ON COMMERCIAL AVIATION SAFETY SPRING 2003
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Jeppesen OnBoard. Making Every Mission Possible The Official Publication of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE
ISSN: 1355-1523 SPRING 2003 ON COMMERCIAL AVIATION SAFETY
FOCUS is a quarterly subscription journal contents devoted to the promotion of best practises in aviation safety. It includes articles, either original or reprinted from other sources, related Editorial 2 to safety issues throughout all areas of air transport operations. Besides providing information on safety related matters, FOCUS Chairman’s Column 3 aims to promote debate and improve networking within the industry. It must be emphasised that FOCUS is not intended as a substitute for regulatory information or company Global Navigation Satellite System Landing System 4 publications and procedures. Technology/Product Development
Editorial Office: The Boeing Company Ed Paintin The Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey. GU24 8HX DVT – What is all the fuss about? 10 Tel: 01276-855193 Fax: 01276-855195 Barlow Lyde & Gilbert e-mail: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900-1630 Monday-Friday UKFSC Members List 12 Advertisement Sales Office: Mike Barrett The Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey. GU24 8HX Hazards of Erroneous Glideslope Indications 14 Tel: 01276-855193 Mobile: 07788-168207 The Boeing Company
Printed by Woking Print & Publicity Ltd The Print Works, St.Johns Lye, St.Johns Woking, Surrey GU21 1RS Minimum Safe Turnaround - A Briefing Paper for 18 Tel: 01483-884884 Fax: 01483-884880 Schedule Planning Departments ISDN: 01483-598501 Email: [email protected] Produced by the ERA Air Safety Work Group Web: www.wokingprint.com
FOCUS is produced solely for the purpose of improving flight safety and, unless copyright is Waging War Against Unsafe Operations 21 indicated, articles may be reproduced providing that the source of material is acknowledged. E.H.Paintin
Opinions expressed by individual authors or in advertisements appearing in FOCUS are those Course Outline for Human Factors Training 23 of the author or advertiser and do not in Aviation Maintenance necessarily reflect the views and endorsements of this journal, the editor or the UK Flight Safety Committee. UKFSC Annual Seminar 24 While every effort is made to ensure the accuracy of the information contained herein, FOCUS accepts no responsibility for any errors or omissions in the information, or its Front Cover: B737-300 in the colours of Jet 2 the low cost operation of consequences. Specialist advice should Channel Express that started operations from Leeds Bradford to destinations always be sought in relation to any particular circumstances. in Europe on 12th February 2003.
1 Editorial
Disruptive Passengers
Three years ago the United Kingdom This change in the law is currently being changes to the laws in order to afford Flight Safety Committee set up a Working processed in Parliament as a Private aircrew greater protection. Group to look into the cause of the Members Bill, by Frank Roy MP for increasing number of disruptive Motherwell and Wishaw. The second It takes time to bring about change, passenger reports. Following this initial reading of this Private Members Bill was particularly when trying to change the law report it was decided that the Working made on the 7th February 2003. and sometimes it appears that nothing is Group should produce a universal Members of the Department for Transport being done. The result is that people feel guidance document that airlines could Working Group are hopeful that the Bill that their efforts are a waste of time. Let use as a model to improve the way they will become law later in the year. me assure you that this is not the case. were handling disruptive passengers. There are groups of dedicated and Recently it has been noted that there has motivated people trying to ensure that At about the same time the Department been a decline in the number of your tasks can be carried out in a safe for Transport (then the DTLR) formed a disruptive passenger reports being environment. Working Group to discuss this issue and submitted to the CAA for inclusion in the to look at what the government could do disruptive passenger database. Some The easiest way to ensure that nothing to try to: airlines show a small increase in the gets done or changed is to stop number of reports submitted but in submitting the disruptive passenger (a) prevent disruptive passenger general the number is down on the same reports, so please continue to submit behaviour and period last year. Common belief is that your reports. there is an increase in the number of (b) to ensure that adequate regulation disruptive passenger incidents but that existed to control and prosecute cabin crews are failing to submit reports. offenders where necessary. To some extent this is understandable as The Civil Aviation Authority was tasked to cabin crew are expected to submit these collect and categorise the disruptive reports following a long hard days work. passenger reports submitted by the Usually this is done in the crew room prior airlines. These were presented to the to departing for home. The most Department for Transport Working Group important thing on the mind of most so that any trends in the number of crews at this stage of the duty is getting reports could be monitored and the scale home and having a bath and some sleep. of the issue known. I would therefore like to appeal to cabin Resulting from the work done by the crew to please remember to submit the Department for Transport Working Group disruptive passenger reports at the end of a proposal was made to increase the each duty. By helping us they will be powers of the police attending to calls helping themselves. Without this from the aircraft captains for assistance information we will not be able to monitor with disruptive passengers. the situation properly or bring about
UK FLIGHT SAFETY COMMITTEE OBJECTIVES
■ To pursue the highest standards of aviation safety. ■ To constitute a body of experienced aviation flight safety personnel available for consultation. ■ To facilitate the free exchange of aviation safety data. ■ To maintain an appropriate liaison with other bodies concerned with aviation safety. ■ To provide assistance to operators establishing and maintaining a flight safety organisation.
2 Chairman’s Column
100 Years of Aeronautical Risk Management by John Dunne, Airclaims
to allow the media to drive the release of information during the accident investigation process. This hasn’t enhanced the accident investigation process and has probably had a negative effect in that it is diverting key members of the team away from their prime role in order to brief the press on the day’s findings.
Following publication of the report into the This year the Aviation World’s diaries are recognise the CFIT risks more clearly in an Boeing 757 landing accident in Gibraltar, full of events to mark Man’s first historic operational environment? Industry is revisiting existing FOQA flight back in December 1903. In the span systems and determining how they may of just 100 years we have made huge and A Beechcraft 1900 accident in Charlotte is be better utilised in the measuring, significant strides by developing an still under investigation; however initial understanding and management of risk in effective, efficient, economic and safe air reports suggest that a combination of everyday operations. It is interesting to transportation system. The progress has miss-rigged pitch controls and a weight note that although large amounts of data been impressive but not always without its and balance issue led to the departure is processed and recorded on the aircraft cost. from controlled flight. Central to the it isn’t all made available to the crew, weight and balance issue is the use of especially in real time. We have made significant progress in standard weights for passengers. How such a short span of time which is due in does your company determine the aircraft Perhaps, taking this initiative a step further, part to the human spirit of adventure and weight? Has your company ever now (in this 100th Anniversary year) is an risk taking and in part to the continuing conducted a risk evaluation exercise to opportune moment for us to examine in development and application of viable risk determine calculated take-off weight detail what data is already available and assessment techniques. However, a against actual take-off weight? recorded in the FDR / QAR systems and review of aviation history will show us that determining what, if any, of that, data we do not always learn from lessons Then in early February the American could usefully be made available to the already painfully learnt. Known risk is not President announced, “The Columbia is crew in real time presentations that could the same as managed risk, neither does it lost.” The investigation process into this potentially enhance their situational always apply to lessons from the past, accident will no doubt be long, detailed awareness. which have been long forgotten. and arduous. NASA is a unique organisation and has been at the cutting Don’t forget that Murphy is alive and well; A quick review of 2003’s accidents to date edge of human endeavour and technology he’s out there and waiting for you to take highlights four CFIT events and a for over forty years. In this time they have that acceptable risk. departure from controlled flight. continually pushed back the boundaries and produced remarkable achievements. A BAe RJ100 in Turkey, an F28 in Peru, an Perhaps significant in the Columbia Antonov 24 in Gabon and an Ilyushin 76 in accident investigation for all of us in terms East Timor were all CFIT events. Over the of lessons learnt will be the evaluation of: years our industry has conducted how the standards are established; how extensive research into CFIT, that has standards are reviewed over a period of resulted in volumes of advisory material time to test their validity; how risks are and enhancements to GPWS. Having detected, assessed and managed; how identified the risks during approach and organisational oversight is measured and landing why are we still seeing skilled conducted; how their continuing safety people taking risks? What is the next step management processes is managed. An we need to take to ensure that people issue that may well impact us all at some time in the future was NASA’s willingness
3 Global Navigation Satellite System Landing System Technology/ Product Development
can be used by suitably equipped European Galileo System) for the basic airplanes as the basis of a GNSS landing positioning service. The GPS constellation system (GLS). The initial SARPS support already is in place and improvements are an approach service. Future refinements planned over the coming decades. The should lead to full low-visibility service Galileo constellation is scheduled to be (i.e., takeoff, approach, and landing) and available in 2008. low-visibility taxi operations. This article describes The basic positioning service is augmented locally - at or near the airport - 1. Elements of the GLS. through a GBAS radio transmitter facility. 2. Operations using the GLS. Because the ground facility is located at a he aviation industry is developing a new T 3. Benefits of the GLS. known surveyed point, the GBAS can positioning and landing system based on 4. Operational experience. estimate the errors contained in the basic the Global Navigation Satellite System positioning data. Reference receivers in (GNSS). The GNSS landing system the GBAS compare the basic positioning (GLS) integrates satellite and ground- 1. Elements of the GLS data with the known position of the facility based navigation information to provide and compute corrections on a satellite-by- the position information required for The GLS consists of three major elements satellite basis. The corrections are called approach and landing guidance. - a global satellite constellation that pseudorange corrections because the Potential benefits of GLS include supports worldwide navigation position primary parameter of interest is the significantly improved takeoff and landing fixing, a GBAS facility at each equipped distance between the GBAS facility and capability at airports worldwide and at airport that provides local navigation individual satellites. The satellite reduced costs, improved instrument satellite correction signals and avionics in constellation is continuously in motion, approach service at additional airports each airplane that process and provide and satellites ascend and descend over and runways and the eventual guidance and control based on the the horizon when observed from any point replacement of the Instrument Landing satellite and GBAS signals (fig.1). on Earth. The GBAS calculates corrections System. Boeing plans to certify the for all the satellites that meet the specified airborne aspects of GLS on the 737, to The GLS uses a navigation satellite in-view criteria and transmits that support Category I operations, by the end constellation (e.g., the U.S. Global information to the nearby airplanes over a of 2003. Positioning System [GPS] the planned VHF Data Broadcast (VDB) data link.
For more than 10 years, the aviation industry has been developing a positioning and landing system based on the Global Navigation Satellite System (GNSS). These efforts culminated in late 2001, when the International Civil Aviation Organization (ICAO) approved an international standard for a landing system based on local correction of GNSS data to a level that would support instrument approaches. The ICAO Standards and Recommended Practices (SARPS) define the characteristics of a Ground-Based Augmentation System (GBAS) service that can be provided by an airport authority or an Air Traffic Service provider. The GBAS service provides the radiated signal in space that
4 Boeing airplanes that are currently being missed approach paths for a produced contain Multi-Mode Receivers given runway. Each approach (MMR) that support Instrument Landing is given a unique identifier for System (ILS) and basic GPS operations. a particular FAS glideslope, These MMRs can be modified to support and missed approach GLS and potentially Microwave Landing combination. FAS data for all System operations. The GLS capability is approaches supported by the supported through the addition of a particular GBAS facility are receiver and processing in the MMRs of transmitted to the airplane the GBAS data provided through the VDB through the same high data link. The MMRs apply the local integrity data link as the correction data received from the GBAS satellite range correction data to each satellite that the airplane and (i.e., through the VDB data GBAS share in common. Because of link). The MMRs process the position and altitude differences and local pseudorange correction and terrain effects the GBAS and the airplane FAS data to produce an ILS- may not necessarily be observing the like deviation indication from same combination of satellites. The the final approach path. airplane systems only use satellite These deviations are then information that is supported by displayed on the pilot’s flight display that is equivalent to that used correction data received from the GBAS. instruments (e.g., Primary Flight Display during an ILS approach. When the airplane is relatively close to the [PFD]) and are used by airplane systems GBAS station, the corrections are most such as the flight guidance system (e.g.. Figure 2 shows a typical PFD effective, and the MMRs can compute a autopilot and flight director) for landing presentation for a GLS approach. The very accurate position. Typical lateral guidance. Flight Mode Annunciation on the PFD is accuracy should be 5 character approach identifier 1) service and GBAS Positioning Service to ensure consistency (GBAS PS). PT 1 service supports ILS-like between the selected channel deviations for an instrument approach. and the approach procedure The accuracy, integrity, and continuity of chosen by the pilot. The service for the PT 1 level have been approach identifier is read specified to be the same as or better than from the FAS data block and ICAO standards for an ILS ground station displayed to the pilot on the supporting Category I approaches. The PFD to provide positive PT 1 level was developed to initially confirmation that the desired support approach and landing operations approach has indeed been for Category I instrument approach selected. procedures. However, this level also may support other operations such as guided Figure 5 shows a typical GLS takeoff and airport surface position approach procedure. The determination for low-visibility taxi. procedure is similar to that used for ILS except for the The GBAS PS provides for very accurate channel selection method PVT measurements within the terminal and the GLS-unique identifier. area. This service is intended to support The approach chart is an FMS-based RNAV and RNP-based example of a Boeing flight- procedures. The improved accuracy will test procedure and is similar benefit other future uses of GNSS to a chart that would be used positioning such as Automatic Dependent for air carrier operations, with Surveillance - Broadcast and Surface appropriate specification of Movement Guidance and Control the landing minima. Systems. using a designated VHF navigation Figure 6 is an example of a possible The accuracy of the GBAS service may frequency. As with the ILS certain GLS future complex approach procedure using support future safety enhancements such identification data are available on other area navigation (RNAV), Required as a high-quality electronic taxi map FMS pages such as the APPROACH REF Navigation Performance (RNP), and GLS display for pilot use in bad weather. This page, which shows the runway identifier, procedures in combination. Pilots could could help reduce runway incursion GLS channel, and associated approach use such procedures to conduct incidents and facilitate airport movements identifier (fig. 3). approaches in areas of difficult terrain, in in low visibility. The service also may adverse weather, or where significant support automated systems for runway Regardless of the selection method the nearby airspace restrictions are incursion detection or alerting. five-digit GLS channel number is encoded unavoidable. These procedures would with the frequency to be used for the VDB combine an RNP transition path to a GLS As important as the accuracy of the data link receiver and with an identifier for FAS to the runway. These procedures can GBAS service is the integrity monitoring the particular approach and missed also use GBAS position, velocity, and provided by the GBAS facility. Any approach path (FAS data set) that time (PVT) information to improve RNP specific level of RNP operation within corresponds to the desired approach. capability and more accurately deliver the GBAS coverage should be more available airplane to the FAS. because the user receivers no longer will Figure 4 shows a navigation control panel require redundant satellites for satellite used to tune navigation radios, including The GBAS is intended to support multiple failure detection (e.g., Receiver GLS, for the 737-600/-700/-800/-900. levels of service to an unlimited number Autonomous Integrity Monitoring). of airplanes within radio range of the VDB The approach plate shows the channel data link. Currently, ICAO has defined two Because the GBAS PS is optional for number for each approach and a four- levels of service: Performance Type I (PT ground stations under the ICAO standards, 6 some ground stations may only provide PT ■ Optimize runway use by reducing the serves all runway ends with a single VHF 1 service. The messages uplinked through size of critical protection areas for frequency the limited navigation the VDB data link indicate whether or not approach and takeoff operations frequency spectrum is used much more the ground station supports the GBAS PS compared with those needed for ILS. efficiently. In fact, a GBAS may even be and specify the level of service for each able to support a significant level of approach for which a channel number has ■ Provide more flexible taxiway or hold instrument approach and departure been assigned. When the GBAS PS is line placement choices. operations at other nearby airports. provided, a specific five-digit channel number is assigned to allow selection of a ■ Simplify runway protection constraints. The siting of GBAS ground stations is non-approach-specific GBAS PS from that considerably simpler than for the ILS station. Consequently, the channel ■ Provide more efficient airplane because GBAS service accuracy is not selection process allows different users to separation or spacing standards for degraded by any radio frequency select different approaches and levels of air traffic service provision. propagation effects in the VHF band. service. Unlike the ILS, which requires level ■ Provide takeoff and departure ground and clear areas on the runway, The GBAS PS and the PT 1 service are guidance with a single GBAS facility. the siting of a GBAS VHF transmitter can not exclusive. If the ground station be more flexible than ILS. The removal of provides the GBAS PS. selecting a From the service provider perspective, the the requirement to provide a large flat channel number associated with any GBAS can potentially provide several area in front of the ILS glideslope alone particular approach automatically will significant advantages over the ILS. First, can represent a very significant savings in enable the GBAS PS service. The receiver significant cost savings may be realized site preparation cost and opens up many provides corrected PVT information to because a single system may be able to more locations for low-minima instrument intended airplane systems as long as the support all runways at an airport. With the approach service. GBAS PS is enabled. ILS-like deviations ILS each runway served requires an ILS also are available when the airplane is and a frequency assignment for that ILS Although GBAS accuracy can be affected close enough to the selected approach which can be difficult because of the by multipath interference, careful siting of path. limited numbers of available frequencies. GBAS receivers can readily eliminate Operational constraints often occur with multipath concerns because GBAS ICAO is continuing development of a the ILS when an Air Traffic Service receivers do not need to be placed near a specification for service levels that would provider needs to switch a commonly runway in a specific geometry, as is the support Category II and III approaches. used ILS frequency to serve a different case with the ILS or MLS. Hence, this runway direction. This is not an issue with virtually eliminates the requirements for the GBAS because ample channels are critical protection areas or restricted areas 3. Benefits of the GLS available for assignment to each to protect against signal interference on approach. In addition, because the GBAS runways and nearby taxiways. From the user perspective, the GBAS service can offer significantly better performance than an ILS. The guidance signal has much less noise because there are no beam bends caused by reflective interference (from buildings and vehicles). However, the real value of the GLS is the promise of additional or improved capabilities that the ILS cannot provide. For example the GLS can ■ Provide approach and takeoff guidance service to multiple runways through a single GBAS facility. 7 Finally, the GBAS should have less frequent and less costly flight inspection requirements than the ILS because the role of flight inspection for GBAS is different. Traditional flight inspection, if needed at all, primarily would apply only during the initial installation and ground station commissioning. This flight inspection would verify the suitability of the various approach path (FAS) definitions and ensure that the GBAS-to-runway geometry definitions are correct. Because verifying the coverage of the VDB data link principally is a continuity of service issue rather than an accuracy or integrity issue, it typically would not require periodic inspection. GBAS systems capable of supporting Category II and III operations internationally are envisioned. Airborne system elements that would be necessary for the enhanced GLS capability (e.g., MMR and GLS automatic landing provisions) already are well on the way to certification or operational authorization. Airborne systems and flight deck displays eventually will evolve to take full advantage of the linear characteristic of the GLS over the angular aspects of the ILS. 4. Operational Experience To date, flight-test and operational experience with the GLS has been excellent. Many GLS-guided approaches and landings have been conducted successfully at a variety of airports and under various runway conditions. Both automatic landings and landings using head-up displays have been accomplished safely through landing rollout, in both routine and non-normal conditions. On the pilots’ flight displays, the GLS has been unusually steady and smooth when compared with the current ILS systems even when critical areas necessary for the ILS approaches were 8 unprotected during the GLS approaches. The Boeing Technology Demonstrator program has used a 737-900 to demonstrate successful GLS operations to airline customers, airplane and avionics manufacturers, airport authorities, Air Traffic Service providers, and regulatory authority representatives. The GLS represents a mature capability ready for widespread operational implementation. When implemented, the GLS will improve safety, increase capacity, and provide operational benefits to airlines, pilots, passengers, airports, and Air Traffic Service providers. Boeing plans to certify the airborne aspects of the GLS on the 737 by the end of 2003 to support Category I operations, with other models to follow. Work is continuing for the airborne certification of the GLS to support Category II and III operations when suitable GBAS ground facilities are specified and made available. SUMMARY The aviation industry is developing the GLS, a new positioning and landing system that integrates satellite and ground-based navigation information. Potential benefits of the GLS include significantly improved takeoff and landing capability at airports worldwide at reduced cost, instrument approach service at additional airports and runways, and eventual replacement of the ILS. Boeing plans to certify the airborne aspect of the GLS on the 737 by the end of 2003 to support Category I operations, with other models to follow. Reprinted from AERO magazine by permission of The Boeing Company 9 DVT – What is all the fuss about? Simon Phippard - Partner Aerospace Department Barlow Lyde & Gilbert, London Readers of this journal and airline of whether air travel causes DVT. Although 56 passengers against 27 airlines. The management will almost certainly be a German court appears to have rejected purpose of the hearing in November 2002 aware of recent court decisions on this a claim on the basis that there is, was to decide whether the atypical subject. Some of the press has been statistically, a low likelihood of any given reaction of any particular passenger to a 1 confusing with reports of conflicting passenger suffering a DVT most courts normal and unremarkable flight, without decisions in Australia and England. The worldwide will look at the evidence and more, constituted an “accident”. Mr aim of this article is to shed some light on particular facts of each case. Justice Nelson held not. what is actually going on and where airlines stand. The issues of law were considered against What did the recent cases decide? a factual matrix, agreed between the Of course Deep Vein Thrombosis (DVT) is parties solely for the purpose of resolution not really a flight safety issue but a Just before Christmas, the High Court in at a generic level of those legal issues. passenger health issue. Nevertheless it London and the Supreme Court in Victoria Under the matrix, it was assumed that the has assumed high profile for airlines in - the senior first instance Courts in each cabin layout was usual, the usual flight recent years and with increased political jurisdiction - both handed down procedures were followed, the aircraft interest and a blurring of the distinction judgments in cases seeking damages seating and systems were in normal between health and safety we may see following alleged instances of DVT working order, and the flight complied with regulators taking a more direct interest. In suffered during air carriage. Neither was, all applicable regulations. It was also any event, the present state of the law however, a final judgment following trial assumed that passengers were at an could have implications for flight with evidence on the facts and so on. increased risk of suffering DVT in operations procedures. Each dealt with legal issues alone - but circumstances where the carrier knew of the effect of the English decision, if upheld that increased risk and did not give them I am not an expert in the medical aspects on appeal, will be to prevent a significant any warning as to the risk or any of DVT. There are many around and not all number of DVT claims against airlines. measures as to how to minimise such risk. share the same view. However some 2 degree of consensus is emerging that The Australian decision was presented What this judgment did not do was to particular factors predispose an individual as a victory for the passenger. It is address the issue of causation - i.e. the to be more likely than others to suffer a nothing of the sort. The airlines had link between instances of DVT, either thrombosis or actually to trigger an applied to strike out the claim on a generally or specifically, and air travel. In instance. Some of those, such as summary basis. To do that the Court other words, the judgment did not depressurisation, prolonged immobility and needed to be satisfied the case had conclude that DVT cannot, or in any one cramped seating or poor posture are often virtually no prospect of success. The instance did not, arise as a result of the present in the airliner passenger cabin. outcome is that Mr Povey has been flight or the aircraft cabin environment. There are few other modes of transport, or granted leave to reformulate his claim - if indeed other activities, which entail sitting he believes he can - to allege that the That is something which any given in the same seat for more than twelve failure of the carriers to warn of the risks passenger will have to try to prove in due hours at a stretch. On the other hand there of DVT might constitute an “accident” - course. Although the decision is a victory are many other factors which can affect which, as you all know, is the principal for the carriers, it does not eliminate anyone, anywhere: these would include trigger of liability under Article 17 of the future claims, which must be likely. age, medical history (including reduced Warsaw Convention. If Mr Povey’s claim Doubtless, they will be pursued on the blood clotting ability, a previous occurrence proceeds, he still has to prove - as a basis that something unusual occurred. or cardiovascular disease), hormone matter of medical evidence - that the DVT This might on the basis of a system medication, recent surgery, obesity or was caused by his travel on the aircraft. malfunction or a seat not reclining dehydration. People fly further, on longer This is, of course, a contentious issue. properly, or that a passenger asked to be sectors, more often, than ever before. The Judge did not come to any moved and was not allowed to do so. Unsurprisingly there is therefore a range of conclusion on it: it has simply declined to Such a passenger would have to views as to whether the aircraft cabin dismiss his case. demonstrate that that unusual event environment is itself the immediate cause constituted an “accident” within the 3 of a thrombosis in any given case. The English decision was rather different. meaning of the Convention, which has It is of course important to appreciate that It attracted considerable publicity been interpreted as “an unexpected and there is no single answer to the question because it was group litigation involving unusual event … that is external to the 10 passenger”. It does not include “the when the Montreal Convention comes into In the meantime, for flight deck crew, the passenger’s own internal reaction to the force, probably later this year. If result- obvious means of minimising the risk is to usual, normal and expected operation of orientated legislation of that nature does take every opportunity to move around! the aircraft”. come into force, airlines may need to reconsider their own position vis à vis passengers, although one might be 1 Rainer Vorlander –v- Deutsche So where do airlines go from here? forgiven for suspecting that liability would Lufthansa, Regional Court of Frankfurt, not be predicated on fault, in which event 29 October 2001 First, operators need to consider their a high standard of care and concern for 2 Povey -v- British Airways and procedures in the event that aircraft passengers’ welfare would be irrelevant. Qantas, Bongiorno J, 20 December systems or equipment which have a 2002 bearing on the passenger cabin Finally, what of the position of flight crew? 3 In re Deep Vein Thrombosis and Air environment are not functioning correctly. This analysis is all about the relationship Travel Group Litigation, Nelson J, 20 If the cabin pressurisation system, or a between airlines and their customers. December 2002. The Times, 17 seat recline mechanism, or the passenger None of these cases have any bearing on January 2003. health video, are not working, a the duty of an airline to its own crews. The passenger may be able to characterise passenger relationship is the most obvious this as an “accident”. source of friction, but flight crew are more regularly exposed to some of the factors Second, operating procedures need to which can contribute to DVT such as address what cabin crew should do in the reduced air pressure. Flight crew event a passenger complains of symptoms frequently spend prolonged which may indicate a clot. Leg or chest periods of time in the aircraft pain is a possible symptom: it is worth and, in the case of flight deck Airstaff Associates establishing, with appropriate medical crew, much of that is in association with guidance, what precautionary steps might sedentary. If immobility is an be taken at that stage - whether it be taking important factor it may be Nigel Bauer & Associates more fluids, moving around the cabin or that cabin attendants are at QUALITY MANAGEMENT FOR OPERATORS * exercises to promote circulation. One gets reduced risk. JAR-OPS Quality Systems, documentation & auditing into a difficult area in terms of how far flight 5 days - LGW - 17 Mar, 16 Jun, 22 Sep, 24 Nov crew can offer medical advice so this is an Much of this is largely NEW SAFETY MANAGEMENT SYSTEMS aspect to be resolved with the aviation uncharted territory, both Practial SMS course for air & ground operators medicine specialists. Nevertheless, recent legally and in terms of 4 days - LGW - Back in the autumn case law in the United States suggests that medical studies and writing AUDITING IN AN OPERATIONAL an inappropriate response to a passenger on the threat to flight deck Air & ground operations auditing health event could itself be an accident, crew. However the duty of 3 days - on request or ‘in-company’ even if the symptoms being suffered by the an airline to provide a safe AUDIT IMPROVEMENT WORKSHOP passenger are – to borrow the well-known place of work may be Experience sharing & improvement of audit process 2 days - LGW - 27 Mar phrase - themselves purely an internal defined - and it varies from reaction to the normal operation of the country to country - there QUALITY FOR SENIOR MANAGEMENT aircraft. may be practical crew New Course - JAR Quality Management Accountability 2 days - ‘in-company’ only welfare issues if neither The political and press interest in the employer nor employee take * Incorporating Nigel Bauer & Associates IRCA certificated Internal Auditor Training course subject may have waned recently, appropriate measures to perhaps due to greater interest in wider minimise any risk. Airlines For further details including In-Company courses and consultancy or auditing services please contact: international political issues. Further would do well to keep an Airstaff Associates: studies on DVT are in hand. Nevertheless, eye open for any firmer Tel +44 (0) 1780 721223 e-mail: [email protected] one hears murmurings of legislation to conclusions on the risk and, Fax +44 (0) 1780 720032 www.airstaff.co.uk circumvent the obstacles to recovery by if those studies are limited Nigel Bauer & Associates: passengers posed by the Warsaw to passengers, consider Tel +44 (0) 1243 778121 e-mail: [email protected] Fax +44 (0) 1243 789121 www.nb-a.demon.co.uk Convention regime - which will not change their implications for crews. 11 Members of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE Full members ALAE CargoLux Dave Morrison Capt. David Martin Chairman Airclaims Astraeus Ltd Cathay Pacific John Dunne Capt. Nick Carter Capt. Richard Howell Vice-Chairman BAA plc Channel Express flybe. british european Francis Richards Rob Trayhurn Stuart McKie-Smith BAC Express CityJet Treasurer Capt. Steve Thursfield Capt. Mick O’Connor Air 2000 Capt. Martin Pitt BAE SYSTEMS Reg. A/C Cougar Leasing Dan Gurney Capt. Shaun Harborne External Affairs Officer RAeS BALPA DHL Air Peter Richards Carolyn Evans Peter Naz Aer Lingus bmi regional Dragonair Capt. Tom Croke Capt. Steve Saint Alex Dawson Aerostructures Hamble British Airways Eastern Airways UK Ltd Dr. Marvin Curtiss Steve Hull Capt. Jacqueline Mills AIG Aviation British Airways CitiExpress Ltd easyJet Jonathan Woodrow Capt. Ed Pooley Capt. Tim Atkinson Air Contractors British International Emerald Airways Capt. Tony Barrett-Jolley Capt. Terry Green Capt. Roley Bevan Air Mauritius British Mediterranean Airways European Aviation Air Charter Capt. Francois Marion Robin Berry David Wilkinson Air Scandic CAA EVA Airways Paul Ridgard Dave Lewis - MRPS Richard Lovegrove Chrys Hadjiantonis - Safety Data Dept. Air Seychelles Brian Synnott - Flight Operations Excel Airways Capt. Curtis Allcorn Alison Thomas - Intl. Services Peter Williams Air Transport Avionics Cardiff International Airport FlightLine Colin Buck Graeme Gamble Capt. Derek Murphy GAPAN Capt. Chris Hodgkinson ADVERTISING IN THIS MAGAZINE GATCO Richard Dawson Goodrich Actuation Ltd Focus is a Quarterly Publication which has a Keith Joyner highly targeted readership of 32,000 Aviation Independent Pilots Association Capt. Mike Nash Safety Professionals worldwide. Irish Aviation Authority Capt. Bob Tweedy IfIf youyou oror youryour companycompany wouldwould likelike toto JMC Airlines advertise in Focus please contact: Capt. Graham Clarke LAD (Aviation) Ltd Steve Flowers Advertisment Sales Office: Loganair Doug Akhurst Mike Barrett, UKFSC, The Graham Suite, Fairoaks Airport, London City Airport Chobham, Woking, Surrey. GU24 8HX. Simon Butterworth Tel: 01276 855193 Mobile: 07788 168207 London-Manston Airport [email protected] Wally Walker 12 Maersk Air FLS Aerospace (IRL) RAeS Capt. Christopher Morley Frank Buggie Peter Richards Manchester Airport plc FLS Aerospace (UK) RAeS Eng. Peter Hampson Andrew Hoad Jack Carter Monarch Airlines flybe. british european Capt. Tony Wride Stuart McKie-Smith Co-opted Advisers MyTravel flybe. british european eng. AAIB Capt. Tom Mackle Chris Clark Phil Gilmartin NATS Ford Air CHIRP Paul Jones F/O Paul Stevens Peter Tait PrivatAir Ford Motor Co. Eng GASCo Capt. Boris Beuc Steve Laven John Campbell Ryanair GB Airways Royal Met. Society Capt. Gerry Conway Capt. Aaron Cambridge Dr John Stewart SBAC GB Airways Eng. John McCulloch - Secretariat Terry Scott Vic Lockwood -FR Aviation KLM uk Servisair Dean Godfrey Eric Nobbs KLM uk Eng. Shell Aircraft Andy Beale Cliff Edwards Lufthansa Cargo AG The Boeing Co. Capt. Nigel Ironside Thor Johansen Condor/Lufthansa & CityLine Virgin Atlantic Airways Capt. Jason Holt MOD Willis Aerospace DASC Col. Arthur Gibson Ian Crowe DASC Eng. HQ STC MOD - Wg. Cdr. Bob Nielsen Group members bmi british midland Capt. Ian Mattimoe bmi british midland Eng. Peter Horner Bristow Helicopters Capt. Derek Whatling Bristow Helicopters Eng. Richard Tudge Britannia Airways Jez Last Britannia Airways Eng. Adrian Vaughan CHC Scotia Capt. David Bailey CHC Scotia Eng. Colin Brown Eurocypria Capt. Constantinos Pitsillides Cyprus Airways Capt. Spyros Papouis 13 Hazards of Erroneous Glideslope Indications All airplanes equipped with instrument One such erroneous indication recently imperative that flight crews also help landing systems are vulnerable to occurred on several 767, 777, and Airbus manage the risk by understanding the capturing erroneous glideslope signals. airplanes, resulting in coupled ILS problem and performing glideslope Boeing, the International Civil Aviation approaches being flown toward a point confidence checks. Organization, and the U.S. Federal short of the runway. This kind of problem Aviation Administration are working can occur on any airplane with any ILS This article describes together to improve awareness and receiver. prevent such errors. Flight crews can 1. Incident involving an erroneous help manage the risk by understanding Boeing has taken action to help prevent glideslope signal. the problem and performing glideslope such incidents by revising operations confidence checks. manuals and working with the 2. Causes of erroneous glideslope International Civil Aviation Organization signals. With the advent of instrument landing (ICAO) and the U.S. Federal Aviation systems (ILS) in the 1940s came the Administration (FAA) to address 3. Flight crew actions. possibility of erroneous or false glideslope maintenance errors that can cause indications under certain circumstances. erroneous glideslope signals. The subtle 4. Industry actions. nature of the indications makes it 14 1. Incident Involving an Erroneous equipment (DME) indications differed equal amplitude. These signals alone do Glideslope Signal slightly from what he would have expected. not provide guidance but are compared with separate 90- and 150-Hz sidelobe On the night of July 29, 2000, an Air New The captain signals radiated by the localizer and Zealand 767 was on a routine flight from executed a timely glideslope to create complex interference Auckland, New Zealand, to Apia, Western go-around 5.5 mi patterns. The patterns are designed so Samoa. The night was moonless, with from the runway that when an airplane is below the scattered clouds that prevented visibility at an altitude of desired glideslope the instruments will of the runway lights. less than 400 ft. sense a predominance of 150-Hz signals; The crew when the airplane is above the desired The flight crew members were successfully glideslope, the instrumentswill sense a experienced in conducting routine executed a predominance of 90-Hz signals; and automatic landing approaches in low second approach by using the localizer when the airplane is on the glideslope, visibility. They considered a routine and ignoring the on-glideslope indications. the instruments will sense equal amounts automatic landing approach to be safe if of 90- and 150-Hz signals (fig. 2.) the autopilot was coupled to the airplane; The ILS was designed to protect against no warning indications were visible, and a 2. Causes of Erroneous Glideslope valid Morse code identifier signal came Signals from the ground navigation aids. Investigation of the Air New Zealand Well prepared before descent, the flight incident revealed important information crew thoroughly briefed for the approach. about the causes of erroneous glideslope When the crew selected the approach signals. Understanding these causes mode, the glideslope capture occurred requires a discussion of the ILS and its almost immediately. All ILS indications normal operation. appeared to be correct. With all three autopilots engaged the captain ILS ground equipment provides horizontal concentrated on configuring the airplane and vertical guidance information to The Royal Aeronautical Society is and slowing it for landing. The crew airplane instrumentation. The equipment acting as the coordinator for over 60 attributed the slightly steep descent of the typically comprises five components: a organisations within the UK that will celebrate 100 years of flight. airplane to its heavy weight and tailwinds. localiier transmission system, a glideslope The crew noted a good Morse code transmission system, a DME or marker Patron: His Royal Highness The Prince of identifier signal and no warning indications. system, a standby transmitter, and a remote Wales At 1,000 ft, the crew completed the landing control and indicator system (fig. 1). checks. Shortly thereafter, the first officer Programme Aims observed the close proximity of the island During normal ILS operation the localizer lights out his side window. The captain and glideslope transmitters each radiate a •To celebrate the achievements in noticed that the distance measuring carrier wave of 90- and 150-Hz signals of aerospace over the first 100 years. •To communicate to the general public the importance of aviation to society and the challenges ahead. •To inspire a new generation to take up these challenges. •To create a scholarship fund to assist that new generation realise their potential. www.100yearsofflight.org.uk 15 Crosschecks A single distance-altitude check does not guarantee the subsequent descent path will be correct. Similarly, a single altitude check crossing the outer marker does riot guarantee the glideslope is correct. The best strategy is to cross-check the airplane altitude against distance periodically during descent. Methods to accomplish this include ■ Crosschecking altitude and DME distance periodically. ■ Crosschecking altitude and flight management system (FMS) threshold distance. ■ Crosschecking altitude and the crossing altitude of the outer marker (or locator, very-high-frequency omni-range [VOR] navigation equipment, or FMS). ■ Crosschecking radio altitude and barometric altitude. ■ Crosschecking ground speed and rate of descent. transmitter malfunctions. If a primary This prevented system transfer to the transmitter malfunctions, the system standby transmitter. No alarm sounded in ■ Questioning air traffic controllers when automatically will transfer to the standby the control tower because the cable that indications do not appear to be correct. transmitter. If the ILS does not change fed information to the tower navigation over to the standby transmitter, or if the status displays had been cut during Similar erroneous indications can occur standby transmitter is faulty, the system construction. As a result, the Air New with the localizer signal. Cross-checking automatically will shut down, and an Zealand flight received only the glideslope the signal with other navigation indicators, alarm will sound in the control tower. carrier wave transmission, which was such as VOR and navigation database interpreted by the instruments as being on course heading and tracking information, It is important to note that, because the glideslope, with no warning indications. can help reduce risks in such occurrences. Morse code identifier signal is earned only on the localizer carrier signal, the flight crew only knows whether or not the 3. Flight Crew Actions Crew vigilance localizer is transmitting. No information on the health of the glideslope, localizer, or The Air New Zealand incident exemplifies Human factors were very important in the other functions is provided. why flight crews need to be aware of the successful outcome of the Air New potential for erroneous glideslope signals, Zealand incident. Crewmembers were alert On the night of July 29, 2000, the even when the ILS is indicating correctly to possible ILS problems because notice glideslope sidelobe amplifier was not and a distance-altitude check is to airmen (NOTAM) bulletins had informed operating in Apia. In addition, the ILS performed at glideslope capture. them that the ILS was unmonitored, and ground equipment had been left in bypass Frequent crosschecks and crew vigilance they discussed this during their approach mode following calibration maintenance. are key in detecting potential problems. briefings. They also paid attention to subtle 16 ■ Recommends that air traffic control Safety forums advise the flight crew, either by voice or through an automated terminal Boeing also promotes discussion of information service (ATIS), that ILS erroneous glideslope indications in maintenance testing is in progress various industry safety forums worldwide. and that the flight crew should not use the glideslope or localizer. Editor’s note: Additional copies of the training video, New Zealand 60 - A Free cues that something might be wrong, even ■ Recommends that maintenance Lesson,” may be obtained from the Flight though the automatic flight systems was personnel turn off the glideslope Safety Foundation, 601 Madison St., Suite indicating normally. Last, the transmitter during localizer testing and 300, Alexandria, VA 22314; telephone crewmembers were willing to execute a turn off the localizer transmitter during 703-739-6700; fax 703-739-6708; web site go-around to give them more time to sort glideslope testing. www flightsafety org. through the conflicting information (fig. 3). Equipment improvements SUMMARY 4. Industry Actions The transmission of erroneous ILS In the case of the Air New Zealand flight, information at Apia on July 29, 2000, Boeing, the FAA, ICAO, and others in the the ground proximity warning system was caused by an unusual set of aviation industry are working together to (GPWS) did not warn the crew flying the circumstances. However, technicians address the problem of erroneous erroneous glideslope. This is because the will continue to conduct testing and glideslope indications. Actions have airplane did not have an excessive maintenance of airfield navigation included issuing maintenance guidance, closure rate with terrain and the flaps aids. A similar situation could occur improving equipment, revising flight crew were in landing configuration. However, in any ILS-equipped airplane during training manuals and operations manuals, an airplane equipped with a terrain what appears to be a routine and facilitating discussions at industry awareness warning system (TAWS) (e.g., instrument approach. safety forums. the Honeywell enhanced GPWS) would have warned the crew of the situation The best defenses against erroneous because TAWS compares the flight path glideslope indications are Maintenance guidance with a terrain database. understanding how the ILS works, equipping airplanes with modern ICAO and the FAA have released TAWS is standard equipment on all in- warning systems, and implementing guidance for the proper conduct of ILS production Boeing airplanes and is training and procedures that ensure ground maintenance activities. The available for retrofit on all models crewmemebers are prepared to take guidance delivered before 2000. appropriate action. Flight crew action should include crosschecking ■ Clarifies the content of NOTAMs that the airplane altitude against distance are sent when maintenance work is in Training periodically during descent. progress and the possibility of false indications prohibits the use of a In addition to improving equipment, Special recognition is given to particular approach aid. Boeing has revised its flight crew training investigators David Stobie, Rod manuals and operations manuals and Smith, Chris Kriechbaum, Bob ■ Recommends that maintenance has sent all airline customers a 26-min Henderson, Joey Anca, and Dr. personnel confirm whether or not a CD-ROM video, “New Zealand 60 - A Gordon Vette for their contributions to NOTAM has been issued before Free Lesson.” The video and revised understanding this incident. beginning ILS maintenance testing. manuals detail the problem of and ■ Recommends that the Morse code solutions to erroneous glideslope Reprinted from AERO magazine by identification feature be suspended indications. permission of The Boeing Company when maintenance testing is in progress. 17 Minimum Safe Turnaround Time - A Briefing Paper for Schedule Planning Departments Produced by the ERA Air Safety Work Group The following paper introducing the several ERA work groups; the Group careful consideration of the relevant concept of calculating safe turnaround meets quarterly, and delegates consist of factors can lead to the calculation of a times was produced by The European airline safety managers and practical Minimum Safe Turnaround Time Regions Airline Association (ERA), Air representatives from major aircraft (MSTAT) which may have important Safety Work Group. It is intended for manufacturers. The paper on Minimum benefits for the airline and crew. aircraft operators to use as a guide when Safe Turnaround Times is just one visible establishing and revising their schedules. product of this Group that can help These include: Obviously airlines operate in various improve safety within the aviation industry. ■ circumstances, and the factors affecting Improved departure (and arrival) turnaround time, outlined in this paper, For more details about ERA visit punctuality are recommendations for consideration; it www.eraa.org and www.fly-safely.org ■ may be necessary for an operator to take Less likelihood of having to account of many other factors. renegotiate a flight plan INTRODUCTION ■ ERA is the principal body representing the Less adverse impact on crew interests of organisations involved in air Airline flight schedules provide time rostering, and transport in Europe’s regions. More than between scheduled arrival and departure ■ 70 million passengers fly with ERA times to allow essential tasks to be Enhanced safety by preventing poorly member airlines each year. completed. These tasks include loading managed and rushed turnaround The Air Safety Work Group is one of and unloading, maintenance, replenishment times. and cleaning, together with the completion of Additionally, this analysis can reveal the essential crew post causes of persistent delays at certain School of Engineering and pre-flight locations, which can then be addressed administration. and perhaps eliminated. Air Safety Management - Typically, airlines allow Often, schedule planners are not standard (minimum) experienced operators, or do not have an exciting new career turnaround times in first-hand knowledge of the difficulties development opportunity the construction of their crews have to cope with in order to Introducing a brand new course designed for those rising in flight schedules. achieve on-time departures from certain their careers in airlines, air traffic control, airports, aircraft and airfields. systems manufacturing and related industries. These do not take MSc Air Safety Management is for those who have an interest into account variable in or a significant level of responsibility for defining and implementing the management of air safety in all areas of the factors at specific AIM industry - not just operations, but also aircraft and equipment locations, or design and manufacture. This course has been initiated in peculiarities at non- The aim of this paper is to offer schedule response to the needs of both the industry and the regulatory authorities. The course is: standard locations. planners advice when calculating the • Businesslike - modules are taught by leaders in the industry Where adverse MSTAT, the use of which will bring • Flexible - modules last three mid-week days conditions exist - for operational and safety benefits to the • Practical - study at your own pace to fit your own schedule example, a airline. • Outward looking - with interest coming from many companies, there are excellent opportunities for networking combination of a • Modules run in London and Dubai crew change, To achieve this aim Flight Safety refuelling the aircraft Managers should use this paper as a For further information, please contact: The Courses Officer, or a large load - it briefing guide with which they can raise School of Engineering, City University, Northampton Square, may not be possible awareness, within their planning and London EC1V 0HB. Tel: +44 (0)20 7040 8112; fax: +44 (0)20 7040 8101; e-mail: [email protected] for the crew to operations departments, of the factors www.city.ac.uk/atm achieve an on-time that affect turnaround times, and the The University for business and the professions departure. benefits that can be gained from realistic In many cases, scheduling. 18 DEFINITION Variable factors, because they are determined in ideal conditions. Ideal unpredictable, cannot be included in the conditions might include the following: The Minimum Safe Turnaround Time MSTAT calculation. (MSTAT) is the minimum on-block time ■ Computer flight-plan available or flight necessary to allow a crew to prepare for a Variable factors include the following: planning completed prior to arrival flight, as well as to complete the paperwork for the previous flight. ■ Crew debriefing ■ Computer load-sheet available ■ Crew recovery ■ No crew change FACTORS AFFECTING MSTAT ■ De-icing and other non-scheduled ■ No cleaning required A number of factors affect the MSTAT. maintenance tasks Some of these are unavoidable; others ■ No catering replenishment required are variable. ■ De-planing disruptive passenger ■ No refuelling required Unavoidable factors include the following ■ Training. (this list is not comprehensive): ■ Moderate passenger load. The above lists are not exclusive; other ■ Flight planning factors may affect MSTAT for particular To calculate the MSTAT for non-ideal aircraft types, for specific operations, or conditions, a correction factor can be ■ Preparation and checking of for certain locations (or, any combination added if any of the above conditions are loadsheet of these). not met. The following hypothetical example shows how the calculation might ■ Crew change work in practice. CALCULATION OF MSTAT ■ Aircraft cleaning The calculation of an MSTAT is not an exact EXAMPLE ■ Refuelling science, what may suit one operator (aircraft type, airport) may not suit another Assume an airline currently allows a ■ Catering replenishment operator (aircraft type, airport). Similarly standard 30 minutes for turnaround time what may work for this year’s scheduling on all schedules. ■ Airframe change might not work for next year’s. The important point is to collect information for Now, suppose that the MSTAT, for an ■ Load characteristics. each type of operation, aircraft type and example aircraft, determined for ideal airport and assess the factors that hinder or conditions is 15 minutes, it is clear that in With the imminent introduction of an EU help turnaround times. Only by using many cases, the standard scheduled regulation concerning aviation security, realistic MSTATs for planning can the turnaround time would be generous, and some turnaround times will be adversely operational and safety benefits be achieved. easily achievable; alternatively, it could be affected. Aircraft are to be security reasonably reduced to 20 minutes and checked, and once checked ‘as clear’ Note: MSTAT may not only be different at still provide greater flexibility within the they are to be guarded, all access to that different airports, but time may vary schedule. airframe will be strictly controlled. Aircrew, considerably between parking bays or airport workers and sub-contractors (their terminals at the same airport. In non-ideal conditions, one or more baggage, tools etc.) will all be required to penalty factors would have to be added undergo full screening and frequent One method of calculating a MSTAT is to to the ideal MSTAT. Suppose they are security checks. The impact of these rules first ascertain a MSTAT for ideal determined to be as follows: may be minimal at large airports where conditions, and then to adjust this ideal security is already at a high standard; time by adding penalty times for known No computer load-sheet: + 5 minutes however, at other locations security could adverse factors. be the main limiting factor when No Ground Engineer for calculating MSTAT. For any aircraft type, the MSTAT may be pre-flight inspection: + 5 minutes 19 Crew Change: +20 minutes Calculation of Minimum Safe Turnaround Final MSTAT: 42 minutes Time (MSTAT) by the Flight Operations Cleaning by crew: +10 minutes Department for each aircraft type and for Note 1: if a crew change occurred each sector of schedules will ensure that Refuelling: +10 minutes at this stop, the total correction schedules are realistic and achievable. would have been limited to 30 This will result in improved flight More than 50 passengers: +12 minutes minutes, making the final MSTAT 45 punctuality and enhanced safety. In some minutes. cases, the use of a reduced turnaround Note: Some of these tasks (cleaning and time so calculated may result in a more refuelling for example) may be combined. Note 2: if the same conditions cost-efficient schedule. Also, these penalty times might be applied to another location, but an suitable when considered in isolation, extra passenger bus was required, The MSTAT calculation will reveal where however, a practical maximum time then an appropriate adjustment critical departure times cannot be safely penalty should be considered, e.g; would have to be made, perhaps achieved. This will focus attention on the another 6-minutes? reasons for delays, permitting appropriate Maximum correction remedial action such as changing the to MSTAT: +30 minutes location of crew changes, tanking fuel, or improving ground handling facilities. It is clear that with one or more factors EXPERIENCE affecting the turnaround of our example Exposing schedulers to the realities of the aircraft, a 30-minute MSTAT would be An ERA member airline has used a draft operations that they plan will help them to inadequate and only achievable by of this paper as a planning tool for their understand the problems that crews face. cutting corners or rushing procedures. aircraft schedulers. Realistic times can then be assigned to the variety of tasks that occur during a As a result, most of the unrealistic turnaround, penalty times can be turnaround times have disappeared from calculated for known variables, and the For example: suppose that for this their schedules. In order to raise the calculation of MSTAT can be confidently sample turnaround a manual awareness of their planners, this operator made for all situations. calculation of the load-sheet was found it invaluable to give practical necessary, cleaning and refuelling experience to their planners by exposing were required, and there were 80 them to as many routes as possible. The RECOMMENDATION passengers, but a ground engineer decrease in delays is harder to assess, was available to complete the pre- as this airline includes flying times in The ERA Air Safety Work Group flight inspection. these calculations. However, quality recommends that all airlines use the indicators of airline performance are lessons outlined in this paper to Ideal MSTAT: 15 minutes frequently being demanded by recalculate their scheduled turnaround customers, and adherence to departure times. Manual calculation of times is a desirable element, in their eyes, loadsheet: + 5 minutes when choosing an operator. Maastricht February 2003 Cleaning/refuelling: +10 minutes CONCLUSION More than 50 passengers: +12 minutes The use of standard turnaround times which do not take account of variations in Total correction: +27 minutes operation, aircraft type or conditions at individual locations, can lead to consistently unpunctual operation, rushed (unsafe) procedures, poor quality performance. 20 Waging War Against Unsafe Operations by E. H. Paintin rules, yet blatant disregard of them involves risk and could result in failure. In business terms this can be equated to the overall business philosophy of the Air Operator and in particular its policy to Safety in the broader sense of the word. At the end of a given period it should be possible to look back at how the operation has functioned and to compare it with the general philosophy of the organisation. Each of the 10 principles will be dealt with independently. Having been trained in the military I have I have, for convenience written the Military Military Doctrine. often mused at the similarity between Doctrine and Principles of War in italics, Military Doctrine is the highest level of keeping Air Operation safe and the to easily identify them from my comments Doctrine and is issued by the Chief of waging of war by the military. in relation to the Air Operator. General Staff. It is concerned with conveying understanding, not instruction. On one hand commercial enterprise as It is based directly upon Government we know it does not have a particularly British Military Doctrine and policy manifest primarily in White Papers. long history, perhaps as little as 150 Principles of War Its function is to establish the framework of years, and as everyone knows aviation understanding of the approach to warfare history is less than 100 years. Fighting Power in order to provide the foundation for its The term “fighting power”, defines an practical application. On the other hand wars have been army’s ability to fight. There are three waged for many thousands of years. interrelated components of fighting power. This is the accuracy and method used by Should there not therefore be some the Chief Executive to communicate what principle that the aviation sector can learn In the aviation business this can be the Management Board expects from its form the military? compared with the ability of the Air employees in terms of Safety Policy. Operator to combat the various hazards Based on what the CEO communicates If we also consider the amount of training and threats to the safety of it’s operation. and the reactions and actions of the that goes into building an efficient army Board Members to safety issues, the and compare it to the relatively minimal Conceptual Safety Doctrine will evolve. training undertaken by Air Operators, it This can be described as the thought should not be surprising that the skill level process behind the ability to fight. It is I say evolve, because it takes time to within some Air Operators is not only made up of: achieve a coherent and consistent Safety inadequate but has stagnated. Doctrine. Many Air Operators have senior The Principles of War managers who pay lip service to safety. In what follows, I hope to draw out the These are broad precepts that influence This attitude is soon detected by learning points that an Air Operator might the conduct of war. There are 10. They subordinate managers and shop floor glean from the experience of the military have relevance at high levels of war where workers who then adopt a “could–not- waging war. In particular I intend to they assert criteria against which courses care-less” attitude themselves. consider the British Military Doctrine and of action can be tested. At lower levels Principles of War as they are currently they provide a guide for planning and Development taught to Candidate Officers of Her conduct of activity on the battlefield. The Development requires bringing an Majesty’s Forces Military Staff Colleges principles of war are based on past innovative approach to bear on all aspects and Academies, at the Royal Military experience where application with of fighting power. Development will be Academy, Sandhurst. judgement has led to victory. They are not clearly seen in the work of Research 21 Establishments and in the application of “morale” which Napoleon quantified in generally the case in many Air Operators operational analysis techniques. The view saying that “Morale” is to the material as today. of Commanders at all levels will also have three is to one. major influence upon the development of Physical the ability to fight. The state of company morale is one area The physical component is the means to that seems to be totally ignored by Senior fight. This includes the organisation of the Business development in its broader Management. It is difficult for middle main elements of combat power, which sense is the responsibility of every staff management to remedy poor morale are: member. The development of new and brought about by poor executive Manpower better business processes needs to be management decisions and behaviour. Equipment actively encouraged. It is by this means Logistics that continuous improvement is brought The constant threat of redundancy, lack of Training and Readiness about. Managers at all levels should be communication by senior management, paying attention to the analysis of the pay increases below the cost of living Due to the ever-pressing need to manage processes employed and for their increase, lack of action in areas of the finances by senior management it is continuous revision where they are found concern raised by middle management often the case the Air Operators have to be in need of overhaul. The Quality and the workforce all have a debilitating insufficient qualified manpower to ensure System is a tool that easily facilitates this, effect on morale. This in turn reflects in the safe operation of their enterprise. as regular audits expose weaknesses that poor productivity, declining work habits Interestingly the Royal Air Force is finding enable revision and the resulting which all affect the safety of the that having privatised some areas of its improvements. The Hazard Analysis and operation. aircraft servicing, the adequacy of Safety Case precipitate the development manpower is becoming an ever- of the Safety System. Napoleon appreciated that one well increasing risk area. motivated soldier was worth three Morale unmotivated men. They worked well and This coupled to the inadequacy of The morale component concerns the motivated their peers. It was therefore equipment to cope with modern aircraft ability to fight. Many theorists and all possible to win battles over forces and insufficient spares holding makes the practitioners of war have pointed to the superior in number. Officers (managers) task of middle management very difficult significance of the morale aspect in were therefore selected for their ability to causing unnecessary stress and fighting. It can be summed up in the term motivate their men. Sadly this is not depressing the morale of its managers and workers. The shortage of skilled manpower, particularly in the engineering area is an ever-increasing area of risk to the Air Operator. Those Air Operators that used to run training schools and apprenticeship schemes no longer do so as part of one or other cost saving scheme. This short sighted policy is destroying their engineering infrastructure with an increasing risk to the safety of the operation. They propound a Company Safety Policy on the one hand whilst destroying their manpower skills on the other. This article will be concluded in Issue 51. 22 Course Outline for the Human Factors Training in Aviation Maintenance In conjunction with Baines Simmons Ltd Course Dates: 01 – 03 April 2003 booked for delegates from the night ■ Safety cultures 27 – 29 May 2003 before the course starts to enable a ■ Error management skills 24 – 26 June 2003 prompt start. 22 - 24 July 2003 Human Performance and Limitations Course Fees: £990 fully residential ■ The brain and memory Course Content ■ Motivation ■ Stress and fatigue Who should attend: The main topics covered within the ■ Sleep and circadian rhythms course are: ■ Shiftwork This course will be relevant for all those ■ The effects of alcohol, drugs, involved in aviation maintenance. It will be General introduction to Human Factors medication, caffeine and diet of particular interest for those companies ■ The meaning of Human Factors who are JAR 145 approved or who are in ■ Why Human Factors are important Environmental Factors the process of applying for JAR 145 status. ■ The size of the Human Factors ■ Environmental factors that affect The course is primarily a knowledge based problem human performance course designed to equip industry to meet ■ How Human Factors have contributed ■ Vision requirements for inspectors and the training requirement within the JAR 145 to aviation accidents factors affecting visual inspection Amendment 5 Maintenance Human ■ The effect of Human Factors on ■ Improving visual inspection reliability Factors (MHF) syllabus. airworthiness ■ The error chain concept Communication ■ Different types of communication and Course Outline: Human Error the effects of poor communication ■ Error and the different types of error ■ Importance of task/shift handover This is a 3 day programme the content of ■ Organisational accidents which is based on the course syllabus ■ Safety nets and system defences Teamwork within the amendment to JAR 145. The ■ Team and individual performance main topics covered by the course are Human Error – Slips and Lapses ■ Effective team work listed below. ■ Difference between slips/lapses and mistakes Organisation’s Human Factor Programme The course material has been collated ■ Main types of lapses ■ Effective error management and from considerable research and hands on ■ Common factors promoting wrong Human Factors programme. experience of Human Factors issues. action Baines Simmons has particular strength ■ Situational awareness For an application form, please contact in the field of Human Factors. The Course ■ Perception and the link to error Manager, Keven Baines, has worked with ■ Complacency and the link to error Laura Watts, a number of industry experts such as Civil Aviation Authority, David Marx and Professor James Reason Human Error – Violations International Services, and has been involved in the subject for ■ The different forms of violations Aviation House, the past ten years gaining a thorough ■ Norms and habits Gatwick Airport South, understanding of Human Factors issues. ■ Resources and the link to violations West Sussex RH6 0YR. ■ Working to approved standards Through the combination of case studies, ■ Procedural compliance Tel: +44 (0)1293 573392 exercises and practical application, the Fax: +44 (0)1293 573990 course is constructed to encourage Avoiding and Managing Error e-mail: [email protected] delegate participation and therefore ■ Human reliability limitations maximise learning potential. ■ Error Management Principles ■ Root cause investigation The course is based at Gatwick and is ■ Cycle of blame and the ability to fully residential. Accommodation is manage error 23 UK FLIGHT SAFETY COMMITTEE ANNUAL SEMINAR 2003 AVIATION SAFETY - THE BALANCE BETWEEN COST AND VALUE 29th/30th September 2003 The Radisson Edwardian Hotel Heathrow Seminar Objective Safety Management can be seen as expensive for all forms of Industry. Regulatory obligations notwithstanding, there are many choices that could be made. This Seminar will examine how value judgements are made and attempt to demonstrate how ‘Best Practice’ need not be ‘Cost Prohibitive’ Programme 29TH SEPTEMBER 2003 1530 – 1700 Registration 2000hrs Seminar Dinner This will take place in the Hotel Foyer After Dinner Speaker - 30TH SEPTEMBER 2003 0800 – 0900 Registration 1210 - 1240 Discussion Session Chairman - Ian Crowe, Willis 1245 – 1400 Lunch 0900 – 0910 Opening Remarks 1400 – 1430 Where you Save and Lose Money John Dunne, Chairman UKFSC TBA 0910 – 0940 Keynote Speech 1430 –1500 Where are you going with Safety Mike Hirst - Loughborough University Related Equipment TBA 0940 – 1020 Regulatory Minima Dave Chapman/Dave Wright - CAA 1500 –1530 Development & Use of Non-Mandatory Safety Tools & the Benefits 1020 – 1050 Board Decisions Cost v Benefits John Savage - British Airways Dave Henry - Consultant 1530 -1550 Discussion 1050 – 1110 Refreshment Break 1550 -1600 Closing Remarks 1110 – 1140 Development of an Affordable System John Dunne, Chairman UKFSC Mike Wood - flybe. british european 1140 – 1210 Examples from other industries Mark Williamson - Willis Space 24 SEMINAR INFORMATION Hotel Accommodation Hotel Accommodation is not included in the Seminar Registration Fee. A rate of £145 (including breakfast & VAT) has been negotiated with the Radisson Edwardian Hotel (valid only until 22nd August). If you require accommodation please contact the hotel directly on Tel:(+44 (0) 20 8759 6311) and quote Block Booking Code 0929 UKF when making your reservation. Seminar Dinner Dress for Dinner – Black Tie Cancellations/Refunds Cancellations received prior to 22nd August 2003 will be refunded 50% of registration fee. Refunds after this date will not be given. If you are unable to attend why not nominate a colleague to take your place. If so, please advise the UKFSC Fairoaks office of any changes prior to the Seminar. ✂ SEMINAR REGISTRATION FORM Please complete one registration form per person (photocopies accepted). REGISTRATION INFORMATION (Please print clearly) First Name: Surname: Company: Job Title: Address: Tel No: Fax No: e-mail: PAYMENT INFORMATION Seminar Fee: £150 UKFSC Member £200 Non-UKFSC Member This includes the Seminar Dinner on the evening 29th September, lunch, refreshments and car parking. This does not include hotel accommodation – please see ‘Seminar Information’ above. Payment is by sterling cheque only. No credit cards are accepted. Bank transfer is available, details on request (please note an additional cost of £6 will be added to cover handling charges). The UKFSC is not VAT Registered. Sterling cheques should be made payable to UK Flight Safety Committee. Do you plan to attend the Seminar Dinner on Monday 29th September? Yes No Do you require a Vegetarian alternative? Yes No PLEASE SEND YOUR COMPLETED REGISTRATION FORM WITH YOUR CHEQUE TO: UK Flight Safety Committee, Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey, GU24 8HX Tel No: +44 (0) 1276 855193 Fax No: +44 (0) 1276 855195 e-mail: [email protected] Confirmation of your registration will be faxed to you on receipt of your Registration Form and payment 25 Visit our website to find out more about our range of services... design & artwork scanning imaging pre-press web design litho printing digital printing print finishing promotional gifts Woking Print & Publicity Ltd • The Print Works • St Johns Lye • St Johns • Woking • Surrey • GU21 1RS Telephone: 01483 884884 • Fax: 01483 884880 • ISDN: 01483 598501 • Email: [email protected] • Web: www.wokingprint.com