PROGRAMS BARS Program Office: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia Director of tel +61 1300.557.162 fax +61 1300.557.182 Global Programs Rudy Quevedo Foundation Fellow James M. Burin
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FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 LEADERSLOG Safety Information PROTECTION BY KENNETH P. QUINN
he aviation industry is the safest for a free pass, even for egregious er- necessary? Who decides? If safety and it has ever been, but must be ror, while others had vastly different occurrence reports are used in civil improved to handle burgeoning understanding, and sought “justice” litigation, criminal prosecutions or demand. To get there, we must be after a crash. To be clear: No responsible administrative enforcement proceed- Tmore predictive and less forensic. Yet, observer believes the industry should ings, will people be less likely to report? national legal regimes and international be immune from the ordinary applica- What are these appropriate uses? guidance to protect safety information tion of criminal law, especially for acts of The ICAO SIP Task Force has are lagging behind global efforts to gross negligence or willful misconduct. wound up its efforts. It will now be gather, analyze and share voluntary and Where do we draw the line? up to the Air Navigation Commission mandatory safety disclosures. These are tough calls, but it’s clear and the Council itself to decide on Basic safety management systems that existing legal protection is in- changes. In the meantime, contracting (SMSs) depend on a climate that is con- adequate to ensure the confidential- states are pushing the throttle forward. fidential, without fear of retribution. ity of safety information. Exceptions Brazil is considering new legislation Yet the quantum safety leap envisioned that permit disclosure for the “proper and training its judges. The European by SMS is imperiled by the lack of legal administration of justice” are too vague Commission has promulgated and pro- protection from criminal attack, civil and too subjective. Existing guidance is posed several directly applicable laws, subpoena and administrative misuse. either misunderstood, or just ignored, including its Regulation 996/2010 on As vice chair of the International inadvertently or purposefully. accident investigation, and in Decem- Civil Aviation Organization’s (ICAO’s) As to solutions, no one size fits ber 2012, on occurrence reporting, to Task Force on Safety Information all. Many jurisdictions are loathe encourage the collaborative advance Protection (SIP), I have worked with to approach their judiciary or law arrangements and safety information Chair Jonathan Aleck of Australia’s Civil enforcement about training. Others protection. New FAA reauthoriza- Aviation Safety Authority and other seeking confidential treatment run tion laws further protect voluntary distinguished professionals for the past up against government transparency. reporting systems from freedom of two years. We reviewed existing legal Most, however, see great value in information–type disclosure. and cultural regimes, trouble areas, in- advance arrangements, cooperative The top priority for states should be ternational guidance and possible fixes. and respectful dialogue, and protec- to create an environment where safety We met with prosecutors and listened to tive mechanisms to prevent a chilling information can be shared without fear plaintiffs and defense lawyers, aerospace effect, if required to provide safety of retribution. This includes ensuring companies, cargo operators, business information in legal proceedings. the availability and integrity of future aviation and victims’ family groups. Current ICAO guidance is intended accident and incident reporting and We heard broad support for, and to strike a balance that is not easy to voluntary reporting systems, and swift confusion over, notions of “just culture.” achieve. When is the use or release action to prevent their misuse. Lives Some thought just culture a euphemism of confidential safety information depend on it.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 5 EDITORIALPAGE
THE NEW Normal
he mere prospect of sequestration was control towers. If a situation should arise in which supposed to be so unspeakably horrible there are not enough controllers available to staff that even a deeply divided and historically both, operations would be consolidated into one, partisan U.S. Congress would never let it meaning that one of the airport’s runways would Thappen. The conventional wisdom was that san- have to be taken out of use. ity eventually would prevail and a compromise FAA’s approach is to minimize the impact would be reached, thus avoiding billions of dollars on the greatest number of travelers. The towers in indiscriminate cuts in the federal budget this slated for closure are at airports that see fewer than year and $1.5 trillion in cuts over the next decade. 150,000 flight operations per year or fewer than We should have known better. Wisdom, con- 10,000 commercial operations per year. The FAA’s ventional or otherwise, often doesn’t play a role in strategy is understandable, but I shudder to think U.S. politics. The country’s two primary political what this could mean for general aviation and cor- parties are concerned more with emasculating porate flying. And what about commercial flights each other than they are with governing, but we’ll scheduled into airports with unmanned towers? let someone else editorialize about that. Perhaps just as disturbing as the fall into se- Here at Flight Safety Foundation and Aero- questration is the notion, voiced more than once Safety World, our focus is safety, and with $637 at the AAAE event, that this is the “new normal,” million to be slashed from the Federal Aviation that the U.S. aviation system is going to have to Administration’s (FAA’s) budget this year (by Oct. learn to make do with less from now on. The im- 1), I think there is ample reason for concern. The mediate pain, of course, will be felt in the form of budget cuts are going to mean furloughs, likely long lines and flight delays, but what is this going to one day every two weeks, for nearly all FAA em- mean for the development and certification of new ployees, and the closing of 238 air traffic control technologies and safety enhancements, or changes towers across the country, among other measures. to existing equipment? How inefficient can the In early March, FAA Administrator Michael system get before it stalls? Huerta spoke at the Aviation Forecast and Policy Summit organized by the American Association of Airport Executives (AAAE), and I asked him about the impact sequestration will have on the safety of the aviation system. He responded that in order to maintain safety, the system may need to take a pen- Frank Jackman alty in terms of efficiency. As an example, he offered Editor-in-Chief that Chicago O’Hare International Airport has two AeroSafety World
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8 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 AIRMAIL
Who Has the Time? he article (ASW, 12/12–1/13, p. 21) on the Suggesting that less-experienced first U.S. rules calling for increased experi- officers (and is he also implying captains Tence for pilots seeking commercial air- with fewer than 20,000 hours?) could not line positions included comments from Capt. deliver the safety demanded by the FAA, and Chesley Sullenberger, which I take some expected by the flying public, seems a harsh exception to. judgment. Capt. Sullenberger argues that 1,500 hours Alan Gurevich of logbook time for airline applicants is not MD-11 first officer, enough. He goes on to say that, had he had a former U.S. Navy Aircraft Commander first officer “with much less experience” than the 20,000 hours his F.O. had on the flight which ended with a ditching in the Hudson River, “we would not have had as good an out- come and people would have perished.” I take nothing away from the airmanship AeroSafety World encourages comments Capt. Sullenberger and his crew displayed that from readers, and will assume that letters day. Yet it seems unreasonable to think that the and e-mails are meant for publication majority of commercial airline first officers, unless otherwise stated. Correspondence is most of whom have far fewer than 20,000 subject to editing for length and clarity. hours, would be so unable to assist a captain in Write to Frank Jackman, director of dire circumstances that they would become a publications, Flight Safety Foundation, 801 direct contributing factor to loss of life or limb. N. Fairfax St., Suite 400, Alexandria, VA I don’t suggest that first officers have not erred. 22314-1774 USA, or e-mail
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 9 INBRIEF Safety News Boeing 787 Plans Approved oeing’s certification plan for the redesigned battery system the battery,” the FAA said. Other changes included improved on its 787 has been approved by the U.S. Federal Aviation insulation of battery cells and the addition of a containment and BAdministration (FAA) — the first step in returning the venting system. airplane to flight. Ray Conner, president and CEO of Boeing Commercial Boeing next will conduct testing and analysis to demonstrate Airplanes, said the company’s planned changes will “significantly that the battery system complies with applicable safety regulations. minimize the potential for battery failure while ensuring that no “This comprehensive series of tests will show us whether battery event affects the continued safe operation of the airplane.” the proposed battery improvements will work as designed,” The FAA approved plans calling for limited test flights said Transportation Secretary Ray LaHood. “We won’t allow involving two 787s that will be equipped with the prototype ver- the plane to return to service unless we’re satisfied that the new sions of the new containment system. design ensures the safety of the aircraft and its passengers.” The FAA said its final approval depends on whether The FAA grounded all U.S.-registered 787s in January after Boeing “successfully completes all required tests and an in-flight battery problem on an All Nippon Airways domes- analysis to demonstrate the new design complies with FAA tic flight in Japan. Other civil aviation authorities around the requirements.” world immediately took similar action. FAA Administrator Michael Huerta added that the plan ap- Boeing subsequently redesigned the internal battery proved by the agency “includes all the right elements to conduct components “to minimize initiation of a short circuit within a comprehensive evaluation of the battery system redesign.”
War Against the Wind R44 Fuel Tanks
uropean scientists are develop- perators of Robinson R44s are ing a new system to identify being urged to equip the heli- Eturbulence and wind gusts before Ocopters with modified bladder an aircraft flies into them. fuel tanks designed to reduce the risk EADS Innovation Works says its of post-accident fires. scientists are using lidar (light detec- The Civil Aviation Safety Author- tion and ranging) sensors, which use ity of Australia (CASA) has sent letters light to identify obstacles and measure to all R44 operators to point out a Airplane: © Ansonsaw/iStockphoto; their distance. Wind: © Anthony Hathaway/Dreamstime.com revised Robinson service bulletin that “The lidar sensor … radiates ul- calls for installation of the modified traviolet (UV) light pulses, typically at a rate of 60 per second, which are scattered fuel tanks by April. by the nitrogen and oxygen molecules present in the air,” EADS said. “In this way, A CASA airworthiness bulletin a total of four rays measure the motion vector of the air 50 to 200 m [164 to 656 ft] “strongly recommends” that the opera- in front of the aircraft’s nose. tors comply with the service bulletin at “Any turbulence that may be present alters the motion profile of the molecules their “earliest opportunity.” and thus the signature received by the system.” CASA noted several recent The system might eventually also be used to measure wake vortices and aid in accidents and incidents involving determining the correct separation between aircraft during takeoff and landing, post-crash fires on R44s with rigid EADS said. aluminum fuel tanks. Nikolaus Schmitt of EADS Innovation Works said that the lidar system could be used to send data to an airplane’s flight control computer “so the aircraft can automatically react” by actuating wing control surfaces. “What our lidar sees is at most a second ahead,” Schmitt said. “That’s long enough for a machine but not for the human brain. But our measurement of the airflow at that distance in front of the aircraft is extremely accurate, so the aircraft really will be able to automatically react to a vertical or horizontal draft on the basis of our advance information.” The system is currently being tested, and some tests were conducted in flight on an Airbus A340. Schmitt says the system might be ready for production in about 10 years. Bidgee/Wikimedia Commons
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 INBRIEF
UAS Site Proposals Wanted
he U.S. Federal Aviation Administration (FAA) is looking for proposals for the development of six unmanned aircraft Tsystems (UAS) research and test sites across the country. The FAA’s request calls on state and local governments, universities and other public entities to submit their proposals for site development. “The expanded use of UAS represents a major next step in aviation innovation and will present economic opportunities both for the communities that are selected for this pilot program and for the aerospace industry in general,” the FAA said. The FAA’s evaluation of the submitted proposals will exam- ine their geographic and climatic diversity, ground infrastruc- U.S. National Aeronautics and Space Administration ture, research needs, population density and air traffic density, and the proposed objectives. “We expect to learn how unmanned aircraft systems operate in different environments and how they will impact air traffic op- erations,” said FAA Administrator Michael Huerta. “The test sites will also inform the agency as we develop standards for certifying unmanned aircraft and determine necessary air traffic requirements.” The agency also requested public comments on FAA efforts to ensure that individual privacy is appropriately protected while the pilot programs are in operation. Privacy requirements will be included in formal agreements between the designated test sites and the FAA.
Stop putting aircraft and people on hold The Safegate Effect
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 11 INBRIEF
New ICAO Annex on Safety
he International Civil Aviation Organization (ICAO) has adopted a new Safety Management Annex — its first new annex to the Chicago TConvention of International Civil Aviation in more than 30 years. Annex 19 is intended to support ICAO’s “global safety strategy, which calls for improved standardization, increased collaboration among avia- tion stakeholders, new information sharing initiatives and prioritization of investments in technical and human resources required to ensure safe operations in the future,” ICAO said. The ICAO annexes contain the standards and recommended practices that provide the framework for the international air transport system. Annex 19 encompasses provisions regarding state safety programs and safety management systems. The annex was developed over the past three years by ICAO, the ICAO member states and key international aviation organizations. Adoption of Annex 19 coincided with ICAO’s announcement of ac- cident data that showed 2012 was one of the safest years ever for global aviation. The data showed that there were 99 accidents in about 31 million flights in 2012 — or about 3.2 accidents per million departures. Aviation fa-
talities in 2012 numbered 372, compared with 414 in 2011. The 2012 figure International Civil Aviation Organization was the lowest since 2004, ICAO said. The data were submitted by the 191 ICAO member states and include aircraft with a maximum certificated takeoff weight of 2,250 kg (4,960 lb) or more.
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Experts from the global aviation industry will be in attendance to share the latest technologies, operational procedures and lessons learned that will keep you operating safely during winter operations.
For more information visit: www.winterops.ca
Hosted by: Air Canada Pilots Association l Association des pilotes d’Air Canada Get the App! INBRIEF
End-Cap Fatigue Cracks
he manufacturer of the Beechcraft 1900D should take action to inspect nose landing gear end caps for fatigue Tcracking and replace those at risk, the U.S. National Transportation Safety Board (NTSB) says. In issuing safety recommendations to the Hawker Beech- craft Corp. (now known as Beechcraft), the NTSB cited its investigations of several recent incidents involving 1900Ds, including the May 17, 2011, collapse of the left main landing gear on a 1900D during landing at Denver International Airport. The airplane sustained minor damage, but no one was injured in the incident. The NTSB said the probable cause was the fatigue failure Martin Rottler/Wikimedia Commons of the nose landing gear end cap, “which resulted in insuf- ficient hydraulic pressure to secure the left [main landing gear] into the down-and-locked position.” The NTSB’s examination of the fractured end cap and of a second end cap provided by Beechcraft showed that both end caps had failed because of fatigue “from multiple origins that initiated in the machined inner diameter and propagated outward toward the cap’s exterior.” The end cap on the incident airplane had accumulated 29,533 cycles since manufacture, the NTSB said. The board noted that an inspection conducted during a 2008 overhaul, 4,585 cycles before the incident, found no discrepancies. Beechcraft changed its recommended maintenance practices in 2010 and 2011, as a result of preliminary incident findings and earlier end cap fractures, the NTSB said, noting that the company currently recommends a repetitive ultrasonic inspection every 1,200 cycles beginning at 8,000 cycles, and an overhaul every 10,000 cycles. The NTSB recommendations called on Beechcraft to determine the fatigue life of the nose landing gear end cap, develop a replacement program based on the fatigue life determination, and revise the repetitive inspection procedure and time interval “to ensure that fatigue cracks are detected prior to failure.”
Warning on Large Height Deviations In Other News …
ilots of flights in oceanic airspace must be aware of the potential effects on Patrick Ky, the executive director of safety of large height deviations (LHDs) — deviations of 300 ft or more the Single European Sky Air Traffic Pfrom the cleared flight level, the U.S. Federal Aviation Administration Management Research (SESAR) Joint (FAA) says. Undertaking, has been named to succeed In Safety Alert for Operators (SAFO) 13004, the FAA said that LHDs are Patrick Goudou as executive director the most common pilot errors. of the European Aviation Safety “The evaluation of oceanic error reports shows LHDs present a potential Agency (EASA). Goudou has held the hazard to continuous operational safety in the airspace,” the SAFO said. “These position since EASA was established in deviations have caused some oceanic airspace to surpass the established target 2003. … New regulations in Australia level of safety and resulted in an elevated vertical risk.” will upgrade flight crew licensing and Common causes of LHDs include air traffic control (ATC) coordination errors; training requirements. The regulations, pilot deviations, “including improper execution of pilot contingency procedures”; which will take effect in December, will and turbulence encounters, the document added. give pilots four years to convert their The SAFO said data show that most crew-related errors involve misinterpreta- licenses to the new Part 61 Civil Aviation tion or misapplication of conditional clearances typically used in allowing flight Safety Regulations. … The Performance crews to fly to more efficient altitudes. Review Body of the Single European Sky “Flight crews must be trained to utilize procedures that ensure that all ATC has produced an online Performance clearances are complied with correctly, particularly clearances with en route Dashboard to show actual and targeted air restrictions such as changing flight levels based on a coordinated time or a navigation services performance data. specific geographic position,” the document said.
Compiled and edited by Linda Werfelman.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 13 COVERSTORY
BY WAYNE ROSENKRANS Updated geospatial data for terrain elevation and obstacles extend aviation safety margins.
eographic information systems (GIS) — routing of trucks carrying hazardous materi- merging cartography, statistical analysis and als and smartphone apps for motor vehicle database access — have existed for about collision avoidance), infrastructure analysis, 50 years, but their role in aviation safety pipeline safety and positive train control. Gsoon will take a few leaps forward, experts told a Impediments to expanded GIS uses in aviation December 2012 forum hosted by the U.S. National safety, however, could include misinformed Transportation Safety Board (NTSB). safety conservatism or delays within this trans- Concepts involved often are analogous to portation mode in recognizing the opportuni- those in highway safety (such as intelligent ties at hand, some presenters said. Everything in Place
14 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 extend aviationsafetymargins. Updated geospatialdataforterrainelevationandobstacles
© User: Swinnerrr/Vectorstock or runway between centerlines within orpart, from an obstacle to arunway from one of part arunway to another depicting distance on map adigital relative accuracy, such as correctly — where are you world inthe —and same levels of accuracy.” same exact levelsthe of quality and the with same the aeronautical answer … dation that allows us to always come up for an aeronautical information foun - formation Exchange (AIX)]…provides standard [Eurocontrol Aeronautical In- given [volume] of airspace. …The data increase numbers the [of aircraft] ina to terrain and obstacles inorder to bringingbe aircraft and closer closer fundamentally because flight, we will terrainthe and obstacles the that affect a concise and clear of idea where are requirements …is that we must have same time. One of predominant the and, of course, enhance safety at the improve travel, improve efficiencies one’s airspace and inorder airports to planes hour per inand out- of every to get, purely and simply, more air ATMbased containment with smaller mation is acquired and maintained. much better handle on how [GIS]infor ofmiles airspace, we to need have a moreflying airplanes same inthe cubic he said, adding, “If we are going to be obstacles and that part the GISplays, safetycritical concerns with to respect GeoEye. Containment, however, entails director, air and marine solutions, of (ATM) systems, said DejanDamjanovic, of management 21st-century air traffic aircraft —and basis the became this — reducing space from the aircraft to demands, alternative the is containment invent more airspace to its satisfy Since aviation the cannot industry Containment Aircraft Enabling FLIGHTSAFETY.ORG GIS addresses absolute accuracy notion primary is message-“The |
WORLD AEROSAFETY | APRIL 2013 - - maintain it forever.” [andcollect validate data] the —and through plan you …because to need must have aprudent and well-thought- obstacles around given …You airports. polygonthe features that constitute the pointthe features, line the features and ibly and detailed complete grasp of all System] future that we have an incred- Next Generation Air Transportation more NextGen inthe critical [U.S. single runway. …It’s going even to be 5,000 and 10,000obstacles around a Unitedin the States to between identify it’s not uncommon inpopulated areas Diego] runway. In ballpark numbers, man-made structures off that one [San overfied 3,000individual buildings or most significant challenge. … We identi- typically man-made buildings —are the single runway. …Polygonal obstacles — come up with to close 500just for a said. “[For] power lines and fences, we — an astonishingly large number,” he at San Diego —2,700points runway per sands of points around asingle runway San Diego International Airport. cited examples from GeoEye’s work at ground and airborne platforms. He light-detection and ranging (lidar) on Shuttle imagery, satellite and imagery Space Administration (NASA) Space raphy, U.S. National Aeronautics and relevant to aviation are photog aerial - Based Navigation Manual. is and collected, ICAO the Performance howdefines aeronautical information Information Services, nautical Organization (ICAO) Annex 15,Aero arethis International Aviation Civil Key documents created to accomplish frame of reference,” Damjanovic said. to within need coexist same the both is as important as absolute accuracy; “So samethe airport. relative accuracy “We’re coming up with literally thou GIS data most methods collection which which - - cases within aGISandcases radar coverage presentwill runway excursion data and maps. for MITREspecialists, example, atlook some of safety the aspects” using is often first step. the We a take also will tivity airspace [appreciating —so that] are —surrounding airspace, ac- special some ofbetween different the airspaces don’t understand what relationships the on [these] amap,”seen he said. “They cedures have or …traffic never actually associated with airspace the or …pro- waythe [is] alot of individuals the of things the that I’ve discovered along puting at specialist MITRECorp. “One Christopher Knouss, ageospatial com - limited topological frameworks, said professionals tend to work indifferent, herently spatial, yet individual aviation Safety-related aviation analyses are in- Directions Research Safety data-mining are doing conversion after othersthen want who to doadditional into modeling the environment … data, but …having to convert it again simulation“The folks are using that intosometimes run incompatibilities. operational quality assurance data analyses combining GISdata and flight context, he said. However, efforts to conduct Topography Missiondatadiscloses Comparing GPSandShuttleRadar from averagingsomeGISdata. the inaccurateridgelineeffect COVERSTORY |
15 U.S. National Aeronautics and Space Administration COVERSTORY
Three-dimensional imagery from GIS data depicts separate airport said David Cowen, chairman, National features, terrain and obstacles at Albuquerque Sunport Airport. Geospatial Advisory Committee. But efforts to establish a common, in- teroperable GIS platform for nearly all federal agencies have made progress, he said, noting, “We have the prototypes of a geospatial platform in place now. … So you can go in and get things … common data, common services, com- mon applications through Web-based interfaces instead of buying desktop GIS [software] and staffing up. This is © GeoEye the way we are going, and this provides conversion of the same data, which intensity of activity from departures [the aviation community] a great way introduces resolution error, biases and data in the selected areas. For example, to enter the [GIS] field. … A robust GIS inaccuracies,” Knouss said. the United States has about 10 million program would enable NTSB to im- departures a year versus some Western prove the way it monitors and manages ICAO’s GIS Applications African countries with fewer than 7,000. its safety programs. NTSB should take Calculating global air carrier accident “ICAO has always grouped these advantage of the platform that now ex- rates with state or region rates, then states by ICAO regions, and West Africa ists and … help guide the stakeholders.” using maps to compare local rates with is an ICAO region,” Merens said. “Once Also in response to the GAO air traffic data for the associated flight we plotted the traffic, we [saw] that we report findings, Stephen Lewis, a information region, provides fresh could not have created a … more unfair director of GIS at DOT, said that the perspectives on safety risks, said Marco [grouping of states for safety-analysis department is setting up a geospatial Merens, technical officer, ICAO Air purposes] because it actually contains policy advisory council. Navigation Bureau. Sometimes, howev- the lowest traffic in Africa, and [yet some Proposed GIS-related infrastructure er, such comparisons have revealed that states] actually have not many accidents. projects — including a three-dimen- it was “unfair to create a region [from … A single accident in that region sional terrain elevation program that states arbitrarily],” he said, adding, doubles or triples the rate, so we can- addresses one of the major aviation risks “That’s actually a known problem in not really use it to measure state safety. in Alaska — would stimulate economic geography … it’s called the modifiable So we’ve actually stopped doing that.” growth, Cowen said. “The pilots flying unit area problem, and so GIS helps us Instead, use of United Nations regions in Alaska are doomed in many cases,” to understand that.” often yields fairer comparisons, he said. he said. “The [GIS] data is terrible in ICAO’s GIS Web portal comple- He also cited GIS color-coding of terms of trying to find a landing strip ments its secure Internet platform for plotted points where losses of separa- there because elevation data is bad.” iSTARS group members to exchange tion have occurred, and overlaying safety intelligence, he said. These these with hazard-mitigation symbols More Accurate Elevations platforms help ICAO produce an inte- on recorded aircraft tracks in specific GIS in the broadest sense can be grated safety analysis that incorporates state airspace of interest, such as a flight “geographic information science or state-level results of its Universal Safety information region. any spatially enabled or location-aware Oversight Audit Program (USOAP). technology,” said Reginald Souleyrette, a A second use of GIS is overlay- U.S. GIS Coordination transportation engineer and University ing accident sites at latitude-longitude The U.S. Government Accountability of Kentucky professor representing Data points on a world map depicting air Office (GAO) in November 2012 issued and Information Systems, Transporta- traffic flows. Referring to such a map, a report1 citing insufficiently coordi- tion Research Board of the National Merens explained color-coding of nated collection of GIS data by the U.S. Academies. Specialists have watched fatal and non-fatal events, states and Department of Transportation (DOT), their field evolve from what they call
16 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 COVERSTORY
a map-view stage to a navigation-view advances such as digital notices to air- (NED) is based on lidar, so far repre- stage to today’s behavioral-view stage. men, she said. senting about 28 percent of elevation “Transportation futurists see a world Much has been published about data for the lower 48 states, he said. with billions of embedded sensors,” he how satellite-based aircraft navigation “Lidar really is a way to map the said, and human-machine and machine- and ATM enable NextGen–SESAR whole vertical profile of a landscape,” machine interaction are affected. capabilities, but sensor technology Danielson said. “We’ve seen drastic NTSB’s interest extends mainly and GIS revalidation of terrain eleva- improvements in the accuracy of our to ways of using GIS to help identify tions and obstacle descriptions are less terrain data using lidar … to map the trends and areas of growing risk in all well known, added Jeffrey Danielson, feature much more precisely in terms of transportation modes. “For example, if physical geographer, Earth Resources its position as well as the actual mor- we start to see a series of accidents and Observation and Science Center, U.S. phology of that feature.” incidents, with GIS we can identify Geological Survey (USGS). The NED, envisioned 15 years ago, patterns, understand relationships Before this century, methods for is a seamless raster database that func- and use its capabilities to help develop measuring elevations at map loca- tions as a layer of the official USGS countermeasures,” said Chairman tions in the continental United States continental U.S. map, with updates Deborah Hersman. presumed users’ needs of the 1960s. six times a year. Its dataset is “edge- For transition to NextGen and the Now aviation safety margins can ben- matched with spatially referenced Single European Sky ATM [Air Traffic efit from far greater data accuracy and meta-data to know what source was Management] Research (SESAR) pro- resolution made possible by lidar, the used to make [each] piece of data,” he gram, GIS standards such as common gold standard for many GIS measure- said. The NED offers multiple resolu- geography markup language for geo- ments. Most of the data going into tions,2 bare-earth terrain imagery, spatial data have become crucial to safe the USGS National Elevation Dataset contours and extensive data from interoperability, said Nadine Alameh, director of interoperability programs, GIS Story Maps Open Geospatial Consortium (OGC). “A few years back, the … global aviation community agreed to adopt or aviation training, Web-based geographic information systems (GIS) have [AIX,] an international framework of potentially significant advantages for the curriculum developers, instructors and instructional media specialists who must cover subjects such as required [GIS] standards specifically for the goal F navigation performance (RNP) area navigation (RNAV) in an engaging and clear of improving air travel safety and op- way to pilots, dispatchers and other aviation professionals. The value of GIS story erational efficiency,” Alameh said. “Lo- maps in particular has been demonstrated in other industries and media with free cation is just so critical to all aspects of examples and templates available at websites such as
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 17 COVERSTORY
participating government agencies. coordinates as X, Y and Z points of the Upgrading Airport Data The currency of the NED varies dra- vertical structure scanned. “Towers are Because the FAA provides funding matically among U.S. states, however, of concern for the FAA and people look- through the congressionally approved so specialists color-code the 1960s ing at obstacles, for example,” he said. Airport Improvement Program, the contours separately from up-to-date, “Using traditional totalization and GPS agency can require the recipient U.S. air- usually lidar-based, contours. [global positioning system] is still your ports to use the latest GIS data submis- Whether mounted on an aircraft, most accurate way of measuring ob- sion standards, said Michael McNerney, ground vehicle or tripod, a lidar system stacles, but lidar does have the potential assistant manager of FAA’s Airport Engi- records a point cloud comprising bil- to be a tool to map obstructions [for an neering Division. The Airports GIS pro- lions of three-dimensional mathematical airport] landing approach.” gram covers about 3,300 such airports as part of the national plan of integrated airport systems, which includes 547 Own-Ship Spotter for Mobile Devices airports certified under Federal Avia- tion Regulations Part 139 standards for scheduled air service. “We are primarily ome of the aeronautical charting specialists within the geographic informa- developing a data collection program tion systems (GIS) community have worked toward low-cost alternatives in GIS,” he said. “Another benefit is to airport moving map displays as a countermeasure to runway incursions S improved safety by having better data, (ASW, 3/12, p. 27). They also are refining the accuracy and integrity of terrain/ obstacle databases in avionics, says Rich Fosnot, senior manager for aviation real-time data, corrected and traceable safety, Jeppesen Aviation and Marine Safety. data. [We are supporting] NextGen [by] GIS data sources play a key role in the continuing evolution of airport mov- embarking on a program to do full-scale ing map technology, enabling the addition of airframe-specific “taxi routes, low- geospatial data collection at engineering- visibility routes, holding positions, tailored airline information, preferred routes, level accuracies [for the certified airports ramp communication frequencies and company-specific deicing areas,” he said. “Accurate airport diagrams is another project we’re working on to make an during 2013 and 2014].” airport moving map [-like product] available to general aviation and to corpo- The accuracy improvement enables rate operators that do not have the Class 3 electronic flight bags with a [U.S. FAA airport specialists to measure on a Federal Aviation Administration (FAA)–approved] airport moving map applica- digital airport layout plan the distances tion,” Fosnot said. between runways, parallel taxiways or Jeppesen anticipates approval from the FAA in early 2013 “to be able to include two adjacent buildings, for instance. the own-ship position on the traditional [static] airport map as displayed by an electronic charting service, but distinctly different from the airport moving map “By 2016, we expect to go full digital/ [because of its use of a] precomposed chart, not a data-driven chart,” he said. “The electronic on airport layout plans and [GIS] information available from airport authorities in some cases is not as accurate all of our digital data,” McNerney said. as required. Maybe not so much in the United States, but in other countries, we’ll The program is collecting data for find errors in the location of taxiway intersections of up to 250 m [820 ft]. The use of more than 100 features of each airport geo-referenced satellite information allows us to locate these taxiway intersections sufficient for standards-compliant accurately. In the future, we hope to introduce the airport moving map to mobile devices such as the [Apple] iPad.” drawings. “[This has] many differ- Advances in GIS also have a role in reducing the risk of controlled flight into ent layers, and has tools to measure terrain, which continues to cause fatalities among industry segments in which distances among a lot of GIS tools,” he aircraft typically do not carry a terrain awareness and warning system (TAWS), said. “One of our outputs is 1.0-ft [0.3- Fosnot said. “The terrain and obstacle databases that we provide the industry m] elevation contours in the airport drive [TAWS,] aeronautical charts, moving map displays, synthetic vision, flight area; our consultants that use the data planning systems, flight procedure design and airspace and airport modeling software,” he said. The basic safety role of these applications is enhancing pilots’ think that’s one of our best products.” situational awareness, which he defined as “perception of the elements in an McNerney said that FAA Airport environment of time and space, the understanding of their meaning and the GIS now collects data for airport airside projection of their status into the near future.” and groundside operations — the — WR movement and non-movement areas — to provide a complete geospatial picture
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Overlaying flights, color-coded by total-number categories, enables ICAO to assess traffic density-hazard level by flight information region.
instrument departure procedures and obstacle evaluation assessments. The system includes two-dimen- sional and three-dimensional views of locations. In three-dimensional view, the specialist instantly can set the viewer’s position at any direction and elevation to FIRs Tra c 2010 Flights study terrain and obstacles. “Cylinders
0–72,028 © International Organization Civil Aviation 72,029–154,629 [drawn by IPDS show each] obstacle with 154,630–252,658 252,659–436,587 436,588–647,628of an airport. This is much different services, aeronautical navigation prod- its accuracy, which has to be taken into 647,629–1,033,497 1,033,498–1,676,958from discrepancies of the past. ucts, technology and air traffic control consideration when there are procedures 1,676,959–3,277,175 “When I was an airport consultant products, and the IPDS at the FAA Air being built because some obstacles don’t and was doing the master plan for Traffic Organization. have a very exact accuracy of the height Houston Intercontinental [Airport], we FAA staff currently uses IPDS or the position [data],” Gonzalez said. were siting a new runway, and the FAA solely for space-based navigation In closing, the USGS’s Danielson was telling us that the runway was too procedures, specifically those using stressed the need for GIS data users in far away from the tower, [saying,] ‘You GPS area navigation (RNAV) and re- aviation to ask about “whatever quality can’t site it there,” he recalled. “We said, quired navigation performance (RNP) assurance methods that an organization ‘Yes, it’s within limits.’ And so they said, levels of technology. Because differ- or group is using in collecting and then ‘Show us your data.’ When we showed ent layers of data are provided using processing the data. … From the USGS them the data, they said, ‘Oh, that’s a GIS format, procedure development perspective, we produce a lot of [ter- where the tower is.’ They were still using specialists instantly can show/hide rain] data, and definitely the meta-data an old airport layout plan that did not overlay data from accurate databases sometimes is lagging behind the data, have the correct tower location. [Else- for elements such as obstacles, fixes, but we’re striving to match that up with where,] a building would be located in airports, runways and navaids with the data in terms of currency. … Meta- the general area, but [on the map] it colors assigned as needed. data probably is one of the most chal- might be … 50 ft [15 m from] where it “This new system uses [AIX] to lenging aspects to geospatial data.” really is. So it’s important to have every- push and pull [GIS] Web services and body looking at the same data, having data; there’s just about everything a Notes safety-critical data for runways and taxi- procedure specialist would need,” Gon- 1. GAO. Geospatial Information: OMB [Office ways, having a very rigorous verification zalez said. “[I believe IPDS will] be- of Management and Budget] and Agencies and validation program.” come useful for NTSB when it comes to Need to Make Coordination a Priority trying to evaluate a procedure that may to Reduce Duplication, GAO-13-94, Building Instrument Procedures or may not have been involved with an November 2012. A new instrument procedure develop- aircraft crash. … A module being de- 2. Current resolutions possible are 1 arc ment system (IPDS), developed and livered within the next 12 to 18 months second, about 30 m (98 ft); 1/3 arc second, deployed in the last five years, gradually will provide ground-based [naviga- about 10 m (33 ft); and 1/9 arc second, is replacing a legacy system to develop tion aid] procedure development. … about 3 m (10 ft). “Bare earth” refers to lidar measuring/depicting the elevations of points procedures for U.S. and some non-U.S. We’re also looking at providing flight on the contour surface as opposed to capa- flight operations under instrument path data on this system.” The ground- bilities such as “first return” from the top of flight rules (IFR), said George Gonza- based module streamlines manual a surface (such as a man-made structure) or lez, representative of mission support processes for building diverse standard the “top of canopy” of trees.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 19 CAUSALFACTORS ‘Inadequate Maintenance’
Improper use of connection hardware began a chain reaction that led to the crash of an AS350 on a sightseeing flight, the NTSB says.
BY LINDA WERFELMAN
20 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 CAUSALFACTORS
Flight path
Tour route Accident site
Las Vegas Airport Sudden climb and turn
The crash in the mountains near To Hoover Dam Hoover Dam killed the pilot and all four passengers.
series of maintenance errors was The helicopter was not equipped maintenance task and the inspection, responsible for the Dec. 7, 2011, with flight data recorders, and they were the NTSB said. crash of a Sundance Helicopters not required. However, radar data from Eurocopter AS350 B2 in the the U.S. Federal Aviation Administra- Maintenance Personnel Amountains east of Las Vegas, the U.S. tion (FAA) showed that the helicop- The mechanic who installed the fore/aft National Transportation Safety Board ter had been level at 3,500 ft, with a servo received his airframe and power- (NTSB) says. groundspeed of 120 kt, until about one plant (A&P) mechanic certificate in De- The pilot and all four passengers minute before impact, and then climbed cember 2008 and worked on maintaining on the “Twilight Tour” sightseeing to 4,100 ft, turned 90 degrees left and general aviation airplanes and business flight were killed in the crash, and the slowed. The helicopter descended to jets before being hired by Sundance in helicopter was destroyed. 3,300 ft and tracked northeast for 20 June 2011. After his hiring, he received Background: U.S. National Aeronautics and Space Administration National Aeronautics U.S. Background: At an NTSB meeting convened to seconds before entering a left turn and indoctrination training in record keeping, review the accident, Chairman Debo- plunging toward the ground “at a rate of maintenance procedures and use of the rah Hersman noted that research has at least 2,500 ft per minute,” the NTSB Eurocopter manuals, as well as on-the- shown that the primary category of said in its final report on the accident. job training, but he had yet to attend any maintenance error is “failing to carry Parts of the helicopter were destroyed helicopter-specific training. out necessary actions. by a post-impact fire. The wreckage was His schedule typically included “And that is our finding from this found in a ravine about 14 mi (23 km) four days of 11-hour shifts, followed investigation. Inserting a small pin, east of Las Vegas. by three days off, three days of 12-hour smaller than a paper clip, and just one The NTSB said the probable causes shifts and four days off. Each shift small step in a routine maintenance of the crash were Sundance Helicopters’ began at 1200. procedure, was the necessary action. “inadequate maintenance of the heli- He estimated that he previously had The omission of this action was the copter, including the improper reuse performed about six fore/aft servo instal- difference between an uneventful flight of a degraded self-locking nut, the im- lations before he began work on the ac- and tragedy.” proper or lack of installation of a split cident helicopter on Dec. 6. He had been The flight began at 1621 local time, pin and inadequate post-maintenance off duty on Dec. 4 and 5, and initially when the helicopter took off at dusk inspections, which resulted in the in- was scheduled to be off on Dec. 6 as well, from Las Vegas McCarran International flight separation of the servo control but was asked during a telephone call the Airport in visual meteorological condi- input rod from the fore/aft servo and previous afternoon to report to work. tions with good visibility. The pilot rendered the helicopter uncontrollable.” He said that he went to bed about 2200 planned to fly to Hoover Dam, about Contributing factors were the me- — four hours earlier than his normal 30 nm (56 km) southeast and then to chanic’s and inspector’s fatigue and the bedtime of 0200 — but fell asleep around
© Sergey Rimsha/Airliners.net© Sergey return to the airport. “lack of clearly delineated” steps for the 0000 and awoke at 0500, feeling good.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 21 CAUSALFACTORS
He reported to work about 0550 and was Sundance determined in a root cause “the loss of control of the fore-aft servo assigned the fore/aft servo replacement, analysis that “the inspector’s percep- would most likely result in a cata- which he said he performed without diffi- tion of the need to expedite the repair to strophic failure of the helicopter.” culty and without feeling rushed. avoid aircraft downtime was a contribut- Investigators found the fore/aft The mechanic who inspected the ing factor leading to this failure.” main rotor servo control input rod in servo replacement had been named The NTSB said its review of main- the wreckage, disconnected from the a quality control inspector about six tenance logs for the four months before input lever; its connection hardware months earlier. He also was one of three the accident revealed no discrepancies. was not found. lead mechanics who directed mainte- The check pilot, who received an nance tasks when management personnel A&P mechanic certificate in 2000 and Sundance Helicopters were not present. He received an airframe worked as a mechanic on Robinson he- Sundance Helicopters had 22 helicop- and powerplant mechanic certificate in licopters for about six years, was hired ters and 50 pilots at the time of the 2002, and had spent about two years in by Sundance as a line pilot in 2010. He accident and, during the off-season commercial aircraft maintenance and had 2,400 flight hours, including about when the crash occurred, averaged seven years in helicopter maintenance 1,400 hours in rotorcraft. Before the ac- 35 tour flights and 40 shuttle flights a before he was hired by Sundance in 2010. cident, he had conducted 10 to 12 flight day to Grand Canyon West Airport. Like the mechanic, he was not checks at Sundance. In 2011, the company operated 31,350 originally scheduled to work on Dec. 6 flight hours and transported more than but was asked during a telephone call Flight Control System 200,000 passengers. the previous day to report to work in The AS350 B2 has a mechanical flight All maintenance, except for com- the morning. He told accident inves- control system, assisted by one hydraulic ponent overhauls, was performed at tigators that he felt rested after about tail rotor servo and three hydraulic main the operator’s maintenance base in seven hours of sleep. He completed the rotor servos. Of the main rotor servos, Las Vegas. inspection of the servo replacement two are lateral servos, “which transfer The last maintenance on the ac- work about 1800, near the end of his the lateral inputs to the nonrotating cident helicopter — which included a 12-hour shift. swashplate (roll),” and one is the fore/ 100-hour inspection and replacement A review of Sundance maintenance aft servo, “which transfers the fore and of the tail rotor servo, the engine and records showed that the inspector, work- aft inputs to the nonrotating swashplate the main rotor fore/aft servo — was ing as a mechanic in June 2011, “failed to (pitch),” the report said. completed the day before the crash. The properly re-install the chin bubble” por- A system of control rods, bellcranks fore/aft servo was replaced with a new tions of the windshield on a helicopter. and levers transfers the pilot’s collective unit, and the mechanic said after the and cyclic control inputs to the “mixing accident that he had no difficulties with unit,” where the inputs are delivered the installation. Servo Control Input Rod Assembly “through the appropriate servo control Eurocopter, in its Standard Practices Split pin input rod to a servo input rod assem- Manual, specifies that a locking nut Washer bly,” the report said. may be reused only if it is “not exces- Each servo is connected to the main sively damaged,” is hard and cannot be rotor transmission case, the nonrotat- tightened by hand. Bolt ing swashplate and the servo control in- The mechanic said that, when de- Self-locking nut put rod. A bolt, washer and self-locking ciding whether any nut could be reused, slotted nut connect the servo control he removed it, cleaned it and inspected Servo control input rod input rod to the servo input lever; the it for damage, then threaded it onto nut also is secured with a split pin (also the bolt “to see if it will thread all the called a cotter pin), which prevents it way down, and if he is able to turn the from unthreading (Figure 1). nut down to where the shank is visible, Source: U.S. National Transportation Safety Board The report said that Eurocopter had he replaces the nut,” the report said. Figure 1 noted in a certification document that In assessing the nut on the accident
22 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 CAUSALFACTORS
helicopter, “he deemed the hardware have loosened as long as it was properly check pilot each had at least one op- airworthy,” the report added. torqued, Eurocopter said. portunity to observe the fore/aft servo After the accident, Sundance direct- Sundance inspected all of its AS350s self-locking nut and split pin; however, ed maintenance personnel to replace after the accident and found all fore/aft they did not note that the split pin was the self-locking nut and other connec- servo connection hardware was proper- installed improperly or not present.” tion hardware at the next scheduled ly connected and safetied. At the same inspection of all of its helicopters with time, the connection hardware was ex- Maintenance Human Factors more than 5,000 flight hours and then amined on the main rotor servos of all Although maintenance personnel were at 5,000-hour intervals. The company Sundance helicopters with at least 5,000 under no time pressure to complete also said that the nut must be replaced flight hours; the examinations showed their work, the mechanic and the qual- with a new nut any time an input rod is that about half of the self-locking nuts ity control inspector both met criteria disconnected from a servo. on the 13 helicopters that had been in- for “susceptibility to the debilitating spected by January 2012 had no locking effects of fatigue,” the report said. Most Likely Scenario capability, the NTSB said. “Because both the mechanic and the The report noted that, “because proper On two helicopters, self-locking inspector had insufficient time to functioning of the control input rod nuts “could be easily and fully tightened adjust to working an earlier shift than is necessary for takeoff,” it was clear or loosened on the accompanying bolts normal, they were experiencing fa- that the bolt and the control input rod with finger pressure,” the NTSB said, tigue. … In addition, the mechanic had were in place when the accident flight adding, “This indicates that the nuts … an inadequate amount of sleep and the began. Laboratory analysis revealed no were not suitable for reuse.” inspector had a long duty day, both of evidence, however, that the connection This prompted the NTSB’s conclu- which also contributed to the develop- hardware was present at impact. sion that, “at the time of the accident, ment of their fatigue.” “Based on the evidence,” the report Sundance Helicopters was not follow- Although the report said that added, “the NTSB concludes that the ing Eurocopter and FAA self-locking fatigue alone could not explain the most likely explanation for the in- nut reuse guidance, which led to the maintenance errors, it noted the flight loss of control is that the fore/ repeated improper reuse of degraded NTSB’s “longstanding concerns about aft servo bolt disengaged in flight, nuts on its helicopters,” the report said. the effects of fatigue on maintenance which resulted in the separation of the The Sundance General Mainte- personnel.” control input rod to the fore/aft servo’s nance Manual requires independent In particular, the NTSB cited the input lever, rendering the helicopter inspections of specific maintenance extended duty time that contributed to uncontrollable.” procedures, including procedures that the inspector’s fatigue, adding that it The report said accident investi- require use of a split pin, by a designat- “continues to believe that establishing gators evaluated several scenarios to de- ed company quality control inspector. duty-time limitations is a key strategy termine how the connection hardware The inspector who checked the to reducing the risk of fatigue-related became disengaged and concluded that work on the fore/aft servo installation errors in aviation maintenance.” the most likely explanation was that said he found no problem during his The report included several safety “the self-locking nut became separated inspection of the accident helicopter. recommendations to the FAA, includ- from the bolt, allowing the bolt to work The company’s check pilot, who ing one that called for the establish- its way out of the joint due to normal conducted a postmaintenance check ment of duty-time regulations based in-flight vibratory forces.” flight the morning of the accident, in part on start time, workload, shift The report noted a Eurocopter letter told accident investigators that he “saw changes, circadian rhythms and ad- that said that, because the nut had two nothing in the left [main gear box] cowl equate rest time. locking devices — the self-locking fea- area during his preflight inspection that This article is based on NTSB Accident Report ture and the split pin — it was designed indicated that the helicopter was not in AAR-13/01, “Loss of Control; Sundance to remain tight. Even if the split pin had a condition to fly.” Helicopters Inc.; Eurocopter AS350-B2, N37SH; not been in place “behind an airworthy The report added, “The NTSB con- Near Las Vegas, Nevada; December 7, 2011.” self-locking nut,” the nut should not cludes that the mechanic, inspector and Jan. 29, 2013.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 23 FLIGHTOPS
s reported in the first article in this Inc. as one part of the Foundation’s ongoing series (ASW, 2/13, p. 22), Flight Safety Go-Around Decision Making and Execution Foundation analyzed 16 years of aircraft Project. The study was designed to aid in un- accident data and found that the most derstanding the psychology of compliance and Acommon type of accident is the runway excur- noncompliance with GA policies when pilots sion. We noted that the almost complete (97 decide to continue to fly UAs rather than call percent) failure to call go-arounds (GAs) as a for GAs. After briefly describing the research preventive mitigation of the risk of continuing approach used in the Presage study, this article to fly unstable approaches (UAs) constitutes the will discuss three aspects of the research no. 1 cause of runway excursions, and therefore results: the pilot characteristics that differenti- of approach and landing accidents.1 ate the two decisions, the objective conditions In this second article, we report on a large that were most associated with continuing to study of pilots conducted by Presage Group fly UAs and GAs, and awareness competency
Why Do We Forgo the Go-Around? BY J. MARTIN SMITH, DAVID W. JAMIESON AND WILLIAM F. CURTIS
24 | FLIGHTFLIGHT SAFETY SAFETY FOUNDATION FOUNDATION || AEROSAFETYAEROSAFETYWORLD || APRILAPRIL 2013 © Ismael Jorda/AirTeamImages.com safety” “Company for support Environmental Awareness “Keeping eachothersafe” Relational Awareness theprocedures”“Knowing Hierarchical Awareness “Adjusting to threats” AwarenessCompensatory and equipment” theinstruments“Knowing Functional Awareness thelimits”“Knowing Task-Empirical Awareness onexperience”“Relying AwarenessCritical thethreats”“Seeing AwarenessAnticipatory “Gut feeling for threats” Affective Awareness Construct Presage Situational Awareness Dynamic Constructs Table 1 Source: The Presage Group the GAoption.the Here’s In our spoiler alert: the sion to continue UAs to fly instead of pursuing how shape they and ultimately drive- deci the event (GAversus scenarios recall UA), showing awareness constructs that two inthe differ former and overlay, where appropriate, those on other, the report results we the will of the one hand with our nine awareness constructs characteristics and objective conditions on the thread together relationships the pilot between in our previous article(Table 1).In order to Model (DSAM)constructs that we described Presage Situational Dynamic Awareness differences as measured for each of nine the FLIGHTSAFETY.ORG Description his/her commitment to safe andcompliant behavior and encourages safety andhow shapes thisinturn Pilot’s experience ofhow theircompany supports safety andcompliance member relationships inamannerthat protects Pilot’s to accurately ability assessandengagecrew- their order sequencing andcorrect Pilot’s ofoperational procedures, knowledge expert compliant operations operational conditions inorder to ensure safe, foror adjustcorrectly present andanticipated future Pilot’s how to andwhento know ability compensate translate what his/herinstruments are indicating Pilot’s how to ofknowing read knowledge and expert envelope ofhis/herequipment Pilot’s oftheoperational knowledge expert as “normal” events experience bankasameansto assesshere-and-now Pilot’s to draw ability from personalandprofessional time andspace potential threats astheymove andchangeover Pilot’s to seeand/ormonitor ability real and cognitive analysisfurther experience that triggersemotional, sensory pants experience, whichischaracterized by an Pilot’s gutfeelings for threats; seat-of-the- |
WORLD AEROSAFETY | APRIL 2013 GA while flying aUA. flying GA while and including adecision on for to whether call a duringexperiences minutes the leading up to pilotsneeded to report indetail, namely, their task would for elicit was what necessary we information “situated that special this recall” within last the fiverienced years). The vivid last the instanceber of aUA- had expe they memorable we (infact, asked pilots to remem- (SAH), that were recent and therefore highly approaches, at or below stable approach heights pilots instances to specific of recall unstable (Table 2,p. 26). results generalized to can pilots be worldwide geographical representation, suggesting our andperience operational as well as types, wide survey, range we achieved agood of pilot ex- stimulate participation. self-reports of pilots’ as well as experiences, to ity was assured to inspire honest and complete nationalities and cultures. Participants’ anonym - geographies, respondent levels, pilot experience aircraft operations, flight fleets, types, physical around world, the representing avariety of to as many survey the pilots as possible from forums. The was goal to recruit and administer ally, as well as through media various social FSF-member and non-member airlines- glob personnel at various pilot associations and through direct communication safety with both Foundation-sponsored were solicited survey and September 2012.Pilot respondents for this than 2,000 commercial pilots February between Presage conducted of an more online survey Pilot Survey constructs we assessed. one of on nine the experiences every DSAM ationally aware than pilots remembering GA reporting of recall their UAs were less situ- to continue aUA or execute aGA,pilots moments leading up to adecision on whether In main the of part study, this we asked Among 2,340pilots the completed who the FLIGHTOPS |
25 FLIGHTOPS
Sample Characteristics of 2,340 Pilot Respondents encourage full reporting, pilots were guided though a set of structured questions to elicit Variable Category Percentage their recall of events. Continent of operations Africa 1% In addition, to help refine the analysis, Asia 25% pilots also reported a variety of basic de- Europe 28% mographic information (such as rank, time North America 34% on type, base of operations, etc.) and flight Oceania 0% operational characteristics (long haul versus South America 12% short haul operations, aircraft type, etc.). The First language Non-English 56% content of the entire survey was reviewed, com- English 44% mented upon and amended in accordance with Initial Training Non-Military 74% the recommendations made by members of the Military 26% Foundation’s International Advisory Com- Current Position Captain 66% mittee, its European Advisory Committee and other advisory team members. First Officer 33% Among pilots who had experienced both Relief Pilot 1% GAs and UAs, we randomly assigned some to Flight Hours (Career) Median 10,000 hours recall a UA, and others to recall a GA event. Range 200–31,000 hours This random experimental assignment al- Aircraft Operation Passenger 88% lowed us to more confidently identify those Charter 4% objective and psychological situational factors All-cargo 7% associated with noncompliance with GA poli- Inactive 1% cies. Pilots who reported they had only flown Type of Operation Short-haul 62% GAs or UAs simply recalled their last event of Long-haul 38% those respective types. While paying particu-
Source: The Presage Group lar attention to the factors influencing a pilot’s decision to continue with a UA, in the results Table 2 below, we discuss differences between GA and UA events independent of a pilot’s prior These experiences include their own history of having flown them. Therefore, in subjective states (their situational and risk the findings to be reported, 57 percent of the assessments, social pressures, fatigue, beliefs pilots gave accounts of a UA they had partici- about their companies’ GA policies, etc.) as pated in, while 43 percent discussed a UA that well as their psychological representations of resulted in a GA. the objective factors characterizing the aircraft and the environment during their approaches UA Group Findings (flight instabilities, visual reference conditions, First, our results showed that pilots flying UAs environmental factors, etc.). These variables were more often first officers (FOs). In look- constitute a full and in-depth recounting of ing through our DSAM lens, and in particular, the objective factors in each situation and their at the lower scores on keeping each other safe resulting psychological representations during (relational awareness) for UA events, it makes the critical time leading up to pilots’ decisions. sense that FOs, who are vulnerable to the These representations, which constitute pilots’ authority structure of the cockpit and therefore states of dynamic situational awareness, were less likely to assume authority from the captain hypothesized to be the main drivers of pilots’ to call a go-around, are more likely to continue assessments of the risks of continuing to fly a with an unstable approach. It is important to UA rather than conduct a GA (Figure 1). To note that pilots’ total flight hours reported at
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the time of the event (an average of 9,250 hours awareness) early in the descent profile, and across the sample), as well as total time on type should the aircraft become unstable after the (average 3,000 hours), did not show any dif- SAH, an immediate “gut feel for this threat” ferences in the likelihood of having recalled a (affective awareness) will be triggered with an GA or UA event, reinforcing the argument that accompanying compensatory action (compensa- the differences between these groups lie not tory awareness) initiating a go-around. primarily in their pilot characteristics, but in Pilots reporting on a UA experience noted their situational awareness readiness to follow more instances of excessive airspeed and inap- the procedures (hierarchical and task-empirical propriate power settings. These results suggest awarenesses) should an instability occur at or that these pilots feel that although the aircraft below decision height. Geographically, there is unstable on these flight parameters, they still was a strong tendency for pilots based in South have the ability to “manage” the aircraft energy America and Asia to report more GAs than UAs, prior to landing. Such a belief naturally requires while those from North America and Europe the active suppression or silencing of a number recalled more UA than GA events. This suggests of our situational awareness constructs, such that operational environments, such as airport as denying the alarms from the gut (affective elevation or complexity of approach procedures, awareness), not seeing the threat (anticipatory or cultural differences, or both, may play a part awareness) and dismissing the standard operat- in these findings. ing procedures ([SOPs], hierarchical aware- Our results show a host of effects and non- ness) that state that under these conditions one effects associated with reporting UAs versus should be initiating a GA. Conversely, deviation GAs (Table 3, p. 28). Among the flight charac- in flight path and low airspeed were more often teristics more associated with choosing to fly reported by pilots recalling a GA event. The UAs are approaches in visual meteorological DSAM model suggests that this makes sense conditions (VMC) and already being unstable given that their gut is actively engaged and sens- when reaching SAH. By contrast, recalled GA ing these threats, and that the risks associated events were more associated with becoming with these factors are more accurately measured. unstable after SAH, and in instrument meteo- These processes trigger the correct adjustment rological conditions (IMC) and non-precision to compensate, that is, by initiating a GA. approaches. These findings suggest that VMC Finally, all the environmental factors may trigger a lack of discipline across two of our we assessed were more associated with the awareness constructs, most notably the gut feel decision to go around: presence of tail wind, for threats (affective awareness) and seeing the wind shear, turbulence, wake turbulence, threats (anticipatory awareness). It is as though the UA pilots are seduced into thinking that because of the VMC they can literally “see” their How Situational Awareness Plays a Role in Decision Making runway miles and miles from touchdown and a stable landing will not be problematic. IMC and more complex approaches such as non-precision Objective Situational Risk Decision require, by definition, a heightened sense of conditions awareness assessment making situational awareness across a number of our di- mensions in order to ensure the aircraft remains on profile. Psychological process In accordance with our DSAM explanatory model, the GA pilots will, in IMC with a pend- Source: The Presage Group ing non-precision approach, “see” these event characteristics as potential threats (anticipatory Figure 1
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Flight Scenario Characteristics
Recall of Statistically reliable GA Events UA Events difference? Flight characteristics Recency of event (mean number of months in past) 31 35 No % Short-haul 66 70 No % Long-haul 34 30 No % VMC approaches 70 85 Yes % IMC approaches 17 8 Yes % Precision approaches 44 39 No % Non-precision approaches 18 12 Yes % Approaches with active instrument reference 32 34 No % Approach without active instrument reference 9 8 No % Manual approach to recognition of instability 42 43 No % Automated approach to recognition of instability 32 27 No % Combined manual and automated approach 26 28 No % Unstable at stable approach height 71 86 Yes % Unstable after stable approach height 29 14 Yes % Respondents who were flying 45 48 No % Respondents who made the decision to go around 80 — — % Respondents who made the decision to continue unstable approach — 57 — % Respondents who discussed a go-around — 44 — Mean altitude at which decision was made (ft agl) 750 814 No Incidence of instability factors (%) Flight path deviation 66 51 Yes
Aircraft speed exceeded VREF +20 knots 53 63 Yes
Aircraft speed was less than VREF 9 4 Yes Sink rate exceeded 1,000 feet per minute 48 50 No Power setting was not appropriate for the aircraft 44 53 Yes Aircraft was not in the correct landing configuration 28 27 No Briefings and checklists were not complete 15 15 No Incidence of environmental factors (%) Tail wind 37 29 Yes Wind shear 23 11 Yes Turbulence 30 19 Yes Insufficient visual reference 21 9 Yes Contaminated runway 14 5 Yes Incidence of ATC factors (%) Occupied runway 6 5 No Inadequate separation on approach 12 12 No Wake turbulence 6 3 Yes Late clearance or poor approach vectoring 38 39 No
agl = above ground level; ATC = air traffic control; GA = go-around; IMC = instrument meteorological conditions; UA = unstabilized approach;
VMC = visual meteorological conditions; VREF = reference landing speed
Source: The Presage Group
Table 3
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insufficient visual reference and contaminated risk confronting them: UA pilots perceived far runways. Our intuitive assumption is con- less risk lurking in the instabilities they were firmed empirically — the more complex the experiencing than did GA pilots. This differ- operational environment, the more engaged ence is perhaps not so surprising given what the pilot’s situational awareness. The fact that they eventually decided to do (that is, to go these environmental factors are less associated around or not) based on these very risk as- with UAs is consistent with the notion of the sessments, but the strength of the difference is psychological seduction of fair-weather flying. large. What our research sought to discover was Pristine flight conditions invite a greater toler- why these strikingly different assessments of ance for the belief that the absence of complex risk occurred. What factors were reported to be environmental factors equates with little or stronger or weaker in the situational awareness no risk to be managed, and suggest to the UA profiles of pilots leading up to their judgments pilot that on one hand, there is a low prob- of risk? Which of these could be implicated in ability of the aircraft becoming unstable, and leading directly to the lowered perception of on the other hand, should it become unstable, risk among pilots in the group continuing to fly the environmental conditions nonetheless lend UAs? In fact, we see evidence that on all nine of themselves to “managing” the instability cor- the DSAM dimensions of situational awareness, rectly and landing uneventfully. The processes the awareness competencies affecting their that lead to these seductive assumptions, how- judgments of risk, pilots who continued a UA ever, require the active numbing or passive reported having less situational awareness than tuning out of the nine DSAM constructs. those who initiated a GA. Many of these effects are very strong (defined as half a point differ- Psychosocial Factors ence on our measurement scales or greater) and Given that these objective, situational risk were observed across the range of items used to factors existed in the events pilots described, assess each construct. how were those factors perceived, explored and Certain elements of the psychological situ- managed by flight crews prior to the decision to ation were or were not present in the two event continue to fly UAs? What levels of situational recall cases in the moments leading up to pilots’ awareness did pilots report that they and their decisions. Whether these situational aspects crewmembers developed in these scenarios, were sufficiently pursued by conscious explora- were these accurate, and how did they contrib- tion and deliberation (and whether they were Pristine flight ute to their assessments of the risks of continu- pursued alone or with other crewmembers) ing UAs? Finally, did aspects of situational is likely to have played a key role in whether conditions invite a awareness differ in the moments leading up to pilots and their crews developed the kind of greater tolerance for the GA–UA decision in a patterning that might complete, dynamic and shared picture of the help explain those decisions to call or forgo a situation that would have allowed them to reach the belief that the call to go around? full and accurate competency across each of The findings of the study on situational these nine dimensions of situational aware- absence of complex awareness and the other psychosocial variables ness that we have described. For example, we environmental we measured are pervasive and robust (Table established that fatigue, while present in many
4, p. 30). Working backward from the deci- of the events, did not differ between the two factors equates sion to continue to fly a UA (Figure 1, p. 27), a types of scenarios. However, the effectiveness highly significant difference existed between by which a pilot adjusted to the threat (com- with little or no risk GA-recall and UA-recall pilots in terms of the pensatory awareness) by implementing proper most immediate cause of their decision whether fatigue management procedures did differ. This to be managed. to call a GA, namely, their perception of the illustrates another example of how, when situ- manageability versus unmanageability of the ational awareness remains high, the pilot sees
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DSAM Dimensions and Psychosocial Factors
Recall of Statistically reliable GA Events UA Events difference? Mean perceived risk score (6-pt scale; higher= higher perceived risk) Assessment of the instability as risky/unmanageable 4.40 2.37 Yes Mean scores on Presage dynamic situational awareness model constructs (6-pt scale; higher= higher awareness) Affective awareness (gut feeling for threats) 4.35 3.31 Yes Functional awareness (knowing the equipment) 4.65 3.33 Yes Critical awareness (relying on experience) 4.24 3.82 Yes Anticipatory awareness (seeing the threats) 3.99 3.32 Yes Task-empirical awareness (knowing the limits) 4.92 4.77 Yes Compensatory awareness (adjusting to threats) 3.54 2.46 Yes Relational awareness (keeping each other safe) 4.54 4.19 Yes Hierarchical awareness (knowing the procedures) 4.61 4.20 Yes Environmental awareness (company support for safety) 5.20 5.06 Yes Mean scores on key psychosocial factors (6-pt scale; higher=higher score on dimension) Presence of fatigue 2.81 2.85 No Proper fatigue management 4.12 3.69 Yes Ability to listen to/understand gut feeling warnings about risk 4.73 4.18 Yes Ability to anticipate a GA 4.18 3.19 Yes Confidence in GA performance abilities 5.34 5.32 No General willingness to challenge crew 4.99 4.92 No Event challenges to authority 2.95 2.93 No Appropriate crew influence on GA decision making 4.99 4.70 Yes Passenger pressure to land 4.02 3.79 No Agreement with company UA/GA policies and procedures 4.59 4.29 Yes Intolerance for deviance from GA policy and procedures 4.91 4.30 Yes Anticipated company support for a GA decision 5.18 4.98 Yes Company incentivization % Who say their company reprimands pilots for performing UAs 47 45 No % Who say their company reprimands pilots for performing GAs 4 4 No Incidence of active consideration/discussion of instability factors (% among those aware) Flight path deviation 79 69 Yes
Aircraft speed exceeded VREF +20 knots 85 69 Yes
Aircraft speed was less than VREF 67 73 No Sink rate exceeded 1,000 ft per minute 73 64 Yes Power setting was not appropriate for the aircraft 68 59 Yes Aircraft was not in the correct landing configuration 81 64 Yes Briefings and checklists were not complete 63 56 No Incidence of active consideration/discussion of environmental factors (% among those aware) Tail wind 65 70 No Wind shear 73 82 No Turbulence 61 52 No Insufficient visual reference 62 67 No Contaminated runway 72 56 No Incidence of active consideration/discussion of ATC factors (% among those aware) Occupied runway 74 66 No Inadequate separation on approach 63 69 No Wake turbulence 50 69 No Late clearance or poor approach vectoring 70 68 No
ATC = air traffic control; DSAM = Presage dynamic situational awareness model construct; GA = go-around; IMC = instrument meteorological conditions; UA = unstabilized approach; VMC = visual meteorological conditions
Source: The Presage Group
Table 4
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and feels the fatigue threat and then adjusts or their situational awareness and influenced their compensates for it. assessments of risk and its manageability. Similarly, the frequency of actual chal- Also of interest are pilots’ perceptions of lenges to authority as reported by pilots in their companies’ attitudes about performing the UA or GA cases did not differ, whereas UAs and GAs. When asked in general whether the quality of the influence the crew had on their companies reprimand pilots for perform- decision making did. When we examined ing either UAs or GAs, pilots in the two event our findings for the factor, “appropriate recall types reported no differences in the Pilots … were crew influence on GA decision making,” consequences their employers would impose we saw that pilots who made a GA decision for compliance or lack of compliance with their more likely to reported that in the moments leading up to companies’ policies. But when asked about report that the the decision they experienced what we judge these matters in the context of the events they to be more appropriate crew discussion and were recalling, UA pilots reported that in those authority structure behavior. Pilots reporting their experiences moments, they anticipated less company sup- in flying a UA, on the other hand, were more port for a GA decision. In addition, they were in the cockpit was likely to report that the authority structure in less likely to agree with their companies’ UA/ influencing their the cockpit was influencing their decision to GA policies and procedures and reported more call a GA or not; that they felt less comfort- personal tolerance for deviations from them. Al- decision to call able in challenging or being challenged about though this is a topic we will explore further in conducting a GA; that they were feeling less our next article, it is worth noting that if pilots a GA or not. support from their crewmembers for calling perceive that there will be less support from the a GA; that they felt more pressure from other company for a GA decision, and basically dis- crewmembers to continue the approach and agree with that company’s GA/UA policies and land; and that they were feeling more concern are more tolerant of deviations, they are primed about a loss of face in calling a GA. In other for non-compliance. words, unlike UA pilots, GA pilots had lever- aged their relational awareness competencies Normalization of Deviance to keep each other safe by creating a more Deficits in situational awareness that would lead supportive, non-judgmental and challenge- to continuing an unstable approach can now accepting cockpit environment and engag- be seen more clearly, and prompt the follow- ing in the appropriate conversations around ing conclusions about how effectively objective operational and flight risks. situational factors are all too often translated to This awareness of keeping each other safe a psychological representation before a decision spilled into other areas of risk assessment for is made. A very specific situational awareness the GA pilots when we looked at how deliber- profile emerges for the pilot who continues an ately pilots recalled having “actively considered unstable approach. Within the UA pilot group, and discussed” various objective situational this profile was characterized by a consistent factors. While there were no differences in and comprehensive denial or minimization of personal consideration and/or active crew situational awareness competencies. In much discussion between GA and UA pilots on any of the same way a dimmer switch can be used to the environmental factors or air traffic control illuminate a room to varying degrees, the UA factors assessed, when considering five of the pilots have selectively turned down or dimmed seven instability factors we measured, GA pilots their situational awareness competencies and, considered them more thoroughly and had in so doing, dulled their sensory and cognitive more communication between crewmembers processes when assessing and evaluating opera- than UA pilots, providing information that tional risks. Because our nine DSAM dimen- most certainly would have better informed sions of situational awareness are by definition
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 31 FLIGHTOPS
inseparable and intrinsically interactive, it is keep each other safe (relational awareness). The fair to ask the question, “Which of the nine gets psychological landscape now lends itself to the turned down first?” pilots being less disciplined about what their Well, on one level it doesn’t matter, princi- instruments are telling them (functional aware- pally because once one dims, it naturally ripples ness) and less concerned about knowing the across all of the other constructs, dimming them procedures (hierarchical awareness) and aircraft all in the process. This is exactly what we see operational limits (task-empirical awareness). in the results, namely an effect across all nine So why do pilots forgo the GA decision in dimensions of the DSAM. On another level, and 97 percent of UAs? We have discovered that taking into account the totality of our findings, it continuing to fly a UA is associated with much can be argued that the dimming of one’s situ- lower levels of perceived risk about the unman- ational awareness competencies actually begins ageability of instabilities experienced at and with the collective collusion on behalf of pilots below SAH. These lowered risk assessments in non-compliance with go-around policy and are in turn associated with a lowered level of procedures. Others have referred to this type of situational awareness on each of the dimen- comprehensive “buy-in” as an example of the sions of the DSAM we have described. For pilots “normalization of deviance.”2 Another way to continuing to fly UAs, threats and risk associated state this is that a group’s non-compliance with a with the objective flight conditions are inad- policy or procedure over time becomes the “new equately translated to a compelling psychological normal” within a culture or organization. risk understanding through a comprehensive, As lived through our DSAM for pilots re- up-to-date and accurate set of dynamic situ- porting instances in which they continued to fly ational awareness competencies. Owing to their UAs, the normalization of deviance taps into the interdependent nature, weakness in situational most fundamental level of situational awareness, awareness in any of these competencies leads to namely the company’s support for safety (envi- a rapid undermining of other dimensions and a ronmental awareness). When a pilot has the ex- fast deterioration in accurate risk perceptions. perience that his/her company and/or regulatory With lowered risk assessment comes the decision body is seemingly uninterested in protecting to continue to fly a UA rather than execute a GA. and monitoring compliance with procedures, he And because most of the time we “get away with or she naturally personalizes this by becoming it,” managing the aircraft’s energy to a successful undisciplined or uncaring. The tendency then is landing, this reinforces the belief that the risks of for a pilot to be less strict about personal com- instability are manageable and perpetuates the pliance with the company’s GA policy. There is cycle of chronically forgoing the GA.
a moment for every pilot flying a UA, whether The Presage Group specializes in real-time predic- at top of descent or at 5,000 ft, where his or her tive analytics with corrective actions to eliminate the situational awareness competencies may begin behavioral threats of employees in aviation and other to dim. Once a pilot’s commitment to a policy industries. Further details of the methodology of their has shifted in general, almost immediately his survey, experiments and results are described at
32 | FLIGHTFLIGHT SAFETY SAFETY FOUNDATION FOUNDATION || AEROSAFETYAEROSAFETYWORLD || APRILAPRIL 2013 e Foundation would like to give special recognition to our BARS Benefactors, Benefactor and Patron members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible.
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Brazil is leading in the development of responsible programs for teaching aviation English.
BY ELIZABETH MATHEWS Photo illustration: Jennifer Moore; Photos: © Cristian Baitg/istockphoto Photos: Moore; illustration: Jennifer Photo
34 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 STRATEGICISSUES
n a world where progress in the teaching should they teach, and for how long?” Progress and testing of aviation English often has was halting and uneven, with more reports of stalled, the aviation industry in Brazil has missteps and failures than successes. turned a significant corner, making safe In that context, Brazil’s civil aviation authori- Iaviation communication a priority. ties and the English language training community In remarks to an aviation English conference focused at the November conference on progress in Brasilia in November 2012, Carlos Eduardo made and solutions that are being implemented. Magalhães da Silveira Pellegrino, the direc- Their presentations, as well as the information tor of Brazil’s National Civil Aviation Agency from representatives of ICAO and the Interna- (ANAC), said Brazil has made a full-scale tional Federation of Air Line Pilots’ Associations commitment to improving aviation English in (IFALPA), provide information that is helpful its airspace. Other representatives of ANAC and to organizations still struggling with their own the Airspace Control Institute (ICEA) also dem- implementation of ICAO language requirements. onstrated the progress that can be made when senior administrators understand the relation- ICAO Standards ship between best practices in aviation English By the time ICAO organized its Proficiency and safe communications. Requirements in Common English Study The progress is especially noteworthy in Group (PRICESG) in 2000, English had long light of the possible role played by inadequate been both a de facto and an official aviation language proficiency in the Sept. 29, 2006, col- safety requirement embodied in a number of lision of an Embraer Legacy 600 and a Boeing ICAO standards and recommended practices 737-800 over the Amazon (ASW, 2/09, p. 11; (SARPs). Nonetheless, despite the obvious safe- ASW, 12/11–1/12, p. 22; ASW, 2/12, p. 41). All ty need for proficiency in a common language, 154 people in the 737 were killed in the crash; and despite the existing ICAO requirement the seven people in the damaged but control- that pilots and controllers “speak the language lable Legacy were uninjured. In its final report used for radiotelephony communication,” there on the accident, the Brazilian Aeronautical was much evidence — including the “trail of Accident Investigation and Prevention Center wreckage” of accidents in which language pro- (CENIPA) recommended that the Department ficiency was a contributing factor — that for of Airspace Control “immediately ensure that many pilots and air traffic controllers, English [Brazilian air traffic] controllers have the re- language proficiency was limited to memoriz- quired level of English language proficiency.” ing ICAO phraseology contained in Document Three years before the accident, in 2003, 4444, Air Traffic Management: Procedures for the International Civil Aviation Organization Air Navigation Services. Without formal ICAO (ICAO) had adopted its requirements for Eng- plain language and testing requirements, the lish language proficiency testing of pilots and industry had not invested in the development air traffic controllers; however, they were not of the needed aviation-specific English lan- applicable until 2008, and little infrastructure guage programs. was in place to support their implementation. Complicating the scenario, commercial In the 10 years since the language standards testers and training providers rushed to the were adopted, ICAO has held international and market; from my perspective, some had more regional seminars, developed speech sample tool business acumen than commitment to safety kits and rating aids, and published supporting or to best practices in language teaching. Even documents. Nonetheless, until very recently, avia- some otherwise responsible aviation organiza- tion English conferences and seminars were rela- tions have tended toward ICAO minimum stan- tively basic, addressing questions such as “Who dards in aviation English — skimping on teacher can teach? What content should they teach? How training, ignoring best testing practices or using
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materials that do not correspond closely to the ICEA demonstrated such a commitment from operational requirements. Similarly, but coming the top. from the opposite direction — moving from an The next important indicator that Brazil has existing position within the language teaching made safe aviation communication a high prior- industry into aviation — some language organi- ity is found in the academic qualifications of the zations have capitalized on the lack of standards leadership team implementing the testing and by repackaging existing materials into “aviation training programs. In keeping with ICAO rec- English” programs. ommendations, the individuals leading Brazil’s Again, from my perspective, whether aviation English testing and training have mas- through ignorance or intent, whether drawn ters degrees or doctorates in applied linguistics by lure of quick profit or a drift into compla- or English language teaching. cency, the effect has been the same: Even some This matters because English language name-brand programs do not deliver acceptable teaching and testing are unregulated industries, results, maintaining a greater focus on market- and too many programs do not adhere to best ing than on content development. This has only practices. Sometimes this is due to aviation added to the confusion and frustration within professionals’ lack of specialized knowledge; a the industry. close reading of ICAO Document 9835, Manual Understanding the many challenges to best on the Implementation of ICAO Language Pro- practices in aviation English instruction un- ficiency Requirements, is the remedy for that. derscores the importance of developments that ICAO included minimum qualifications in its were recently exhibited at the International Civil recommendations because some regions have Aviation English Association (ICAEA) Aviation lacked academically well-prepared language English Conference, with its theme of “Testing instructors. In those cases, the solution is to and Training: A Common Aim?” ensure a team leader has the best qualifications and to commit to ongoing professional develop- Brasilia Conference ment for teachers. Presentations from ANAC, ICEA and the Brazil- Most distressingly, too many commercial ian academic community demonstrated that providers — even those based in English- Being a native Brazil’s efforts since 2009 in aviation English as-a-first-language countries, with access to proficiency have been dedicated, sophisticated well-qualified English language teaching or speaker of English and mature. So it is worth examining what Bra- testing professionals — have tended toward zil is doing right. ICAO minimum standards, providing teachers does not qualify an Effective language programs share certain or program managers who have only minimal
individual to teach characteristics. Successful programs involve qualifications to teach English. Being a native understanding the nature of language learning speaker of English does not qualify an individu- English. and having realistic expectations for learner al to teach English. progress, as well as providing the conditions that However, the aviation English industry has allow for language learning, and for assessment become competitive. Organizations should insist of progress. that the provider either supply instructors with The first requirement in an effective large- ICAO’s “best” qualifications or commit to provid- scale corporate or work-oriented language ing ongoing, high-quality training to their instruc- program is an executive-level commitment to tors until all instructors meet these qualifications. the process. No matter how well-prepared or well-intended instructors or testers are, without Academic Qualifications Matter a commitment from senior administrators, it is In contrast to the qualifications of many people difficult to achieve much progress. The presen- working in the aviation English field, the applied tations from Pellegrino and others at ANAC and linguistics and language teaching academic
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backgrounds of the aviation English specialists Brazil’s aviation English programs take such who spoke at the conference in Brazil reflected an approach. The program presented for control- the country’s commitment to best practices. lers, in particular, by Patricia Tosqui Lucks and The expertise of their aviation English leader- Jairo Roberto da Silva of ICEA, demonstrated this ship teams was evident in the programs and the commitment to cross-training, as controllers who research presented. achieve ICAO Level 5 English proficiency1 or Their initial success is a reminder of the better can be invited to cross-train as co-teachers importance of ICAO’s recommendation that to work in partnership with English instructors in Best practices in academic qualifications matter, that the inten- the classroom — a resource-intensive but effec- tion is to protect the end user and that the tive technique, demonstrating an extraordinary aviation English programs offered to pilots and controllers must commitment to best practices. be effective and efficient. Whether a country or require not just that organization is, like Brazil, growing its own in- Research and the Future English teachers house programs, or subcontracts the program Particularly gratifying is that the comprehen- to an external aviation English provider, the first sive approach to aviation English in Brazil collaborate with step is to identify an individual or team repre- centers on “home grown” programs being de- senting ICAO’s best qualifications for language veloped and led by Brazilian English language subject matter teaching or testing to guide the entire process. experts and aviation subject matter experts. experts, but also External providers and experts can add Team Approach meaningful value or direction, but the focus, that both sides The third indicator of the quality of the Brazil- naturally, should be on developing in-house ian aviation English program was evident in its expertise and capability. understand one team approach. Again, in adherence to ICAO Among the presentations was the dis- guidance materials, English instructors are cussion by Ana Monteiro of ANAC of her another. working with aviation subject matter experts. analysis of challenges to oral comprehension in Each presentation was co-presented by a lan- aviation. She recommended that existing tax- guage specialist and a subject matter specialist. onomies of communication factors be revised, As essential as English language teaching considering that new categories are coming to expertise is, English teachers working alone light as our understanding of language as a hu- will almost certainly miss the mark on aviation man factor improves. content. In fact, much experience in aviation Overall, the research presented by Monteiro, English development has proved that more as well as the programs presented on pilot than simply a team approach is essential. Best training by Ana Bocorny of Pontifical Catholic practices in aviation English require not just that University of Rio Grande do Sul in Porto Alegre, English teachers collaborate with subject mat- Brazil — responsible for much pilot English ter experts but also that both sides understand training — and on testing by ANAC and ICEA one another and learn what is important from representatives, suggests that Brazil’s aviation their colleagues’ perspectives. Academics need English community is taking a leadership role in to learn about the culture of aviation safety and the industry. have more than a passing familiarity with flight If the academic standards and commitment operations. Operational experts need to under- to best practices that have been demonstrated stand the basics of adult language-acquisition at the top of Brazil’s aviation English infrastruc- principles and to trust their academic colleagues ture are carried down to the base, if the teach- to deliver aviation English content in ways that ers in the classrooms are as well prepared as encourage learning and stimulate acquisition. the leadership teams presenting at the Brasilia Finally, a team approach helps generate organi- conference, then the classroom teaching can be zational buy-in. expected to be communicative, interactive and
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engaging to learners — essential conditions for enhance flight safety. Aviation English teachers language learning. must also be safety advocates, he said. One remaining question that was not entirely clear at the conference is the content focus of avia- Progress tion English classes in Brazil. ICAO recommends Although progress is being made, that does not content-based aviation English, an approach mean that aviation English standards have been that has not yet been well enough understood or fully implemented, nor does it mean that progress embraced by most commercial providers of avia- will be rapid, or that the teams will not encounter tion English. Again, because language teaching rough air. The sheer amount of training time re- is an unregulated industry, material providers quired to achieve pilot and controller compliance sometimes claim a content-based approach, but with language-testing SARPs also can exceed the claim is based on a tenuous understanding that of other new safety-training requirements. of content-based language teaching, or materials Implementing large-scale language training and present a haphazard application of content-based testing programs required by a country as large as learning. However, as the effort matures and as Brazil demands commitments of time, effort and programs undergo revision and development, the resources by individuals and organizations. industry may grow to better understand and apply Considering the difficulties the aviation in- content-based aviation English.2 dustry has experienced in the first decade after adoption of the ICAO language requirements, ICAO and IFALPA it is only right to celebrate what looks to be a Adding to the sense that aviation English is ma- country heading toward aviation English suc- turing was the presentation by Nicole Barrette- cess. From these indications, Brazil has estab- Sabourin, a technical officer with ICAO, who lished the conditions to make language-learning explained ICAO’s recently launched language programs successful: a commitment from the test endorsement program. Dozens of avia- top, well-qualified linguistic teams guiding the tion English tests, as noted, have come into the effort and close cooperation between language unregulated language testing market. There have specialists and operational experts.
been evidence of poorly designed or inad- Elizabeth Mathews, an applied linguist who led the inter- equately implemented testing, and reports of national group that developed ICAO’s English language cheating and outright fraud. Thus far, among at proficiency requirements, researches the role of language least nine testing programs that have undergone as a factor in aviation communication and advocates for the ICAO review, four have been either en- improving the quality of aviation English training and teacher training. dorsed or conditionally endorsed. A voluntary, low-cost program, this ICAO effort represents Notes an important step, pushing the industry toward better language testing and excluding the worst 1. ICAO’s requirements, which define six levels of lan- testing offenders. guage proficiency ranging from Level 1 (pre-elemen- In another presentation, Rick Valdes, a tary) to Level 6 (expert), say that Level 5 (extended) is characterized by, among other traits, pronuncia- Boeing 767 captain for United Airlines and tion and intonation that “rarely interfere with ease the IFALPA representative on the PRICESG, of understanding,” vocabulary that is sufficient for reviewed obstacles to best practices in aviation effective work-related communication and responses English in the context of threats to safety. that are “immediate, appropriate and informative.” “We know there are companies out there that 2. The Center for Applied Linguistics
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Vulnerability-discovery methods of ASIAS gain acceptance across national borders.
Sharing the Wealth BY WAYNE ROSENKRANS
reators of the Aviation Safety has about a year of experience working participants following a phased expan- Information Analysis and Sharing closely with a number of similar inter- sion plan to include other parts of the (ASIAS) program in the United national partnerships, said Jay Pardee, aviation community. ASIAS will include States imagined years ago that the FAA’s chief scientific and technical domestic corporate general aviation, Ctheir methods could be a good fit for advisor for vulnerability discovery and military, helicopter, manufacturers other countries and their airlines and safety measurement programs, in a and other government agencies.” An possibly non-airline interests within recent briefing for AeroSafety World. example of effect on another govern- aviation. Currently, this government- According to FAA, ASIAS leaders ment entity is the relationship forged industry partnership funded by the U.S. also expect to fufill their intention to a few months ago with the National enter for Advanced Aviation System Aviation Advanced for enter C Federal Aviation Administration (FAA) “increase the numbers and types of Transportation Safety Board (NTSB; MITRE Corporation The Development,
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see “Agreement Launches ASIAS–NTSB Work- issues relevant to unstabilized approaches, terrain ing Groups,” p. 42). awareness and warning system (TAWS) alerts, As when it launched in October 2007, ASIAS traffic-alert and collision avoidance system continues to focus on known-risk monitoring, (TCAS) resolution advisories (RAs), runway vulnerability discovery and directed studies excursions and other potential threat indicators. typically prompted by findings of ongoing safety “We help measure the effectiveness of actions data analyses, the needs of the Commercial Avi- in their region’s airports by looking at our own ation Safety Team (CAST) and concerns raised ASIAS information and — in a protected fashion by the U.S. airline industry during semi-annual … a de-identified fashion — sharing that with Aviation Safety InfoShare meetings (ASW, 5/08, the [RASG-PA] industry-government cochairs,” p. 25). The system’s techniques, data sources and Pardee said. “The advantage is, from the ASIAS algorithms have appealed to several countries, airline member perspective, we can achieve but patterns and structures recently created for improvements in the safety of airports that our the Latin American and Caribbean Region have airline members fly into within Pan-American yielded an especially sound model, Pardee said. countries. It has been a very successful experience “We’ve forged a relationship with some for ASIAS and the RASG-PA organization — a additional regions and countries around the model we do intend to use around the world. We world,” he said. “The Regional Aviation Safety periodically review the data with them, look at Group–Pan America [RASG-PA] uses the same the progress they’ve made, and it’s a relationship principles that we use in ASIAS and CAST; it is that continues to prosper. ” an industry-government partnership [ASW, 2/13, The ASIAS–RASG-PA collaboration has p. 42]. The ASIAS Executive Board has agreed to been able to delve deeply into threat detection share our U.S. airline member experience flying and mitigation monitoring partly because of into some 22 airport locations” with RASG-PA’s mutual trust, he said. “We get down to look- industry-government teams representing those ing discretely at the details of those types of airports. A memorandum of understanding effec- precursors, and we monitor the frequency and tive in January 2012 defines the ASIAS–RASG- location jointly with RASG-PA helping them PA working relationship. to take corrective action,” Pardee said. “Airlines “The information is in an aggregated, protect- that are domiciled in that region benefit from ASIAS analysts ed, de-identified state, which is the way we use it the same improvements as U.S. airlines in safe- applied the TCAS under our governance within ASIAS,” Pardee said. ty, CFIT [controlled flight into terrain] reduc- RA algorithm to “They’ve adopted at this point in time 11 CAST tion, improvement in unstabilized approaches, surveillance-radar safety enhancements. Many of them were built reduction in TAWS alerts, reduction in TCAS tracks while exploring based on knowledge from ASIAS, which we share RAs, so we are using the data effectively.” for any systemic to assist RASG-PA in implementing solutions for risk after a Boeing problems we have knowledge about, that we have NextGen Safety Assurance 767-300 flight crew experienced in our own country. They’ve agreed One of the most recent ASIAS directed stud- responded to a they will adopt 33 starting with those elements that ies — focused on operations using area navi- non-safety-critical are the most logical for their safety issues.” gation (RNAV) off the ground (ASW, 3/12, p. “DESCEND” RA while The focus during most of the first year of 28) — was completed, and study-based safety passing 7,600 ft on the relationship was providing quarterly safety enhancements currently are under develop- the HYPER STAR into information reflecting ASIAS member airlines’ ment by CAST, said Michael Basehore, FAA’s Washington Dulles experience operating into the 22 RASG-PA ASIAS program manager.1 The latest directed International Airport. airports, as an indication of the effectiveness study — focused on STAR (standard terminal of their risk-reduction solutions. Members of a arrival route) RNAV operations — is looking at U.S. government-industry issue analysis team risk factors in the context of a wider NextGen provide technical data that identify the safety research program that began in 2010, Basehore
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Agreement Launches ASIAS–NTSB Working Groups
he U.S. National Transportation Safety Board (NTSB) has mechanism. “If they say ‘we need to take this little turn over gained access, on a case-by-case basis, to a vast store of here because we discovered something related during the Tsummarized safety data gathered, analyzed and protected investigation,’ and if it’s within the line and the framework of within the Aviation Safety Information Analysis and Sharing the initial permission that was given for the setting up of the (ASIAS) program to prevent airline accidents (Table 1, p. 44). work group, then they can continue doing that,” he said. “If When a formal NTSB request is approved under the it’s outside of that scope, then the ASIAS Executive Board will November 2012 memorandum of understanding, the board make a determination whether to allow them to do that.” reciprocates by granting ASIAS access to archived digital The memorandum bars any of the parties from using flight data recorder (DFDR) data specifically related to the FOQA data, aviation safety action program reports, air traffic request. Regardless of whether an accident occurs, ASIAS is safety action program reports or non-publicly available data working with the NTSB to acquire archived DFDR data that, to measure an individual data contributor’s performance when added to the ASIAS databases, might reveal accident or safety. ASIAS protocols already had limited FAA analysts’ precursors or indications of systemic risks. Various restrictions access to aggregate and/or de-identified information for preserve the U.S. airline industry’s voluntary — and now purposes outside of ASIAS. indispensable — flows of safety information from routine “One of the benefits I see in looking at the NTSB DFDR flight operations, according to the NTSB and the U.S. Federal data archives is that we can use those signatures, those digi- Aviation Administration (FAA). tal data patterns, bring them into our vulnerability discovery Collaboration under this highly structured and controlled activity within ASIAS, and then digitally look across all of framework stands to enhance all parties’ predictive methods the digital databases to see if we see any indication of that (ASW, 3/13, p. 43; ASW, 11/11, p. 32), said Paul Morell, a cap- same pattern,” said Jay Pardee, the FAA’s chief scientific and tain and vice president, safety, security and environmental technical advisor for vulnerability discovery and safety mea- programs, US Airways, and industry co-chair, ASIAS Executive surement programs. “Not necessarily [studying] the accident Board (AEB). From his perspective, most noteworthy is that itself, but we’re interested in the precursors that would be in the memorandum’s provisions only apply in an accident that DFDR trace prior to an event.” involving a U.S. air carrier in the United States. “The absolute cornerstone of ASIAS is that nothing leaves “In essence, we’re expanding the database for ASIAS in order the working group until the NTSB and the IAT make a determi- to do our research,” Morell said. The ultimate advantage to ASIAS nation that it should become part of a public record or part of members will be gaining new insights from the NTSB relation- their investigation,” Morell said. “At that point in time, all that ship and carrying over data that help the Commercial Aviation is brought to the AEB, and the Executive Board will make a Safety Team to develop effective risk mitigations, he added. determination whether or not that can be released. If not, then Any accident that meets these criteria provides “NTSB an op- the NTSB can’t use it in their report but they still have an idea portunity to talk to our IAT [ASIAS initial analysis team tri-chairs] of where they should go or what they should do.” and AEB co-chairs, and to see if there could be something, some For example, if the NTSB investigates a commercial jet kind of information we may have where we can help them in runway overrun accident involving excessive time elapsed their investigation,” Morell said. Ideally, knowledge will expand between touchdown and the flight crew’s spoiler deploy- beyond an isolated case being investigated by NTSB, he said. ment, the NTSB will not be permitted to use any aggregate NTSB-ASIAS interaction for a given event begins with these ASIAS information that could be used to compare the ac- investigators. “First of all, there’s a protocol within the NTSB cident crew’s performance with the industry norm. to determine whether they will ask ASIAS to engage,” Morell However, if a commercial jet landed short of a runway said. “Once they make a determination within the NTSB, then after experiencing fuel system icing during approach to an there is the informal query, NTSB talking to the IAT tri-chairs. airport — and ASIAS-member airlines’ FOQA and engine We either determine ‘we can probably help you’ or ‘we really data were accessed to support this investigation — these cir- don’t have what you’re looking for.’ Once we get the formal cumstances likely would be favorable for concurrence by the request, then we engage and we meet at MITRE Corp. [the AEB in NTSB’s desire to publish comparisons of the accident not-for-profit, FAA-funded research center that has steward- scenario with multi-airline experience. ship of ASIAS data]. We have the NTSB representatives and “There’s a perfect example where you’re using informa- we have the IAT representatives create a working group.” tion from all these sources but you’re not comparing an The working group uses the formal request as its scope of airline or a crew, you’re looking at a generic view of how a work but with a practical degree of flexibility and adjustments system operates,” Morell said. that are made possible — but not guaranteed — by another — WR
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said. Called Optimization of Airspace air transport operators operate in adja- current tactical safety concerns from and Procedures in the Metroplex cent airspace (ASW, 8/09, p. 34). ASIAS are using this airspace-design (OAPM), the program has been study- “ASIAS, in a protected fashion, tool, which has the detection algo- ing the benefits of changes to airspace contributes what the known tactical rithms built into it” for preemptive and procedures through local teams in threats are in those areas, whether they risk reduction, he said. 21 NextGen-defined metroplexes.2 are TAWS warnings, TCAS alerts or A similar activity recently begun “[ASIAS works] with these OAPM unstabilized approaches,” Pardee said. by ASIAS to strategically “design risks teams as they look at the different “We provide that safety information to out of the system” throughout NextGen metroplex areas, and shares with them metroplex teams along with the tools implementation has been detection of the information that we’ve gained that ASIAS developed to detect them in tactical safety concerns during local from a directed study, known-risk the first place.” Two software modules adjustments to new arrival procedures monitoring or benchmarks that we’ve identify TAWS-warning hotspots and based on performance-based navigation already identified for their metroplex,” TCAS RA hotspots, patterns detected (PBN), Pardee said. “As new RNAV ar- Basehore said. Notably, he added, this through analysis of radar tracks. rivals, as an example, are being designed, input — unlike retrospective safety The modules are plug-ins to the we take advantage of the opportunity analysis — occurs before airspace, route NextGen airspace redesign software to address our TAWS issues, and lead or procedure redesign is even initiated. called Terminal Area Route Genera- airline members are part of that activity,” ASIAS has collaborated to date at three tion Evaluation and Traffic Simulation he said. Another activity has been the metroplexes, raising awareness of issues (TARGETS). “As a new airspace or preparation of safety-assurance metrics such as non-safety-critical TCAS RAs route or procedure is developed, it’s for NextGen, defining evidence of the when general aviation and commercial done with knowledge of where the required level of safety. TRUTH: Developing a custom
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“Over the past eight months we’ve categorize or classify the severity of the sources such as aviation safety action reached out to the different NextGen various penetrations of these safety bar- program (ASAP) reports. “We have portfolio managers,” Basehore said. riers. That’s a strategy that I see us delv- seven ASAP trends that we monitor The message for them covered ASIAS ing into further this year,” Pardee said. on a regular basis, and probably five capabilities relevant to NextGen plan- Among raw materials that ASIAS or six more under development so that ning, risk baselines, and conducting the analysts recently have begun to fuse with we can mine the text data just the way post-implementation determination of other sources are recordings of auto- we mine the numerical digital data” successes/failures and associated risks. matic dependent surveillance–broadcast except for calculating trends not rates Throughout ASIAS, new safety met- system (ADS-B) messages, and voice with ASAP reports, Basehore said. rics — for example, geographic distribu- communication between pilots and The NextGen implementation tion of anomalies and adverse trends air traffic controllers, FAA said in its report cited ongoing work by ASIAS, such as TCAS RAs with their contribut- 2012 NextGen implementation report.3 including “helping the FAA and stake- ing factors — also are undergoing re- “We’re starting to look into the pos- holders with better characterization finements to ensure useful information sibilities of digital voice-track data,” and understanding of missed approach- can be produced as NextGen precision Basehore said. “In some of the studies es, runway overruns, rejected takeoffs, evolves. “We could then get a better not knowing the conversation that was autobraking and energy states on final handle on understanding locations, occurring between the controller and approach. This nuanced understanding flows and maybe more importantly, to the pilot has left us in a lurch. For ex- is expected to aid in accident preven- ample, we’d see in a departure tion.” The report pointed to ASIAS an aircraft leaving the pro- initiatives to develop a new method ASIAS by the Numbers, February 2013 cedure, but without analysts to query multiple databases with one Fact Figure knowing whether there was a search directive; add air traffic control Airline members of ASIAS 44 conversation where the con- (ATC) facility-performance data from Safety databases 46 troller said ‘yes, you can cut FAA’s Air Traffic Organization to ana- Hybrid databases 78 the corner short’ or the pilot lyze safety effects of unplanned service Standards datasets 7 said that he was turning for interruptions; develop data standards Airlines providing FOQA data 24 avoidance conditions. We’re in and integration capabilities to add digi- Total flight operations in FOQA data 10 million the research phase of actually tal flight data from voluntary sources in Airlines providing ASAP safety reports 44 acquiring voice-track data to general aviation, especially de-identified ASAP reports accessible to ASIAS 125,000 meld it with data for particular aggregate data from corporate flight ATSAP reports accessible to ASIAS 50,000 potential safety issues that we operational quality assurance programs CAST safety enhancements from ASIAS 6 have seen.” (C-FOQA); improve the query and Metrics monitored by ASIAS for CAST 51 Fully understanding an visualization software on secure Web altitude deviation during an ar- portals used by ASIAS members; and ASAP = aviation safety action program; ASIAS = Aviation Safety Information Analysis and Sharing; ATSAP = air traffic rival, as another example, could revise data standards for FOQA data control safety action program; CAST = U.S. Commercial Aviation Safety Team; FAA = U.S. Federal Aviation require this capability. “Our sources and sources of voluntarily sub- Administration; FOQA = flight operational quality assurance research right now is about get- mitted text reports. (routine flight data monitoring); TCAS = traffic-alert and collision avoidance system ting that voice data and being Note: ASAP reports originate from airline pilots, flight able to ‘pin it’ to that particular Winning Over Airlines attendants, maintenance technicians and dispatchers; radar track to get the full realm Venues long used by U.S. airline directors ATSAP reports originate from air traffic controllers. Examples of non-airline data sources are the aircraft of what’s going on,” he said. of safety to confidentially share lessons analytical system; airport surface detection equipment, model X; airspace performance metrics; National Flight Although not new to learned, methods, anecdotes and trends Data Center; National Offload Program radar tracks; ASIAS, data mining of narra- among peers have not been superseded. traffic flow management system; and TCAS operational performance assessments. tive texts — including auto- But one airline’s perspective illustrates the
Source: FAA classification of reports by relative influence of ASIAS, said Paul Mo- computer algorithms — has rell, a captain and vice president, safety, Table 1 become more sophisticated for security and environmental programs, US
44 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 THREATANALYSIS
Airways, and industry co-chair, ASIAS For Morell, the second advantage Notes Executive Board. is the ability to contribute effectively to 1. FAA. NextGen Implementation Plan. March “At US Airways, our SMS [safety the safety of the entire airline industry, 2012. In 2012, ASIAS was involved in a management system] deals with FOQA, without diminishing the value of shar- directed study of risks while FAA validated ASAP, a lot of the things that are going ing experiences with safety committees the safety and capacity benefits of imple- on with ASIAS,” Morell said. “But we’re of airline associations, academia and menting RNAV off the ground in three of 21 NextGen metroplexes, designated as very limited in the scope of what we’re industry initiatives. “ASIAS analysts can Houston, Memphis and North Texas. looking at.” For him, the key advan- go in there, and look, and see where I 2. FAA. The report says, “OAPM is a tage of ASIAS has been the company’s might not even think I have a problem systematic and expedited approach to ability to tap ASIAS databases “to look personally at our airline but by the implementing PBN procedures and associ- at aggregated data or different air- small amount that I’m contributing, ated airspace changes in major metro- ports or different types of data and to and different airlines are contributing politan areas. Expected improvements also compare and use the Web portal now, I’m enabling a ‘larger SMS’ — be- from OAPM include efficient descents, dashboards” to analyze issues such as cause that’s what ASIAS is.” diverging departure paths and decoupling of operations among airports within the unstabilized approaches. All told, this cycle — threat identi- metroplex airspace.” He explains, “I might be think- fication by ASIAS and InfoShare, then ing we’re doing really well, but I can risk mitigation and systemwide solutions 3. FAA. The report says, “The aim of [OAPM] is to have study groups identify compare US Airways against the ag- through CAST safety enhancements, and near-term PBN improvements coupled gregate. … I can see that maybe I have finally ASIAS measurement of risk miti- with airspace sector adjustments that can a problem at one airport, but am I the gation effectiveness — has been a widely be completed in major metropolitan areas only one that has that problem?” welcomed advancement, he said. within three years.”
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BY RICK DARBY That’s FRAT A study of flight risk assessment tools found strong support from their users.
Evolution of Business Flight Risk Assessment
light risk assessment tools (FRATs) have shown FRAT Scores for 10 Operators their value, and indications are that further refinement of the assessment process will Percent of Legs F Reviewed by provide even better results, according to a study Phase Score Management conducted by the VanAllen Group and presented Average scores for all legs at the 2012 Corporate Aviation Safety Seminar.1 Scheduling 36.0% 4.7% This was no academic exercise. “The goal of Preflight 37.8% 2.5% the study was to accelerate the evolution of FRATs,” Post-flight 35.2% 3.3% the author’s paper says. It describes a second gen- Average scores for domestic legs eration of FRATs that is available in the market- Scheduling 33.6% 4.6% place: “They are the software evolution of the first Preflight 36.5% 2.6% generation hard-copy models [paper forms] that Post-flight 32.7% 2.8% were integral elements of the initial safety manage- Average scores for international legs ment systems protocols and resources.” Scheduling 48.7% 4.6% Ten major non-commercial aviation depart- Preflight 44.7% 2.0% ments participated, representing “high end” op- Post-flight 50.2% 5.4% erations, most operating both domestically and Range of individual participant scores internationally. Turbojets were the only type of Scheduling 19.5% –82.7% 0%–32.2% business aircraft involved. Twenty percent of the Preflight 16.6%–70.8% 0%–12.9% FRATs were created by their own participants, Post-flight 16.9%-72.5% 0%–13.7% and the rest used commercial FRATs from five FRAT = flight risk assessment tool different vendors. Note: “Score” indicates the percentage of the score that The study collected data and participant would have triggered a management review. For example, a score of 36.0 percent would represent slightly more than responses for flights from August 2011 through one-third of the risk that would have led to a review. January 2012. Because of the variety in FRAT Three participants (30 percent) did not incur any scores requiring management review, despite flying legs with metrics and scoring schemes among opera- substantial risks.
tors, it was decided to use the requirement for Source: The VanAllen Group a “management review” — given a score of 100 percent — as the basic criterion (Table 1).2 Table 1
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 47 DATALINK
“For the first three months, we gathered a 4,000-ft [1,219-m] runway at sea level.” baseline FRAT and trip-leg data,” the paper says. Again the FRAT score was 65 percent. “This created an average FRAT score for each “It is obvious that FRAT scoring is not an exact participant. … At the midpoint, we asked the science,” the paper says. participants to deliberately seek to lower [im- The numbers may have told one story — or prove] their scores throughout the second half.” no story — but the participants told another. Average FRAT scores were collected at the “The majority of the participants reported strong end of the study. No overall lowering was found, positive benefits gained from the FRAT process,” however (Table 2). the paper says. “They also indicated the benefits The FRAT scores at times seemed counter- continued to increase throughout the study.” intuitive. Some apparently higher-risk flight After its conclusion, the researchers con- segments did not meet the “management ducted a meeting and conference call with all review” hurdle: the operators. When asked the most important benefit they had gained from using a FRAT, • “Three training flights, among the highest- participants offered responses such as these risk events in business aviation, averaged (paraphrased and summarized): a score of 30 percent [less than one-third of the score that would have triggered a • “It forces crews to talk about trip issues. It management review].” is a teaching and learning tool.”
• “Three hundred eighteen ferry flights, • “We found a number of FRAT conversa- which have an accident rate four times tions led to ‘Aha!’ insights.” greater than passenger-bearing legs, aver- • “We now have historic data, not just lore, aged a score of 44 percent, with only 7 to help us modify our training to make it percent of the flights reviewed.” much more meaningful.” • “A medium jet on its international factory • “Our crews shifted from ‘checking the delivery flight, [with] no mentor pilot [and] boxes’ to truly understanding our opera- no translator, was flown on a 14.7-hour tions, the risks incurred and how to most duty day. The crew was the owner and his effectively manage or mitigate those risks.” chief pilot.” The FRAT score was 65 percent. • “We transitioned from using a FRAT • “The same medium jet, with the same for International Standard for Business crewmembers with less than 50 hours Aircraft Operations (IS-BAO) compliance in type, conducted a night landing into to it being a useful tool for measuring and managing safety.” Average FRAT Scores for 10 Operators, by Study Period The FRAT is valuable, the paper says, not only for the information it provides but also for the Period 1 Period 2 Change process itself, raising awareness and changing Scheduling score 33.6% 38.8% 15.4% increase attitudes. Preflight score 38.5% 37.1% 3.7% decrease Participants were asked to reply to additional Post-flight score 32.2% 38.3% 18.9% increase questions about their FRATs. For example, Average 34.8% 38.1% 10.2% net increase “How important is your FRAT to your SMS FRAT = flight risk assessment tool [safety management system], on a scale with 5 = Note: Period 1 was prior to the beginning of the study; period 2 was during the study’s second half, when participants were asked to make an effort to lower their scores. critical to 0 = not at all?” The average response “Score” indicates the percentage of the score that would have triggered a management review. was 4.2. Another question was, “How effective
Source: The VanAllen Group is your FRAT as a risk management tool, on a scale with 5 = extremely to 0 = not at all?” The Table 2 average response was 4.0.
48 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 DATALINK
The average number of data points assessed Canadian Aviation Accidents, 2007–2012 by users’ FRATs was 51 (with 90 the largest num- ber). The number of human factors data points 2007-2011 tracked ranged from five to 18, with an average 2012 2011 Average of 10. Total 290 257 292 Accidents in Canada involving “That translates to about 20 percent of data Canadian-registered aircraft 267 240 272 points focused on human factors,” the author Accidents outside Canada involving told ASW. “Yet, about 70 percent of accidents Canadian-registered aircraft 8 7 8 and incidents are human factors–sourced. This Accidents in Canada involving disparity underscores the need for more com- non-Canadian–registered aircraft 16 10 13 prehensive development of FRAT data points.” Source: Transportation Safety Board of Canada The paper forecasts that FRATS in the not Table 3 too distant future will be completely integrated with flight operational quality assurance pro- Canadian Fatal Accidents, by Aircraft Type, 2007–2012 grams, and with as many data points as possible automated. 2007–2011 2012 2011 Average “The crew would have current flight risk Total 42 35 36 ratings as a cockpit readout, with risks and miti- Airplane 25 23 23 gations displayed upon request,” the paper says. Helicopter 7 8 7 “When a significant change in the risk occurs, Ultralight 8 3 5 a message would be displayed with mitigation Other aircraft types 2 1 1 recommendations listed. A parallel message could be shared with management. … Variances Note: “Other aircraft types” includes balloons, gyroplanes, gliders, dirigibles, hang gliders and similar aircraft types. would be recorded, reported and discussed. Source: Transportation Safety Board of Canada Procedural intentional noncompliance events, a major factor in accidents and incidents, would Table 4 become much less frequent.” The next generation of FRATs will be much 2012 accidents, compared with 44 in 2011 and more effective, the paper says. an average 48 in 2007–2011. “In 2012, a total of 636 incidents were Canadian Accidents Up, reported,” the TSB said. “This is a 6 percent de- Incidents Down in 2012 crease from the 2011 total of 677 and a 21 percent decrease from the five-year average of 808.” viation accidents reported to the Trans- portation Safety Board of Canada (TSB) Notes totaled 290 in 2012, an increase of 13 A 1. Agur, Peter v. Jr. “Second Generation FRATs: 3 percent from 2011 (Table 3). However, the Strengths, Weaknesses and Next Generation 2012 number was close to the average for the Opportunities.” Flight Safety Foundation, 2007–2011 period. Proceedings of the 57th annual Corporate Aviation Fatal accidents numbered 42 in 2012, Safety Seminar.
17 percent more than the 2007–2011 aver- 2. For example, at one operator a score of 26 would age (Table 4). Six of those 42 involved com- prompt management to review the trip leg, while a mercial aviation airplanes, and five involved score of 19 might have the same result at another op- commercial aviation helicopters. Sixty-three erator. For the sake of apt comparison, both would fatalities resulted from the 2012 accidents, a be scored equally by the researchers as 100 percent. decrease from 67 in 2011 and an average 66 in 3. TSB. “2012 Statistical Highlights: Aviation 2007–2011. There were 50 serious injuries in Occurrences.”
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 49 Save the Date
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Error Tolerance, SMS for AviAtion–A PrActicAl Guide Human Factors 6 Error Containment Safety Management Systems I Human factors includes the non-technical skills needed for an SMS.
BY RICK DARBY
SCHELL Game SMS for Aviation — A Practical Guide. 6: Human Factors Civil Aviation Safety Authority of Australia (CASA), 2012. 28 pp. safety performance without a full understanding
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more components can lead to human perfor- • Set priorities and manage tasks — priori- mance problems,” the module says. tize safety above personal concerns. “For example, an accident where com- • Maintain effective communication and munication breaks down between pilots in the interpersonal relationships. cockpit, or engineers at shift handover, would be characterised by the SCHELL model as a • Maintain currency. liveware-liveware problem. Situations where pilots or engineers disregarded a rule would be The System characterised as liveware-software.” “If you want to find actual solutions for the problems human errors cause, you often need The Skills large systemic changes,” the module says. “For Another way of looking at human factors is that example, you might have to modify mainte- “human factors training should focus squarely nance rostering to combat fatigue, or revise your on providing aviation safety-critical person- flight manuals to make them easier to interpret.” nel with the non-technical skills to manage Beyond systemic changes, error tolerance can the prevention/consequences of human error. be built into the organization and operator pro- This implies that making errors is normal and cedures. This is something like a human-centered expected. The consequences of error are just as version of the redundancy that engineers include important as the causes. in aircraft systems design, so that a single-point “Non-technical skills are the decision mak- failure is extremely unlikely to be catastrophic. ing and social skills that complement technical “Error tolerance refers to the ability of a skills. For example, inspecting an aircraft engine system to function even after an error has oc- using a borescope is a technical skill performed curred,” the module says. “In other words, an by a licensed maintenance engineer. However, error-tolerant system is one in which the results maintaining situational awareness (attention of making errors are relatively harmless. An ex- to the surrounding environment) during the ample of building error tolerance is a scheduled inspection of a wing, to avoid tripping over aircraft maintenance program. Regular inspec- Error tolerance can hazards, is a non-technical skill.” tions will allow multiple opportunities for catch- The module lists as the main categories and ing a fatigue crack in a wing before it reaches a be built into the elements of non-technical skills managing fa- critical length. tigue; managing stress; alcohol and other drugs; “As individuals we are amazingly error organization and team-based cooperation and coordination; deci- tolerant, even when physically damaged. We are operator procedures. sion making; situational awareness; communica- extremely flexible, robust, creative and skilled at tion; and leadership. finding explanations, meanings and solutions, One key to developing non-technical HF even in the most ambiguous situations. Howev- skills is threat and error management (TEM), er, there is a downside: The same properties that the module says. TEM begins with recognition give human beings such robustness and creativ- — of human errors, of threats to safety and of ity can also produce errors.” undesired aircraft states. How can creativity and flexibility produce, as A second key is professionalism, which en- well as reduce, errors? Part of the problem is that compasses these abilities and qualities: we extrapolate from the known to the unknown • Maintain discipline — follow approved — for instance, we fill in missing information. procedures to perform a given task. We surmise, especially in task-saturated or time-pressured situations. Usually, this creative • Assess situations — know what’s going on response is rational, based on experience. Some- around you. times, though, the reality differs from the norm • Make decisions — take decisive actions. and the conventional assumption is mistaken.
52 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 INFOSCAN
“Our natural tendency to interpret partial/ to hit the aircraft, particularly in strong wind. missing information can cause us to misjudge The pilot reports this concern via the company situations in such a believable way that the mis- hazard reporting process. The company safety interpretation can be difficult for us to discover,” manager considers the human factors issues the module says. “Therefore, designing systems involved, and, in talking with ramp staff, finds that predict and capture error — in other words out that sometimes people forget … to secure installing multiple layers of defences — is more the wheel brake properly. likely to prevent accidents that result from hu- “On inspecting the stairs, the safety manager man error.” finds that there are no signs on them to remind Supplementing error tolerance is error con- operators to activate the wheel brake. Simple hu- tainment. Error containment strategies include man factors solutions would be to install a sign ‘Any major change policies that “formalise acknowledgement that prompting operators to secure the wheel brake, errors are ‘normal’; [include] regular systemic and to ensure that all airport staff are regularly within your analysis to identify common errors and build reminded of the danger of unsecured stairs.” organization has the stronger defences; identify risk of potential errors The module’s SMS checklist for hazard through normal operations behavioural observa- identification and reduction includes items such potential to introduce tion programs; identify potential single-point as these: failures (high risk) and build stronger defences; or increase human • “Do you consider HF issues in general risk [and] include the concept of shared mental mod- assessments where hazards are identified?” factors issues. ‘ els in team-based training initiatives.” • “Are the HF issues involved with hazards The Fit understood?” CASA recommends blending HF principles into • “Are different error types with hazards at least these SMS elements: recognised? Are the workplace factors that • Hazard identification and reduction to as increase error potential for hazards, such low as reasonably practical; as high workload, or inadequate equip- ment availability or design, considered?” • Change management; • “Do you consider human performance is- • Design of systems and equipment; sues in regular staff workshops identifying • Training of operational staff; potential safety hazards?” • Task and job design; • “Is your hazard-reporting process user- friendly and does it prompt users to con- • Safety reporting and data analysis; and, sider HF issues? What errors might result • Incident investigation. if the hazard is not managed well?” Each of these subjects is discussed with an ex- planation of its HF content, an example scenario Change Management and a checklist. To illustrate the methodology, The module describes how HF fits in with the here is how the module examines the first ele- other identified SMS elements, noting, “Any ment, integrating HF into hazard identification major change within your organization has the and reduction. potential to introduce or increase human fac- “Your hazard identification program can tors issues. For example, changes in machinery, reveal potential or actual errors and their un- equipment, technology, procedures, work organ- derlying causes,” is the summary statement. An isation or work processes are all likely to affect example follows: performance and cause distractions. “A pilot notices the mobile aircraft stairs be- “Carefully consider the magnitude of ing left unsecured and the potential for the stairs change: how safety-critical is it? What is its
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 53 INFOSCAN
potential impact on human performance? Con- performance factors might have contributed to sider human factors issues especially during the the event.” transition period of the change.” The Preconditions Design of Systems and Equipment As in other aspects of SMS, human factors “Poorly thought-out equipment design can have goes hand-in-hand with a paradox: solutions a major impact on the performance of your cannot always be applied at the location or staff, and you should ensure that there is a good time when errors are made. Mitigation often fit between the equipment and those using it,” resides at a different level, the conditions that CASA says. “The design of equipment such as predispose fallible humans to error. Those displays and control systems, alarm systems, sig- conditions can be far in time or distance from nals and warnings, as well as automated systems, the “sharp end.” may involve significant human factors risks.” For instance, take the issue of unsecured mobile stairs discussed earlier on the subject Training of Operational Staff of hazard identification and reduction. The “Before training operational staff in non- suggested solution is to install a sign reminding technical skills, do a training needs analysis, so operators to be sure the wheel brake is locked. that you know which error management mea- But incident analysis might discover that a ‘The same sures to target to which groups — individuals dozen kinds of errors have been made in con- and/or teams.” nection with airstairs. Should management post decision-making, signs warning of them all? How many signs can Task and Job Design gate area personnel read while attending to their communication “Tasks involving excessive time pressure, a duties? If they forget to set the brake as they breakdown and complex sequence of operations, relying overly have been emphatically trained to do, will they on memory, or that are physically or mentally remember the reminders? distraction problems fatiguing, are likely to negatively affect perfor- These questions are not carping — they mance. Task design is essentially about task go to a fundamental issue in human factors. you see in a serious matching — make sure that tasks and activities Telling people not to make mistakes prob- accident you will are appropriate and suited to a person’s capabili- ably does not help much. Personnel typically ties, limitations and personal needs.” are trying to perform their work correctly. If also tend to see in distractions or time pressure cause them to Safety Reporting Systems and Data Analysis forget to secure the stairs, they’re even less minor occurrences.’ “Generally, the same decision-making, commu- likely to remember a warning sign, let alone nication breakdown and distraction problems numerous signs. you see in a serious accident you will also tend If any conclusion can be drawn from this, to see in minor occurrences. Your safety report- it may be that HF — like the SMS itself — is an ing system should not only collect information interrelated whole. Individual steps are useful, but about notifiable occurrences and incidents, but should not lead to a “check-off” mentality that also hazards, near-misses and errors that other- says, “We’ve done this, that and the other so we’re wise might have gone unnoticed.” good to go.” SMS is above all a habit of mind.
Incident Investigation Note “Make sure your investigation procedures detail 1. The other modules concern SMS basics; safety policy clearly how human factors considerations are in- and objectives; safety risk management; safety assur- cluded. … Your investigators need to be trained ance; and safety promotion. A DVD is included with in basic human factors concepts and design the kit. All modules are available online at
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FSF13002m_HouseAd.indd 2 2/7/13 9:08 AM ONRECORD ‘Mission Pressure’ Cited in Overrun Emergency medical services flight encountered fog at destination.
BY MARK LACAGNINA
The following information provides an awareness of problems that might be avoided in the future. The in- formation is based on final reports by official investigative authorities on aircraft accidents and incidents.
JETS
Pilots Flared High, Landed Long the far end of the runway, and the pilot flared the Learjet 25D. Substantial damage. No injuries. airplane too high,” the report said. “After land- ission pressure to land” was cited ing long on the runway, the pilot said he applied by the U.S. National Transportation maximum braking and reverse thrust but could “M Safety Board (NTSB) as a contribut- not stop the airplane before exiting the runway.” ing factor in a runway-overrun accident that The Learjet struck ILS localizer antennas substantially damaged a Learjet 25D of Mexican and came to a stop in a flat, grassy area about registry that was completing an emergency 1,000 ft (305 m) from the departure end of medical services flight in low instrument meteo- the runway. The operator of the airplane told rological conditions (IMC) at Houston. None of investigators that there was no pre-existing me- the six occupants of the airplane was injured in chanical malfunction or failure that would have the March 4, 2011, accident. precluded normal operation of the airplane. The Learjet had departed from Tuxtla Gutiér- “The operator [also] stated that the decision rez in southern Mexico at 0140 local time with two not to delay the flight and to land in marginal passengers, two medical crewmembers and two conditions was influenced by medical consider- flight crewmembers. As the airplane neared the ations for the passenger, who needed immediate destination — Houston’s William P. Hobby Airport specialized medical treatment,” the report said. — about four hours later, the automated weather observing system was reporting 3/4 mi (1,200 m) Crew Forgot About Shortened Runway visibility in mist, an indefinite ceiling at 200 ft and Airbus A319-111. No damage. No injuries. surface winds from 200 degrees at 3 kt. hile preparing for a four-sector trip The flight crew apparently conducted the beginning at Stansted Airport, London, instrument landing system (ILS) approach to Wthe morning of July 4, 2012, the flight Runway 12R, which is 7,602 ft (2,317 m) long crew reviewed a notice to airmen (NOTAM) and 150 ft (46 m) wide. The report said that the about runway construction in progress at the runway was dry. third stop of the trip: Prague Airport in the “The pilot and the copilot both reported that, Czech Republic. The NOTAM said that, due due to the fog and low visibility, they could not see to the construction on Runway 24, the runway
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length temporarily would be reduced from 3,715 aware during planning that the available length m (12,188 ft) to 2,500 m (8,203 ft). was reduced, they referred only to the normal Late that afternoon, “the aircraft landed at charts,” the report said. Prague on Runway 30 after the third sector of “[The commander] also noted that the the duty, and the flight crew started preparation crew’s preflight activities had been interrupted for their final flight to Stansted” with 149 pas- by a visit to the flight deck by an acquaintance sengers and six crewmembers, said the report and thought that this distraction may also have by the U.K. Air Accidents Investigation Branch. been a factor.” “The runway in use for takeoff was Runway 24. The pilots listened to the ATIS [automatic Engine Separates on Takeoff terminal information service] broadcast, but it Boeing 707-300. Destroyed. Three minor injuries. was reportedly in heavily accented English. They he failure of a midspar engine-mount fitting did not glean from it that the runway length was that was known to be susceptible to fatigue reduced and had forgotten the content of the as- Tcracking and that should have been replaced sociated NOTAM seen at the preflight stage.” with a more fatigue-resistant version was the As a result, the pilots used the normal length of probable cause of an accident during an at- the runway when they calculated the A319’s take- tempted takeoff at Point Mugu Naval Air Station off performance. The report noted that the pilots near Los Angeles the afternoon of May 18, 2011, had not seen the construction activity on Runway the NTSB report said. 24 when they landed on Runway 30. Moreover, The report also said that an erroneous “the work in progress on Runway 24 was at the maintenance entry made when the 707 was in the departure end, not easily visible to the crew at the hands of a previous owner, incorrectly indicating start of the takeoff roll,” the report said. “The com- that the engine-mount fitting had been replaced mander noted later that there were no warnings in accordance with an existing airworthiness from ATC [air traffic control] or ground signage bulletin, was a contributing factor in the accident, indicating that the runway length was reduced.” which destroyed the airplane and resulted in The takeoff initially appeared normal to the minor injuries to the three flight crewmembers. flight crew, but then they saw that the A319 was The airplane was operated by a company that rapidly nearing the runway-construction area. provided aerial-refueling services on contract to “The aircraft rotated and became airborne at the the U.S. Navy. Manufactured in 1969 and con- An erroneous planned speeds but approached much closer to verted to a tanker in 1996, the airplane had accu- the works than would have been intended,” the mulated 47,856 flight hours and 15,186 cycles. maintenance entry report said. “The event posed a considerable The 707 was within weight-and-balance made when the 707 distraction for the crew which, combined with a limits when it departed from Runway 21 at Point frequency change immediately after takeoff, led Mugu to refuel McDonnell Douglas F/A-18s off- was in the hands of to [their failure] to select the landing gear up or shore. Surface winds were from 280 degrees at check that it was retracted prior to reaching the 24 kt, gusting to 34 kt, creating a crosswind for a previous owner … landing gear limit speed.” The flight proceeded the takeoff on the 11,102-ft (3,384-m) runway. was a contributing to London without further incident. “According to the crew, the takeoff roll was The commander told investigators that the normal,” the report said. “At rotation speed factor in the accident. oversight regarding the shortened runway could [152 kt], the captain rotated the airplane to be attributed to “reduced crew awareness at the an initial target pitch attitude of 11 degrees end of a lengthy duty period.” He also said that airplane nose-up.” a contributing factor was the presence in their Shortly after the airplane lifted off about route manuals of charts showing both the nor- 7,000 ft (2,134 m) down the runway, the crew mal (full) length of Runway 24 and the reduced heard a loud noise as the left inboard engine length of the runway. “As the crew were not separated and propelled itself above and over
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the left wing. The nacelle and pylon that redesigned fittings had been down and the cabin pressure altitude also separated and then struck and installed in 1983. The report noted that slowly began to climb. The bleed air broke off the inlet cowling on the left U.S. “federal regulations do not require needed for cabin pressurisation was outboard engine. an owner/operator acquiring an aircraft no longer available, and therefore the The captain applied full right rud- to physically verify the compliance of flight crew had to immediately initiate a der and nearly full right aileron in an every AD for which compliance has descent to a safe altitude.” attempt to maintain directional control, been recorded.” The crew requested and received but the airplane continued to drift left. clearance from ATC to descend to FL Both of the right engines were produc- Bleed Air Overheat 100, “the maximum recommended ing maximum power, but the power Airbus A320-214. No damage. No injuries. altitude for unpressurised cabins,” the produced by the damaged left outboard efore departing from Helsinki, report said. During the descent, the engine was negated by the drag created Finland, for a scheduled flight ECAM generated a warning about the by the absence of the inlet cowling, the Bto London with 140 passengers cabin altitude, which had reached 9,450 report said. The airplane descended, and six crewmembers the morning of ft. The pilots donned oxygen masks, and the captain leveled the wings just March 5, 2011, the flight crew found and the captain, the pilot flying, ex- as it touched down on the runway. The that the no. 1 (left engine) bleed air tended the speed brakes to increase the 707 then veered off the left side of the system was inoperative and that repair descent rate. At no time did the crew runway and came to a stop in a marsh had been deferred per provisions of the declare an emergency. near the departure end. minimum equipment list (MEL). “The aircraft momentarily, and “All three crewmembers success- “According to [the MEL], it was slightly, exceeded its maximum air- fully evacuated through the left forward permissible to fly the aircraft for 10 speed during the descent,” the report entrance via the escape slide” before the days with one engine bleed air sys- said. “There was no high terrain or, in airplane’s fuselage was nearly consumed tem out of service,” said the report this case, any other flight activity below by fire, the report said. by the Safety Investigation Authority the planned route. … At no stage of the The midspar fitting that had failed of Finland. “The aircraft had already occurrence were the passengers at risk, was among several that attached the flown for seven days with this techni- nor did the automatic pressure control engine to the wing and had a history of cal limitation. The previous flights had deploy the passenger oxygen masks in fatigue cracking that had caused at least been uneventful.” the cabin.” three previous accidents. “To address The flight to London was initiated The report noted that the crew the midspar cracking issue, a series of with the cross-bleed valve open to sup- did not start the auxiliary power unit, Boeing service bulletins (SBs) and FAA ply bleed air from the no. 2 engine to which can supply sufficient bleed air [U.S. Federal Aviation Administration] both air-conditioning packs. However, for pressurized flight below 20,000 ft. airworthiness directives (ADs) were about 10 minutes after reaching cruise However, during the descent, the crew published between 1975 and 1993,” the altitude, Flight Level (FL) 360 (approxi- was able to reset the no. 2 bleed air report said. Among them was an AD mately 36,000 ft), the pilots noticed system. Investigators later determined requiring compliance with SBs recom- fluctuations in the no. 2 bleed air pres- that the system had overheated due to a mending repetitive inspections of the sure and the cabin altitude indications. malfunction of the fan air valve or the original fittings until they were replaced The A320 was over the Baltic Sea, north thermostat. “The pre-cooled air was too by a redesigned, stronger fitting. of Öland Island, Sweden, at the time. hot; therefore, the temperature sensor The aerial-refueling company had A few minutes later, the electronic of the system worked as per its design acquired the 707 in 1994 and had centralized aircraft monitor (ECAM) and shut off the overheated system,” the inspected the midspar fittings after generated a fault warning for the no. 2 report said. converting the airplane to a tanker. bleed air system. “The bleed air temper- The no. 2 bleed air system had However, the company deleted the ature of the right engine had exceeded cooled sufficiently during the descent inspection requirement from its main- its maximum permissible value (247 to resume normal operation, and the tenance program after finding a main- degrees C [477 degrees F]),” the report crew leveled the aircraft at FL 140. tenance record indicating (erroneously) said. “As a result of this, the system shut “Seeing that the engine bleed air system
58 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 ONRECORD
continued to function normally and there was pitch trim systems. “The pitch trim wheel spun sufficient fuel to take them all the way to London, without effect or friction,” the report said. the flight crew decided to continue the flight to “The captain slowed the airplane to the speed their destination at a lower flight level [than origi- at which it was trimmed and ran the checklist nally planned], FL 250,” the report said. for jammed elevator trim.” Completion of the Although bleed air temperature neared the checklist actions did not rectify the problem. limit during the last 20 minutes of cruise flight, The crew declared an emergency and the A320 was landed without further incident in diverted the flight to San Antonio, Texas. “The London. captain did a controllability check to [ensure] no other control issues existed,” the report said. “He Elevator Trim Cable Snaps then flew a long final approach to an uneventful Cessna Citation 560XL. Minor damage. No injuries. landing at San Antonio.” he flight crew was conducting a positioning Examination of the airplane revealed that flight from New Orleans to Houston the af- the elevator trim cable had failed due to fatigue. Tternoon of April 8, 2011. The flight was un- “The fracture occurred 11 inches [28 cm] from eventful until the Citation reached about 22,000 the roller chain that tracked through the eleva- ft during the climb to cruise altitude. “The tor trim actuator,” the report said. The cable had captain noticed an abnormal feel in the flight been installed during manufacture of the Cita- controls, followed by the pitch trim annunciator tion, which had accumulated 5,445 hours before light coming on,” said the NTSB report. the incident occurred. He disengaged the autopilot, and the air- In April 2012, a year after the incident, plane abruptly pitched nose up. He moved the Cessna Aircraft issued a service bulletin recom- control column forward to correct the pitch atti- mending replacement of the elevator trim cables tude and attempted unsuccessfully to relieve the in 560XLs with cables made of “improved rope control forces with the electric and the manual wire material,” the report said.
TURBOPROPS
Dual Engine Failure “The crew did not attempt to restart the CASA 212. Destroyed. One fatality, one serious injury, right engine,” the report said. “Their priorities one minor injury. were aircraft controllability, climbing to a higher bout three hours after departing from altitude, recovering the birds [two externally Saskatoon, Saskatchewan, Canada, to deployed sensors] and returning to Saskatoon.” Aconduct a local geophysical survey flight Neither pilot noticed that the master caution the afternoon of April 1, 2011, the right engine light had re-illuminated after it was reset follow- lost power. “No annunciators or warning lights ing completion of the checklists for the right- were illuminated, and there were no abnormal engine failure. In addition, the left fuel quantity engine instrument indications,” said the report and fuel pressure lights had illuminated. by the Transportation Safety Board of Canada. The C-212 was at about 1,300 ft AGL and 3.5 The flight crew had felt the right engine nm (6.5 km) out on final approach to Runway 27 shudder before it smoothly spooled down, the when the left engine “smoothly lost power with no report said. The aircraft was at 400 ft above surging,” the report said. “The captain [the pilot ground level (AGL) at the time. The crew ap- monitoring] was looking at the engine instruments plied full power to the left engine, feathered the at the time, and all indications had been normal.” right propeller and secured the right engine. Realizing that they could not reach the They declared an emergency and turned back to runway, the crew turned toward a road. How- the airport. ever, they saw traffic on the road and decided
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 59 ONRECORD
to land the aircraft on a grassy area next to the While conducting the corresponding road. Nearing the grassy area, the pilots saw a checklist, the crew noticed that the smoke concrete noise-abatement wall too late to avoid abated soon after they closed the left bleed it. “The aircraft landed astride the wall at 90 kt,” air valve. They continued the flight without the report said. further incident to Toulouse. The C-212 was destroyed by the impact. The Investigators determined that a fault in the survey equipment operator was killed, the first automatic temperature controller had caused officer was seriously injured, and the captain the heating system to shut down. Moreover, sustained minor injuries. they found that a warm air duct previously Investigators determined that the shudder had been split by a sharp instrument during a felt by the pilots before the right engine spooled maintenance inspection of the air condition- down was caused by failure of a gear on the ing system and then repaired improperly with torque sensor shaft, which in turn caused loss of a sheet of aluminum and gray adhesive tape. drive to the engine-driven fuel pump. “The im- Heat transferred to the adhesive subsequently mediate result would have been fuel starvation had caused it to deteriorate, and the rapid of the engine, flameout and the loss of power,” increase in heat when the crew selected the the report said. manual mode caused it to melt. Fuel starvation also was the likely cause of the loss of power from the left engine. The first Gear Extension Falls Short officer had placed the aircraft in a slight left Bombardier Q300. Minor damage. No injuries. bank, per procedure, following the failure of the faulty “inhibit switch” caused the nose- ‘The immediate result right engine. This caused fuel to flow from the wheel steering system to malfunction as center collector tank into the wing tanks and the flight crew prepared to depart from would have been A one of the two ejector pumps, which pump fuel Hamilton, New Zealand, for a scheduled flight from the wing tanks into the collector tank, to with 41 passengers and a flight attendant to Wel- fuel starvation of the unport. The nozzle in the other ejector pump lington on Feb. 9, 2011. engine, flameout and was found to be partially blocked by unidenti- “The faulty switch caused a loss of hydraulic fied debris; the pump therefore was unable to pressure to the nosewheel steering,” said the the loss of power.’ deliver a sufficient quantity of fuel to the collec- report by the New Zealand Transport Accident tor tank. Investigation Commission. “The nosewheel steering system was considered nonessential, Smoke Prompts Emergency Descent so, in accordance with the approved minimum Beech King Air B200GT. Minor damage. No injuries. equipment list, the aeroplane departed Hamilton he airplane was cruising at FL 230 dur- with the system inoperative.” ing a ferry flight from Melun, France, to The faulty switch also prevented normal TToulouse the night of April 15, 2010, when extension of the landing gear on final ap- the flight crew noticed that the cabin heating proach to Hamilton. The crew conducted a system was not providing sufficient heat. They go-around and completed the “Alternate Gear reset the system from the automatic mode to Extension” checklist, which resulted in exten- the manual mode. sion of the main landing gear but not the nose “A few moments later, acrid smoke pen- gear. The crew diverted the flight to Wood- etrated the cabin,” said the report by the French bourne Aerodrome and landed the Q300 with Bureau d’Enquêtes et d’Analyses. “The cap- the nose gear retracted. tain and copilot put on their oxygen masks, “There was nothing mechanically wrong switched off the heating, declared an emer- with the alternate landing gear extension sys- gency … and began an emergency descent to tem,” the report said. “The nose landing gear did Flight Level 100.” not extend because the pilots did not pull hard
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enough on the handle that should have released The report noted that the force required to the uplock. If the uplock had released, the nose release the uplock during flight simulator train- landing gear would have lowered under gravity ing was much less than the force required in the and locked down.” aircraft itself.
PISTON AIRPLANES
‘Minimal Experience in IMC’ probable cause of the accident and that his Beech 58C Baron. Destroyed. Four fatalities. “minimal experience flying in actual instrument he Baron was en route under instrument conditions” was a contributing factor. flight rules from Scott City to Topeka, both Tin Kansas, U.S., the afternoon of April 22, Caught in a Crosswind 2011, when the pilot found that the back-course Piper Aerostar 602P. Substantial damage. No injuries. localizer approach to Runway 31 was in use at nbound from Lock Haven, Pennsylvania, U.S., the destination, and the airport was reporting a the pilot was cleared to land on Runway 26 at 500-ft overcast and 10 mi (16 km) visibility. IPhiladelphia International Airport, which was The NTSB report noted that the private reporting surface winds from 330 to 340 degrees pilot had 438 flight hours, including 29 hours at 14 to 18 kt, gusting to 25 kt, the afternoon of in multiengine airplanes, 50 hours of simulated April 2, 2012. The runway was 5,000 ft (1,524 instrument time and 11 hours in actual instru- m) long and 150 ft (46 m) wide. ment conditions. He had earned a multiengine “The pilot said that he landed on the left rating two months earlier and had logged 0.7 main gear, with the right main intermittently flight hours in IMC since earning an instrument touching the ground, and tried to lower the rating five months earlier. right wing to improve wheel-to-runway contact Nearing the airport from the south, the but was unsuccessful because of a wind gust,” pilot received vectors from ATC to establish the the NTSB report said. “He felt the left main airplane on the localizer back course. After the gear become ‘mushy’ as he was braking to Baron flew through the inbound course, the avoid an overrun.” controller issued a heading to re-intercept it, The Aerostar then veered off the left side of terminated radar service and told the pilot to the runway onto a soft, grassy area. The main contact Topeka Tower. landing gear collapsed, and both wings were The airplane again flew through the inbound substantially damaged before the airplane came course. The pilot declared a missed approach but to a stop. then asked the tower controller if he could circle to land. The controller told him to conduct the Set Up for a Stall published missed approach procedure, climb to Beech 76 Duchess. Substantial damage. One serious injury, one minor injury. 4,000 ft and re-establish radio communication with the center controller. During the climb, the he pilot said that he thought the Duchess pilot requested clearance to conduct the global was near its maximum gross weight for the positioning system (GPS) approach to Runway 36. Tdeparture from Perris Valley (California, “The pilot was maneuvering in IMC to set U.S.) Airport the morning of July 30, 2011. Nev- up for the GPS approach when the airplane ertheless, he began the takeoff from the mid- departed controlled flight and impacted terrain,” point of the 5,100-ft (1,554-m) runway, applying the report said. “The airplane struck the ground full power before releasing the wheel brakes, the in a left descending turn at high speed.” NTSB report said. NTSB concluded that the pilot’s failure “The pilot [had] selected Runway 15, to maintain control of the airplane was the which had a 6-kt tailwind component at the
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 61 ONRECORD
time of the attempted takeoff,” the report The pilot was seriously injured, one passen- said. Before reaching the normal airspeed for ger sustained minor injuries and two passengers rotation, the Duchess pitched nose-up and escaped injury. became airborne. Shortly thereafter, the left Investigators calculated that the airplane cockpit door opened. The pilot was closing was more than 273 lb (124 kg) above maximum the door when the airplane stalled, struck an gross weight and that the center of gravity was embankment and crashed in an open field 0.4 in (1.0 cm) aft of the limit. In addition, “the about 1,000 ft (305 m) off the end of elevator trim tab was found in the full nose-up the runway. position,” the report said.
HELICOPTERS
Thin Air, Overweight Takeoff road. Both occupants sustained serious Bell 206B. Substantial damage. Two serious injuries. back injuries. he pilot did not perform weight-and- Pilot Loses Consciousness balance calculations before attempting to Robinson R44. Substantial damage. take off from Midrand, South Africa, with T One fatality, one serious injury. a full load of fuel and two passengers and their baggage the afternoon of May 27, 2012, accord- he pilot and a crewman were conducting a ing to the report by the South African Civil geophysical survey that required landings at Aviation Authority. Twaypoints about 2.5 km (1.4 nm) apart. After Aural and visual low rpm warnings were completing about 80 takeoffs and landings south of generated soon after the pilot lifted the heli- Newman, Western Australia, the morning of Sept. copter into a hover. He set the helicopter back 3, 2011, the crewman saw that the pilot, who was on the ground, offloaded one passenger and seated in front of him, had slumped forward. some baggage, and attempted another takeoff. “The crewman attempted to rouse the pilot, Investigators determined that the JetRanger but all attempts failed, and the helicopter’s was 140 lb (64 kg) over maximum gross weight descent rate was not arrested,” said the report for the conditions, which included a density by the Australian Transport Safety Bureau. The altitude of 7,000 ft. crewman was seriously injured when the R44 “The pilot was able to become airborne struck terrain. The pilot regained consciousness due to the fact that he was able to gain momentarily but succumbed to chest injuries airspeed by remaining within ground ef- sustained during the impact. fect for a considerable distance,” the report Investigators found that the pilot had sought said. “Once he started to climb, conditions help from medical practitioners several times after changed and power required to sustain flight losing consciousness, once because of a “vasovagal exceeded the power available, and the rpm episode” involving lowered heart rate and blood started to decay.” pressure, and once because of a blow to the head. The pilot told the airport traffic control- None of the prior episodes of loss of conscious- ler that he was having an engine problem and ness occurred during flight. “The information was going to fly one circuit of the pattern to contained in the pilot’s aviation medical records evaluate the problem. The helicopter was on a did not accurately reflect the pilot’s medical his- left downwind leg when he reported that the tory, elements of which may have, if known, led engine was losing power and that he was go- to further medical testing and influenced the ing to land. Shortly thereafter, the JetRanger subsequent renewal of the pilot’s Class 1 aviation struck a tree and a concrete fence next to a medical certificate,” the report said.
62 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 ONRECORD
Preliminary Reports, February 2013
Date Location Aircraft Type Aircraft Damage Injuries Feb. 2 Rome, Italy ATR 72-212A substantial 2 serious, 2 minor, 46 none
Surface winds were from 250 degrees at 28 kt, gusting to 41 kt, and wind shear had been reported before the ATR 72 landed hard, bounced several times and veered off Runway 16L. Fiumicino Airport’s Runway 25 was closed for construction.
Feb. 3 Assis, Brazil Beech King Air C90A destroyed 5 fatal
The King Air was on a night flight from São Paulo to Maringá when it crashed in an open field.
Feb. 6 Tunis, Tunisia Airbus A320-211 substantial 83 NA
No fatalities were reported when the A320 veered off Runway 19 while landing in a rain squall with surface winds from 250 degrees at 16 kt, gusting to 38 kt.
Feb. 6 Casa Grande, Arizona, U.S. Beech King Air E90 substantial 2 fatal
The King Air was on a go-around following a bounced landing during an instructional flight when witnesses saw it enter an “extreme” left bank and nose-down pitch attitude, and descend to the runway.
Feb. 9 Blue River, British Columbia, Canada Beech 1900C substantial NA
No injuries were reported when the 1900 veered off the runway and struck a snow bank while landing during a scheduled passenger flight.
Feb. 10 Acton, California, U.S. Bell 206B substantial 3 fatal
Dark night visual meteorological conditions (VMC) prevailed when the JetRanger struck terrain while maneuvering in a valley for filming by a movie crew.
Feb. 11 Charlesville, Liberia CASA/IPTN CN-235-220 destroyed 11 fatal
The Guinean military transport struck sloping terrain during an approach to Monrovia in instrument meteorological conditions (IMC).
Feb. 11 Muscat, Oman Boeing 737-33A substantial 108 none
The airplane veered off the runway after the left main landing gear collapsed on landing.
Feb. 11 Ponderosa, New Mexico, U.S. Bell 206B-3 substantial 3 none
The helicopter was on a wildlife-survey flight at 200 ft when the engine lost power. The main rotor blades partially severed the tail boom, and the helicopter rolled over during the forced landing.
Feb. 13 Donetsk, Ukraine Antonov 24RV destroyed 5 fatal, 47 NA
Visibility was 250 m (0.2 mi) in fog when the An-24 touched down hard, bounced twice and came to a stop inverted while landing during a night charter flight.
Feb. 13 New Smyrna Beach, Florida, U.S. Cessna T337C destroyed 1 fatal
The pilot declared an emergency shortly before the Skymaster struck terrain while departing in day VMC.
Feb. 14 Yeehaw Junction, Florida, U.S. Cessna 310H substantial 3 fatal
Air traffic control radar showed that the 310 entered a rapid descent shortly after the pilot, who was not instrument-rated, requested assistance after encountering IMC during cruise flight.
Feb. 20 Thomson, Georgia, U.S. Beech 390 Premier 1A destroyed 5 fatal, 2 serious
All five passengers were killed when the airplane struck an unlighted utility pole and terrain during a go-around in night VMC.
Feb. 21 Santa Lucia, Mexico Pilatus PC-6 Turbo Porter destroyed 2 fatal
The single-turboprop airplane crashed out of control during a military training flight.
Feb. 24 Homestead, Florida, U.S. Cessna T337G substantial 4 minor
The rear engine lost power while the Skymaster was cruising along the coast at 900 ft. The front engine did not respond when the pilot attempted to increase power. The airplane then flipped over while being ditched in Biscayne Bay, but all the occupants were able to exit the airplane before it sank and were rescued by boaters.
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.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | APRIL 2013 | 63 SMOKEFIREFUMES
Selected Smoke, Fire and Fumes Events, October–December 2012
Date Flight Phase Airport Classification Subclassification Aircraft Operator Shannon, Ireland Oct. 2 Cruise (SNN) Entertainment system Smoke Boeing 777 American Airlines The crew reported an acrid odor and smoke in the area of the right no. 2 door. They declared an emergency and diverted the flight to SNN, where it was landed without incident. Maintenance personnel found an inflight entertainment system cooling fan that had overheated. The inflight entertainment station was removed from service and the circuit breaker pulled. Maintenance inspection for the fan was deferred according to the minimum equipment list (MEL). The flight was continued to its destination, London Heathrow, without incident. Maintenance replaced the inflight entertainment system cooling fan, and a system ground check showed normal operation. Independent Oct. 2 Cruise Cleveland (CLE) instruments Smoke Embraer 135KL Chautauqua Airlines The crew reported that during flight, an electrical odor was present in the cockpit. The crew diverted to CLE and landed the airplane without incident. Maintenance isolated the issue to the first officer’s chrono button in the yoke. The item was deactivated and then deferred. The deferral was cleared two days later when the first officer’s chrono switch on the yoke was replaced. Operational checks revealed no further defects. Bombardier Challenger Oct. 8 Climb Chicago (ORD) Air distribution system Smoke CL-600 American Eagle Airlines Approximately 10 minutes into the flight, the no. 1 and no. 2 flight attendants reported a burning odor coming from the rear of the aircraft. They reported that it resembled burning wood, but no smoke was visible. The crew declared an emergency and returned to ORD. Emergency services were dispatched. The aircraft was landed without incident and taxied to the gate with aircraft rescue and firefighting (ARFF) units following. The ARFF crew inspected the aircraft inside and out and could not locate the source of the odor. The aircraft was removed from service. Maintenance performed visual check of the lavatory, behind the mirror and trash bin and under the sink. They performed an operational test of the recirculation fans in accordance with the maintenance manual. No malfunction was discovered. Overtemperature, Oct. 8 Cruise Toyko (NRT) Air distribution system smoke Boeing 777 American Airlines The cabin crew reported that a strong electrical odor was detected in business class around rows 11, 12 and 13. Power ports and the inflight entertainment system were turned off, and the smell dissipated. The flight was landed at NRT without incident. Maintenance found that the aft upper recirculation fan had overheated. They deferred the fan replacement according to the MEL. A system ground check showed normal operation. Oct. 10 Cruise Philadelphia (PHL) Engine Smoke Airbus A330 US Airways The crew reported a strong odor throughout the cabin and cockpit, especially in the aft cabin section. The crew and some passengers experienced throat and lung irritation. The flight was returned to PHL and landed without incident. Maintenance troubleshot the cabin air quality, analyzed the bleed air and checked for engine odor on the left and right engines. The right engine was removed and replaced along with the right engine check valve. Bombardier Challenger Oct. 28 Cruise — Humidity control system Smoke CL-600 Express Airlines The smoke detector in the lavatory sent a warning indication at 1,500 ft above ground level, although no smoke was visible. The crew consulted the quick reference handbook (QRH) and declared an emergency. An overweight landing was conducted without incident. Technicians complied with the work scope for smoke in the cabin and found the coalescer soiled. They removed and replaced the coalescer socks. The auxiliary power unit (APU) checked out with no problems and no further defects were noted. Technicians performed a high-power engine run with the environmental control system selected to engine bleeds and APU bleeds. No smoke was noted and the aircraft was returned to service. Turbine engine Nov. 3 Climb Chicago (ORD) compressor section Smoke Boeing 737 American Airlines When climbing through about 5,000 ft, a very strong odor was present in the cockpit and cabin. The QRH procedure for smoke, fire or fumes was followed. The odor started to dissipate but returned a couple of times. The crew returned the flight to ORD. Maintenance found excessive lubricant on fan blades from the previous night’s blade lubrication. No other discrepancies were noted. The technicians performed a high-power run with no odors noted. Following a system ground check, the aircraft was returned to service. Smoke, warning Bombardier Challenger Nov. 25 Cruise Detroit (DTW) Humidity control system indication CL-600 Express Airlines The flight departed DTW and performed an air return due to reported smoke in the cabin. The lavatory smoke detector indicated a caution on climbout, and a flight attendant reported smoke coming from the back of the cabin. A passenger reported an odor of electrical fire. Maintenance found dirty coalescers and deicing fluid in the engine inlets. They removed and replaced the left and right pack coalescers in accordance with the aircraft maintenance manual. Operations checks showed no problems and technicians performed high-power engine runs and left and right pack burn. All checks were good and no smoke was noted. Washington Dulles Smoke, warning Nov. 30 Climb (IAD) Air distribution fan indication Airbus A320 JetBlue Airways The crew declared an emergency and diverted to IAD because of an aft avionics rack smoke indication. Maintenance found that the aft rack cooling fan assembly had seized and a wire terminal lug had overheated. They removed and replaced the cooling fan assembly and re-terminated the wire 9842. Operations checks revealed no further problems. Dec. 9 Descent — Air distribution fan Smoke Boeing 737 Delta Air Lines During descent, an acrid odor issued from the air conditioning system but dissipated after landing. During maintenance testing, with the right pack off, the odor returned. Maintenance replaced the right recirculating fan in accordance with the maintenance manual. Following an operations test, the aircraft was returned to service.
Source: Safety Operating Systems and Inflight Warning Systems
64 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | APRIL 2013 66th annual International Air Safety Summit IASS 2013 october 29–31, 2013
Omni Shoreham Hotel Washington, DC, USA
The 66th Annual International Air Safety Summit (IASS 2013) will be held October 29-31, 2013 at the Omni Shoreham Hotel in Washington, DC, USA. Please visit website below for hotel details and further details about the event as they become available.
flightsafety.org/IASS2013 @Flightsafety #IASS2013 IATA Safety Report 49th Edition Now Available!
Measuring the safety performance of 2012.
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