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Propulsion System Malfunction Plus Inappropriate Crew Response (PSM+ICR)

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Propulsion System Malfunction Plus Inappropriate Crew Response (PSM+ICR) FLIGHT SAFETY FOUNDATION NOVEMBER–DECEMBER 1999 FLIGHT SAFETY DIGEST SPECIAL DOUBLE ISSUE Propulsion System Malfunction Plus Inappropriate Crew Response (PSM+ICR) Human Factors Report FLIGHT SAFETY FOUNDATION For Everyone Concerned With the Safety of Flight Flight Safety Digest Officers and Staff Vol. 18 No. 11–12 November–December 1999 Stuart Matthews Chairman, President and CEO Board of Governors In This Issue Robert H. Vandel Propulsion System Malfunction Plus Executive Vice President 1 James S. Waugh Jr. Inappropriate Crew Response (PSM+ICR) Treasurer Carl Vogt General Counsel and Secretary Controlled-flight-into-terrain Accidents Board of Governors Decline in First 11 Months of 1999 194 ADMINISTRATIVE Boeing data show one CFIT hull-loss accident involving a Ellen Plaugher large, Western-built commercial jet airplane. Executive Assistant Linda Crowley Horger Manager, Support Services FAA Publishes Guidelines for 196 FINANCIAL Aircraft Data Communications Systems Elizabeth Kirby Advisory circular outlines standards developed Controller in cooperation with international civil aviation authorities. TECHNICAL James Burin Boeing 727 Strikes Runway During Director of Technical Programs 198 Joanne Anderson Missed Approach Technical Assistant Ann Hill Manager of Seminars and Workshops Robert H. Gould Managing Director of Aviation Safety Audits and Internal Evaluation Programs Robert Feeler Manager of Aviation Safety Audits Robert Dodd, Ph.D. Manager, Data Systems and Analysis Darol V. Holsman Safety Audits MEMBERSHIP Carole L. Pammer Director of Marketing and Business Development Ahlam Wahdan Assistant to the Director of Marketing and Business Development PUBLICATIONS Roger Rozelle Director of Publications Mark Lacagnina Senior Editor Wayne Rosenkrans Senior Editor Linda Werfelman Cover image: Copyright © 1999 PhotoDisc Inc. Senior Editor Karen K. Ehrlich Production Coordinator Ann L. Mullikin Flight Safety Foundation is an international membership organization Production Designer dedicated to the continuous improvement of flight safety. Nonprofit and Susan D. Reed independent, the Foundation was launched in 1947 in response to the aviation Production Specialist industry’s need for a neutral clearinghouse to disseminate objective safety information, and for a credible and knowledgeable body that would identify David A. Grzelecki threats to safety, analyze the problems and recommend practical solutions to Librarian, Jerry Lederer Aviation Safety Library them. Since its beginning, the Foundation has acted in the public interest to produce positive influence on aviation safety. Today, the Foundation provides Jerome Lederer leadership to more than 850 member organizations in more than 140 countries. President Emeritus Foreword This special issue of Flight Safety Digest presents a report on factors that have been involved in accidents and incidents when flight crews responded inappropriately to malfunctions of turbine-airplane powerplants and related systems. The report is the result of two years of study by a multidisciplinary task group chaired by the U.S.-based Aerospace Industries Association (AIA) and The European Association of Aerospace Industries (AECMA). The study was prompted as the result of an accident involving a twin-turboprop commuter airplane that struck the ground Dec. 13, 1994, during a missed approach at Raleigh-Durham (North Carolina, U.S.) International Airport.1 The two pilots and 13 passengers were killed, and five passengers were seriously injured. In its report on the accident, the U.S. National Transportation Safety Board (NTSB) said that a transient negative- torque condition caused an engine ignition light to illuminate while the crew was conducting an instrument approach. NTSB said that the captain assumed incorrectly that the engine had failed and that the captain subsequently failed to follow approved procedures for an engine failure, for a single-engine approach and go-around, and for stall recovery. The task group assembled by AIA and AECMA studied this accident and several similar accidents and incidents that have occurred since 1959. They found that, despite improvements in propulsion systems over the years, the frequency of such accidents and incidents has not changed. Inappropriate crew response to transport-airplane propulsion system malfunctions causes an average of three accidents in revenue service and two accidents in training each year. The propulsion system malfunctions cited in the report should not have caused accidents or incidents; the accidents and incidents were caused by flight crews who did not respond correctly to the malfunctions. The activities of Flight Safety Foundation are focused primarily on human factors (especially flight crew error), controlled flight into terrain (CFIT),2 approach-and-landing accidents and loss of control. The Foundation is publishing this report in an effort to give wider distribution to useful information on factors involved in inappropriate response by flight crews to propulsion system malfunctions, and how these errors can be reduced. — FSF Editorial Staff 1. U.S. National Transportation Safety Board. Aircraft Accident Report: Uncontrolled Collision with Terrain, Flagship Airlines, Inc., dba American Eagle, Flight 3379, BAe Jetstream 3201, N918AE, Morrisville, North Carolina, December 13, 1994. NTSB/AAR-95/07. October 1995. See also: Flight Safety Foundation. “Commuter Captain Fails to Follow Emergency Procedures after Suspected Engine Failure, Loses Control of the Aircraft During Instrument Approach.” Accident Prevention Volume 53 (April 1996): 1–12. 2. Controlled flight into terrain (CFIT) occurs when an airworthy aircraft under the control of the flight crew is flown unintentionally into terrain, obstacles or water, usually with no prior awareness by the crew. This type of accident can occur during most phases of flight, but CFIT is more common during the approach-and-landing phases, which typically comprise about 16 percent of the average flight duration of a large commercial jet. FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • NOVEMBER–DECEMBER 1999 i Propulsion System Malfunction Plus Inappropriate Crew Response (PSM+ICR) G.P. Sallee (co-chair) Aerospace Industries Association D.M. Gibbons (co-chair) The European Association of Aerospace Industries FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • NOVEMBER–DECEMBER 1999 1 Contents 1.0 Executive Summary ...........................................................................................................................................3 2.0 Introduction ........................................................................................................................................................4 3.0 Definitions ..........................................................................................................................................................6 4.0 Data Collection, Analysis Process and Results .................................................................................................8 5.0 Propulsion System Instrumentation and Failure Warning Systems ............................................................... 24 6.0 Simulator Capabilities and Realism with Respect to Propulsion System Malfunctions ............................... 26 7.0 Flight Crew Training ....................................................................................................................................... 28 8.0 Human Factors ................................................................................................................................................ 31 9.0 Regulatory Requirements................................................................................................................................ 38 10.0 Conclusions ..................................................................................................................................................... 39 11.0 Recommendations ........................................................................................................................................... 41 Appendix A: Contributing Organizations and Individuals .................................................................................... 44 Appendix B: U.S. National Transportation Safety Board Final Recommendations from Investigation of Jetstream 31 Accident, 13 Dec. 1994 ............................................................ 47 Appendix C: Letter from U.S. Federal Aviation Administration (FAA) to Aerospace Industries Association (AIA) ...................................................................................... 49 Appendix D: Letter from AIA to FAA ................................................................................................................... 51 Appendix E: Summary of Turbofan PSM+ICR Events ......................................................................................... 52 Appendix F: Turbofan Training Accident Summaries .......................................................................................... 72 Appendix G: Summary of General Electric/CFM International Commercial Fleet Rejected Takeoff Study....... 75 Appendix H: Summary of Turboprop Data ............................................................................................................ 77 Appendix I: Summary of Turboprop Training Events ........................................................................................ 145 Appendix J: Fleet Survey of Engine Failure Indications —
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