AeroSafety WORLD 2013 IN REVIEW Jet crash rate near all-time low RISKY BUSINESS Unmarked low-altitude towers SMS FOR UAS Getting in on the ground level
NEW REPORT POINTS TO SOLUTIONS VULNERABILITIES OF AUTOMATION
THE JOURNAL OF FLIGHT SAFETY FOUNDATION FEBRUARY 2014 IATA’s Safety Strategy is a comprehensive approach to identify organizational and operational safety issues. PRESIDENT’SMESSAGE ChangeSEAT ou may have heard by now that I will be International Civil Aviation Organization, MITRE leaving Flight Safety Foundation in mid- and the National Business Aviation Association. February to become the senior vice presi- So, speaking of IATA, this seat change will allow dent of safety and flight operations at the me to continue to help drive the data initiatives from InternationalY Air Transport Association (IATA). a different constituency within the worldwide air- This seat change comes with bittersweet emotions. line industry, and potentially blend those initiatives For the past three and a half years it has been with the initiatives coming from the Foundation. my privilege to further the mission of the Foun- So much of what we have been doing at the Foun- dation while working with an excellent staff and dation for the past 10 years has been leading up to a highly professional Board of Governors. As this point, and I am very excited to see it progress. president and CEO, I have worked to ensure that While the Foundation has provided me a fan- the Foundation remains a prominent organization tastic perspective on a broad range of aviation safety today, as well as in the future. entities and issues, I am excited to return to my While in the left seat at the Foundation, I have wheelhouse of airline operations and safety. Plus, I learned so much from our members and support- will still be able to associate with all of you, but in ers from all walks of aviation and aviation safety. It a different capacity. I want to thank all of you for always amazes me how much passion people have supporting me and the Foundation. Your expertise, for safety and how we all work together for the com- dedication, hospitality and kindness have been over- mon goal of keeping the aviation industry as safe as whelming. I look forward to seeing the Foundation it can be. It has been an honor to help promote that continue to gain altitude and to help where I can! goal, and, hopefully, to contribute to the continued As I move over to my new seat at IATA, the advancement of aviation safety around the world. Foundation’s board has launched a search for a Safety has obviously come a long way since the new president and CEO. In the interim, board 1940s, when commercial aviation really began to members Ken Hylander and Bill Bozin will serve take off. Many of you have heard me say that com- as acting president and CEO, and acting chief placency is one of our biggest concerns as we move operating officer, respectively. I thank them both into the next generation of aviation operations. In for their continued dedication to the Foundation order to overcome that tendency to be complacent, and its missions. we must be not only proactive, but also predictive. Being predictive means using the mountains of data we are all collecting to really analyze what is happening in flight, air traffic and ground opera- tions. That is the key to the future. The Foundation is poised to play a large part in that data collection Capt. Kevin L. Hiatt and analysis effort in many parts of the world, work- President and CEO ing in collaboration with partners such as IATA, the Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 1 AeroSafetyWORLD
contents February 2014 Vol 9 Issue 1 features
12 CoverStory | Addressing Automation’s Vulnerabilities
19 2013Review | Jet Crash Rate Nears All-Time Low
23 HelicopterSafety | Disorientation Probably Figured in Crash
30 ThreatAnalysis | Unmarked Towers Pose Unexpected Risks
34 AviationMedicine | FAA Mulls Sleep Apnea Crackdown
39 InSight | SMS for UAS 12 departments
1 President’sMessage | Seat Change
5 EditorialPage | Safety First
7 FoundationFocus | Purdue University Student Chapter 19 8 SafetyCalendar | Industry Events
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 23 30 34
9 InBrief | Safety News
43 DataLink | Wildlife Strikes
47 InfoScan | James Reason’s Error Messages 51 OnRecord | 757’s Fuel Leak 39
AeroSafetyWORLD telephone: +1 703.739.6700
Frank Jackman, editor-in-chief, FSF director of publications [email protected], ext. 116 About the Cover Even in highly automated cockpits, the most demanding situations increase the crew’s task complexity and workload, a new study says. Wayne Rosenkrans, senior editor [email protected], ext. 115 © Darren Howie/AirTeamImages.com Linda Werfelman, senior editor [email protected], ext. 122
We Encourage Reprints (For permissions, go to
| | FLIGHTSAFETY.ORG AEROSAFETYWORLD FEBRUARY 2014 | 3 April 16–17, 2014 Sheraton San Diego Hotel and Marina San Diego, California
SAVE THE DATE
For details, visit our Web site at flightsafety.org/BASS2014 To register or exhibit at the summit, contact Namratha Apparao, tel: +1.703.739.6700, ext. 101, [email protected]
To sponsor an event, contact Kelcey Mitchell, ext. 105, [email protected] To receive membership information, contact Susan Lausch, ext. 112, [email protected] To advertise in AeroSafety World magazine, contact Emerald Media Cheryl Goldsby, [email protected], tel: +1 703.737.6753 Kelly Murphy, [email protected], tel: +1 703.716.0503 EDITORIALPAGE
SAFETY First n the lull between the Christmas and New Year’s talking about just operating the UAS safely at holidays, the U.S. Federal Aviation Administra- the test sites, but about learning from the test site tion (FAA) announced the six locations it has cho- operations as we do in commercial and business sen as unmanned aircraft systems (UAS) test sites operations. Ias part of the research and certification effort that Tom Anthony, director of the Aviation Safety eventually will see UAS integrated into the National and Security Program at the University of South- Airspace System [NAS] (“Safety Briefs,” p. 9). The ern California, and colleague Harrison Wolf establishment of a test site program was mandated contend in the InSight article (“Right From the by the U.S. Congress in the FAA Modernization and Start,” p. 39), “The United States has an historic Reform Act of 2012, and represents a significant opportunity to influence the safe integration of milestone in the UAS integration process. civil unmanned aircraft systems in its National The research and testing will not be accom- Airspace System by implementing a safety man- plished overnight. According to the FAA, test agement system (SMS) for UAS operators now site operations will continue until at least mid- — before the full UAS integration into the NAS.” February 2017. There are a myriad of problems Anthony and Wolf go on to propose that UAS to be solved and issues to be worked out, not the operators using any of the six test sites be required least of which are widely held privacy concerns. But to report operational data to the FAA to identify one day, in the not too distant future, manned and hazards and develop mitigations. remotely piloted aircraft will ply the same airways InSight articles, by their nature, are opinion over the United States. pieces, and this one is no different. The opinions In its document “Integration of Civil Un- expressed in the article are the authors’ and not manned Aircraft Systems in the National Airspace necessarily those of Flight Safety Foundation. Still, System Roadmap,” the FAA says, “Ultimately, UAS Anthony and Wolf make a good argument, and, if must be integrated into the NAS without reduc- I were in a decision-making role at FAA, I would ing existing capacity, decreasing safety, negatively seriously consider it. impacting current operators, or increasing the risk to airspace users or persons and property on the ground any more than the integration of compa- rable new and novel technologies.” It is imperative that safety be baked into civil/ Frank Jackman commercial UAS operations from the outset, and Editor-in-Chief that means during the testing phase. I’m not AeroSafety World
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 5 Serving Aviation Safety Interests for More Than 65 Years OFFICERS AND STAFF Chairman ince 1947, Flight Safety Foundation has helped save lives around the world. The Board of Governors David McMillan Foundation is an international non-profit organization whose sole purpose is to President and CEO (Acting) Kenneth J. Hylander provide impartial, independent, expert safety guidance and resources for the Chief Operating S Officer (Acting) William G. Bozin aviation and aerospace industry. The Foundation is in a unique position to identify General Counsel global safety issues, set priorities and serve as a catalyst to address the issues through and Secretary Kenneth P. Quinn, Esq. data collection and information sharing, education, advocacy and communications. The Treasurer David J. Barger Foundation’s effectiveness in bridging cultural and political differences in the common cause of safety has earned worldwide respect. Today, membership includes more than ADMINISTRATIVE 1,000 organizations and individuals in 150 countries. Manager of 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 Services Coordinator Ahlam Wahdan Kelcey Mitchell, director of events and seminars [email protected] Consultant, Student Technical product orders ext. 101 Chapters and Projects Caren Waddell Namratha Apparao, seminar and exhibit coordinator [email protected] 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 [email protected] Global Programs Rudy Quevedo Foundation Fellow James M. Burin
BASIC AVIATION RISK STANDARD BARS Managing Director Greg Marshall
facebook.com/flightsafetyfoundation
@flightsafety Past President Capt. Kevin L. Hiatt Founder Jerome Lederer www.linkedin.com/groups?gid=1804478 1902–2004
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 R Runway Excursion Runway Approach Stabilized Rudari said, “It’s an enormous privilege causal factor inaccidents worldwide. resource management problems as a tive students’ work inprogress on crew Winter said, citing 11currently the ac- strong …entering year,” its second full Organization. at International the Aviation Civil student and asummer 2013intern chapter secretary, aPurdue graduate ASW by Summit (IASS), and he was interviewed during FSF the International Air Safety main findings of descriptive this study forria astabilized approach. pilots industry-accepted the crite meet - excursions professional evenwhen occur tors that might help explain how runway year2012–2013 academic were risk fac- assigned research project during the findings of chapter’s the Foundation- Florida Institute of Technology. Among assistant professor of aviation at science chapter’sthe first president and now Aviation Technology, says Scott Winter, at Purdue the University Department of reexamines 2003–2010data. FSF StudentChapteratPurdue University FLIGHTSAFETY.ORG “The student“The chapter going is still In October, Winter presented the Safety Foundation Student Chapter inaugural members of Flight the positive results for seven the teamworkesearch-based yielded with Lukas Rudari, current the |
WORLD AEROSAFETY | FEBRUARY 2014 and …unstabilized or with excessive speed runway, landing long same ….contaminated tended to remain the top three risk factors may slightly, vary the rank the orderwhile comparison] that found out [from the dents from 1995–2010. runway-excursion acci- data comprising 520 questions with adifferent subset of FSF proposedcessfully to explore derivative parison. As afollow-up suc- effort, they of similarity or difference com inthe - ing only Boeing-related aircraft. Co. ofBoeing 2003–2010events involv- that matched inastudy those by The 2008–2010 events from an FSF dataset runway excursion analyses covering at IASS began as acomparison of andtabases doresearch with that data.” for us to have access to [ASW money matters, it’s so agreat opportunity affordablea very price. For students, Flight Safety Foundation for, actually, to have resources access the to all of “Essentially, we Students on degree the first focused The project Winter presented ], to- da the +
proach [stabilized/unstabilized].” ‘unknown’ interms of of type ap the - approaches. …About 50accidents were resulted from excursions after stabilized stretching from 1995to 2010—that ing accidents [FSF] —inthe database that there were 183out of 520land the - have an excursion? …We identified go wrong [and] cause aircraft the to adding, “At what point something does tions of multiple variables, he said, similar pattern of variables and interac - commercial and jets turboprops had a than major airlines. Business and jets excursions sectors other inindustry follow-up analysis included runway approaches,” Winter said. The team’s FOUNDATIONFOCUS — Wayne Rosenkrans Rudari andWinter |
Wayne Rosenkrans 7 ➤ SAFETYCALENDAR
FEB. 4–6 ➤ MRO Middle East. Aviation MARCH 26–27 ➤ Safety in Aviation Asia. MAY 20–22 ➤ IATA Cabin Safety Week. Dubai, United Arab Emirates. Helen Flightglobal. Singapore. Alex Aubrey,
MARCH 19–21 ➤ ARSA Annual Repair MAY 13–15 ➤ RAA 39th Annual Be sure to include a phone number, Symposium and Legislative Fly-In. Convention. Regional Airline Association. St. website, and/or an email address for Aeronautical Repair Station Association. Louis, Missouri, U.S. David Perez-Hernandez, readers to contact you about the event. Arlington, Virginia, U.S.
8 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 INBRIEF Safety News UAS Sites Operators of the six sites will ix sites have been chosen by the U.S. Federal Aviation conduct research Administration (FAA) as unmanned aircraft systems in several areas. S(UAS) test sites to be used for research into the certifica- For example, the tion and operational requirements for incorporating UAS University of into the National Airspace System (see “Right From the Alaska’s research Start,” p. 39). plan, which calls The six sites are in Alaska, Nevada, New York, North for test site loca- Dakota, Texas and Virginia. tions in Hawaii U.S. National Aeronautics and Space Administration The FAA said that factors considered in the site-selection and Oregon as process included geography, climate, location of ground well as Alaska, includes the development of standards for un- infrastructure, research needs, airspace use, safety, aviation manned aircraft categories, state monitoring and navigation. experience and risk. “In totality, these six test applications The state of Nevada will examine UAS standards and op- achieve cross-country geographic and climatic diversity and erations, operator standards and “a concentrated look at how help the FAA meet its UAS research needs,” the agency said. air traffic control procedures will evolve with the introduc- Transportation Secretary Anthony Foxx said that the tion of UAS into the civil environment and how these aircraft sites would yield “valuable information about how best to will be integrated with NextGen [the FAA’s plan to overhaul ensure the safe introduction of this advanced technology the national airspace, known formally as the Next Genera- into our nation’s skies.” tion Air Transportation System].” FAA Administrator Michael Huerta added, “We have Griffiss International Airport, near Rome, New York, will successfully brought new technology into the nation’s avia- work on testing and evaluations, and validation and verification tion system for more than 50 years, and I have no doubt we processes under FAA safety oversight, as well as UAS sense- will do the same with unmanned aircraft.” and-avoid capabilities and operations in the congested airspace of the northeastern United States. The North Dakota Department of Commerce will conduct UAS human factors research in addition to its plan to “develop UAS airworthiness essential data and validate high reliability link technology.” Texas A&M University – Corpus Christi plans to develop safety requirements for UAS vehicles and operations, along with airworthiness testing procedures. Virginia Polytechnic Institute and State University (Virginia Tech) is planning UAS failure-mode testing and an evaluation of operational and technical risk areas. The Virginia Tech pro- posal includes test sites in New Jersey as well as Virginia. The law calls for test site operations to continue at least until February 2017.
Safety Review
he Australian government has ordered an independent review of the nation’s aviation safety regulation network, including the effectiveness of agencies involved in safety regulation and their relationships and interactions with one another. T Warren Truss, deputy prime minister and minister for infrastructure and regional development, said the review is intended to “reassess how our safety regulatory system is placed in dealing with this dynamic and evolving sector.” The review, to be conducted by a panel of aviation safety experts, will “benchmark Australia’s safety regulation against other leading countries,” the minister’s office said, noting that the panel will be headed by David Forsyth, chairman of Safeskies Australia and former chairman of Airservices Australia. Members will include Don Spruston, former director general of civil aviation for Transport Canada and former director general of the International Business Aviation Council, and Roger Whitefield, former head of safety at British Airways. The panel is expected to submit its final report to Truss in May.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 9 INBRIEF
Comparisons Wider Use of PEDs
he U.S. air traffic control system viation authorities in Europe and the United States have authorized the has more flexibility than its Euro- expanded use of portable electronic devices (PEDs) by passengers. Tpean counterparts in responding to A The European Aviation Safety Agency (EASA) and the U.S. Federal imbalances in demand and capacity, ac- Aviation Administration (FAA) issued updated guidance to airlines saying that cording to a report by the Eurocontrol they had determined that PEDs, when used in non-transmitting “flight mode” (or Performance Review Commission and “airplane mode”) present no risk to safety. the U.S. Federal Aviation Administra- Siim Kallas, EC vice president responsible for transport, said in December tion Air Traffic Organization. that he had asked EASA to speed up its safety review of the use of PEDs in trans- The report, published in December, mitting mode; new guidance should be published early in 2014, he said. compares the operational and economic “We all like to stay connected while we are traveling, but safety is the key performance of air traffic management word here,” Kallas said. “I have asked for a review based on a clear principle: If it’s (ATM) in Europe and the United States not safe, it should not be allowed, but if it is safe, it can be used within the rules.” from 2008 through 2012, a period char- EASA’s December guidance said PEDs could be used in flight mode “in all acterized by declining traffic. phases of the journey, from gate to gate.” The goal of the joint study on which FAA guidance also said that, after airlines could prove to the FAA that their the report was based was “to under- airplanes would allow safe use of PEDs in airplane mode, the devices would be stand differences between the two ATM permitted during all phases of flight, although cell phones cannot be used for systems in order to further optimize voice communications because of Federal Communications Commission (FCC) ATM performance and to identify best regulations. The FCC has said it is considering changing its regulations banning practices for the benefit of the overall cell phone calls during flight to allow the airlines themselves to decide whether air transport system.” passengers should be permitted to make cell phone calls during flight and under The study found that variations in what conditions. performance indicators were often as- The FAA said that its PED Aviation Rulemaking Committee had deter- sociated with differences in ATM policy mined that “most commercial airplanes can tolerate radio interference signals or operating strategies, including “when from PEDs.” The panel recommended that after individual airlines verify that and where air traffic flow management the devices can be used without causing interference, their in-flight use should measures are applied; a more frag- be permitted. On some occasions, however, passengers will be asked to turn off mented structure of service provision PEDs during landing, the FAA said. in Europe; greater flexibility of the U.S. Cell phones are treated differently than other PEDs because of their stronger system in mitigating demand/capacity signals, the FAA said. imbalances through the use of traffic flow initiatives that are coordinated across multiple en route centres; and Ann Mullikin airline and airport scheduling, their im- pact on airport throughput [a measure- Ann L. Mullikin, Flight Safety Foundation’s ment of the number of aircraft handled longtime art director and graphic designer, in a specific time period] and the ability died Dec. 27, 2013, in Alexandria, Virginia, to effectively sustain airport throughput U.S., after a brief illness. She was 59. in bad weather.” Ann worked at the Foundation from The report suggested “a more com- 1997 until 2012, and was responsible for prehensive comparison” of the quality the design of AeroSafety World, introduced Wayne Rosenkrans of ATM service, especially in regard to in 2006. J.A. Donoghue, editor-in-chief of safety, capacity and other factors that ASW at the time, praised Ann as “an excellent artist and collaborator … who estab- affect performance. lished an artistic identity for the magazine that was one of solid professionalism.” “A better understanding of trade- Ann also taught graphic design for The Art League, an Alexandria organiza- offs, such as maximizing capacity tion offering courses in fine arts and crafts. and throughput against maximizing Before joining the Foundation, she was graphics department manager for a predictability, would be needed to management consulting, engineering and information technology company in identify best practices and policies,” Arlington, Virginia. She also spent 11 years as a flight attendant and purser for Pan the report said. American World Airways.
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 INBRIEF
Proposed Penalties Banned Airlines
he U.S. Federal Aviation Administration (FAA) has proposed a $325,000 civil penalty he European Commission against Southwest Airlines, alleging that the airline operated a Boeing 717 that had (EC), in the most recent Tbeen improperly modified. Trevision of its “air safety list,” has added all air carriers based in Nepal to the list of those banned from operating in the European Union (EU). Siim Kallas, EC vice presi- dent responsible for transport, said the commission hopes that the ban will result in improve- Anthony92931/WikiMedia Commons ments in aviation safety in The modification involved the Aug. 29, 2011, installation of a switch intended to en- Nepal. Kallas said he had asked able flight crews to test the airplane’s windshield heating system. The 717 was operated by the European Aviation Safety AirTran Airways, which is merging with Southwest. If the switch had been installed prop- Agency to develop a Nepal- erly, flight crews would have been able to “isolate the windshield anti-ice system that was ese aviation safety assistance causing a warning that the windshield heater was failing,” the FAA said. However, when project. the switch was installed, the center and left windshield warning systems were reversed, the After consultation with FAA said. civil aviation authorities in The airplane was operated on 1,140 passenger flights before the problem was cor- Libya, the EC said that the rected, the agency added. voluntary restrictions that have In an unrelated matter, the FAA proposed a $304,000 civil penalty against Great Lakes kept Libyan airlines from oper- Aviation for conducting 19 flights using airplanes that were not in compliance with Federal ating in the EU would continue. Aviation Regulations. The airplanes — Beech 1900s — were operated in January 2011 with Those restrictions have been in deicing fluid that exceeded the maximum allowable temperature; the temperature limit place since the Libyan revolu- was intended to prevent damage to the airplane or the deicer. tion in 2011. Both airlines were given 30 days to respond after receiving the FAA’s civil penalty letter. The revised list prohibits EU operations by all airlines certified in 21 countries — a total of 295 airlines — plus two additional airlines certified in other countries. Ten additional airlines are subject to specific operational restrictions. Kallas said that recent efforts indicate safety progress in several countries on the list, especially the Philippines, Sudan and Zambia.
Icarus/WikiMedia Commons
In Other News …
The Australian Civil Aviation Safety Authority administered 11,252 alcohol and drug tests in the 2012–2013 financial year, with seven people testing positive for alcohol and two testing positive for drugs, the agency says. … The International Civil Avia- tion Organization and the International Air Transport Association have established a new global training alliance, designed to “intensify and refine air transport training and learning resources” to address expected shortages of air transport personnel. The organizations cited forecasts that call for a doubling of aviation system capacity by 2030 and a need to hire thousands of new pilots, air traffic controllers and maintenance personnel.
Compiled and edited by Linda Werfelman.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 11 COVERSTORY
Automation
VulnerabilitiesBY WAYNE ROSENKRANS
12 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 COVERSTORY
lthough difficult flight path–management procedures, and [failures] in flight management tasks are handled routinely by professional system (FMS) programming.” pilots operating highly automated jets, the At a December 2013 investigative hearing of most demanding situations still tend to sig- the U.S. National Transportation Safety Board Anificantly increase the pilots’ task complexity and (NTSB), Abbott and another working group workload, says a U.S. working group of subject co-chair — David McKenney, a United Airlines matter experts. For example, in cases in which air captain representing the International Federation traffic control (ATC) suddenly issued an amended of Air Line Pilots’ Associations — fielded ques- clearance/vector changing the preplanned flight tions about the relevance of the new report to an path — say, for temporary deviation from a com- accident five months earlier (see “NTSB Hearing plex instrument flight procedure — some pilots on Crash of Asiana Airlines Flight 214,” p. 16). told the working group they struggled at times to Asked about the integration of philosophies recover the optimum flight path by relying solely and policies of human-centered design into flight on modes of the automated systems. Moreover, deck automation during the last 15 years, Abbott complete or partial reversion to manual flight told the hearing that “one of the important gaps operations to resolve brief confusion could be that … sometimes does happen is a difference problematic, the working group’s analyses showed. between the philosophy and the design, and the Actual and potential safety consequences of way that the systems are actually operated.” this and related problems, and new recommen- McKenney testified, “Manual flight opera- dations for integrated solutions, form the core of tions is not just the stick-and-rudder skills that the final report on operational use of flight path everybody thinks it is. The term means [the management systems, issued in late 2013 by the psychomotor skills,] the cognitive skills, the Flight Deck Automation Working Group.1 airmanship, how we fly the aircraft [and] how Kathy Abbott, chief scientific and technical we use these automated systems to actually adviser for flight deck human factors at the U.S. maintain the flight path. … What we are recom- Federal Aviation Administration (FAA) and a mending is that we create an operational policy co-chair of the 34-member working group, said for flight path management which highlights in 2010 that the airline industry’s “impressive … that the responsibility of flight path man- safety record” partly can be attributed to flight agement rests with the pilot — and that the crews intervening as expected to mitigate flight automated systems are only one of the tools. path–related risks during flights, underscoring … Pilots [are trained] to rely on the systems all the reason for addressing persistent problems the time, but they are not taught to question the in flight path management. This initiative also systems. They expect the system to work when U.S. study dovetails with government-industry efforts they use it and when it doesn’t, then they get in airplane upset prevention, recognition and caught short.” of flight path recovery, the report said. In addition to presenting and cross-referencing management “Incident and accident reports suggest that exhaustive analyses of accident/incident data, anomalies flight crews continue to have problems interfac- line operations safety audit (LOSA) data, updates ing with these systems and have difficulty using deidentified voluntary reports from front- these flight path management systems,” Abbott line personnel and structured interviews with recommended told the 2010 Flight Safety Foundation Interna- industry specialists, the report integrates some solutions. tional Air Safety Seminar in Milan, Italy. “We exclusively obtained, confidential material from found vulnerabilities2 in [automation] mode individuals and organizations. and energy-state awareness, manual handling, For each of the findings, the report links and managing system malfunctions or failures. and summarizes the contribution from each These included failures anticipated by designers, respective source. A table compares the new [failures] for which there were no flight crew recommendations with those in the related 1996 Felix Gottwald/AirTeamImages.com © Felix
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 13 COVERSTORY
flight crew procedures to improve Crew Coordination, Problem Solving and Manual Handling Skills autoflight mode awareness as part of an emphasis on flight path manage- ment. For the longer term, equip- ment design should emphasize reducing the number and complex- Evolving ity of autoflight modes from the pilot’s perspective and improve the feedback to pilots (e.g., on mode transitions) while ensuring that the design of the mode logic assists with Evolving Normal/Typical pilots’ intuitive interpretation of failures and reversions.
3. “Develop or enhance guidance for documentation, training and pro-
Normal/Typical Normal/Typical Basic/Reversionary cedures for information automation Scope of Operation/Interrelationships — Pilot Knowledge and Skills Needed 1960s Time Frame 2000s systems [including communications automation] (e.g., EFBs [electronic
Notes: flight bags], moving map displays, Parallel evolutions of flight deck technology, airspace/operations and demands that professional performance management calcula- pilots continually increase their knowledge and skills have been a driver/factor in persistent flight tions, multi-function displays) or path and energy management problems. Levels of pilot skill once considered normal/typical in the 1960s now have become basic/reversionary. The new normal/typical level (2000s) requires pilots to functions. Describe what is meant be system-of-systems managers who can adapt to their evolving operations yet retain their basic/ reversionary level of cognitive and manual handling skills to handle non-normal situations. by information automation and what
Source: Flight Deck Automation Working Group systems [or] equipment are included; define terms associated with informa- Figure 1 tion automation; develop guidelines concerning the content and structure FAA report on flight deck automation most explanatory text (capitalization and of policy statements in flight opera- interfaces,3 adding today’s status of punctuation have been edited, and num- tions policy manuals for information relevant FAA and industry mitigation bers have been added, for ASW editorial automation; and develop operational efforts — including whether the later style or clarity). procedures to avoid information working group reiterated, updated or 1. “Develop and implement standards automation–related errors. dropped each older recommendation. and guidance for maintaining and 4. “In the near term, develop or enhance improving knowledge and skills Recommendations guidance for flight crew documen- for manual flight operations that The following excerpts selected by ASW tation, training and procedures for include the following: Pilots must from 14 of 18 recommendations also FMS use. For the longer term, re- be provided with opportunities to reflect the scope of inquiry; the four that search should be conducted on new refine this knowledge and practice were omitted concern ways to improve interface designs and technologies the skills; training and checking the regulatory process to expedite that support pilot tasks, strategies should directly address this topic; aircraft/equipment certification, encour- and processes, as opposed to ma- and operators’ policies for flight age consistency in new pilot-automation chine or technology-driven strategies.” path management must support and interfaces, improve data collection/ Among contextual notes, the report be consistent with the training and analysis to advance knowledge of human says, “Consideration should be given practice in the aircraft type. factors in flight path management, and to a new, much simpler flight path improve accident investigation practices 2. “For the near term, emphasize and management system design from the in these contexts. The excerpts also omit encourage improved training and pilot’s perspective [closely integrat-
14 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 COVERSTORY
ing new FMS designs with evolving flight crews] based on manufacturer to support the flight path manage- airspace requirements]. procedures, continuous feedback ment task, and provide operational from operational experience and les- policy for the use of automated sys- 5. “Research should be conducted sons learned. This guidance should tems. Distinguish between guidance and implemented on processes and be updated to reflect operational ex- and control. Encourage flight crews methods of verification and vali- perience and research findings on a to tell [ATC] ‘unable’ [to comply dation ([including] validation of recurring basis. For the longer term, with instruction/clearance] when requirements) during the design of conduct research to understand and appropriate. Adapt to the opera- highly integrated systems that spe- address when and why SOPs are not tor’s needs and operations. Develop cifically address failures and failure followed. The activities should place consistent terminology for automat- effects resulting from the integration. particular emphasis on monitoring, ed systems, guidance, control and 6. “Flight crew training should be en- cross-verification and appropriate other terms that form the founda- hanced to include characteristics of allocation of tasks between pilot tion of the policy. Develop guid- the flight deck system design that are flying and pilot monitoring. ance for development of policies for needed for operation of the aircraft 9. “Operators should have a clearly managing information automation.” (such as system relationships and stated flight path management policy Among contextual notes, the interdependencies during normal as follows: The policy should high- report says, “The operator’s policy and non-normal modes of operation light and stress that the responsibility should provide guidance on the op- for flight path management for exist- for flight path management remains erational use of automated systems ing aircraft fleets). For new systems, with the pilots at all times. Focus [including] examples of circumstanc- manufacturers should design flight the policy on flight path manage- es in which the autopilot should be deck systems such that the under- ment, rather than automated systems. engaged, disengaged, or used in a lying system should be more un- Identify appropriate opportunities for higher or lower authority mode; the derstandable from the flight crew’s manual flight operations. Recognize conditions under which the autopilot perspective by including human- the importance of automated sys- or autothrottle will or will not en- centered design processes.” Among tems as a tool (among other tools) gage, will disengage, or will revert to contextual notes, the report says, “Newer designs should focus on the Examples of Pilot-Related Insights From Automation Data flight crew’s ability to understand normal system operations and their Threats resulting ability to function effectively with- from insu cient pilot knowledge out error, especially when failures LOSA Accidents occur. … The integration of multiple Pilots are out of Major incidents systems should be designed such the control loop ASRS reports that the flight crew has clear, defini- FMS tive and well understood actions in programming the event of failures or degraded errors modes.” 0% 10% 20% 30% 60%50%40% Proportion of Source Data Citing Issue 7. “Develop guidance for flight crew
strategies and procedures to address LOSA = line operations safety audit; FMS = flight management system; ASRS = Aviation Safety Reporting malfunctions for which there is no System specific procedure. Notes: The working group’s analyses of events used database subsets that fell within the scope and time 8. “For the near term, update guid- frames specified in its final report. The data shown do not represent the frequency of occurrence for all accidents, major incidents, ASRS reports or LOSA reports from these time frames. ance … and develop recommended Source: Flight Deck Automation Working Group practices for design of standard operating procedures (SOPs) [for Figure 2
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 15 COVERSTORY
NTSB Hearing on Crash of Asiana Airlines Flight 214
he release in late 2013 of a U.S. government-industry report titled Operational Use of Flight Path Management Systems roughly coincided with a public investigative hearing on Dec. 11 by the U.S. National Transportation Safety Board T(NTSB). The subject was the crash of Asiana Airlines Flight 214, a Boeing 777, at San Francisco International Airport. Preliminary NTSB factual reports and the agency’s public statements about the event — in which the aircraft struck a seawall before reaching the landing runway threshold during a visual approach while the glide slope of the instrument landing system was out of service — say that one of the investigators’ areas of focus is the pilots’ interface with flight deck automation. Among subject matter experts called to testify at the investigative hearing were Kathy Abbott, chief scientist and technical adviser for flight deck human factors, U.S. Federal Aviation Administration (FAA), and David McKenney, a United Airlines captain representing the International Federation of Air Line Pilots’ Associations. They spoke in their roles as co- chairs of the Flight Deck Automation Working Group, and they also provided personal opinions. Abbott said, “We saw that autoflight mode-confusion errors continue to occur, and we saw that FMS [flight manage- ment system] programming and usage errors continue to occur, as well as others. … The data suggest that the highly integrated nature of current flight decks and additional add-on features, and retrofits in older aircraft, have increased flight crew knowledge requirements and introduced complexity that sometimes results in pilot confusion and errors in flight deck operations. … We identified vulnerabilities in that pilots sometimes rely too much on the automated systems and may be reluctant to intervene.” Some manufacturers of aircraft and avionics can address automation concerns with current human factors knowledge, she said, noting in part that “we found that human factors expertise has been increasingly incorporated into the design pro- cess at most manufacturers but is still inconsistently applied at some manufacturers. Furthermore, human factors specialists or human factors expertise may not exist in some organizations or is called in very late in the [design/engineering] process.” Since a 1996 FAA report on the interfaces between flight crews and modern flight deck systems, the Automation Subcommittee of the Air Transport Association of America (now Airlines for America) produced four papers on recom- mended practices for training and use of automated systems, and a U.S. Commercial Aviation Safety Team safety enhance- ment facilitated further work on mode awareness and automation policy for airlines, she said. Abbott told the hearing that among the FAA’s most relevant regulatory amendments or new regulations implemented between 1996 and 2013 is Federal Aviation Regulations Part 25.1329 on flight guidance systems, which include autopilots, autothrottle/autothrust systems and flight directors. Others are Part 25.1302, Installed Systems and Equipment for Use by the Flight Crew, covering design-related pilot error, and amendments to Part 25.1322 on flight deck alerting systems. Updated guidance based on the period’s research includes Advisory Circular 25-11 on electronic flight deck displays. NTSB panelists asked the working group co-chairs, “Why did it take 17 years to update the 1996 report?” Abbott said that the deliberative rulemaking processes involved are inherently time consuming, and that automation-related improvements to pilot training — a number of them dating from the 1996 report — needed to be implemented gradually by the industry, given time to become effective and then assessed over a number of years for the FAA to determine the safety results. McKenney told the hearing that a key 2013 report finding was that during an airline pilot’s career, skills evolve over time. “This increase in pilot knowledge and skills is not diminished as a result of the automated systems but is actually in- creased,” he said. “It also requires pilots to be even more of a pilot [in terms of manual flight operations] and also a systems manager, where we have to not only control the aircraft but also manage the additional systems that have been put in the flight deck.” Another working group consensus was that overall there is “incomplete understanding of complex relationships in modes of flight director, autopilot, autothrottle and autothrust and [FMS] computers, including such things as system limi- tations, the operating procedures and the need for confirmation and cross-verification — as well as the mode transitions and behavior,” he said. Training improvements that, for now, appear to be most relevant to the current Asiana accident investigation, he said, are knowledge of when to use various combinations of the automated systems, the situations that can lead to distractions and strategies to prevent these distractions, both on the ground and in flight. Other key areas appear to be knowledge re- lated to the mode logic and maintaining awareness of the state of the system modes, task workload management, automa- tion management, automated system mode management and decision making, McKenney said. — WR
16 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 COVERSTORY
another mode; and appropriate com- of references should be developed heading or altitude). … This may be binations of automatic and manual that identifies the core documents exacerbated in the future by some new flight path control (e.g., autothrottle relevant to ‘recommended prac- airspace procedures that are so complex engaged with the autopilot off).” tices’ for human-centered flight deck and require such precision that flying 10. “Discourage the use of regional or and equipment design. Early in the manually is impractical or not allowed, country-specific terminology in design process, designers should because of the likelihood of deviation. favor of international harmonization. document their assumptions on … Although there is general industry Implement harmonized phraseol- how the equipment should be used consensus that monitoring, cross- ogy for amendments to clearances in operation. verification and error management are important, these topics are not always and for reclearing onto [approach] 13. “Revise initial and recurrent pilot train- explicitly trained.” procedures with vertical profiles ing, qualification requirements (as To produce the report, the working and speed restrictions. Implement necessary), and revise guidance for group analyzed accidents, incidents and education and familiarization out- the development and maintenance normal operations for various periods reach for air traffic personnel to of improved knowledge and skills ending in July 2009 and conducted in- better understand flight deck sys- for successful flight path manage- terviews with manufacturers, operators tems and operational issues associ- ment. … Improve the oversight of air and training organizations. Other sourc- ated with amended clearances and carriers and [U.S. Federal Aviation es were “reports from related activities,” other air traffic communications. Regulations] Part 142 training centers. In operations, minimize the threats including those confidentially submitted 14. “Review and revise, as necessary, associated with runway-assignment by individuals and organizations; vari- guidance and oversight for initial changes through a combination of ous types of observations and analyses and recurrent training and qualifi- better planning and understanding during LOSAs, from the archives of cation for instructors/evaluators … of the risks involved. the LOSA Collaborative; and personal to successfully teach and evaluate knowledge and experiences of working 11. “Continue the transition to PBN airplane flight path management, group participants, including James M. [performance-based navigation] including use of automated systems.” Burin, then Flight Safety Foundation’s operations and drawdown of those director of technical programs. conventional procedures with lim- Accident Insights ited utility [or potentially higher Among the diverse insights brought to Notes risk (e.g., those procedures that the working group, a number are now be- lack vertical guidance)]. As part 1. Flight Deck Automation Working Group. ing considered coincidentally by accident Operational Use of Flight Path Management of that transition, address proce- investigators assigned to recent accidents. Systems: Final Report of the [FAA] dure design complexity (from the “Since the working group com- Performance-based Operations Aviation perspective of operational use) and pleted its data collection and analysis, Rulemaking Committee/[U.S.] Commercial mixed-equipage issues. Standardize several accidents have occurred where Aviation Safety Team Flight Deck Automation Working Group. Sept. 5, 2013. PBN procedure design and imple- the investigative reports identified vul- mentation processes with inclusion The third co-chair of the working group is nerabilities in the events that are similar Paul Railsback of Airlines for America. of recommended practices and les- to those vulnerabilities identified in this sons learned. This includes arrivals, report,” the report said. “These vulner- 2. The working group definedvulnerability , in the context of flight path management, departures and approaches. abilities represent systemic issues that as “a characteristic or issue that renders 12. “Ensure that appropriate human continue to occur. … Other factors that the system or process more likely to break factors expertise is integrated into affect the pilots’ [automation-related] down or fail when faced with a particular the flight deck design process in decisions include the high reliability set of circumstances or challenges.” partnership with other disciplines, of the systems (fostering insufficient 3. Abbott, Kathy et al. “The Interfaces Between with the goal of contributing to a cross-verification, not recognizing Flightcrews and Modern Flight Deck human-centered design. To assist in autopilot or autothrottle disengage- Systems, FAA Human Factors Team Report.” this process, an accessible repository ment, or not maintaining target speed, June 18, 1996. <1.usa.gov/1cZpsf3>.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 17 Come to Explore Safety and Quality in the Real World; Turning Theory into Best Practice
MARCH 31ST – APRIL 2ND 2014 A valuable event and excellent Westin Bayshore Resort & Marina, platform to improve individual Vancouver, BC, Canada knowledge and exchange ideas. “ Stephan Koehler, AIR-TEC This is absolutely the best ” conference series that I have ever attended. “ Bill Rankin – Technical Fellow, Boeing ”
40 Sessions Exceptional value World-class speakers Outstanding networking Unprecedented training opportunities
PLATINUM
GOLD SILVER BRONZE
PARTNERS IN SAFETY MEDIA Aviall AMERICAN EXPRESS Lenovo Sponsors correct at time of publication
Don’t miss out www.chcsafetyqualitysummit.com 2013REVIEW
nlike the previous two years, Unfortunately, there were two again dominated the turboprop fatality the worldwide commercial jet commercial jet upset aircraft accidents numbers. Business jets had eight major accident rate did not achieve a in 2013, the first in two years, and the accidents in 2013, an improvement record low point in 2013, but it return of controlled flight into terrain from their 2012 total of 13. Uwas still an excellent year for aviation (CFIT) accidents continued. Four of the There are now over 23,000 commer- safety. The 2013 commercial jet major seven commercial major jet accidents cial jets in the world (Table 1, p. 20). Of accident rate was 0.24 accidents per mil- were CFIT accidents. these, approximately 4 percent are East- lion departures, which is up from 2012’s Commercial turboprops also ern built, and 17 percent of the world’s record rate of 0.14, but below 2011’s regressed slightly from their 2012 commercial turboprop fleet is Eastern then-record rate of 0.28. The 2013 rate is record low point in terms of number of built. The commercial jet inventory grew the second-lowest rate ever recorded. accidents for the year. CFIT accidents about 2.5 percent from 2012, while the
Global data show another near-record-low commercial jet accident rate.
Year in Review 2013BY JAMES M. BURIN © Indonesian Police/Reuters
On April 13, 2013, Lion Air Flight 904, a Boeing 737-800, struck the sea approximately 20 m (66 ft) from shore and 300 m (984 ft) southwest of the Runway 09 threshold at Ngurah Rai International Airport, Bali, Indonesia, during an instrument approach to the runway in rain.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 19 2013REVIEW
The Fleets, 2013 Major Accidents, Worldwide Commercial Jets, 2013
Western Eastern Date Operator Aircraft Location Phase Fatal Type Built Built Total Jan. 29 SCAT Air CRJ-200 Almaty, Kazakhstan Approach 21 Turbojets 22,113 1,007 23,120 April 13 Lion Air B-737 Bali, Indonesia Approach 0 Turboprops 4,797 1,101 5,898 April 29 National Airlines B-747 Bagram, Afghanistan Takeoff 7 Business jets 18,072 July 6 Asiana Airlines B-777 San Francisco Landing 3 Source: Ascend Aug. 14 UPS A300 Birmingham, Alabama, U.S. Approach 2 Table 1 Nov. 17 Tatarstan Airlines B-737 Kazan, Russia Approach 50 Nov. 29 LAM EMB-190 Bwabwata Park, Namibia En route 33 commercial turboprop inventory decreased about 2 percent. The business jet inventory grew 2 per- Controlled flight into terrain Loss of control–in flight (upset aircraft) cent from the previous year. Thus, for the first Source: Ascend time in many years, the leaders in growth were Table 2 commercial jets, not business jets. The numbers in Table 1 reflect the total Commercial Jet Major Accidents, 2002–2013 fleets. The numbers of active aircraft, the aircraft actually in use, are somewhat smaller. Western built Eastern built 20 Approximately 8 percent of the commercial jet fleet is inactive, including almost 40 percent 15 of the Eastern-built commercial jets. Approx imately 14 percent of the turboprop fleet is 10 inactive. For the third year in a row, there were inactive business jets, with 3.5 percent of the 5 inventory inactive. Number of accidents Table 2 shows the major accidents that oc- 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 20122011 2013 curred in 2013 for all scheduled and unscheduled Year passenger and cargo operations for Western- Source: Ascend built and Eastern-built commercial jet aircraft. Five of the seven accidents happened during the Figure 1 approach and landing phase of flight. As men- tioned, four of the seven were CFIT accidents, Western-Built Commercial Jet Major Accident Rates, 1999–2013 and there were two upset aircraft accidents. . Figure 1 shows the total number of com- Major accident rate 5-year running average mercial jet major accidents and the number of . Eastern-built aircraft accidents for commercial . jets since 2002. Over the last five years, an aver- age of 5 percent of the active commercial jet . fleet was Eastern built, but they accounted for . 30 percent of the major accidents over that same . period. There were no Eastern-built commercial
Accidents per million departures . jet major accidents in 2013. 2010 2011 Figure 2 shows the commercial jet major Year accident rates and the five-year running aver- Note: Total departure data are not available for Eastern-built aircraft. age. This rate is only for Western-built jets Source: Ascend because, even though we know the number of major accidents for Eastern-built jets, we do not Figure 2
20 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 2013REVIEW
have reliable worldwide exposure data Major Accidents, Worldwide Business Jets, 2013 (hours flown or departures) to calculate valid accident rates. After a decade of Date Operator Aircraft Location Phase Fatal negligible improvement in the accident Feb. 20 The Vein Guys Premier I Thomson, Georgia, U.S. Landing 5 rate for commercial jets, a very positive March 4 Global Jet Luxembourg Premier I Annemasse, France Takeoff 2 trend of improvement that started in March 17 7700 Enterprises Premier I South Bend, Indiana, U.S. Approach 2 2011 is evident, and the five-year run- May 5 Private Lear 60 Valencia, Venezuela Approach 2 ning average continues to decrease. Sept. 29 CREW MMCLLC Citation CJ2 Santa Monica, California, U.S. Landing 4 The eight major accidents for busi- Oct. 18 Dufrense, Inc. Citation I Derby, Kansas, U.S. Climb 2 ness jets in 2013 (Table 3) were below Nov. 19 AirEvac International Lear 35 Ft. Lauderdale, Florida, U.S. Climb 4 their 12-year average of 10.5. As with Dec. 17 Mallen Industries Premier I Atlanta Approach 2 Eastern-built aircraft, calculating accident rates for business jets is difficult due to Controlled flight into terrain the lack of reliable exposure data. One Source: Ascend rate that can be calculated is the number Table 3 of major accidents per 1,000 aircraft. Figure 3 (p. 22) uses this metric, and it Major Accidents, Worldwide Commercial Turboprops, 2013 shows an improvement in the business jet accident rate over the last nine years. Date Operator Aircraft Location Phase Fatal Table 4 lists the major accidents Jan. 23 Kenn Borek Air DHC-6 Terra Nova Bay, Antarctica En route 3 involving Western-built and Eastern-built Feb. 13 South Airlines AN-24 Donetsk, Ukraine Approach 5 commercial turboprop aircraft with more Goma, Democratic Republic March 4 CAA Fokker 50 of the Congo Approach 7 than 14 passenger seats. The 22 major turboprop accidents in 2013 are about av- March 8 ACE Air Cargo Beech 1900 Anchorage, Alaska, U.S. Approach 2 erage, and above the record low of 17 set April 7 Sahel Air Service Beech 1900 San Tome and Principe Approach 1 in 2012. Figure 4 (p. 22) shows the num- April 17 Lao Air DHC-6 Vientiane-Wattay, Laos Takeoff 0 ber of turboprop accidents since 2002. May 16 Nepal Airlines DHC-6 Jomson, Nepal Landing 0 CFIT accidents continue to dominate the May 16 Flying Dragon Y-12 Shenyang, China Climb 0 Aviation accident and fatality numbers for com- June 1 Sita Air DO-228 Simikot, Nepal Landing 0 mercial turboprops. In 2013, eight of the June 10 Merpati Airlines MA-60 Kupang, Indonesia Landing 0 22 major accidents were CFIT accidents. June 13 SkyBahamas Saab 340 Marsh Harbor, Bahamas Landing 0 Over the last seven years, 30 percent of June 29 Batair Cargo EMB-110 Francistown, Botswana Approach 2 the commercial turboprop major ac- Aug. 9 Ukraine Air Alliance AN-12 Leipzig, Germany Start 0 cidents have been CFIT accidents. CFIT, approach and landing, and up- Sept. 9 CorpFlite DO-228 Viña del Mar, Chile Approach 2 set aircraft accidents continue to account Oct. 3 Associated Aviation EMB-120 Lagos, Nigeria Takeoff 13 for the majority of accidents and cause Oct. 10 MASwings DHC-6 Kudat, Malaysia Landing 2 the majority of fatalities in commercial Oct. 16 Lao Airlines ATR-72 Pakse, Laos Approach 49 aviation. Of the seven commercial jet Oct. 19 Air Niugini ATR-42 Madang, Papua New Guinea Takeoff 0 major accidents in 2013, five were ap- Nov. 3 Aerocon Metro III Riberalta, Bolivia Approach 8 proach and landing accidents. Over the Nov. 10 Bearskin Airlines Metro III Red Lake, Canada Approach 5 last five years, 70 percent of commercial Dec. 2 IBC Airways Metro III Arecibo, Puerto Rico En route 2 jet major accidents have been approach Dec. 26 Irkut AN-12 Irkutsk, Russia Approach 9 and landing accidents. Figure 5 (p. 22) Controlled flight into terrain shows the CFIT accidents for all com- Source: Ascend mercial jets since 1999. The upward trend since 2009 is quite disappointing Table 4
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 21 2013REVIEW
because more than 95 percent of all commercial Major Accidents, Business Jets, 2005–2013 jets have been equipped with TAWS (terrain
1.25 awareness and warning systems) since 2007. Over the previous six years, there have been 38 com- 1.00 mercial aircraft CFIT accidents (14 turbojet, 24 turboprop). Only three of these 38 aircraft were 0.75 5-year equipped with an operating TAWS. In those three 0.50 average: 0.49 aircraft, the TAWS provided 30 seconds or more of warning of the impending collision with the 0.25 ground. In the last two years, over 50 percent of Accidents per 1,000 aircraft 0.00 the commercial jet fatalities have been caused by 2005 2006 2007 2008 20092010 20112012 2013 Year CFIT accidents. In 2006, upset aircraft accidents took over from CFIT as the leading killer in com- Source: Ascend mercial aviation. Over the last three years, com- Figure 3 mercial jets have suffered 11 CFIT accidents and two upset aircraft accidents. Because of this, and the number of CFIT accidents involving turbo- Major Accidents, Worldwide Commercial Turboprops, 2002–2013 prop aircraft, CFIT is poised to regain its title as 40 the leading killer in commercial aviation. 39 Western built Eastern built Upset aircraft accidents continue to be one 30 33 29 of the leading killers in commercial aviation. 31 31 26.1 (12-year average) 20.6 (5-year After having no upset aircraft accidents since 24 24 23 average) 20 May of 2010, airlines had two in 2013, as noted. 21 20 22 17 There are numerous international efforts under 10 way to reduce the risk of upset aircraft accidents, Number of accidents and the recent decrease in upset accidents indi- 0 cates these efforts may be having some success. 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year The classification term major accident was introduced in 2006 by Flight Safety Foundation Source: Ascend and means that any of the following conditions Figure 4 are met: 1. Aircraft destroyed. (Destroyed means the CFIT Accidents, Worldwide Commercial Jets, 1999–2013 aircraft is not repairable, or if it is repair- able, the Ascend Damage Index (ADI) is 10 9 CFIT accidents over 50 percent. The ADI is calculated by 5-year running average 8 dividing the cost of repairs by the cost of 7 6 the aircraft when it was new.) 5 2. Multiple fatalities to aircraft occupants. 4 3 3. One fatality to an aircraft occupant and 2 aircraft substantially damaged. CFIT accidents per year CFIT accidents 1 0 2002200120001999 2003 2004 2005 2006 2007 2008 2009 2010 2011 20132012 These criteria ensure that an accident classification Year is not determined by an aircraft’s age or its insur- ance coverage, and they give a more consistent and CFIT = controlled flight into terrain accurate picture of consequential accidents. Source: Flight Safety Foundation James M. Burin, former FSF director of technical pro- Figure 5 grams, is a Foundation fellow.
22 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 Susan Reed T crash (78nm)north of 145km Marree, South —were inthe television documentary killed gers —members crew of working afilm on a (ATSB) says. island, Australian the Transport Safety Bureau ditions after from departing aSouth Australia Eurocopter AS355 F2crashed indark night con- FLIGHTSAFETY.ORG The 16,000-hour pilot and his two- passen disorientation seconds inthe before his probably contributed to apilot’s spatial positioninga global system (GPS)unit ofhe selection wrong the destination on |
WORLD AEROSAFETY | FEBRUARY 2014 ing to correct point fly-to the inaGPSunit, the helicopter and flight probably incruise attempt- workload associated with establishing the tion included dark night conditions, pilot high (Figure 1,p. 24). intentionally beganagentle right turn at 1,500ft spatiallybecame disoriented seconds after he ATSB2013, the said that pilot the probably helicopter was destroyed. Australia, at Aug. time 1902local 18,2011.The “Factors contributing to disorienta the - In its report, released inNovember final BY LINDAWERFELMAN Darkness, spatialdisorientation and aheavyworkloadfigured in thefatal2011crashofan AS355, theATSB says. HELICOPTERSAFETY |
23 HELICOPTERSAFETY
pilot’s limited recent night flying and instrument helicopter flew east, then northeast, “contrary to flying experience, and the helicopter not being what [witnesses] expected, as they understood equipped with an autopilot.” that the crew were returning to their accommo- The report said that the accident flight was dation at Muloorina Station (96 km [52 nm] away one in a series that began Aug. 17 in Sydney, New on a southerly bearing),” the report said. South Wales. The helicopter landed that evening One witness radioed the helicopter pilot in Parachilna, South Australia, and departed at to question the flight path, but there was no 0716 the next day for the first filming flight of response. Investigators could not determine the day. Other flights in the Lake Eyre region whether the helicopter’s radio had been turned followed, and the helicopter landed early in the on, but they noted that, as expected, there were afternoon at Muloorina Station, 48 km (26 nm) no radio communications with air traffic ser- north of Marree, where luggage was offloaded vices during the brief flight. and the helicopter was refueled (Figure 2). The The helicopter was not equipped with a helicopter left Muloorina Station at 1418, and, flight data recorder or a cockpit voice recorder, after the first stop, flew to an island in the Cooper and neither was required. Data recovered Creek inlet, landing around 1715. Plans called from the helicopter’s GPS unit showed that the for the crew to return to Muloorina Station after helicopter entered a shallow right turn and, 12 completing their work on the island. seconds later, began a downward spiral that When the helicopter departed from the island continued for 38 seconds, until the helicopter site at 1859, it “initially climbed vertically while crashed into the ground at high speed and a moving rearwards … most likely to maintain a vi- bank angle of about 90 degrees. sual reference to the campfire, which was the only The report said witnesses at the departure available ground light source,” the report said. site — members of a tour group on the island — At 500 ft, the helicopter turned left to a head- had watched the helicopter’s descent, “followed ing of 035 degrees, then climbed to 1,500 ft. The by a fireball and an orange glow.” They notified authorities and began Path of Accident Flight a search, locating the wreckage about 3 km Lake Eyre (1.6 nm) east-north- east of the departure 131 seconds 133 seconds site at 2040. The report said
121 seconds that the initial depar- 171 seconds 148 seconds ture path, with the 161 seconds accident location turn at 500 ft, was 108 seconds “consistent with the 0 seconds 103 seconds departure point pilot using one or from island both of the helicop- 32 seconds ter’s … GPS units 61 seconds … and tracking to a destination selected prior to departure.”
3,619 ft The 035-degree outbound track “can Satellite image: Google Satellite best be explained Source: Australian Transport Safety Bureau by the pilot having Figure 1 selected an incorrect
24 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 HELICOPTERSAFETY
destination on one or both of the GPS units,” Accident Site the report added, noting that data for another planned landing site, which had been pro- grammed into at least one GPS, called for the Cowarie Station helicopter to fly within about one degree of the
035-degree track. Accident site “Errors in selecting a waypoint on a GPS Departure site (Cooper Creek Inlet) unit are not uncommon, and are potentially Lake Eyre more likely to occur during preflight planning in low-light situations,” the report said. Even Muloorina Station if the pilot did not hear the radioed question Marree aboutThe Bell his 206B departure crashed path, in a wooded“the data-entry area near error Green Cove Springs, Florida, after flying wouldinto night probably instrument have meteorological become evident conditions. to the pi- lot at some stage during the climb or soon after
Northern reaching 1,500 ft. … It is likely that the right Territory turn after reaching 1,500 ft was intentional, and Western Queensland Australia South Parachilna Australia it was initiated in order to correct an unin- New South Wales tended problem with the initial departure track Victoria to the northeast.” 100 miles Tasmania
In the last seconds of the flight, “given that and Space Administration; National Aeronautics image: U.S. Satellite by Susan Reed 2.5 modified Steiner/WikimediaThomas CC-BY-SA inset map: the pilot was probably manipulating the flight Source: Australian Transport Safety Bureau controls but not apparently recognising the Figure 2 descent and increasing bank angle in sufficient time to recover, it is likely that he was spatially approval for the use of nondirectional beacons disoriented,” the report said. “The circum- and VHF omnidirectional radios) in 1979. He stances of the flight included limited percep- had never held a civil command instrument rat- tual cues of a problem, elevated workload and ing, which had more stringent requirements and potential for distraction, a pilot with limited was required for night aerial work and charter instrument flying recency and an aircraft with flying, or GPS navigation approval. He was no autopilot. These types of factors have been endorsed in several helicopter types, including associated with many previous spatial disorien- the AS355. tation accidents, including accidents involving According to the last entry in the pilot’s log- a gradually increasing bank angle and descent book, not quite two months before the accident, over a significant time period.” he had 16,353 flight hours, most of them in helicopters. That flight time included 484 hours Owner and Chief Pilot at night, including 3.4 nighttime hours in the The accident pilot was the owner, managing di- previous year. rector and chief pilot of the third-party operator Accident investigators found “no relevant re- hired by the helicopter’s owner, a Sydney media cords” for the period between June 27, 2011, and organization, to take charge of its helicopter Aug. 17, and family members and colleagues operations. The pilot had provided services to could not remember whether he had flown dur- the media organization for more than 20 years, ing those months. the report said. To carry passengers at night, the pilot was He had obtained a commercial pilot license required to have flown three night takeoffs and for helicopters in 1977, while he was a pilot for landings in the previous 90 days; there was a re- the Australian Army, and a night visual flight cord of one night landing, at the operator’s base rules (VFR) helicopter rating (which included in Sydney, during that period.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 25 HELICOPTERSAFETY
LOC-I in Helicopters
reventing, recognizing and spatial disorientation–positional aware- automation; and unexpected transitions responding to rotorcraft upsets ness. Very often, a combination of … from visual meteorological conditions Pmust evolve in a manner similar factors [aggravated by pilot errors in (VMC) to instrument meteorological to the prevention of loss of control–in airspeed and power control] can lead conditions (IMC). flight (LOC-I ) involving large commer- to loss of control and subsequently [to] “I have sat in simulators and seen cial jets, according to Geoff Connolly, semi-controlled flight into the terrain.” the startle effect on an experienced pilot a captain and consultant experimental Various LOC-I causal factors have sitting alongside me who inadvertently test pilot, FlightExperimentations. been proposed, but a few have been enters IMC,” Connolly said. “He’s not ex- Speaking at the Royal Aeronautical cited repeatedly in U.K. investigations, pecting it, and the startle effect is real.” Society’s 8th International Flight Crew he said, adding, “The lack of automatic One of the helicopter LOC-I Training Conference in London in stabilization or autopilots, particularly in threats, incipient vortex ring state, September 2013, he said, “LOC-I in VFR [visual flight rules] operations, is a requires attention to fundamental helicopters is most often because of particular factor.” rotary-wing aerodynamics. On the He identified commonalities among plotted lift/drag curve for a helicopter, seven of many reports he reviewed, sug- “we can come all the way back up the gesting that future mitigations be more curve, as speed reduces, until we end integrated from an LOC-I perspective. up in the hover,” he said. “So we have The commonalities were degraded vi- a large area of our flight envelope sual environment (including dark night where we can be in a low airspeed– conditions and low visibility in weather); high power demand area. … Vortex visual illusions (“a particular problem ring state [is] effectively the helicopter offshore where things can be very equivalent of the [airplane wing] stall. black,” he said); human factors; crew … The good news: We can recover. resource management, including pilot And, funny old thing, recovery is stick monitoring; cockpit design/human- forward, select an accelerative at- machine interface; system performance/ titude, allow the airspeed to increase handling qualities; depth of pilot and you will get out of the condition.”
Susan Reed understanding of automation/lack of (continued next page)
A May 2009 operator’s proficiency check no problems with the pilot’s performance. The was the pilot’s last recorded biennial flight re- flight did not include dark night conditions, how- view, although an April 2010 proficiency check ever, and the check pilot noted that the accident was “conducted to the same standard and by the pilot’s next check flight “should address night same approved testing officer as the May 2009 flight in marginal VMC [visual meteorological check,” the report said. conditions] to revise instrument scan skills.” The pilot turned 60 in October 2010 and Previous check flights had revealed “no sig- was required by civil aviation regulations to nificant concerns” about the pilot’s instrument complete an annual proficiency check or flight flight skills. review in order to serve as pilot-in-command Because the operator’s flights were conducted on any passenger-carrying commercial flight. by single pilots, the accident pilot’s colleagues Because the last proficiency check had been had limited opportunity to observe his perfor- conducted April 27, 2010, he was ineligible to mance, the report said. Media personnel who had conduct commercial flights with passengers flown with him said that their operations rarely after April 27, 2011. required night flights, although one previous pas- The 2010 proficiency flight included 0.7 senger reported a flight that had involved about hours of night flying, and the check pilot found 30 minutes of night flying and no problems.
26 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 HELICOPTERSAFETY
Discussing the seven reports with during visual approach to an oil rig in flying skills and scenarios involving possible LOC-I elements, Connolly poor visual conditions at night (ASW, “disorientation, loss of control, deci- noted that sometimes pilots with the 11/11, p. 24). “There were no stabilized sion making and judgment — think- highest levels of flight experience approach criteria — something we’ve ing about energy management and failed to recognize or recover from learned from our fixed-wing breth- vortex ring.” upset situations, including incipient ren,” he said. “Our synthetic training devices vortex ring state. In a 1991 offshore Although an accident on Aug. 23, have improved immensely,” Connolly ship-to-helideck approach by two such 2013, in the Shetland Islands, North added. ”There are still deficiencies in pilots in night VMC, the helicopter Sea, remains under investigation, the mathematical modeling of some lost airspeed and descended at a high Connolly said that preliminary facts emergencies — like vortex ring, tail rate into the water.1 In a 1992 case, the from official sources — “the airspeed rotor failures and so on. But they are crew was flying a shuttle between oil reduced, the aircraft started to descend what we’ve got, and we must use them rigs at night in snow showers, rough and then ended up descending rapidly as best as we can. … We should be seas and with the wind gusting 55 kt into the water” — imply a need to con- educating ourselves and going beyond while turning downwind (with possible sider LOC-I scenarios (ASW, 10/13, p. 8). just training. … We need improved downdraft effects).2 “The pilot flying Mitigation efforts so far — such as and greater depth of knowledge of reduced power and raised the nose, revised weather limitations for night automated systems.” airspeed reduced to zero and the rate operations under VFR; electronic flight — Wayne Rosenkrans of descent started to increase; full instrument systems; synthetic vision Notes power failed to stop the aircraft enter- aids (including head-up displays and 1. Australian Bureau of Air Safety ing the water,” he said. forward-looking infrared) to coun- Investigation (BASI). “Puma SA 330J A 2006 accident involved a night teract visual illusions; new autopilot Helicopter VH-WOF, Mermaid Sound, approach to an oil rig platform in poor capabilities and limitations; enhanced Western Australia, 12 May 1991.” BASI visibility and rain (ASW, 1/09, p. 26). helideck lighting standards; standard Report B/915/1020.
“Overall, it was considered likely that most assessment, including a routine stress electro- of the pilot’s night flying in recent years would cardiogram, in November 2010; no problems have been near built-up areas with a significant were found. amount of terrestrial lighting,” the report said. The report said that the week before the Normal Operations accident, the pilot had been vacationing in an The helicopter was manufactured in 1988 and area located three time zones away from Sydney, registered in Australia in 1989. When the acci- but he returned five days before his flight duties dent occurred, it had accumulated 11,920 hours began Aug. 17 and was considered well rested. total time. It was maintained in accordance with He flew 7.5 hours on Aug. 17, landing at 1637, manufacturer requirements and certified for and began flying at 0716 the next morning, after day and night charter operations under night a period of time off that gave him an opportu- VFR. The pilot had told maintenance personnel nity for eight hours of sleep. Before the accident during the flight to the Lake Eyre region that the flight, he had conducted eight flights in 4.3 helicopter was operating normally. flight hours. The helicopter had two GPS units — a The pilot had a Class 1 medical certifi- Garmin GPS400W on the center pedestal cate and had undergone an aviation medical below the instrument panel and a portable
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 27 HELICOPTERSAFETY
Garmin GPSMAP 495, which was mounted in some cases exceeded regulatory requirements. above the instrument panel on the center pil- However, the operator “did not effectively man- lar of the windscreen. age the risk associated with operations in dark The helicopter also had a radar altimeter night conditions,” the report said. system that indicated height above ground level In addition, the operator did not require a up to 2,000 ft; however, at more than 30 degrees written risk assessment before each flight. of bank and more than 20 degrees of pitch, the The Australian Civil Aviation Safety Au- device displayed an altitude greater than the thority (CASA) said, in a May 2011 safety trend actual height above ground level. indicator assessment of the operator, that it was The helicopter was not equipped with a advising the chief pilot to adopt a formal safety ground proximity warning system, and one was management system and to consider imple- not required. The helicopter also lacked an au- menting a fatigue risk management system, topilot — a factor that the report said “increased although neither was required. the likelihood that an unusual attitude would develop during the right turn” — but, an autopi- Safety Issues lot was not required for night VFR flight. Noting that VFR flights were permitted in dark night conditions — “effectively the same as Light From a Campfire instrument meteorological conditions” — the Members of the island tour group said there were report said the ATSB had identified the follow- no clouds and minimal winds before the takeoff, ing safety issues: about one hour after sunset, and they classified •• The absence of “sufficient requirements the ambient illumination level as “dark.” for proficiency checks and recent experi- “Apart from the tour group’s campfire on the ence to enable flight solely by reference to island, there were no other known sources of instruments”; and, terrestrial lighting cues available in the vicinity of the helicopter’s flight path,” the report said, •• The absence of requirements for “autopi- adding that the moon was not visible at the time lots and similar systems that are in place” ‘The pilot said of the crash, and stars would have been the only for flights conducted under instrument source of light. flight rules. the darkness was A pilot who had flown in the area several In response, CASA noted that pilot licensing years earlier for the same media organization rules that took effect in December 2013 require “frightening.”’ said the stars had not been visible because of pilots to “demonstrate competency during bien- glare from the instrument lights, and there was nial night [VFR] assessments.” The agency said no visible horizon. “The pilot said the darkness it would provide additional guidance material was ‘frightening,’ and he had to fly the helicopter on night VFR operations, consider related rules by flight instruments for the flight to Marree,” changes, clarify its definition of nighttime “vis- the report said. ibility” and promulgate a regulation requiring The departure site lacked markings, light- either an autopilot or an IFR-qualified two-pilot ing and wind indicators that were specified by crew in passenger-carrying night air transport Civil Aviation Advisory Publication (CAAP) flights in helicopters. 92-2 (1) as necessary for night operations, the The report said that another issue involving report said, noting that the operator’s operations the operator’s risk control systems was rendered manual told pilots to comply with the CAAP. moot because the company stopped conducting flight operations after the accident. Safety Management This article is based on ATSB Transport Safety Report The report credited the operator with using a AO-2011-102, “VFR Flight Into Dark Night Involving system of risk control for night VFR flight that Aerospatiale AS355F2, VH-NTV.” Nov. 14, 2013.
28 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 PRISM Complete Safety Management Solution
PRISM’s unique internet-enabled solutions coupled with our dedicated in-house Helicopter Safety Experts address the challenges of setting up a functional and effective Safety Management System (SMS) PRISM Affiliations: PRISM Services Include: • SMS Briefings for Executives • Training Classes available for Helicopter Operators (Delivered in English or Spanish) • SMS Facilitation Services (Develop, Plan, Implement) • On-site SMS Evaluation and Guidance • Manual Review and Development • Certification Consultant • “ARMOR” a Web-based Safety and Quality Management Tool Compatible with iPad®
[email protected] +1 513.852.1010 www.prism.aero THREATANALYSIS Unmarked Meteorological Towers Bring Low-Altitude Risk
Wind-monitoring sensors, installed without notice, can present an unexpected hazard to pilots of low-flying aircraft.
BY ED BROTAK
owers equipped with sensors to measure MET users — and appealed to state officials to winds for power-generation feasibility address the concerns. studies can put at risk pilots and aircraft The NTSB said earlier in 2013, “Currently, it operating at low altitudes, especially is unknown how many METs are erected in the Tduring aerial application of crop-protection United States.” chemicals, seeds and fertilizers. The first of three accident reports selected Meteorological evaluation towers (METs), as examples by the NTSB reflects key issues. On erected temporarily to measure winds for Jan. 10, 2011, at 1057 local time, a pilot with electric power-generation feasibility studies in a commercial pilot certificate and over 26,000 the United States, in recent years have become total flight hours in airplanes flew a Rockwell common in some areas. After a number of acci- International S-2R Thrush Commander — a dents, the National Transportation Safety Board single-engine, turboprop airplane designed for (NTSB) and the agricultural flying industry aerial application — directly into an unmarked advocated changes to the current federal level 198-ft (60-m) MET while performing a routine of aviation safety oversight — which ultimately seeding operation on Webb Tract Island fields
resulted in requests for voluntary measures by in Oakley, California. Visual meteorological of Nebraska University Lincoln John Hay, © F.
30 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 THREATANALYSIS
nearby weather station, was 10 mi (16 km). The probable cause was “the pilot’s failure to maintain clear- ance from the antenna tower” and contribut- conditions (VMC) with 10 mi (16 km) visibility ing factors were “the recency of the tower’s Unmarked were reported. construction and the lack of obstruction lights The pilot flew over the field, then descended on the tower.” to begin the seeding. Witnesses said he made The third accident — involving a personal, Meteorological no observed evasive maneuvers to avoid the non-agricultural flight — occurred Dec. 15, unpainted metal tower and its guy wires, and in- 2003, at 1416 local time, when an Erickson vestigators concluded that “his ability to detect (Glasair)/SHA Glasair TD, a single-engine it [the tower] visually was extremely limited,” homebuilt airplane, collided with an MET near Towers and he never saw it. The aircraft crashed into Vansycle, Oregon, in VMC with 10-mi vis- the ground, killing the pilot; the airplane was ibility. The pilot held an airline transport pilot substantially damaged. certificate with over 11,000 total flight hours In its final accident report, the NTSB con- (determined by investigators). Both he and a “Many METs Bring Low-Altitude Risk cluded that the probable cause was “an in-flight passenger were killed. The 164-ft (50-m) an- are unmarked, collision with an unmarked [MET] during an emometer (an instrument for measuring wind aerial application flight, due to the pilot’s failure to velocity) tower they struck was sited among unlighted and not see and avoid the obstacle” and that “contributing a field of wind turbines. The probable cause to the accident was the lack of visual conspicuity of was “the pilot’s failure to maintain adequate referenced in any the MET and the lack of information available clearance with the anemometer pole/wires to the pilot about the MET before the flight.” during low altitude flight” and the contribut- FAA notices or The report also noted that “because many ing factors were “the pole and the pilot’s low publications for METs … are just below the 200-ft [61-m] altitude flight.” threshold at which U.S. Federal Aviation Ad- pilots.” ministration [FAA] regulations would require Need for Measurements the applicant to notify the FAA of the MET and To better understand and predict the weather, to provide a lighting and marking plan for FAA meteorologists have for years probed the assessment, many METs are unmarked, un- atmosphere above the ground. Radiosondes lighted and not referenced in any FAA notices — balloon-borne instrument packages — are or publications for pilots.” regularly released twice a day from hundreds Two similar fatal accidents occurred earlier. of sites around the world and often rise to over On May 19, 2005, at 0944 local time, an Air 100,000 ft. Closer to the ground, towers are Tractor AT-602 (a single-turboprop agricul- often equipped with instrumentation to collect tural airplane) collided with a 197-ft (60-m) data from the low-altitude atmosphere, which unmarked and unlighted MET 15 days after meteorologists call the “boundary layer.” Such the tower had been erected in Ralls, Texas. This information is critical in producing more accu- crash involved an experienced pilot with 21,000 rate forecasts for the aviation industry. But most flight hours, performing a flight maneuver after of these towers are relatively low compared with a second aerial application (herbicide spraying) METs and pose no significant hazard to aircraft. on an area of trees. Part of the right wing sepa- METs, however, are a specialized, derivative rated in the collision and was found adjacent version of such towers. As the demand for re- to the base of the tower; the top 3 ft (1 m) newable, natural energy sources has increased, of the tower were severed. The plane crashed designers and engineers at many energy com- and burned, killing the pilot and destroying the panies have turned to groups of wind-driven
© stevemc/123RF.com © airplane. Visibility at the time, as reported by a turbine generators for producing electricity.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 31 THREATANALYSIS
appear from one day to the next in a previously vacant field. The major risk factor is that the dull metal used for the tower, and the supporting guy wires, are difficult to see from the air. The tower and wires easily blend into the surroundings, making them a hazard to pilots of low-flying aircraft. At particular risk, as evidenced by two of the fatal accidents cited, are pilots performing aerial application. By the nature of their tasks, these pilots must fly at low altitudes, often within 10 ft (3 m) of the ground. Historically, the typical wind The FAA and the But to be practically, environmentally and farm sites have been in rural areas, far from loca- NTSB want MET economically feasible, they have to be installed tions where they would create obstructions for users to make the where there is a fairly constant wind. aviation. But this is no longer the case. For this towers and their To test possible sites for these wind farms, reason, the National Agricultural Aviation Asso- supporting wires energy companies first erect METs. These towers ciation (NAAA) has been in the forefront of call- more visible, with are equipped with anemometers as well as vanes ing for action to mitigate the risks of unmarked, the use of orange to determine wind direction. The instruments unregistered and unexpected towers. and white paints and are located at various heights on the tower. The Even prior to the 2011 accident, the NAAA marker balls. towers themselves are assembled quickly and are had noted that 25 percent of fatal accidents (in usually left up for a year, sometimes several years. which 24 pilots were killed) during agricultural This provides the long-term wind data necessary flying for aerial application were due to colli- to make economically driven decisions. sions with towers and/or their guy wires. As for the METs, NAAA Executive Director Andrew Why So High? Moore said, “They go up overnight — literally Why do these towers have to be so high — often overnight. And there’s no central database to log 200 ft or more? Large wind turbines are massive. their existence.” Blades can be over 100 ft (30 m) in length and U.S. wind farming is practiced in many re- sit on a supporting tower, which itself is often gions but most notably in the Plains states. The over 200 ft high. The entire wind turbine can open terrain and steady winds are ideal for the easily rise 300 to 400 ft (91 to 122 m). People in wind turbines. Texas leads the nation in wind- the wind-energy business talk about winds at generated electricity. Along the West Coast, “hub height,” the height at which the blades con- California has numerous sites, and is second nect to the main structure. in wind turbine numbers. The Midwest and Although typical METs have substantial the Northeast also have sites. Only the South mass, they can be erected in a matter of hours. and Southeast remain untouched so far. Many Some companies specialize in their construction countries around the world also have turned to and installation. wind-energy production, and they have encoun- Tubular, galvanized metal types have tered the MET risks to aviation. thin poles with the wind-sensing equipment mounted at predetermined heights. They are Mitigations So Far assembled at ground level, then tilted up- After the Oakley accident, the NTSB sent out a right and supported by a system of guy wires. special safety alert in March 2011 warning pilots Lattice-type METs are more elaborate. Their about METs.1 It described the problem and prefabricated sections are connected and lifted urged pilots to “be vigilant” when flying where into place. Often, a nearly 200-ft tower can these towers might be located. Just five days © F. John Hay, University of Nebraska University Lincoln John Hay, © F.
32 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 THREATANALYSIS
prior to the Oakley accident, the FAA had issued In May 2013, the NTSB issued another a request for public comments about voluntary safety recommendation letter,2 which included marking of such towers. The FAA requires that recommendations to a number of the stake- any tower over 200 ft be clearly marked and holders in this issue. The agency recommended lighted and be listed on a publicly accessible that the FAA require all METs to be marked federal registry. and create “a publicly accessible national data- As noted, heights of many METs fall just base for the required registration of all meteo- under the FAA’s 200-ft threshold. Applications rological evaluation towers.” The NTSB further for city, county or state construction permits recommended that other federal agencies (the — such as for the one issued by Contra Costa Departments of Interior, Defense and Agricul- County and applicable for the Oakley MET ture) involved in approving the installation of erection in April 2009 — explicitly state that the METs instruct the applicants in standard avia- tower will be just short of the limit for requir- tion marking procedures. ing federal assessment of obstruction marking, The NTSB also recommended that the lighting and registration. American Wind Energy Association in its Wind Energy companies also consider factors such Energy Siting Handbook acknowledge the avia- The FAA determined as the lower cost of obtaining government per- tion hazard that the METs pose and encourage that requiring mits and erecting 60-m METs compared with voluntary marking. Finally, the NTSB recom- standard 80-m (252-ft) types; and keeping secret mended that the 46 states and the District of lighting on such from competitors sites where wind measure- Columbia that do not currently require METs ments (wind prospecting) will occur. to be registered in a directory do so, and that all towers would be The policy decision by the FAA in June 2011 states require marking these towers. unreasonably was to recommend voluntary marking of towers The University of Nebraska Lincoln Exten- under 200 ft. How would the FAA like MET sion program and the Nebraska Aviation Trades difficult. users to increase the level of safety? First, paint Association have produced and posted on the towers with alternating aviation orange and YouTube two videos highlighting the dangers of white stripes from top to bottom. Also, install unmarked METs, including footage shot from one high-visibility sleeve on each guy wire and flight.3 The videos show the benefits of properly install eight high-conspicuity, spherical marker marking such towers. balls on the wires. Edward Brotak, Ph.D., retired in 2007 after 25 years as The FAA determined that requiring light- a professor and program director in the Department of ing on such towers would be unreasonably Atmospheric Sciences at the University of North Carolina, difficult because of the often-remote locations. Asheville. The agency also opted not to require national Notes registration of such towers, although officials acknowledged that local or state governments 1. NTSB Safety Alert SA-016, Meteorological can register them. In fact, 10 states (Califor- Evaluation Towers, is available at <1.usa. nia, Idaho, Wyoming, North Dakota, South gov/1cR9V1Cl> to educate pilots about these safety issues. FAA guidance on conspicuity Dakota, Nebraska, Kansas, Missouri, Michi- for METs is in Advisory Circular 70/7460- gan and Montana) have issued guidelines or 1K, Obstruction Marking and Lighting, <1.usa. enacted laws dealing specifically with towers gov/1i1GOwe>. ranging in height from 50 ft (15 m) to 200 ft, 2. NTSB. Safety Recommendation A-13- according to NTSB research. Some states, such 21, May 15, 2013.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 33 AVIATIONMEDICINE Sleep,BY LINDA WERFELMAN Interrupted The FAA is considering more aggressive screening of pilots for potentially deadly sleep apnea.
34 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 © MirekP/iStockphoto 2013, certification. medical receive before they treatment OSA to undergo with diagnosed those requiring —and der disor to have the likely most —those pilots would address also agency’s the concerns. as “a more palatable solution for pilots” that representatives to develop what AOPA described discussions inJanuary with aviation industry Tilton had told that them FAA the would open andOwners Pilots Association (AOPA), said Pilots’ organizations, including Aircraft the no decisionbeen on it when might effect. take spokeswoman said inlate there December had was “considering” proposal, the and an agency Federal Aviation Administration (FAA) said it before it can effect. take House,by full the Senate the and president the disorder.sleep The proposal must approved be treating of apilot or controller air traffic for a requirementrevised involving testing the or a proposal to require formal for rulemaking any House of Representatives committee approved tional area of responsibility. In addition, aU.S. of apnea sleep would outside be - tradi their interventionssaid wholesale for potential cases representing aviation examiners, medical which feedbacktheir on proposal, the and by a group objected towhich lack the of opportunity for greeted by protests from pilots’ organizations, planned changes, but announcement the was released shortlybe after announcement of the threshold for have obesity —also OSA,he said. 30 percent of with aBMIbelow those 30—the circumference of 17in(43cm)or more. About “Measuring Obesity,” p. 36)—and aneck tors sometimes label“morbidly obese” (see of 40or —acategory higher - that BMIcalcula among mass people with index abody (BMI) C FLIGHTSAFETY.ORG Tilton outlined plan the inNovember In aftermath the of objections, those U.S. the Initially, Tilton said details would that policy 1 noting that OSAis “almost universal” has proposed screening the most obese obese most the screening proposed has Fred Tilton Surgeon Air U.S. Federal apnea (OSA), sleep of obstructive tions” implica safety “significant the iting |
WORLD AEROSAFETY | FEBRUARY 2014 2 - - apnea, of form common sleep most the OSA is Implications Safety certificate. amedical receive could before they treatment to undergo required be and specialist a sleep who is to aphysician more referred be would or of 40 scores with pilots pilot; ofBMI every the to calculate examiners medical requiring be would he step, said, next The seminars. examiner FAA and medical meetings safety at pilot ailment the discussing and pamphlets educational OSA by publishing against paign hypertension, to cite just afew,” just to cite hypertension, said. Tilton and disturbances personality death, cardiac sudden dysrhythmias, cardiac impairment, cognitive sleepiness, daytime excessive cause it can because implications safety significant brain. the and blood the in dioxide more carbon and oxygen less in result of not breathing periods these or longer, up seconds to aminute; sometimes for sleep 10 aperson’s during in breathing Soft palate Soft Tilton said his office had begun its cam its begun had office his said Tilton it has and sleep, restorative “OSA inhibits 3 which causes repeated interruptions interruptions repeated causes which Blocked airway Uvula Air ow Epiglottis Tongue - AVIATIONMEDICINE enlarged tissueatthe apnea occurswhen and tongue—relax sufferers alsohave back ofthemouth. Obstructive sleep throat —muscles soft palate,uvula the airway. Some enough toblock that supportthe muscles inthe |
Susan Reed 35 AVIATIONMEDICINE
under-diagnosed in the general and crew popu- Measuring Obesity lation.”4 The manual quotes one unidentified specialist as estimating that “about 3 percent of the middle-aged pilot population” has OSA, edical authorities typically rely on the body mass index (BMI) although many are unaware of the problem. to measure overweight and obesity. BMI can be determined by Musing an online calculator1 or by dividing2: The manual says that ICAO is especially •• Weight in kilograms by height in meters squared, for example, concerned about OSA because of its associa- 68 kg ÷ (1.65 m)2 = 24.98; or, tion with an increased risk of coronary artery •• Weight in pounds by height in inches squared, and multiplying disease, hypertension and stroke. by a conversion factor of 703, for example, “Crewmembers treated for OSA normally [150 lb ÷ (65 in)2] x 703 = 24.96. only recognize the extent of their performance The following are standard categories associated with BMI ranges decrement once it is successfully remedied with for adults: treatment,” the manual says. BMI Weight Status The manual recommends that medical ex- Below 18.5 Underweight aminers follow a course of action similar to that 18.5–24.9 Normal discussed by Tilton, suggesting that examiners 25.0–29.9 Overweight ask two questions of pilots whom they believe 30.0 and higher Obese may have OSA: “Do you snore at a level that dis- turbs someone sleeping in the same room?” and Some BMI scales also include an additional category of “morbidly “Do you have a tendency to fall asleep or doze at obese” or “extremely obese,” which they apply to BMI scores of 40 and above. inappropriate times?” So, while a 6 ft (2 m) tall pilot would be considered to have a Pilots who answer yes to either question, normal weight at 175 lb (79 kg), he would be considered overweight as well as those with a neck circumference at 185 lb (84 kg) and obese at 221 lb (100 kg). At 295 lb (134 kg), he greater than 17 in or a BMI greater than 30, would have a BMI of 40. should be questioned in greater detail. If their — LW Notes responses lead medical specialists to suspect OSA, the pilots should be considered tempo- 1. Many health-related websites include BMI calculators, such as this one published by the U.S. Centers for Disease Control and Prevention (CDC) at rarily unfit to fly and sent for a sleep study,
36 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 AVIATIONMEDICINE
(48 km). Air traffic control (ATC) tried the incident,” the report said. “This and the risk increases with age and repeatedly to contact the flight crew, but condition likely caused him to experi- with a buildup of fat or a decrease in there was no response. After 18 minutes ence chronic daytime fatigue and muscle tone in the muscles involved of silence, the crew contacted ATC and contributed to his falling asleep during in breathing.7,8 followed their instructions to turn back the incident flight.” Experts at the National Institute to Hilo, where they landed the airplane The captain told NTSB incident of Neurological Disorders and Stroke without further incident. None of the 43 investigators that he and the first officer (NINDS) at the U.S. National Institutes passengers and crew was injured.6 fell asleep after they leveled at cruise of Health (NIH) describe an episode of In its final report, the NTSB cited as altitude. sleep apnea this way: the probable cause of the incident “the “It was comfortable in the cockpit. The person’s effort to inhale air cre- captain and first officer inadvertently The pressure was behind us,” he said. ates suction that collapses the windpipe. falling asleep.” Contributing factors “The warm Hawaiian sun was blaring This blocks the air flow for 10 seconds were “the captain’s undiagnosed ob- in as we went eastbound. I just kind of to a minute while the sleeping person structive sleep apnea,” as well as several closed my eyes for a minute, enjoying struggles to breathe. When the per- days of early-morning start times. the sunshine, and dozed off.” son’s blood oxygen level falls, the brain The 53-year-old captain’s OSA responds by awakening the person was diagnosed and characterized as Most Susceptible enough to tighten the upper airway “severe” during a medical exam soon OSA is relatively common and occurs muscles and open the windpipe. The after the incident, but “symptoms more frequently among men than person may snort or gasp, then resume (such as snoring) and risk factors women. About half of those who snoring. This cycle may be repeated (such as obesity) were present before have the condition are overweight, hundreds of times a night.9
© DeVilbiss
Treatment for obstructive sleep apnea often involves use of a continuous positive airway pressure (CPAP) machine, which blows a stream of air through a tube and into a mask over the nose, or sometimes over both the nose and mouth.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 37 AVIATIONMEDICINE
Anyone sleeping near a person Sometimes, a mouthpiece made by Agency data in late 2013 showed that with OSA is likely to hear the loud an orthodontist or dentist is recom- 4,917 FAA-certificated pilots who were snoring and gasping for air that is one mended to adjust the lower jaw and being treated for sleep apnea held special of the most common symptoms of tongue to help keep the airway open issuance medical certificates.11 Of those, sleep apnea. during sleep. 367 pilots had BMIs of 40 or more. Other symptoms include frequent In cases of moderate or severe OSA, The FAA says the plan outlined by sleepiness during the day; headaches the most common treatment involves Tilton does not represent a change in in the morning; memory problems or the use of a CPAP machine (photo, p. the agency’s medical standards on OSA difficulty concentrating; irritability, 37), a device that blows a steady stream but rather “a new approach to help depression, mood swings or changes of air through a tube to a mask that fits [aviation medical examiners] find undi- in personality; difficulty in perform- over the patient’s nose or both the nose agnosed and untreated OSA.” ing skilled motor tasks and a dry and mouth. The pressure from the air mouth or sore throat after waking. helps keep the airway open. Notes In addition, ICAO noted that people Sometimes, another overnight sleep 1. Tilton, Fred. “Perspective: New with moderate and severe OSA have study is needed to identify the correct Obstructive Sleep Apnea Policy.” Federal experienced “an unusually high rate of settings for the CPAP machine. After Air Surgeon’s Medical Bulletin Volume 51 road traffic accidents.” the settings are determined, a techni- (Number 4, 2013–2014): 2. cian visits the home to set up the CPAP 2. Miller, Alyssa J. FAA Puts Sleep Apnea Sleep Study equipment according to a doctor’s Policy on Hold. Dec. 19, 2013.
38 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 Sign: © Porcorex/iStockphoto UAV: © mipan/123RF.com T to-day developments within UAS operations. on hazard actual based data derived from day- opportunity to amend regulatory the framework overwhelming and persuasive. Paramount is the U.S.the strategic roadmap. article havein this retained older the term from aircraft mend adoption of term remotely the operated UAS integration into NAS. the We recom also - (SMS) for UAS operators now —before full the by implementing asafety management system FLIGHTSAFETY.ORG The advantages of such an SMS strategy are into its National Airspace System (NAS) unmannedcivil aircraft systems (UAS) tunity to safe influencethe integration of he United States has an historic oppor to replace unmanned vehicle aerial |
WORLD AEROSAFETY | FEBRUARY 2014 , but - mistakes of others. erational safety issues, including from those the UASall operators. The operators op learn - will lessonsThese would circulated be then among hazards and develop systemwide mitigations. erational data to FAA the to systemwide identify any of test these sites required be to report op- FAA inreturn? expect companies.technology But what should the provewill for aboon developing the UAS civil UAS technologies “UAS (see Sites,” p. 9). This accompanying airspace for development the of granting authorization for sixtest sites and Federal Aviation Administration (FAA) is We propose first that UAS operators using The circumstances are The U.S. perfect. SMS mustbebuiltintoUASdevelopment — beginningwithtesting. BY THOMASANTHONYAND HARRISON WOLF INSIGHT |
39 INSIGHT
Our method is clear. Each operator using a operator-based safety system. It is not a regula- test site would be required to implement a basic tor-based safety system. SMS designed to identify hazards, assess risk, The critical thing is for each operator to implement mitigations and ensure that the miti- establish from the start a system that identifies, gations work. The International Civil Aviation assesses and mitigates safety hazards before they Organization (ICAO) has spent much useful ef- can result in damage, injury or death. Collection fort within the last decade developing SMS guid- of safety data from test site operators can come ance that is simple, direct and straightforward. later when the FAA has a mechanism in place. Unfortunately, the FAA has not taken the All the essential elements and functions already same path for UAS operators. Implementation of are well established for commercial air transport SMS within the UAS community should have as — replication would not be difficult. its central guiding principles simplicity, clarity The FAA should limit the reporting of raw, and ease of implementation. Just as ICAO has deidentified data by these operators to pre- served as the foundation for civil aviation devel- defined categories representing safety-hazard in- opment worldwide, the establishment of SMS as formation of the most value to UAS operations a basis for UAS regulatory development is too across the nation. The collection and screening good an idea to ignore. We are at a crossroads of raw safety data would be done entirely by the and must choose the right road to minimize risk operator, like gold being sifted from the gravel in the full integration of civil UAS. along a river. Only the “gold” data would need to On Nov. 7, 2013, the FAA published Integra- be reported. The “rocks and gravel” data would tion of Civil Unmanned Aircraft Systems (UAS) in remain with the operator (Figure 1). the National Airspace System (NAS) Roadmap.1 This approach would place a minimal Section 3.5 of this document, titled “Procedures extra oversight burden on the FAA because the and Airspace,” says: agency’s NAS-level analytical resources would remain focused where they are most valu- ICAO has issued guidance requiring Mem- able. Reporting could be expanded as database ber States to implement safety management capability is expanded and the low-hanging fruit system programs. These programs are essen- of safety improvements are harvested. The FAA, tial to manage risk in the aviation system. freed from examining loads of unimportant data, The FAA supports this and is a leader in could identify, analyze and recommend changes the design and implementation of SMS. through regulation, providing a safer framework Technical challenges abound, including the for UAS regulatory integration and amendment. ability to analyze massive amounts of data We in the aviation community must ac- to provide useful information for oversight knowledge that unless civil UAS operators and assessment of risk. worldwide start to share operational safety data The Roadmap goes on to say: “A key input to a with the appropriate national civil aviation safety management methodology is the use of authorities, no realistic progress can be made to- safety data. Valuable data collection is under way, ward an effective regulatory framework that will but development of a safety-reporting database is ensure safety while providing an environment currently limited to reporting requirements from conducive to the development of UAS technolo- existing COAs [certificates of authorization or gies. A single major accident involving a UAS waiver] and experimental certificate holders.” aircraft and a commercial passenger aircraft Because the FAA is not ready to accept could result in a legislative environment hostile safety data via an automated data collection to the full integration of UAS technologies. instrument does not negate the importance of While discussing the complexities of SMS requiring operators using the test sites to imple- implementation, the FAA identified in its UAS- ment SMS as a condition of operation. SMS is an NAS Roadmap that SMS should be a component
40 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 INSIGHT
of test sites. What the FAA did not specify must have. The main UAS users come from was who would be responsible for developing, separate backgrounds: those who have military monitoring and sharing data. Historically, some aviation experience and those with hobbyist aircraft manufacturers have declined to share aviation experience. Both cultures bring unique safety data without a regulatory requirement. challenges, biases and operating procedures that We believe operators have more precedents and incentives to share SMS data because they are on Mining the UAS Safety Gold the front lines, not wanting to lose an aircraft, cause injury or be involved in an incident or FAA Gold accident. The University of Southern California’s Aviation Safety and Security Program has been fighting for the integration and widespread use of SMS in commercial air transport for more than two decades, and the aviation industry is Lessons learned just beginning to reap the rewards. most important Though safety remains the primary concern from test site system of most aviation professionals, there is a related “elephant in the room” that the United States must address when discussing UAS integra- tion — privacy. Privacy concerns have taken Test Site 1 center stage, surpassing safety concerns in the public eye. Many groups advocate strong privacy Test Site 2 Test Site 3 protections, attempting to influence legislation at various government levels to limit what types of UAS-obtained data can be collected by operators. Manufacturers, operators, regulators and the Test Site 4 Test Site 5 Test Site 6 public should be wary of these limitations — es- Lessons pecially if they would apply to flight operations learned from each safety data as well as UAS sensor data. Unless area within each test privacy concerns are addressed as integral to site UAS deployment, the effort for full integration could be a non-starter.
Our proposed requirement for operators Management to implement an SMS as a condition of opera- tion can be a significant first step in addressing privacy concerns by removing the misunder- ATC OPSEC standing that UAS operations are anonymous and outside the scope of normal civil aviation authorities. There may, in fact, be an opportu- OPS 1 OPS 2 OPS 3 nity for SMS safety data to remedy some privacy Test Site concerns by opening to public disclosure facts such as UAS flight status, route and mission. Raw data Gold data This can only help to ensure more open and Note: Each organizational level identifies the most important hazard/safety data and as this transparent civil flight operations. information moves upward, it becomes systematically applicable knowledge.
It is important to start, at the beginning of Source: Thomas Anthony and Harrison Wolf UAS testing for full integration, to create the safety culture that this new aviation community Figure 1
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 41 INSIGHT
they are accustomed to, which will affect their In a recent visit to an operator of Predator- aviation approach. type aircraft, I was quickly corrected after using Military users may not understand the impor- the even-earlier term “UAV” (unmanned aerial tance of mishap reporting in the current civil-data vehicle). One of the operator’s senior managers context, but they already know how to report, asked me, “Do you know how many people it what might be included in their reporting or at takes to operate one of these things?” least that reporting is required. Typical hobbyists “No, I do not,” I said after thinking for a have existed in a world relatively free of regulation moment. and within their own, restricted airspace using He nodded, and replied with a grin, “About “right-of-way” rules designed to reduce accidents 10 or 12 people at any given time.” It was clear involving model, not conventional, aircraft. that this was not the first time he had had to These independent cultures already are mix- correct someone’s terminology. ing in the UAS community — and a major differ- That’s all it took to convince me. Further, at a ence in approach results. The difference, however, recent conference in Canada, a large contingent should not affect how reporting takes place, the of attendees initially agreed that there could depth of information shared or with whom the not be human factors issues connected with information is shared. All UAS and non-UAS op- operation of remotely piloted aircraft, as there erators, manufacturers and regulators will benefit wasn’t a pilot aboard. But certainly, with 10 or from sharing in-depth accident and incident data. 12 individuals involved in their operation, many Last, a word about the term “UAS.” A tremen- missions involving these aircraft are replete dous amount of misunderstanding exists with re- with human factors issues and hazards. Within gard to UAS, much of it because of inappropriate minutes of a UAS presentation, the attendees terminology. Foremost is the word unmanned. were convinced of their mistake — but it takes a The appropriate term is remotely piloted. There change of understanding about what these new is a pilot; the difference is that the pilot is located vehicles really encompass. somewhere other than the aircraft. The future of U.S. remotely piloted aircraft is at a critical crossroads. The opportunity is at hand to choose the proactive approach to safety, which is now recognized as the standard throughout the world. That is SMS, the future of aviation safety. The opportunity will only come once to make SMS a basic requirement for operators of remotely piloted aircraft during the initial stage of development.
Thomas Anthony is the director of the Aviation Safety and Security Program at the University of Southern California. Harrison Wolf is the staff UAS specialist within the program responsible for development of the course “Safety Management for Remotely Piloted Aircraft.”
The opinions expressed here are the authors’ and not neces- sarily those of Flight Safety Foundation.
Note
1. FAA. Integration of Civil Unmanned Aircraft Systems (UAS) in the National Airspace System (NAS) Roadmap. dia/uas_roadmap_2013.pdf>. Protection and Border Customs U.S. 42 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 DATALINK BY LINDA WERFELMAN Striking Increases Data show more U.S. aircraft were struck by wildlife in 2012, but related damage to commercial aircraft declined. he number of reported wildlife strikes period, the number of reported strikes — of involving civil aircraft increased nearly six- birds, terrestrial mammals, bats and reptiles — fold between 1990 and 2012, with a record totaled 131,096, the report said. 10,726 strikes in 2012 (Figure 1), according Commercial air carrier aircraft accounted for Tto a report prepared for the U.S. Federal Avia- 87,670 (67 percent) of total strikes and 6,246 (58 tion Administration (FAA).1 Over the 23-year percent) of those recorded in 2012, the report said. In comparison, Wildlife Strikes Involving U.S. Civil Aircraft, 1990–2012 the 1990 data showed that the 1,354 com- 11,000 mercial aircraft strikes 10,000 Terrestrial mammals, bats, reptiles accounted for 73 Birds percent of the total. 9,000 The rate of strikes for 8,000 commercial air car- 7,000 riers rose from 15.14 6,000 per 100,000 aircraft 5,000 movements in 2000 to 25.12 in 2012. 4,000 Despite the overall Number of reported strikes 3,000 increase in the pe- 2,000 riod’s reported strikes, 1,000 the number of damag- ing strikes was lower 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 in 2012, when 606 Year such strikes were re- ported, than it was in Source: U.S. Federal Aviation Administration 2000, when the figure Figure 1 reached a peak of 764 FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 43 DATALINK In that category, dam- Damaging Wildlife Strikes Involving U.S. Civil Aircraft, 1990–2012 aging strikes totaled 900 228 in 2012, down from 353 in 2000. Terrestrial mammals, bats, reptiles 800 Birds Data showed no 700 decline in damag- ing strikes involving 600 commercial aircraft 500 above 500 ft AGL or general aviation 400 aircraft. In fact, the 300 number of damag- ing wildlife strikes Reported with damage strikes 200 involving commercial 100 aircraft above 500 ft AGL increased slight- 0 ly to 151 in 2012, up 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year from 142 in 2000. Overall, data Source: U.S. Federal Aviation Administration show a total of 381 damaging wildlife Figure 2 strikes involving commercial aircraft Damaging Bird Strikes Involving Commercial Aircraft at Varying Heights, 1990–2012 in 2012, down 25 percent from the 400 record 510 reported 350 > 500 ft above ground level in 2000. The rate of ≤ 500 ft above ground level damaging strikes to 300 commercial air- 250 craft over the same 200 period declined 12 percent, from 1.73 150 per 100,000 aircraft 100 movements in 2000 Number of damaging bird strikes bird Number of damaging 50 to 1.53 in 2012, the report said. 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 “These declines Year in damaging strikes for commercial Source: U.S. Federal Aviation Administration aviation in the airport Figure 3 environment have occurred in spite (Figure 2), the report said. The decline has been of an increase in populations of hazardous most pronounced for commercial aircraft in the wildlife species and demonstrate progress in airport environment — at or below 500 ft above wildlife hazard management programs” at air- ground level (AGL), the report said (Figure 3). ports certificated under U.S. Federal Aviation 44 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 DATALINK Regulations Part 139 to handle air carrier either completed a wildlife hazard assessment, operations with aircraft that can seat more than were completing an assessment or had taken nine people, the report said. a federal grant to conduct one. The report The population increase in those hazard- credited risk-mitigation efforts at many of these ous wildlife species is one factor that is cited airports with contributing to the general decline in explaining the increased number of wildlife in damaging strikes since 2000, despite increas- strikes. For example, the resident (non- ing populations of many large bird species. migratory) population of Canada geese in the The report said that the National Wildlife United States and Canada increased to 3.8 Research Center, operated by the FAA and million in 2012, up from 500,000 in 1980, the U.S. Department of Agriculture’s Animal and report said. Plant Health Inspection Service (APHIS), has As populations of those species have in- focused its recent strike-prevention research creased, so has air traffic, with commercial air in several areas, including evaluating avian traffic in the United States growing from 18 radar systems. million aircraft movements in 1980 to 23 mil- “The assessment effort is part of the FAA’s lion in 1990 and up to 29 million movements in overall investigation into the effectiveness of each year that followed. Over the years, many air commercially available avian radar detection carriers have retired airplanes with older, noisier systems at U.S. civil airports when used in engines and replaced them with quieter two- conjunction with other known wildlife man- engine airplanes that are more difficult for birds agement and control techniques,” the report to detect and avoid. said. “Though it is well established that radar These factors mean that wildlife strikes are can detect wild birds, there is little published likely to continue in- creasing over the next Airports Where Wildlife Strikes Were Reported, 1990–2012 decade, the report said. 800 Strikes were Non-U.S. airports reported at 1,771 700 General aviation airports U.S. airports over FARs Part 139 airports 600 the 23-year period, in- cluding 531 Part 139 500 certificated airports and 1,240 gen- 400 eral aviation airports; 300 strikes involving Number of airports U.S.-registered aircraft 200 also were reported at 273 non-U.S. airports, 100 the report said (Figure 0 4). In 2012, strikes 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 were reported at 643 Year airports, compared with 332 in 1990. Notes: U.S. Federal Aviation Regulations (FARs) Part 139 airports are those certificated for air carrier operations with aircraft that can seat more than nine people. The report said Source: U.S. Federal Aviation Administration that in 2012, all Part 139 airports had Figure 4 FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 45 DATALINK information concerning the accuracy and often involved a precautionary or emergency detection capabilities related to range, altitude, landing, as noted in 4 percent of wildlife strike target size and effects of weather for avian radar reports.2 At the top of the list of most hazard- systems” (ASW, 3/09, p. 38). ous species were snow geese, followed by black Other research has examined the likely effects vultures, turkey vultures, northern pintails and of limiting the access of birds and other wildlife Canada geese. to storm water ponds and other attractive areas The number of strikes decreased dramati- on and near airports, developing and using cally with altitude, with 72 percent of all strikes new technologies to harass and deter hazardous involving commercial aircraft occurring at or species and using pulsating lights mounted on below 500 ft. Above that altitude, data showed aircraft to enhance wildlife deterrence. that the number of strikes involving commercial Although many airports have taken steps aircraft decreased 34 percent with every 1,000 ft to mitigate wildlife strike risks, little has been increase in height. done to reduce the number of wildlife strikes Since 1990, the report said, aircraft have outside airport boundaries, the report said, been destroyed in 60 wildlife strikes. On aver- recommending enhanced wildlife manage- age, strikes have cost the U.S. civil aviation ment efforts aimed at areas within 5 nm (9 industry $957 million and 583,175 hours of air- km) of airports. craft down time annually, the report estimated. Over the entire reporting period, 482 spe- Worldwide, since 1988, 250 people have cies of birds were involved in 97 percent of the been killed and more than 229 aircraft have reported wildlife strikes, the report said; the been destroyed in wildlife strikes, including a most damaging strikes have been associated with September 2012 accident in which a Dornier waterfowl, gulls and raptors. Forty-two species 228-200 crashed after being struck by a vulture of terrestrial mammals accounted for 2.2 percent during a takeoff in Nepal, killing 19 people. of wildlife strikes, with deer and related species In recent years, the FAA has developed linked to the most damaging strikes. In addition, programs intended to make it easier to report 15 species of bats were involved in 0.6 percent of a wildlife strike online or using mobile devices. strikes, and 11 species of reptiles in 0.1 percent. Information is available at November. Bird strikes were more frequent dur- 1. Dolbeer, Richard A.; Wright, Sandra E.; Weller, John; ing the day (62 percent), and strikes involving Begier, Michael J. Wildlife Strikes to Civil Aircraft in terrestrial mammals were more likely at night. the United States, 1990–2012. Report prepared by Both birds (60 percent) and terrestrial mammals the FAA and the Wildlife Services agency of USDA’s (64 percent) were most likely to be struck dur- APHIS. FAA National Wildlife Strike Database Serial Report Number 19. September 2013. Available ing landing. Thirty-seven percent of bird strikes from the FAA at 46 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 INFOSCAN Error Messages James Reason looks back at his career and ideas. BY RICK DARBY BOOKS “I started to reflect upon my embarrass- ing slip,” he says. “One thing was certain: There Slips, Mistakes and Violations was nothing random or potentially inexplicable A Life in Error: From Little Slips to Big Disasters about these actions-not-as-planned. They had a Reason, James. Farnham, Surrey, England, and Burlington, Vermont, number of interesting properties. First, both tea- U.S.: Ashgate, 2013. 149 pp. Figures, references, index. making and cat-feeding were highly automatic, teapot and a cat set James Reason on the habitual sequences that were performed in a very path to becoming a renowned expert familiar environment. I was almost certainly A on error in complex industries such as thinking about something other than tea-making aviation. or cat-feeding. But then my attention had been As Reason tells the anecdote in his new book, captured by the clamouring of the cat … . one afternoon in the early 1970s, he was brewing “This occurred at the moment I was about to tea and about to put the tea leaves in the pot when spoon tea into the pot, but instead I put cat food the cat — “a very noisy Burmese” that slightly into the pot. Dolloping cat food into an object intimidated him — showed up and howled insis- (like the cat bowl) affording containment had tently to be fed. Reason opened a tin of cat food migrated into the tea-making sequence.” and spooned some out … into the teapot. A Life in Error is not, despite the title, an “I little realized at the time that this bizarre autobiography, although Reason occasionally slip would change my professional life,” Reason describes personal events to illustrate points. says. A lecturer in psychology at the University Unlike his more academic books that have made of Leicester, he was going through a dry spell in him one of the most influential theoreticians research topics. in risk management, this new publication (so FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 47 INFOSCAN far available only in paperback and as a Kindle bounces off a tree and onto the green — could download) is written in an informal style with- hardly be called correct performance.” out sacrificing scientific rigor. He distinguishes two basic ways in which an A simplified version of the theories that objective can fail to be achieved: have been the basis of his career, A Life will be • “The plan of action may be entirely ap- especially valuable to operational personnel propriate, but the actions do not go as whose jobs bear on safety, without specializing planned. These are slips and lapses (absent- in it. Such readers could range from top-floor mindedness) or trips and fumbles (clumsy executives to frontline workers. Even special- or maladroit actions). Such failures occur ists who are familiar with most of the content at the level of execution rather than in the should appreciate the book’s concision, smooth formulation of intentions or planning. flow and glimpses into its author’s personality. Most people believe they know what an error • “Your actions follow the plan exactly, but is, yet the concept can be surprisingly hard to the plan itself is inadequate to achieve its pin down. “Dictionaries send us on a semantic desired goal. These are termed mistakes circular tour through other [similar] terms such and involve more complex, higher-level as mistake, fault defect and back to error again,” processes such as judging, reasoning and Reason says. “That dictionaries yield synonyms decision making. Mistakes, being more rather than definitions suggests that the notion subtle and complex, are much harder to of error is something fundamental and irreduc- detect than slips, lapses, trips and fumbles. ible. But we need to probe more deeply into … It is not always obvious what kind of a Most people believe error’s psychological meaning.” plan would be ideal for attaining a particu- lar objective. Thus mistakes can pass un- they know what Error is connected in the human mind to other constructs — plan, intention, action and noticed for long periods — and even when an error is, yet the results: “The success or failure of our actions detected they can be a matter of debate.” can only be judged by the extent to which they Reason adopted the error-type classification concept can be achieve, or are on the way to achieving, their formulated by Jens Rasmussen, a Danish control planned consequences.” engineer, that recognized three performance surprisingly hard to Reason suggests the following as a useful levels — skill-based (SB), rule-based (RB) and pin down. working definition: knowledge-based (KB). Reason says, “Using The term “error” will be applied to all his framework, I was able to distinguish three those occasions in which a planned distinct error types: skill-based slips, rule-based sequence of mental or physical activities mistakes and knowledge-based mistakes.” fails to achieve its desired goal without the The cat food/teapot error was an example intervention of some chance agency. of an SB slip. “Activities at the SB level involve Only the last phrase might raise a question for routine and habitual action sequences with little some people. Reason takes into account the in the way of conscious control,” Reason says. possibility that a goal might be achieved, but not “There is no awareness of a current problem; because the plan worked as intended. actions proceed mainly automatically in mostly “If you were struck down in the street by familiar situations.” a piece of returning space debris, you would Such actions sound simple and easy. What not achieve your immediate goal [to cross the can go wrong? Often it is a distraction (which street], but neither would you be in error, since might include an outside event, stray thought or this unhappy intervention was outside your con- daydreaming) that leads to confusion about the trol,” Reason says. “By the same token, achieving context of the action. The routine is carried out your goal through the influence solely of happy as it is meant to be, but it is the wrong routine chance — as when you slice a golf ball that for the situation. 48 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 INFOSCAN RB and KB mistakes differ from SB individual error makers,” he says. “But working and for the most part brings slips in that they come into play only the appearance of violations required no bad consequences.” when the person acting realizes there a shift away from a purely cognitive He is skeptical that “get tough” is a problem to be solved. Both require information-processing orientation to policies toward rule violators who are thinking about a solution, but insofar as one that incorporated motivational, caught will improve matters much. they are mistakes, the solution chosen social and institutional factors, and Most do not get caught; some believe is incorrect. paramount among the latter were rules they have no choice if they are to meet “There are two kinds of problem: and procedures.” their productivity targets in spite of un- those for which you have pre-packaged Why would anyone deliberately feasible and excessive requirements. In- solutions (RB level) and those for violate procedures designed, at least stead, Reason believes a better approach which you have not (KB level),” Rea- in theory, to safeguard people — in- is “to try to increase the perceived ben- son says. In the former case, once a cluding the operators committing efits of compliance. That means having problem is recognized, the need is to the violations? Reason cites several procedures that are for the most part determine the appropriate response motivations. Corner cutting or routine workable, correct and available. They that has already been formulated — violations are intended to save time should describe the quickest and most for instance, a checklist published in and effort, or to work around what are efficient ways of doing the job.” a quick reference handbook. Devising perceived as unnecessary limitations. From studying violations, it was KB solutions for problems whose exact Thrill seeking provides stimulation a short step to developing the ideas nature may be unclear or for which for some people as they “push the that Reason is most associated with — no standard solution exists requires envelope.” Necessary violations are a “holes” in the layers of defense against analysis and creativity. counterweight to the tendency of or- error that occasionally align to create a Yet another kind of error, viola- ganizations to issue ever-stricter rules, path of vulnerability, latent threats that tions, strongly impressed Reason as a usually in response to the most recent lurk undetected and organizational fac- result of the 1986 Chernobyl nuclear accident, which operators at the sharp tors. All these conditions are now rec- power plant disaster in Ukraine. The end find impractical. ognized in orthodox risk management. explosion of the reactor’s core could be Reason cites the “balance sheet” de- I counted three possible absent- traced to two distinct types of unsafe veloped by German psychologist Petra minded slips by the author or editor act. Reason says, “There was an un- Klumb in connection with violations: in the book. He says, “Chapter 5 deals intended slip at the outset of the fatal with absent-minded slips and lapses.” • Perceived benefits: “An easier experiment that caused the reactor to But they are the subject of Chapter 4. way of working; saves time; operate at too low a power setting … . “In Chapter 10, we move from errors to more exciting; gets the job done; Unable to bring the power level up to violations,” he says, with the next page shows skill; meets a deadline; the desired 20 percent, the operators headed “Chapter 9, Violations.” In that looks macho.” deliberately persisted with the trial and chapter, he correctly gives the year of in so doing made a serious violation of • Perceived costs: “Possible ac- the Chernobyl nuclear accident as 1986, safe operating procedures. cident; injury to self or others; but in the chapter on organizational “They did this partly because they damage to assets; costly to repair; accidents, he dates it to 1985. did not really understand the physics of risk of sanctions; loss of job; dis- Reason has nothing to be embar- the reactor, but also because of their de- approval of friends.” rassed about. He has long made the termination to continue with the test- The potential benefits versus poten- point that everyone will make errors ing of the voltage generator — which, tial costs might seem to most people, from time to time, which includes ironically, was intended as a safety especially those not actively involved world-famous researchers in the field. device in the event of a power loss.” with the work, as a bad trade-off. But Like many of the colleagues he has in- Chernobyl marked the beginning Reason points out that “the benefits fluenced, he is concerned not with the of a new, wider phase of Reason’s of non-compliance are immediate and impossible task of eliminating all error study of error. “Up to this time the the costs are remote from experience: but building barriers against it and focus had been very largely upon violating often seems an easier way of reducing its consequences. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 49 ONRECORD Fuel Leak Prompts Diversion The engine was not shut down as required, and the 757 was landed with an excessive fuel imbalance. 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 Pump Seal Damaged The pilots discovered the leak about two Boeing 757-200. Minor damage. No injuries. hours after departing from Helsinki. During an he incorrect installation of a seal in the apparent routine hourly fuel check, they noticed coupling between a fuel tube and the high- that fuel consumption was significantly higher Tpressure fuel pump on the 757’s right engine than calculated. “On closer examination, the likely caused a significant fuel leak during a pilots concluded that there was a fuel leak and chartered flight from Helsinki, Finland, to Las traced it to the right fuel system or engine,” Palmas in Spain’s Canary Islands the afternoon the report said. “The fuel leak was so large that of Jan. 15, 2011. The flight crew diverted the the captain decided to land at the nearby Paris flight toward Paris. Charles de Gaulle airport.” In a recently released English translation Investigators later calculated that, due to of the final report on the serious incident, the the leak, fuel consumption from the right fuel Safety Investigation Authority of Finland said system was about 63 kg (139 lb) per minute that the crew did not shut down the engine, as higher than the left fuel system. The crew did prescribed by the quick reference handbook not declare an emergency, but air traffic control (QRH), during the diversion. (ATC) handled the flight as an emergency after “The pilots’ deviation from QRH instruc- the pilots explained the reason for the diversion. tions caused the maximum allowable fuel imbal- Although the QRH required a shutdown, “the ance to be exceeded as the fuel leak continued, captain decided not to shut down the right engine which led to operations outside the approved until during the ground run since the right engine performance envelope, and the incident devel- was running well and he considered it safer to fly oped into a serious incident according to ICAO with two live engines under these circumstances [International Civil Aviation Organization] clas- rather than with one engine,” the report said. sification,” the report said. Other factors in the captain’s decision to Despite the excessive fuel imbalance, the leave the right engine running were the absence crew was able to land the 757 without further of any sign of a fire and the need to reduce the incident in Paris. There were 210 passengers and fuel load to lighten the 757’s landing weight. eight crewmembers aboard the aircraft. Moreover, the captain apparently did not trust FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 51 ONRECORD the left engine. “According to the (NTSB) report said that disassembly of fans and that the operator of the 777 captain, there had been vibration in the the left engine showed that the aft end of was experiencing about one equipment left engine during the flight,” the report the midshaft that connects the fan with cooling fan failure per year. “However, said. “Vibration had also occurred on the low-pressure turbine had fractured. the subject event was the second such previous flights [and was not corrected Further examination revealed that failure in two months and the second by maintenance performed before the synthetic oil had entered a cavity between related diversion since 2008.” aircraft departed from Helsinki].” the midshaft and the center vent tube. The aircraft was landed with a fuel The oil deteriorated and caused corro- Excursion on Snowy Runway imbalance of 1,700 kg (3,748 lb), or 815 sion pitting and the eventual failure of the Learjet 35. Substantial damage. No injuries. kg (1,797 lb) above the prescribed max- shaft. “The exact source or mechanism s the pilots taxied the Learjet for imum. “Reverse thrust was not used by which the oil entered the dry cavity a departure with eight passengers during the ground run, as the pilots between the fan midshaft and the center Afrom Pueblo (Colorado, U.S.) estimated that it might suck any leaking vent tube is unknown,” the report said. Memorial Airport the evening of Feb. 2, fuel into the hot section of the engine,” 2012, the automatic terminal informa- the report said. “The captain shut down Smoke Traced to Cooling Fan tion system reported winds from 360 the right engine on the runway.” Boeing 777-200. Minor damage. No injuries. degrees at 15 kt and 3/4 mi (1 1/4 km) Investigators found that the main- he 777 was 38,000 ft over the North visibility in snow. tenance performed immediately before Atlantic and about four hours The NTSB report said that the cap- the flight included replacement of the Tinto a flight from Philadelphia to tain chose to take off with a crosswind right engine’s accessory gearbox, on London with 174 passengers and 13 from Runway 08R because, at 10,498 ft which the high-pressure fuel pump is crewmembers the night of Dec. 1, 2012, (3,200 m), it was longer than Runway installed. Their post-flight examination when the pilots detected smoke on the 35 (8,310 ft [2,533 m]). of the engine revealed that the O-ring flight deck. The commander said that While taxiing to Runway 08R, the seal in the coupling was deformed and the smoke became “quite bad,” so he de- captain estimated the snow depth on the partially unseated. clared an emergency, initiated a descent taxiways was about 1/8 in (3/8 cm). “The “The most probable cause leading to to 15,000 ft and diverted the flight to control tower reported that they had no the fuel leak … is that the fitting of the Shannon (Ireland) Airport. current runway-condition reports since seal was originally too tight, for which “During the descent, the flight crew there were no recent landings or depar- reason the seal may have been pressed carried out the smoke checklist in ac- tures,” the report said. “The captain said incorrectly against the edge of the groove cordance with the QRH, and the smoke the snow on the runway seemed to be when it was installed during maintenance cleared,” said the report by the Air Acci- no heavier than what he observed on the before the incident flight,” the report said. dent Investigation Unit of Ireland. “They taxiway, and he could see the end stripes reported that they received a status on the runway.” Corrosion Triggers Shaft Failure message to the effect that the right-hand The captain recalled that the takeoff McDonnell Douglas MD-10-30F. Substantial damage. equipment cooling fan had failed.” initially was normal. However, as the air- No injuries. The crew changed their flight plane neared V1, or about 120 kt, he felt he freighter was accelerating condition from an emergency to an ur- it “lurch” right. “He immediately applied through 60 kt on takeoff from Port- gency but, because of the increased fuel full left rudder [and] full left aileron and Tland (Oregon, U.S.) International consumption at 15,000 ft, continued to reduced power, but the airplane contin- Airport the afternoon of Feb. 13, 2012, Shannon, where the aircraft was landed ued off the right side of the runway,” the when the flight crew heard sounds without further incident. report said. “The airplane traveled across similar to a compressor stall, felt abnor- Examination of the cooling fan several taxiways before coming to rest mal vibrations and saw the left engine’s revealed that a bearing race had upright south of the runway on the grass.” exhaust gas temperature increase. collapsed, resulting in contact and Both main landing gear separated, The crew rejected the takeoff and tax- overheating of internal rotating and sta- and the nose gear and the right wing ied the MD-10 back to the gate. The U.S. tionary parts. The report said that this were substantially damaged, but there National Transportation Safety Board is a common failure mode for rotary was no fire. 52 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 ONRECORD NTSB concluded that the probable cause of afternoon of Feb. 19, 2013. A flight attendant the accident was “the captain’s failure to main- was opening the galley door for a service tain airplane control during an attempted cross- crew when a gust dislodged papers inside the wind takeoff on a contaminated runway.” galley. “As she attempted to retrieve them, the Fall From a Service Door wind blew her out the door,” the NTSB Embraer 145LR. No damage. One serious injury. report said. “The safety strap had not been urface winds were at 25 kt, gusting to 35 attached at the time of the event. The flight kt, as the airplane was being prepared for attendant experienced a serious injury to her Sdeparture from Cincinnati, Ohio, U.S., the vertebrae.” TURBOPROPS Inexplicable Engine Shutdown said that their reason for shutting down the left Cessna 425. Substantial damage. No injuries. engine could not be clarified. “Since the inves- he flight crew said that the left engine’s tigation did not reveal any mechanical engine interstage turbine temperature rapidly damage, it is highly likely that the engine was Tincreased and torque decreased to zero dur- generally capable of producing power.” ing a medevac positioning flight from Hanover, Germany, to Munich the night of Feb. 2, 2010. ‘I’ve Got It. Don’t Worry’ The crew requested and received clearance from ATR 42-300. No damage. No injuries. ATC to descend from 23,000 ft to 15,000 ft. he pilots had been on duty about 9 1/2 “The crew could not state which actions hours and were conducting the last of three they had carried out after the descent clearance Tcargo flights the morning of Feb. 22, 2012, and during shut-off and securing of the left when the stall-warning horn sounded and the engine,” said the report by the German Federal stick shaker activated during an ILS approach to Bureau of Aircraft Accident Investigation. The Glasgow, Scotland. investigation revealed that they had not feath- “Simultaneously, the autopilot disconnected,” ered the propeller. said the report by the U.K. Air Accidents Inves- Radar data indicated that groundspeed tigation Branch (AAIB). “The copilot called, ‘Fly varied from 210 kt to 80 kt as the pilots the aircraft [expletive].’” The commander almost conducted the instrument landing system immediately pitched the aircraft nose-down (ILS) approach to Munich’s Runway 26L in to –10 degrees and advanced the power levers instrument meteorological conditions that [from about 20 percent torque] almost to full included 1,800 m (1 1/8 mi) visibility in snow. power, saying as he did so, “I’ve got it. I’ve got it. Airspeed was below the prescribed minimum Don’t worry.” single- engine approach speed when the 425 As airspeed increased to 125 kt, the com- descended below the glideslope about 3 nm (6 mander leveled the aircraft but did not reduce km) from the runway. the torque setting of 98 percent. The overspeed The crew increased power from the right warning activated as the approach flaps limit engine, and the aircraft veered left and struck of 170 kt was exceeded. The commander then snow-covered terrain about 100 m (328 ft) from reduced power to slightly above flight idle. the runway threshold and 60 m (197 ft) left of The copilot suggested that the autopilot be re- the extended centerline. engaged, and the commander replied, “Shhh, Examination of the left engine revealed no just steady on.” anomalies. Noting that the crew could not recall The ATR was descending through 1,500 any other power plant parameters, the report ft on the glideslope when angle-of-attack FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 53 ONRECORD reached 10.5 degrees, just below the stick- Nosewheel Steering Malfunctions shaker threshold. “The flight crew attempted Fairchild SA227. Substantial damage. No injuries. to re-engage the autopilot, but it disconnected he Metroliner veered right after touching immediately,” the report said. “Simultaneous- down about halfway down the 5,800-ft ly, engine torque was increased to 45 percent, T(1,768-m) runway at Somerset, Kentucky, airspeed increased and the angle-of-attack U.S., the afternoon of Jan. 2, 2010. “The pilot reduced.” applied full left rudder and full reverse on The crew had not established radio the left power lever but was unsuccessful in communication with the tower controller, correcting the alignment of the airplane,” the as previously instructed. When queried by NTSB report said. the approach controller, the copilot replied, “He then engaged the nosewheel steering “Stand by. We’ve just got … a few problems.” button on the left power lever, and the airplane The copilot then advised that the problem had began a more aggressive turn to the right. It been resolved and that they would switch to departed the runway, traveled down an em- the tower frequency. bankment and came to rest against the airport The remainder of the approach was boundary fence.” The right wing and both uneventful until a nacelle-overheat warning propellers were damaged by rocks, but the pilots activated on touchdown. “The flight crew did and their passenger were not hurt. not action the associated procedure,” the report The Metroliner was repaired and returned said. They taxied the ATR to the gate and shut to service, but an intermittent loss of steering it down. The copilot later reported the incident subsequently was encountered. The problem to the company. was traced to damaged wires in the nosewheel The AAIB concluded that the crew’s perfor- steering harness. mance during the approach “may have been af- “Although an electrical anomaly contributed fected by tiredness or fatigue” and demonstrated to the [Jan. 2] loss of control, the fact that the a lack of adherence with standard operating pilots landed long and potentially with excess procedures, ineffective monitoring and dimin- speed resulted in less runway and time available ished cooperation. to recover from the anomaly,” the report said. PISTON AIRPLANES Stall on Missed Approach positioning system data indicated that the air- Cessna 414A. Substantial damage. Two fatalities, four serious injuries. plane flew through the approach course several eather conditions deteriorated rapidly times during the approach and was consistently as the 414 neared the uncontrolled below the glideslope,” the report said. Wairport in Hayden, Colorado, U.S., The airplane was below the published the afternoon of Feb. 19, 2012. Visibility decision height and right of the extended decreased to 1/4 mi (400 m), the ceiling was runway centerline when the pilot initiated overcast at 400 ft, and surface winds were a missed approach. Groundspeed decreased from 290 degrees at 10 kt, gusting to 14 kt. during the climb, and the 414 stalled and The NTSB report said that the precipitation struck terrain. The pilot and one passenger type was not reported but that heavy snow were killed; the other four passengers were was likely. seriously injured. The pilot conducted the ILS approach “The airplane’s anti-ice and propeller anti- to Runway 10. “A review of on-board global ice switches were found in the ‘off’ position,” 54 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 ONRECORD the report said. “It is likely that the airframe The NTSB report said that the pilot chose to collected ice during the descent and approach, land with a quartering tailwind on Runway 12 which affected the airplane’s performance and and lost control of the Chieftain after touch- led to an aerodynamic stall during the climb.” down. “During the landing roll, a wind gust pushed the nose of the airplane to the right, and Control Lost in Crosswind the airplane began to slide momentarily on an Piper Chieftain. Substantial damage. No injuries. icy patch on the runway,” the report said. “While he Chieftain was on a visual flight rules sliding sideways, the left main landing gear air-taxi flight the evening of Feb. 16, 2013, contacted bare pavement, which resulted in the Tto Dutch Harbor, Alaska, U.S., which was collapse of the left main landing gear.” reporting winds from 339 degrees at 26 kt, gust- Damage to the landing gear and wing was ing to 35 kt, a 1,200-ft overcast and 5 mi (8 km) substantial, but the pilot and his two passengers visibility in blowing snow. escaped injury. HELICOPTERS ‘Threshold of Control’ Engine Fails in Icing Conditions Bell 206B3. Substantial damage. Two minor injuries. Hughes 500. Substantial damage. No injuries. he JetRanger was dispatched to film a truck he pilot told investigators that the auto- accident on a road in hilly terrain near ignition system was armed when the engine TPerth, Western Australia, the morning of Tlost power after the helicopter flew through Jan. 19, 2013. Day visual meteorological condi- an area of moderate to heavy snow during a tions with northeasterly winds of 10 to 15 kt flight from Canton, Ohio, U.S., to Dayton the prevailed at the accident site. morning of Jan. 29, 2013. After hovering and maneuvering about 500 “The pilot entered an autorotation and ap- ft above the ground for three minutes, the pilot plied excessive aft cyclic during the touchdown initiated a right turn to complete the filming and in a field [in London, Ohio], which caused the depart from the area. “The helicopter was exposed main rotor blades to flex down and sever the tail to a crosswind from the left while at an airspeed boom,” the NTSB report said. The pilot and his around the 30-kt threshold value for susceptibility passenger escaped injury. to loss of tail rotor effectiveness,” said the report by Examination of the engine revealed no the Australian Transport Safety Bureau. mechanical anomalies. The report said that the As the right turn began, the nose moved left Hughes 500 rotorcraft flight manual prohibits and then rapidly to the right, and the helicop- flight into known icing conditions and requires ter began to rotate. “The pilot responded with the fuel to meet the anti-icing capability of control inputs and regained sufficient control JP-4 when operating in temperatures below 41 to carry out a forced landing, but [he] did not degrees F (5 degrees C). apply full left pedal as recommended for loss of Weather conditions in the area included tail rotor effectiveness, resulting in a likely delay snow and freezing fog, an 800-ft overcast and in recovery,” the report said. a surface temperature of 16 degrees F (minus The JetRanger rolled over after touching 9 degrees C). “A review of fueling records re- down in a clear area on sloping terrain. The vealed that no anti-icing additive was added to pilot and the photographer sustained minor in- the fuel,” the report said. “The pilot was aware juries and were attended by emergency services of the icing conditions, but he continued the personnel at the site. flight.” FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2014 | 55 ONRECORD Preliminary Reports, November 2013 Date Location Aircraft Type Aircraft Damage Injuries Nov. 1 Springdale, Arkansas, U.S. Beech King Air C90 destroyed 2 fatal The King Air struck terrain while diverting to Springdale after the pilot reported that he was low on fuel. Nov. 1 Caledonia, Minnesota, U.S. Piper Aztec substantial 3 fatal, 1 serious Visual meteorological conditions prevailed when the Aztec struck terrain during approach. Nov. 2 Coburg, Germany Piper Seneca destroyed 3 fatal The Seneca struck trees on approach in unreported weather conditions. Nov. 3 Riberalta, Bolivia Swearingen Metro 3 destroyed 8 fatal, 10 serious Instrument meteorological conditions (IMC) prevailed when the Metro landed long and veered off the wet runway after completing a circling approach. Nov. 3 Devil’s Hole, Channel Islands, U.K. Pilatus Britten-Norman Islander substantial none The pilot and four crewmembers escaped injury during a forced landing after both engines lost power during a night search mission. The fuel selectors were found positioned to the empty tip tanks; the main tanks were nearly full. Nov. 6 Donnelly, Idaho, U.S. Cessna U206F substantial 3 fatal The airplane struck terrain at 8,000 ft during an air taxi flight from McCall to Challis, both in Idaho. Nov. 10 Red Lake, Ontario, Canada Swearingen Metro 3 destroyed 5 fatal, 2 serious The flight crew declared an emergency shortly after crossing the final approach fix during an area navigation approach. The Metro then struck power lines and terrain near the runway threshold. Nov. 10 Owasso, Oklahoma, U.S. Mitsubishi MU-2B-25 destroyed 1 fatal The airplane was on final approach to Runway 18L at Tulsa International Airport when the pilot reported a control problem and that the left engine was shut down. Witnesses said that the MU-2 was in a shallow left turn when it entered a steep, spiral descent. Nov. 12 Junction, Texas, U.S. Cessna T310R destroyed 2 fatal Witnesses heard the 310 circling, then the sound of an impact. IMC prevailed in the area; the airplane was not on a flight plan. Nov. 17 Kazan, Russia Boeing 737-500 destroyed 50 fatal IMC prevailed when the flight crew reported that they were going around because the aircraft was “not in a position to land.” The 737 entered a steep climb and reached about 700 m (2,300 ft) before descending rapidly to the ground. Nov. 18 Xalapa, Mexico Cessna 414 destroyed 2 fatal The 414 was in cruise flight in marginal weather conditions when it struck terrain near a mountaintop. Nov. 19 Mouffy, France Socata TBM-700 destroyed 6 fatal A witness saw the aircraft emerge from a cloud layer in an uncontrolled descent. Nov. 19 Fort Lauderdale, Florida, U.S. Learjet 35A destroyed 4 fatal Shortly after taking off for a medevac positioning flight to Cozumel, Mexico, the flight crew declared an emergency and told air traffic control that they wanted to return to the airport. The Learjet struck the ocean about 3 nm (5 km) from the airport. Nov. 25 Kibeni, Papua New Guinea Cessna 208B destroyed 3 fatal, 7 minor The Grand Caravan was on a charter flight from Kamusi to Purari when the flight crew sent a distress signal and diverted to the Kibeni Airstrip. The aircraft crashed in a river during the attempted emergency landing. Nov. 29 Bwabwata National Park, Namibia Embraer 190-100 destroyed 33 fatal Contact with the ERJ was lost during a scheduled flight from Maputo, Mozambique, to Luanda, Angola. Low visibility and heavy rain associated with thunderstorms hindered initial search efforts. The wreckage was found the next day about 200 km (108 nm) east of Rundu, Namibia. Nov. 29 Saint Mary’s, Alaska, U.S. Cessna 208B destroyed 4 fatal, 6 serious Visibility was 1 mi (1,600 m) when the Grand Caravan crashed about 4 nm (7 km) from the airport on approach. This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed. 56 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2014 Multiple Aviation Industry Segments, One Message: Safety. f the entire aviation industry should collaborate on one thing, it is safety. IAt a time of constrained resources, increased regulation and unprecedented scrutiny, the Flight Safety Foundation continues to be the leading advocate for safety and prevention of accidents, thereby saving lives. Show your commitment to the aviation community’s core value — a strong, e ective global safety culture. Join the Flight Safety Foundation. “Honeywell has been a partner with the Flight Safety Foundation (FSF) for more than 40 years in supporting the FSF mission to continuously improve fl ight safety.” — Don Bateman, Honeywell Corporate Fellow and Chief Engineer- Technologist for Flight Safety Systems and Technology Flight Safety Foundation Member Enrollment Membership/Donations/Endowments BARS Program O ce Headquarters: Ahlam Wahdan Susan M. Lausch Level 6 | 278 Collins Street 801 N. Fairfax Street, Suite 400 membership services coordinator managing director of membership Melbourne VIC 3000 Australia Alexandria, Virginia U.S. 22314-1774 Tel.: ext. 102 and business development GPO Box 3026 Tel.: +1 703.739.6700 membership@ ightsafety.org Tel.: ext. 112 Melbourne VIC 3001 Australia Fax: +1 703.739.6708 lausch@ ightsafety.org Tel.: +61 1300 557 162 Fax: +61 1300 557 182 ightsafety.org Email: bars@ ightsafety.org SURPRISINGLYSURPRISINGLY SIMPLESIMPLE REMARKABLYREMARKABLY HUMANHUMAN "We analyzed, assessed and evaluated the program to be a far superior model than what we were currently utilizing." West Coast Aviation Director INTRODUCINGINTRODUCING SAVVYdocSAVVYdoc™™ DocumentDocument ManagementManagement Heli-Expo Booth #5915 • Feb 25-27 • Anaheim, CA +1.843.342.5434 • BaldwinAviation.com