t .

J~`J "rrJJ~ J~~ W- Countdown - Ta-Disaster ~ Blast From The Past W- Ejection . ~ Best of the Rest w- To Intervene or Not To Intervene? The Copilot's Catch 22 De-Deicing -,."Iw w1= , - Canada `l; Table of Contents r~' r~~ JlJ r Editorial , From the Editor 1 ...... ,. . ..., .,. . ., .. ..,...... Frctt» thr Eciltor ~J~ ~ ~tt~ ~IJ-r havc been attempting to ascribe a theme to each issue oi Flight Comment . Hopefully the linkagr amongst the lead articles will generate discussion and 2 . ..,..., ...... , ...... ,.,. .. ., ., Countdown ~1'o Disaste_r Directorate of Flight Safety Bar to Distinguished perhaps encourage you to do ftuther reading. 7'he theme of this issue is 4 ....,...... _...... As 1 ~ee It! Diredor of Flight Safety conuttunicalic~n . _ _--- -- __ Col M. Legault 5 ...... De-Deicing Service Order Editor For people that live in the so-called information age we do a very poor job of CollishawD .S,O., O.B .E ., D.S .C., D.F.C., Raymond Lt. Capt.1 .S . Medves communicatinl;. Aerhaps some of our comrnunication problems are simply 6 ...... ,...... Blast From The Past (T.Maj .) RAF21 Sept 1918 Art Diredion the result of having lo try to proeess the huge amount of inforntation we are 7 . . .., ...... C)SH Answerti. .. FPFE c_tn the ~'V'1:f3! DGPA-Creative Services-98C5-0015 qt exposed to each and every day. Although 1 tend to believe that while we have ,~ brillianl syuadron Icader of exccptional daring, tvho . Photographic Support becorne experts in sending the message, we still remain sadly lacking in lislen- 8 . .. ., ...... Fjc~tron ha~ destroyed 51 enemv machine~ . Early one morning CF Photo Unit-Rockdiffe ing abilities. Fog Horn Leghorn i~ alive and wcll. he, ~s~ith another p ilot,~attacked an enemv aerodrome . Cpl K. Allan 10  ., . . . . _ .. . .,...... ,...... Eiest of the (Zt~sl ~I'he article "Countdown to Disaster" relates Seein b~ tltree ntachines hrou i,~ht out of a burnin J han ar Translation a tra~ic sienario svhere I~tck o1 Coordinator communication leads to a mid-air collision . Cuuld soniething similar happen 15 ., ...... 'Io Intervene or Ncrt 'l~t Intervene? he dived tive times, tirin~ bursts at these from a very and drol r i~rng Official Languages here? You betcha. lf ,you can read this article and don't find yoursrlf 5hakin~ "1'he Copilot's Catch 2? Iow alliludc, E l ombs on the Ir~ rng quar- ters. He then saw an enemy aeroplane descending over Printer your head anci thinkin~ back to sume "what are we doin~ here?" missinn Y ou Tri-co are either verv luiky or blissfully unaware . 25 ......  ...... Could this be you? thr acrodrornc ; he attackcd it and drove it down in Ottawa, Ontario tlames. Later, when returninl; from ~t reconnaissance 1'ou are on tire! A sintple statement you would think would he hard to miscon- of the d~rrnaged hangars, he was attacked by three The Canadian Forces strue. liut what ha l> }>ens when the ~()nlmrrrllCatllln It i ; no t ,~t c1dr~ c5~cd ~ c o rrcctly . Albatross scouts, ti,ho pursued hitu our lines, when to Fli ht Safet Ma azine A dehacle - and all the result uf imprrrisr communication. he turned ~3nd ~jtt~tcked one, ti~~hich fell out of control 9 Y g Departments ,rncl ~r~~shed . " flight Comment is produced 4 times a Communicating with outside agencies are not the only hroblems we encountcr. year by the Directorate of Flight Safety . Have you ever on 22 ...... ...... , . ...., .. .., ., .. ..,. ...., hrorn the Investil;ator The contents do not necessarily refled heen the flight deck when everyone is talking, hut no one is . official policy and unless otherwise listening? Ur the self-induced sterile cockhit where nc~ one is talkin~ or listenin~? 26 ...... For hiUletitiron~111Sn1 stated should not be construed as Scarv stutt: The article "To intervene or not lo intervene? The copilot's ( :atch ?2" regulations, orders or directives . offer~ esrellent advise on ho~~~ critical intormation shnrrld be conunuui~ated on the tlight deck and the article "l~oth starboard engines have gone!" shows Contributions, comments and criticism ,j fir .~l-ralr practical dentonstration of communicative skills in truly trying are welcome; the promotion of flight circumstances safety is best served by disseminating . ideas and on-the-job experience. Send LaStly there is non-verbal commtrnication . We,end nc~n-verbal submissions to : communication ATr: all the time (childrC:n are masters of the lorn~ i . 'l'he te~hnician who didn't pull Editor, Flight Comment the chocks on lhe I lercules tvas really telling the aircrew "regardless of what On the Cover Directorate of Flight Safety vott want to do, l am not r;oin~ to let vou kill vourselves." 1 don't think he could NDHQ1Chief of the Air Staff have found a ntore rllrctive svav to communicate his ntes.,a7eF, . ln Sopwith triplane N 5492 "Black Mana" of No 10 Syuadron RNAS piloted by Flight , Major-General George R. Pearkes Bldg . this case sc~meone was listening. Commander Raymnnd Collishaw on 27 June 1917 . On this date Fl~yht Commander Ottawa, Ontario K1A OK2 Karl Allrnenroder, victory ace of Jasta 1 Colhshaw shot down and killed Lieutenant a thirty 1 Telephone: (613) 995-7495 We do tend to listen better when the message is one we FAX: (613) 992-5187 ~tianl to hcar. ()ne message I received at the flight s,tfety Other B Fllght trip)anes and Canadian pilots, were : E~mail: ac912~issc.debbs .ndhq.dnd .ca conference was to pluck the l)F5 saf~tv bird . Flic)ht Sub-Lieutenant Nash in N 5376 "Black Shee " _ p ~~5 1 h~iVe neVer bi:fll a tall llt llul' luran n1~1S- Flight Sub-Lieutenant Ried in N 5483 "Black Roger" Subscription orders cot I am mcrre than hapf~y to listen, liuzz R. Fliyht Sub-Lieutenant Alezander ~n N 5487 "Black Prince" should be directed to : S,rle h~rs gone to the big Flight Sub-Lieutenant Sharman in N 6307 "Black Death" Publishing Centre, CCG, u1LI1IGV5~. Ottawa, Ont. K 1 A OS9 roost in the sky. ~ 4w,llm,e 7r Olwt " Bln,i Fm~ il~. N.a Raymond Collishaw was arguably the greatest air leader Canada has ever produced . Telephone: (613) 956-4800 " Ykrnrn ~ . currfirrrrerl orr pra~le 4 ~ IkrtollkW~ .v He was the most successtul fiyhter pilot of lhe Royal Naval A~r Service and h~s mspired Annual subscription rate : r (olnlnnur,~ .\'q'f Inb .rM n,-aM4r ; iarA u leadership made the "Black" Flight of No. 10 Squadron RNAS one of the most admired for Canada, S19.95, single issue 55 .50; .~c tka~ . for other countries, 519.95 US ., ('a nn~Li and feared units on the Western front . Raymond Collishaw later saw service in Russia single issue $5.50 U5 . Prices do not during the Bolshevik revolut~on and ~n North Africa dunng World War Two . He reached indude GST. Payment should be made the rank of Air Vice-Marshal and was made a Companion of the Order of the Bath . to Receiver General for Canada . This Additionally he received the Distinguished Service Order twice, the Distinguished Service Publication or its contents may not Cross, the DisUnguished Flyng Cross, as well as both military and civil grades of the be reproduced without the editor's approval . Order of the Brltish Emp~re . The citation for his Bar to the Distrngu~shed Service Order is printed above . 155N 0015-3702 Painting by Mr. Roy Ahopelto A-15-000-0061JP-000 The target arca was Firc Support Base Barbar,a, a gun Black Une's right-hand loadrnaster saw this meant thev emplacernent in the arttty's liigh Kange training area were headin g for Black Two. He called Hal es ba~k~ - ~ I eft vv hrlc,' ~ suuthwest afTotvnsville. on Black Two, Burke was told by his lelt-hand loadmaster : "He's turning right come right:' But Black Two's right-hand Countdown To Disaster No aerial maps were provided at the brieting. No recunnais- loadmaster saw the danger uf hitting Black Three: "We can't . sance had been done bv the pilots. The only map was one hlil 11'ir~ 1~1E' ('lr(d111 0~' h~ move right:' The formation was still off track. dravvn by the SAS, mainly to guide the ground assault c~r,enrs rhar leci 1~4 svl- + 1~ . troops. It was put up on a whiteboard and it was wrong - it The target was difficult to see, not only hecause it flat on c1i~~rs ra thc~ir ilrath> ur~ ., as / de ~icted a nonexistent un em ~lacemcnt to the northwest the ground but because the atierglow the l:~~r~~ I' ;'ci`ryfrar, irrAu;trctliu :~ ti 1~ 1 S 1 sunset meant target of the point ~i here, Hales's helicopter, Black C)ne, was to area was in shadow and u~or:ct rrrilitary c~i`a>ter cirree tlre not visible with the night goggles. r~ drop its troops. G'a~~n< the crew cuuld not yet see the targets meant loadmasters a~unterterrorist exercise . t pstairs otf luaded its troohs without ,t problcm. who ought to have been ensuring the hclicopters ivere in thc '1'ownsville ~armv building, properly separated had their attention diverted. 5peci,~l Air Service Regiment Later the SAS and the aviators disiussed the operation soldiers gathered in private to again, separately. The SAS ~,~anted important changes: that A few htrrldfed metres from the targct, the gun positions plan the next dav's miatiion, a the two helicopters providing tire support be released from that detined the drap ~ones emerged frorn the gloom and a , '  . rescue of ` hosta~cs rnvolvin g six the forrnation ertrly, and that thc sound and visibility of all third right turn was made by Black Une . (At least, that is hcli~o l~ters and live ammunition. the Blaik Hawks be reduced. accordtng to the board, whrch drscounted evtdence trom I)ownstairs> appctrcntly excluded ihe pilot of Bl;~ik Four, immcdiately behind, who believed At the rneeting of air irew, thc pilot uf Black Two, Captain In lhe n~rnle Ut~ Seiur'ltv, i17P ,tll' Black Two turned leh into Black One .l cretvs rvho tvould have to llv the David Burke, suggested to Hales that he had drupped his troo ~s at the wron ~oint. l ti~1ti irntnlerterrorist troo ~s to the 1 gl lalcs disa g reed, but the p air The evidence suggests this fatal last turn by Black One was 1 a arentlv resolved the issue tarf;et held their cwvn meetinu~ . pp bv, ar~;reein K thev; would both due to Hales's confusion about where he was to drop his go to exactl,y the sarne points in the night mission. Hales troops. He had approachcd Irum a different direction than hverv' so olten, whenever com- also su gg ested thev tlv a new route , u 1~ a vallev , to mask thc during the day. ln these circumstanies, the board believed, hined 1~lannin J was ialled for, aircraft's a ll> >roach . Hales's su F~erior ~ hla'or) (:hristo 1~her he mlght have needed to rely un his mental image of the ofliiers lroru bolh uruts took to the stairs . It was the would Icad thc flight . '1'he pair werr ,rlready larniliar - Hales )ameson, says he responded: "(;et f ,., ed . That's crazy mate, inaccurate whiteboard map. evening of lune 1 l, l~)~~(~, and the tirst dav of Dav Kutor 96, hacl heen copilot tu Bellis, himself a former army Black it would ictke a ntonth , . .- to praitise, lUe'll do it exactlv as tve alr,tn rc,t rtl c~xer~is ~ e dc,r ~ ned te maintain ihe,A. . ca 1 abrlr I-lawk helicupter pilut, in previuu~ c~xer~ises. did this atternoon:' "ft seems Gkelv that Captain Hales, convinced this was not ties tcn~ a helicopter-hornc counterterrorist strikr . the gun emhlacernent of hi; rig point, turned right and The mission of f unc 12 was to rescue hosta~es taken by But they didn't: the (light was lowcr and slightly, but cru- tracked towards the rig point of t3l~jck'I'wo," the board found. "~1'his vv~ts the lirsl oicasion on which detailed ic~mbined "tcrrorists':'Iwo runs tiverc planned - one in daylight and cially, otf the path taken by day The six Black Hawks took Une of Bttrke's crew in Black Two at plannin~ tuok place," noted the Bl~tck llawk hoard ol une at night. Accor-dint; to the hoard, it was probably that otf at about 6.30pnt . 'There was no moon, little wind and shouted hlnl to move . inyrnr~~ report released this week. "Albeit, rnuch of it was evening, up or da`vn lhe stairs, th ;tt liales learned the SAS the rem,jins of the sunset glowed on the hurizon, The aews u 1~ Burke didn't kn ow wh et 1te r Black thrcc~ ~ `v~ as still besidc - was , nut faie-to-f~ce :' woulcl like the Rlack F{avvks ta assault in a formation that wore night-~~ision goggles. At a point about 1 l km from the him it not - so didn t that way. Burke was trying to pul thrce Ira~l hcliioptrrs line ;tbreast - ihal i,, next to each target, ,~ three minute call was given . The helicopters began climh when Hales sought to avoid ;~ a~llision with a left- 'hhe irt uirv tried to ~iece to ether the kev t~~ctors that y , 1 g other and ~epar~3ted by no less th~~n tvvo rotur-widths . "contour tlight'; dipping and rising ovcr the ridges and bank that brought Black One's rotors smashin~ inro the led to the deaths of 123 solcliers vvhen two Blaik I lava~k valleys at abotrt 100 knots. tail of the other helicopter. hclicopters cullided at abc~ut h.~~pm on )une 1?, the dav I lales, a relativclv inexpcrienced pilot and new to the posi- the fi~llnwing those initial, separate mectings, tiun nt "tli ~ht lead'; app arentlv: aK reed to this p ro P usal . It '1'he route was north towards the target, with thc plan that Ea~lt of f'our roturs struck once and a tifth strike seems turned out to be a very b;td ideet, the three lectding E31ack Hawk. came in abreast. t'nusually for likely, according to the evidence of engineers who ex,tmined tieven soldiers, their names deleted from the public reprn~t, the wreckage.'I'he tirst passed through the fuel tank, the a flight leader Black One was on the left of the three instead tvere held accuuntable bv the inyuiry Five v~ ill fair action, The Perth-based SAS keeps its counter-terrorism syu;tc{ron other three struck the engine. of the middle, a posilion that made right-hand turns more three ol'them di~iiplinary (but not ir-iminal) char~es that un a high st;rge ol readiness. But the heliiupter crews cit prublematii. It was at ahuut this ~oint Ihe forrnatiun be an Blaik carr~~ posible jail ternts. Totimsville are also reyuircd i~rr uthcr ctrmv tasks and had 1 g Une w;ts qtuckly dcromed. Fuel from Blaik Two was trained liir Da Rotc~r onlv a few weeks hefore. The tltree- to go utt to the left of thc route it had used durint; the day. suiked over its engines, resulfinl; in a midair explosion ;and ) , . Yct the report does not appear to seek scapet;o~tts . lt argues abreast formation v~~as not 1 ra~tivrd. . . Most ol the p ilo ts n o h~cd,' - ~ hut n c~ c~ ne told Hales. tire. It rolled over and , at a luru _ 0 trmes that of gravity, the there were 16 separ~rtr hrintary links in a ihain ol event~ '1'hc next call w;ts the 30 secund ~all. It was the signal t~~r the aircratt 1~lummeted u P side down and ex1 ~loded on im l~act, that ntade the disaster inevitahle. T~,~entv six uther con- Thi~ Ic~rntation, es 1~eiiallv , when crews'vision is restricted Eleven men died. Hales . two Black 1 {awks with snipers to move off. But the call rtta,y wa5 arnong lhcm Incredibly, two trihuting faiturs, inclucling thc serious crosion ol ;tvi;rtion hy nit;ht-visiun gogglrs Iwhiih reduce field of vision to soldicrs survived an SAS trooper . have eonfused the crevvs hecause it was made at least a ;tnd a loadrttaster ~kills due tn unserviieable heliinhter ; and inadeyuate pay abuut one-tifth of normal) is inherently risky, a~iording to minute befurc thc tarKet would be reached . an~1 cunditiuns, ;tre also listrd. the bc~c~rd . The chan~rs ol suntrthing going wrong uncier (~n hoard Black Tvvo, Burke said something like: "l'm sorry guys, we're dead :' "Don't f . .. ing give up now," hre~,ure ,tre cc~n~ic{erable, especially when the middle Crew lookinK for the target at the 30 se~ond iall vvould have on us his So the bl ;tnle is s ~read wid~lv and over ~~ time tr.rnle ul left-hand loadmaster, Sergeant Bill or 1 . ;tiriratt h~r~ nc~ roc~m to m~rnoetn~re out of trouble. been unable to sre an}~thing yet - triggering, aicording to Mark, said thought . Sevtral 1''C~ll'ti . lillt lt w~IS UIl lUlle 11 th,tt Ih~ n1C~st Inlmtdl ;ltP Burke didn't . At IDam on lune 1?, all the air crew and SAS troops gath- expert witnesses, anxietv. l~roblem~ be ~an to emer ~~e ~nd the up stairs-downstairs ?~ 1ti'ith the tail seition in t, ttters, the helr~o'- ~ ~ l~ ~ an r r planning that cvcning is ~iled as one of the contributing ered for thc dav', bricling, `I'he phtn tvas that four ~roups Inside the helicopters the SAS troopers got ready to rope 1 tcr c g tc rc tate hoverin clockwise and was airborne for a turther tive to 10 ;ecunds, factor~ in the c{i~a;ter. uf SAS troo 1~s would ra 11> >el on ro 1~es from the dowm . Blaik One, tlown by Hales, Black Ttti~o, flotvn by Burke wanted to it upright the Blaik I lawks ~jnd att.tik the terrorrsts, using live ammuni- Rurke, and Black 'I'hree mo~~ed breast of each other in order keep because Bla~k 1 lawk was 11u~t ul thr iunt;tct that evenin T oicurred bett,~een Ca tain designed with p tion. Thev wnuld he backed bv SAS ~nipers in tt~~o c~ther to drop their troops a line . No move had yet been ntadc to substantial crash safetv features . tiean B~Ilis from the SAti and ~ ;aptain Krl~~in I lales oi ~th heli~c~ 1 ~ters anci mortar ~u Il> >ort . correct the tlight path . Blaik One madc the tirst of three ;w i~rtion regiment, a rel.ltively inexperienced ufticer who c'orrtiiruc~d orr pct~~~e 5 rnoves to the right at about the 30second call, tollowed by a second shortlv atter. 2 Flight Comment No. 3, 1998 Fliqht Comment No, 3, 1998 3 " "

Capt John T. Park C130 Pilot Yokota AB, Japan

As I See It! e cr1l ~ot out and starteri lookirrg at t{re aircrcr/t we of soapy water. ltZistakenlv,, this washing soLution was early of my tenure as Chiet of the Air n these days lr~ac~ jusi ihnrorc byThl ~ deicecl. lt laokerl like n bi thought to be deice fluid. TA tilled it up the rest of the Staff, I am pleased to have the opportunity to write buuc~t c'ake rvith w)ritish icin~~P orarec~ ull over it, truck with real deicer.l'Ue got the truck with the 5015U an As 1 See It column for our Flight Comment streaks rrrnnirt~kT dotvrr the ;idcs. Icicle; hrcrrg ct/f~~rops nfrd soapy water and deicing tluid!

magazine . 'I'he editor has informed me the theme of ~t' (~,~ wiu V ti ! s. ~I'ow! this issue is effective commtmication. There is more Atter deicing the tail section, the engineer came intu lhe than a little serendipity at work here, as I believe that This story touk place in November 1994. It represents aircraft and closed the crew entrance door to prevent and inherent risks that military and civilian deicer from getting in the aircraft . As bulldozers continued productive and successful communicalion is the thc challertges when with runway, monitored the last keystone ot any safety prugramme . aviation must face dealing deicing aircraft . ln to remove snow frorrt the he recent years, aircrah mishaps, both minor and major, of the deicing from the center escape hatch. lt was naw nur tli ght salelv.P ro gramme em P hasizes o P en and have made the aviation communitv hopefully more vigi- dark. The Snuw was still falling heavily as we prepared for honest occurrence reporting and the dissemutation of lant aboul deicin g! ~rocedures and ol ~erations in winter engine start. We had a full cargo load and a snow covered that information as its primary preventive tool . Factual, precipitati~n. As parts of the Urtited States achieve record rumvay. w5th the KCK, the engineer ligured critical lield trmely, ~ar td frank communication , coup led with the snowfalls this year, a stor,y about my own first winter length at 7,000 feet Over 1,0011 feet to spare beyond the conscientious efforts of all our Etersonnel, contributed weather o l~eration comes to mind. actual runwav, len g th No P roblcm. As we cuntinued with to our lowest ever accident rate in 1997. ( am always the before-starting-engines checklist, the loadmaster (out- I was a copilot stationed at Yokota AB, Japan, anci this trlled wrth prrde whcn I read the crtatrons of the side the airplane ) rcported that the airman uut there with particular ntrssron was tlown mto Ivlrsawa AI3 about 13 recipients of (~ood Show and For Professionalism him refused to pull chocks. huurs into our crew duty day. t'nlike Yokota, Misawa is awards. The outstandtng efforts of our personnel are My message to you about safety is simple - nathing is blessed with snow and ice much earlier in the year. On this The pilot asked, "What's lhe prublem?" clearly curtununrcated, yet barrrers to succcssiul conunu- more important than safety in a peacetime environntent . particular clay, our tirst two stops were in fair weather, but nication remain. Those barriers can utclude imprecise "He says he won't pull the chctcks because there is ice on Nothing! How can the primacy of safety he reconc%led htisawa reported low visibility due to blowing snow and language, unwarranted or non-existent cmphasis, the planc:' with the oal af successful mission accom ~lishment? snow shuwers . This was its first ma~or snow tall of the personal or corporate agendas, iilcontplete or inaccurate g l Easily.'vllhile our aim is to "do the job; the job cannot st~t5(trt . "l~'hat ice is he talking ahout?" inytrired the pilot. inforniation, inappmpriate tone, and lack of understanding . be dnne when our personnel are injured or killed and 1ti'ltile much ctf our daily cuntmunication is innocuous, Our crew rechecked the weather immediately before tak- "'1'he ice on thr side ol lhe airplane," said the loadmaster. our eytripment is damaged or destroyed. a~itical flight safety inFormation must be transmitted in ing off and once again en route.l'hr snow was sti11 coming As they carried ctn this conversation, I looked back at the a clear and timely matter. '1'he P.A.C.E . ntodel, explained I see the air force as a pruud team tltat accomplishes down, but the visibility had improved to about 1 .5 rtltl . No, 4 prop and could see iucles hanging off the blades ftrrther in this issue, is an excellent example. Should you its missions professionally. Strong individual leadersltip The landing was likc something ollt of a simulator mis- against the hacklighting of the ramp lights . in a situation that reduires an emergen~y find yourself at all levels will foster safe, gralifying and productive sion. We broke out of the weather on the II,S about 1,500 don't hesitate to give it - you oftcn have only "Pilot, there are icicles on the props! Something ain't warning, carcers for our people. To achieve these guals,l reyuire AGL and had clear visibility below the clouds, but every- had better use it at right!" I said with a slight wavering in my voice. une`silver bullet'to shoot and You your total and honest rummitment to our safety pro- thing was white. I had to crosscheek that I was on the in non-time-critical situations, the right time. Conversely, grarnme. As I see it. " localizer course. . . lhe runway shuuld be straight ahead . We all got out and started looking at the aircraft we had ert~phasis can cause a loss of excessive and inappropriate About 2 miles out, we picked up the "rabhit" and looked just thoroughly deiccd . lt looked like a big bundt cake credibility and result in a really critical message being the outline of the runway lights.'vVe had apparently rnade vvith whitish icing pouring all over it, streaks running message Lieutenant-General D.N. Kinsman ignored. To properly cummunicate your safety uur approach between snow showers, The next one was at down the sidcs . lcicles hunr; oi'f p ro F~s and wing ti 1~s . Wow! delivered at the correct time, in lhe ~orrect it must be Chief of the Air Staff the west end of the field and headed our way This was Something was really messed up! The engineer, pilot, and I in the correct medium. forrn and my lirst lancling on about 4 inches of newfallen snow. As got real quiet for a minute as we at eaclt c~ther with wide advertised, the snow was blowing around quite a bit as eyes.lNe all suddenly realised that the young airman who the C130 slowed below 70 knots in full reverse power. An mfused lu pull chocks had probably just saved our lives. . uneventful, vet memorable landing! ~,~rrtir~r~~~~ 1i~~,rrr ~t Je r 1 could just picture us starting engines and taxing out into ~rom t e itor r~ tlpon engine shutdown, thr snow started a heavy fa11 the darkness.'I'he sheet of ice on the tlight controls would give way to 3,000 psi of hydraulic pressure, and we would I huhe vrru enjuy thr crwer pcrinting of the tiuptti~ith almost passea uut altugctlter, In i>rdc:r to tind oul what a g ain . Atter unloadin ga nd loadin g carg o fnr ? hours , th e never sus ~ect a thin . As we rolled down the runwa ~, tirl lane. Thcr~~ ~ 'tir, a ceter d ~~ncv fc~r ~co,le tc~ think of (:rreat was happening Lt lc~nes askecl mc tu llv al as high a speed snow had accumulated yuite a bit on the top of the l lerc. 1 g } 1 1 acceleration would be normal.l3ut when I said "Go" and titi'ar aircraft as hcing slructrrrally weak; nolhing could be a; hc~ssihle over a hut in which «~as a iamera uh~cur,~, t,- rc~ The engineer called for a deice truck. And this is where it the tilot ~ulled back on the voke nothin from that ~oint f~trthrr from the truth . Sir ~ernun lirown is yuoted from ieciing an image on tu a tahlr. A~ thr aeruplane, Sop~,~ifh gets real interesting. Iie did an excellent job uf direct to I (" , ~ g 1 i - , ~ ' ,, , on would be as predicted. With all uur lifting surlaces ~ov- "The fighting'1'ripl,rnes" by Fv,tn Hadinl;harn, 1~ ?~30, 11etiv uvc~r lhc lol its im,rt,t >1as shc tvn thrc ul, t in g the transient, alert (TA1 p ersonnel on thorou gYhl lh~ lens on to the h,~her, ~md, b~~ mcans of a metrc~ncmte, deicing the aircraft . The problent was not where they ered tivith a layer of ice, plus the eatra weight, l started to `llne of the things we di~l not Ullderstanct was that as wondcr how many knots above our charted take-uff ~peed he was able to pcunt it everv second as 1 made ~ircles . were spraying the p lane, but with what . the aircraft gut l;t~ter and fa~ter, so we cxperien~ed some we would need to limp into the air. Would be able clear At t ert~iards it was a sim 1~le calculatiun tu find out what As ntentioned earlier, this was the tirst major snowfall for rathrr ~~xtraurdinarv ellccts, It we Ilew t~~st and then did the hills at the end of thc runway or makr the minimum g had hecn apl,lud, . . h~lisawa that . a tit;ht turn, or, (i~r instance, iiived an ainralt and then vear Une uf T,q's trucks was full of deice tluid> climb gr~idients? Wltat if we lost an engine after take-oft? and the other had pulled it ovc~r in too tight a loc~p, a sort ot haziness crept `Lt )c~nes t~~und hv repcatrd cxpcrintent that 1 could hold been used for washing an aircraft several days earlier. Well, this wash truck was still half full up over onr's r~~ec, rither like a mist; and there wtre occa ~.5 g for l0,rcon~i,, and that I cc~ul~l hulcl (~ r; tor contirrued orr page 15 sions if vou, htld thc ti ~~ht turn ti~r too lun,;; wherr ,vou ~}-5 secortds . "

4 Flight Comment No, 3, 1998 Flight Comment No. 3, 1998 5 meamti~hile and he t1oated back to earth, landing in front of lhr beruused ctmbulance and tire crews who were rushing to the assistance Blast From The Past of Tonv Davies .llon y ~ recovered ftrllv, You are on flre! the nose ot the tank along the western boundarv and pancaked rn from his nastv, in'urvl . ground, the noisr of this being over- the 1~lou ghed field o I'1' osite with t}te OSHAnswers .. , ,a~c~rcise Vi~ilnrtt resrclted in an come by that of the engines. The Hunter's tail overhanging the grass Number Three urrpreudertted series o~events on rough surface of the taxiway quickly vcrge. Fortunatelv there was no traf- ~~1crv?ith wherr 3 aircra/t were wore a hole in thc tt~nk, there were tic about at the tirne! The station's The Javelin pilot watched all this involvc~cl irr sericirrs nccidents in the sparks and the firel caught tire but emergency crews roared off towards going on, saw red Very tlares being FREE on the caurse or f0 rrrirrutes. Jn 1955 f3oz fired and people iumping up and mercifully did not explode. '1'hc the incident althou gh thankfullv, kn(~insorr x~c~.~ n yotrrtg Flig{tt 1 ietrtertartt lavelin continued to taxi trailing Davies escaped unscathed. down gesticulating madly but still serr~irrQ ai Hors{r~~m St Faith, '1'o ihis t1

Flight Comment No. 3, 1998 7 6 Fli 9 ht Comment No. 3, 1998 - " I I I I

I I I I I

Heard ul compressiott Iractures? ~l his is when they occur. The t~ront portion of your vertebr~t are squeezed together bv the unnatural benilin~ of your hack and some receive hairline frcrctures, Don't believe it? ~ti'e have had several cases of~ the top ot flving heltnets being dantaged by tht~ sr~t pan asscmbly!

Snap! The paraihute pull~ yeru rle,tr ol lhe seat. [f the WHAT CAN GO WRONG? ~r,tt h~i, heen tumhlin~ Iwhich is more likelv ifvou, e'ectI What Y our mother never told Y ou durin~ a rullin~ manoeuvre or s } ~in 1 then there mav, he Pins? ~1Vtiru 1)evple rrr tlre hrst?y yelirs lrcat'e drecl (leiarr

8 Flight Comment No . 3, 1998 Flight Comment No . 3, 1998 9 rnountain waves. 'Lhe were all wearing ,tircraft qtuckly ralled through rnore our full tivc~ l,oint h~trncsscs, with than 4~ degrees in heavv buffet (an aur seats raised up and forwards to angle one ~a~ctuld never appro~tch in such see outside.'I'he Captain reduced an aircrali, let alone in the vacuum-thin speed to .78 A1ach becattae ol the air ctt e~treme altitude). turbulence and, as nld autopilots are prone to dropping out from time tct Quicklv refocusing on his artificial time, he had his hands on the control horizon , 1~lartin could hardlv, believe his eyes as he saw the b;~nk rapidly wheel to intervene immediatelv if increase ~ast ~~ dr rees, Thinkin ~ the Rest that happened or in case the autopi- I g c his gvro . lot couldn't cope :' must have toppled lrom ;r major electri~al failure, he immediatelv Here 1 should mention that the 707's looked across at the battcrv-.P owered single 19:~Os technology autopilot standbv instrument, hut that con- h;rs limited abilities, even w-hen tirnted/the aircrait's P crilous attitude. maintained to perfection . ~1lthough At the same time, with lightning su lI> >osedlv, ca P able of holdin g head- retlexes Ca l~tain Ber gelund disen- ing and height, tracking a VOR radial ~a ~ed the auto I~ilot, and held full left and following an ILS it does none ,tileron and rudder to try to get the of these thin~s with ntodern di g ital stricken freighter back to an even kerl. precision, and frequently r~~akes hi er cuntrol in ~uts lhan 18,000 707 hc~ur5 . All three ~~~ere verv onwards as the available loads dictated. gg l "Both starboard en 9 ines une wetuld hope for. The ex ~erienied in 'i'hird lUorld lonc;- I)espite their earlier trihulations, the l manut~ttturer's proud hoast have 9 one!" h~tul air c~lrgo c~perrltions, ;tnd dtrrin~ crew m;tnaged tc+ push-back on was that tt could apply auto- he carlv; morning Alt~ine cloud lhe Past t~~rtnight they haJ circum- schedule at Oi(Ill l'T(;. matic up elevator in turns! vvas t;rey and buntP)~ a; the navigated Alrtia srveral times. The 707's maximum takeoff weight hcavv l~oeing 7t17 struggled for ln ;m attempt to get ahove A lclng-haul charter pilot's litc is is 1 ~ l tons. ~\iih ~9 tcrns of fucl in altituclt. Laden with luel and n~ining the turbulent cloud lacer, never easy bul sonte davs can he its tanks, 5N-~1AS weighed all ctf that equipment, lhe freighters multinational taxied past and one toc~k a photo- r\1~trtin reyuested Flight uvc,rse than ctthers . hiartin deseribes as its four high-hours hut rcliallle crew wa,~ ;m~ic~trs to ~lintb out of the graph : He later told Ivlartin "Yott Level ~ 30. The airi,rctft the start af 31s1 ~`,1ar~h ly9? a~ IT3I)313 turbcrlans gradually acceler turhulence and into the clear blue skv used every inch o1 that runway on was rrally a little hea~y tc~ "Rloody awful:' lt began with a ~lam ated it alcln g I,uxemhour g 's ~I,()00 thev, cuuld ~,~~lim l?se ~~bove 33,0(-)0 feet. takeoff: The aero ~lane brcame achieve this altitude immcdi- wake-up aiter ;~ brief rest at a sm ;tll, metre Rtmwa '~. (~enerally reckctned I tiuddrnlti~, with a loud dc~uhle repcrrt Y .rirbornc at 071 Sz. atelv, bul the crrw hnped tc~ a~ld out-of-tc~t~'n pensiun (having to have been draw'n bv VC-1 0 the aira-att rolled hard ril;ht . make ~ gentle cruise-climb to heen displared hy a conference frc~m rivallin ~ salcsrnen the 707's takec~Ff ~Taking usc° of a runway~-end valley g get out ol the increasinglti' Strrartuns; fuel, the stricken airliner the airport hotel the previous dayl pertc~rmanie charts were alwavs opti- to accelerate, the crew retracted the t rctugh cloud, f A new 707 ~,~as started its tinal desccnt. ln the cock- and a long laxi drive in the' d;trk mistic, hlost c~f us tamiliar with the E3oeing's tlahs, Their smoke-tr~tiling only cvcr stresscd to +?.5 and -1 (T) . The tlight deck was .t ~acophony crl pit, the cc~pilot' .~ mind tlg > heside nte and ccmccn- ,everal times tct silence the tir~ hc~ll ltirere thcv up cc~ it? b1'ithin half ;tn sctme Engli~h cunstruction wc~rkers unrestricted to ~light Level ?90 . ,t treiC;hter and owmcd bv a successic~n . -  , , ,, lratecl on luokint; out ti~r a hreak in by hressing the cancel huttcm cm the h~tur thcy Gvould know. .. litlrng Ihc nc~~' utntrol tcnticr s cuI c la . Using their ttti'in l)ntega I~tng-range ol ntainlv Brili~h freight comhaties the clouds. As thev slowlv sla ~rrecl glareshield, hut tc, no eifecl,lti~arning Theti~ vv~aved tu lhr ~revv a~ the t3ueing navig~ttion sets, the ircuv srl cc,urse g~ I'he highly experienced crew had who used it predominantlv tor high- ctn u t ~ l ,ast 3',300~teet, the ?-,~rev : ;kti ~ lights illuntinatcd anel tlashed . (wer totvards the distant ~'()R besiile uvorked togrthcr lor just two weeks. weight, long-ciist ;rnce tlit;hts acrc,ss ahcwc gradually be~ame lighter, with thc hell's din a ~trident horn bcgan picluresque Lake Geneva . C;aplain Ingemar Bergelund, ~t Swede the North Allantic as (_~-Bl~'Lf ancj n~r~tsional glimpses of hlue, sct thev signalling inrrra~ing cahlr1 altitude in his mid Gllies, had Ictggcd ? ~,000 (;-tiNGH . The ~tircraft had recentlv Nearly an h~ur later, as thev ~russed kne"' thev were nearlv clear. ;tnd dtivindlin t,~ lif'e-su llc, > >r tt'n l,ct}gcn~ r ~ , , hc~urs on many airliners, including a been ai:c uircd bv the hano-re Tistered the Swiss horder, for the irevv', ltul ~s. 1 . g thev had reachrd '1'hc atnber light and tone of the decade or more un 7117s. } G; ~t ~ vcar- Nigerian ~omp~lm' Tr;tns-Air Lld fi~r I'L290 and achieved a cruise s ~eed ~~f l altrtude ;tlerter had lust indicated The aerc~plane was descending f,tst, c~ld Ent;lish fir,t oFlicer ~lartin Emcrv an African charler frei ;;ht opcr;~tiitn i~9ach .80 acrr 300 knots IASI as lhev- - 700 fcet to levrl-otl when suddenly, slipping down hall sidcways on the had prrvicrusl,y 1i~llowed hrief careers hased in I.u~enthr~urti . Its planned turncd south, on track tirr ;~1artit;ues . shaking itself lik~~ a wet dng, the ragged edge c~f ~antrol, and perilously as air tratfic controllcr and tlving flight that dav ;ts ~NI~ (,71 was frnm (h~IT(;) 1`1;trtin describes the ride as hig jet staggerrd undcr thc ncar- clo ;e to a'ji't-upset' when its increas- instructur, and had amassed ~16, ;00 I u~emhuurl; rct I~~os (Nigcria) wit]t they appmaihed the 111ps as "Rough stmultaneous du~l h~immer hlc~uvs ing ~\lach numher wc~uld rapidly hc~urs, morc than hall of them ~tn hig a htll load uf nearlv tc~rtv lc~ns ot as hell in verv dark stratiforrtl cloud . c~1 two deep, dull, ntull led thuds. render the manu,tllv-pcnver~d con- jet tranahc~rts, including 4,500 on petromining cyuipment lor I~sso, Althctugh it tivas turbulent, we saw As these twin trenutrs resc~unded trols immuvahle even under the t}vo 7117,. Fli ;;ht enginrer Terr~' Rc~on~, thrn on tc~ Accra I(-~hanal, B;tmako nothing on our radar; f think the through the entire air(rame, the hilots' amtbined elforty, stl ;u ,l l3rit in his earlv fihies, had over Ine~tr Timhuktou in t\lalil, and bumps m«st h:lve b~~n ~uuscd bv

10 Flight Comment No. 3, 1998 - Flight Comment No. 3, 1998 11 This realization gave Tvlartin a horri- dearance over the Alps, and were However the two-engine landing Atter a te4v seconds turmoll the ble feeling ol deja vu lor, as a young able to steer visually around the checklist requires an additional t and an uncompre- a turn hut, between gasps tor breath, would ~oan find out vvith .~ horritied altltulie wirtd hlowing, lrum thcir righl uar- ~um }t anti clcctrics. l(~nly cl 707's requcsting the 1171rllmlUn S:lte hending air traftic control, thev were the captain replied that he couldn't was that they had lotit both l ter. The 707 s maxlmum landing shock, inboard engines havc hvdraulic (119tiA1 in thrir ~rrea and radar vectors likcly tn perish w~ithout anvbody ever do it; in tact he could no longer even right engines. That is, they had weight is l 1? tons, hut at this time their l~ t tm p s , and number three's t,Jenerator to, a landing . ~1TC aid not seem to knowing why. Sn he pulled out his keep straight . But if he did not turn robbed of thesr ;~S would still have weighed about not ju~t been normallr~ supplies power to the essen- understand the ~eriousness ol their camera and took a photograph of now they wottld all be buried in the enr;incs' [hrust, which woulci have 13; tons, lor which the entergency tial busbar for the (~a p tain's E~rinl~trv , plight, ctnd kept asking for their the damaged right wing. good earth of Provence, and the h, but [hev had Vref lthreshold speedl is Iti0 knots. been hazardous enou g instruments) . position, ~omeihing Alartin hoped exhau~ted captain seemed to be los- povvcr-plant~, pods, At 2?,000 feet they popprd t?sing the normal half-headwind shed the entire to get ti~um thcm, He esplained their uut of ing directional control, so 1lartin struts and all. \1'ith thrm Each crew member was fullv o~cupie~t cloud to see snowcapped peaks all incremcnt Iwith a minimum uf eight suhporting structural 1~rohlem and declared reachee} across and throttled back the gorte ttivo of their four electrical with his owm tasks, `fhe Cahtain tvas ., around, and a further cloud lavrr knotsl they should ha~c al l roached. . - had 'lirltited manoeuvrmg but still got two live engines. .~s the induced vaw one ot the two main working physiwllv very hard, wre~tling below, Fortunatelv thrv still had on lour engines at 158 knots . generators, no useful responsc . swung the arrcral[ rnto a lclt bank, he

Flight Comment No. 3, 1998 13 12 Flight Comment No, 3, 1998 ------reestablishcd nearlv tull power on the rudder and tttade small adjustment ;, anti-skid and spin-up protections it is had to jurllp from the main entr~' inboard l°ngine and opened up lhe while Alartin nlodulated the power, not surprising that, even using caretul door because its slide did not intlate. outhuard as much as he dared, to retaining as much as po5sible on the short `squirts', he eventuallv burst some As he hit the grounli M~irtin shouted t'rSLUr~ tiUllte ~OUtC01 . inboard rngine to keep them ~loft . af th~ l~~res, but tlol briure their speed to his collea tes "Cume on 'y ~ou lot, To Intervene or Thev dared not reduce airspced ti'a~ ~C~Itltll g llnlleC ~Ontr01. bloodv well run!" and stumbled for- Bllt nolv thell' ln~l'e~t5ed detiCellt Cate, below ?00 knots for fear ol losin~ tti~ard to get atvav, trom the wreck. Captain Bergelund perfnrmed a per- with onlv linlited thrusl lo offset the dircctional control, ti'et they had Looking back, he desa'ibed the fect landing and kcpt straight as ~tn drag of th~ l~tnliing gear, m~tde sn 1Gstral tailwind . I'1'h~ Ilaming hulk as louking like the Torrev Not To Intervene? thirtv knuts of into-wind ,t > >roa~h seem im ossible. ~trro~~ despite the lack ot both ll P maximum P crmissiblr laihti~ind for Canvon , and was deli g hted to see his ~ But even svorse ~sas to ~onte for, as hydraulic nose-svheel stecring and ldtllllng a iU/ Is ten k110t5 .1 cou g~hin g fellaw crew memhers sta?,h J 7er slowed to exiend the~ fl~p~ by differ~ntial braking but, with a tail- thev from the roilin g black srnoke like lohn The Copilot's their etnert;encv eleitrical svstcm,, Landing with only psrtial flap at svind, it w~ts inevitable that thev ltiavnr gunslingers emerging trom the there w~as an ex 1~losiott . Fuel esca 1tin ?~7 I ~0 tons and well over ?UO krlots would eventually lose airectional embers ot the ()1\ Curral. lront the ruptured tank; and line, in (on wlteels anci tuldercarriage stressed conlrol as s 1~eed reciuced . About the rit;ht s~°ing had bren ignited b~~ for clnlv l 1Z tons at l9~ kt~1 thcv three-quarters of the way along thc As they left, the fire service arri~-ed Catch bare rlertri~al ~~~ires protruding from t o t t~h l'd down 1'ust l ~ast the nunthers runway the No ? engine reverser to hose the airframe, tirst tvith tivater, Dr Robert 0. Besco (Capt AAL, Ret.) President, PPI (M00949) 111 3 hyl(111'S 1(lck~t . itlUtil ol lltl and slightly letl uf the centreline . inexorably pulled them off the lett then with loarn, "1'hanks to lheir right-side 11aps were bluwn ~ttivay i the 1~1artin later said "1 h~td never seen an side and, titi~ilh a wrv sruile, illartirl tintelv intervention the cargo was Introduction and Back 9 round airrraft liebris danlaging the elevaturl, the airport go hy su fa .~t!" Trving to, get reialls travellin~~ fast acro,s the i,Jrass saved~and the 5uffend littlc widely accepted cause of pilot error accidents in the last twentv years .,  . , , tcl stup thirtv metrcs shurt ol a large further dama e, ivin T the investi Tat- wing spars tivere seriousls disrupted, thrtr sl lld undcr ~c ntrc l, as theti' g g ¬~ ¬~ has been P oor Cock 1~it Resource Mana getnent (CR~i) . It has become ) ing team guod evidertre to work un, ~tnc i the ,tircratt a g ain he~Jan~ rollin g crossed the fence he relin a tushed the stecl L) C Iv~` 1 T PAtiS. TH IS P()ItiT la wcll-eslablished fact that the deficient and flawed attitude and > thrc> ttle h~~t ~-k No throttles to his c~tptain and grahbed si~n . A; thev ruckcd and slithered to rtl,ht. ~lartin had tc From tirst losing the engines to knrn~~ledge components of pilot perforruance have been a major prnblem in 1 ellglIle eti'eJl mol'e a5 the Cl)Illla~ra- li~r the spoilers while thev were still in a h~ill at ri ~ltt an ~les to thc runwav, skidding to a halt took a ntcre CR~ti9 perlormance breakdowns (Arbon, Mouden, and Feeler, 1990; Besco, the air I'~jlthough unly the auxiliary he hecame astiare ot a hi ~h volutne tion hegan e

14 Flight Comment No . 3, 1998 - Flight Comment No. 3,1998 15 To Intervene? The Copilot's Catch 22 ~~n~~~,~~E~<~ and accepted operational procedures To Intervene or Not will resolve the intervention conilicts Table 1 : The Green Eagle Code of Ethics and land the airplane safely on the 1 .'The I)C-8 loss of contrnl at Toledo, Ohio (NTSB, ly9?); dysfunctional but conscious Captain have never been well ground . Don't sleep wh~le your Captain is. defined or universallv acce ted. The rocedures for ado tin , P P P g Encourage your Captarn to smoke 2. The L-1011 wind shear accident at DIP~'~' Airport, a t~ew strategy or tlight plan that has not been developeci Texas ( NTSB, 1986); by the Captain are also missing froni current Standard The Need for the Structure It's hell to fly with a nervous Captain, especially ~f you're the one making him nervous! 3. The }15-748 electrical failure in Pinckneyville, Operating Procedures (SOP(s). "PA.C.E:' provides a hierar- of Intervention Illinois (NTSB,198~); chy of intervention stralegies for both situations . "PA C.E:' Every airline organization needs to Don't interfere if your Captain absolutely insists on making a fool of himself . is effective when the Copilot is not flyu~g the airplane (Pilut develop and implcment its own specific out of 1ti'ashington Vational, (NTSB,1982) ; Copilots Catch 22 : 4 . The 737 Not Plying (PNF) and is just as usetul when the Copilot is "PA.C.E." progression steps with stan- manipulating the corltrOlS (Pilol Flying I PF I. "PA.C.E." You are damned if you ignore your Captarn's m~stakes . 5. The llC-8 fuel e~iaustion in Portland, Oregon, dardized terminologies, semantics, and very general inquiries and progre~s~s to a last You are damned if you do something about them (NTSB,1979); starts with syntax. The structured phrase~ and the statement th,it the First Ofticer is novv assuming command universally accepted definitions are to Keep your lousy attitude a secret . (~ . The 727 into uulles INTSB,1975); and cuntrol of the ~~ircr~aft, be uscd bv subordinate cre~~~ members Survival Rules: 7 . The 1>C-8 freighter into Cold Bay> Alaska, l NTSB,1974) ; tivhen thev.P erceive anornalie;. In P ar- Don't fly with a Captain nicknamed "Lucky" ; ticular, paying special attention to the Need for a Precise lan 9 ua 9 e of Don't fly at night; 8. The Com~air into Ncw I iaven, Connecticut, opening statements u~ each step of the Interventlon Don't fly in bad weather ; (NTSB, 1972); intervention hierarchy. The arccpted Don't mess with the red switches ; Subordinate tlight crew members Lti~ill use lhc "P.A.C.E:' wording for each progressive step 9, The L-188 into a thunderstorm at Dawson, Texas, hierarchy of inquiry and intervention strategies to success- needs to he learned verbatim by all Never, ever eat a crew meal m the dark . (NTSE3, 1969); lully cope ~tirith an extremely rare but potcntially lethal senionty' 1 ev e .ls of tlig ht crew members. Speak very, very softly when you speak to your Captain . until the last trip of the month 10. The LearJet out of Palm Springs, California, I NTSB, I 967 ); performance break duwn of the Cahtain . First ~~fticers These initial opening intervention Don't make better landings than your captain, trained and rehearsed in the intervention progression will statements should cover at least four The two basic rules of a Captain's authority : l 1 . The F-27 into Las Vegas, Nevada, (CAB, I96:~). initiate "PA .C.E ;' when lhere is an indication of upper stcps in progression of increasing Rule One . The Captain is always right. perfurmance break down in airline cockpits. Creative ad- risk,. These accidents are all examples of subordinates knowing ioncern for the immediacy of the Rule Two . If the Captain is ever observed making a m~stake, see Rule One. in life that the Captain was denying serious risks and displaying libhing, on the tlight cleck, will not be productive Intervention models and strategies When you upgrade to Captain, you must counterproductive and unreason~tbly perilous behavior. threatening sltUatlollti . The commercial airline Copilot must be structured so that the imme- right all of the time . that their respecaive needs the equivalent message used by the militar,v pilot . 1 . Accept responsibility for being These flight dc~i.k crews all knew drate tLght safety threats are lessened oblivious to 1'hcre is no misunderstanding, hesitation or mistake in the 2 . Compensate for all of those ~nept and disrespectiul Copilots_ Ca I>tains were either denYg in , discocu~ting or by ~ach step in the sequence. Steps action to be taken when the vving ntan call~, `Blue Leader, morgue, jail, FAA hearings, and Chief Pilot's office, lethal dangers. Unfortunately, not one of them could do in the progression should bc made Keep your Captain out of the the Captain's behavior, performance, Break hard left, now!" anything to change without fear dlat the statements will It's better to be down here, arguing about how you are going to do it up there; Most of them could not even get the actions or strategies. The airline Copilot and the tighter pilot wing man share m~~ke the cun~ent situation worse. than to be up there arguing . Captain to acknowledge the problern. many ~iuties and responsibilities. Clne is to protect the and 'I'hcse eommunication patterns first the door of the airplane . After all, there demands lead Always let your Captain be the ~ut In several other recent accidents, the Copilots did not Captain or flight leader when the rnission skills must also enablr junior crew narrowing perception . It may not be any stairs . record rcny comments prior to the crash (NTSB,1994) . to a focusing of attention and ol members ro utfurm senior crew hot lt is possiblc that these Copilots had detected thc anomalies becomes a question of survival when threats and dangers members of their concerns without Buy your Captain scuba gear, skateboards, power tools and dog ski lessons . that tall outside of thc attention span of either the air- and were reluctant to speak up in any manner, i.e. caught emerge fear of reprisal to the suhordinates, As a Copilot, your primary job is to detect and correct mistakes : line Captain or lighter pilot leader. 'I'he Copilot and the Wing long term career security or promo- up in the "Copilot's Catch 22," 1 . First, your own mistakes . ntan buth have .r responsihility to protect their respective lead- tion potential. 2 . Second, your Captain's mistakes . ers trom ihi5 potenti,tlly lethal form of pericptual ncirrowing . The "Co P ilot's Catch Z2' is: Nat long ago, before the arrival of 3 . Finally, everybody else's mistakes . Each step in the intervention sequenre must pravide CRh-1, an unwritten but universal if you ignore a Capt~rul's mi~takes! Never, ever awaken your Captain when he is smiling in h~s sleep 2~a . You are darnned wavs to reduce the hazardous risks and to increase the motto of Cupilots was "Shut Up Talk up the advantages of early retirement ?2h. You are damned il you do nr say something about them! 1~robabilitv nf an uneventful resolution . Additionall ~, and Move t)p ." There was a twofold p racticed intervention hierarchies ~an delirse the 1~otential implication in that statement . First, Don't expect your Captain to : Thc possession of "P A .C.E:' tools, skills, and procedures for open cockpit hostilities that cauld erupt when the it corrld be implied that when a 1 Pick up the meal check on a layover, coiild have promptcd these non-contributing Copilots to Captain does not acknowledgr perceptual narrovving, Captain is doing SUInetlllng wrong, with flying background; intervene with the non-performing Captain . It is also possi- mistakes or performance decrements. Policies ol ev~ry the Copilot should ignore it and Iet 2 . Be impressed your ble that the Copilats, cited hy the NTSB, lvere also oblivious aviation organization mutit support a well defined hierarchy the Captain be grounded for his 3 . Think flying is more fun today than it was m the good old days; to thc dangers their Captains wcre ignoring. It is possible of intervention, in urder for Copilots to bc effective and mistake. Secondly, it could be implird 4. Hear and understand the ATC request the first time; that the Copiluts lacked the airmanship skills and experi- accepted as protectors of the Captains "six o'dock position': by junior i rew members that if they 5. Believe the FAA is doing a satisfactory job ; cncc to even detect the problems, i.e. "they didn't knotiv that The designs ior the two-person ~ockpit in .~ complex were critical of a Captain, they could 6. Buy anything without asking for an airline discount ; they didn't know:' long range ~ircraft have caused an tven greater need for only lose by letting negative judg- 7. Wear a small-sized or a low-priced wnst watch; well-detinrd hierarchie5. In the three- ~erson cock ~it, a "Fhe critica) need to take over the controls from an incapaci- l l ments become publrc. A corollary 8 Wear expensive uniform shoes; confirmation system can be used in thc intervention tated or un~onscious Captain has bcen recognized for years to this motto was the principle "The 9. Respect the competency of senior airline management; process simihir to the voting systems used in auto-land (Orlady, Krdera and Harper, 19~3). The technrques tor keJl to success in this or~crnization is to 10. Purchase his own newspaper to read on a trip. . In the two-pluce cockpit, only established taking ovcr tl~e contrnls of the airplane lrom a dangerously Gght controls kcc°p ti~c~ur i ritical npiniorrs nrrc~ (orrsJ~ cattihr~fes ~r ~c~tret."

Flight Comment No. 3, 1998 17 16 Fli 9 ht Comment No. 3, 1998 - - I "E?A.C.E."-Probing, rllerting, Challenging, Emergency Vernacular translat~on "Captain, you are about ta self To Intervene or Not To Intervene? The Copilot's Catch 22 ~.>~~~;~~~e Warnin g-is a four ste pl~ro gression goin g from an inc1 uirv, destruct. You have the e9 uivalent of a verv, an g,rv and armed to a disaster warning. The progression is gradual and opera- bogey in your six o'clock position .llre are all about to get Table I shows a set of ironic ethical principles and codes of There is considerable scientitic evidence that personality tionally relevant. the civil aviation equivalent of a 2G millimeter enema." conduct lor Copilots dcvcloped over ?5 ycars ago. Known as diflerences are not now and have never been related to pilot tor next . Each step Step 4: EMERGENCY WARNING. The Green Eagle Code of Ethics, thev were developed as a performance differenies (Besco,199~ ; L)olgin and Gibb, Each step is a building block the step serves as a non threatening signal to the Captain that a ton g ue-in-cheek p alitical counter force to the org anization I989 ; and Hunter and Burke,19921 . Since the majority of "Captain, if you dort't immediately increase our safety mar- response to each step is required . of senior pilots known as the Grey Eagles. It was thought that llight crews do not exhibit these poor characteristics of gins, it is my duty and responsibility to immediatcly take the (ireen Eagles Code might help relieve, in a humorous mental health, individual cre~ti~ members ~~~ill not acknowl- The examples below are "P.A.C.E:' steps that cauld and over control of the airplane" way, the sometimes awkward relationship between (:aptains edge that the opcrational risks of poor CRlvt exists on their should have been used by the Copilot of the I iS-i48 in Example from NS-748: "Cca tnin, if you dorr't irrrmerliately and iunior crew members, This ~ode also illustrates t}tat particular flight decks. A9ost flight crew members will reject the Air Illu~ois, night IFR (Instrument Flight Rules), com- p reverse course arrrl get back tv night VFR ccrnditiorrs, l rnust CRA1 P roblems have their roots dee p in conflictin g or g aniza- the unproven academic theory that unsanitary mental plete electrrcal tarlure accrdent (NTSB,1985). The atrcraft tuke uver contrvf ojthe airpfane. l icrrrnut n(1ow you tu subjeit tional policics and practices. hcalth traits are thr primary sources of these (:RM errors . departcd Springfield in night, \'FR conditions on an IFR the pcuserrger; tv such rtrr unnecessary and high risk ovj c'ertcrin Consequently, crew members will judge that, as competent flight plan through a line of predicted thunderstornls, to deratlr. Under these conditions, it is rrry drcty aruf resporrsihility Formal Written Polic Needs to and reasonable tlight crew memhers, they are not at risk to Carbondale, the final destination and corporale mainte- Y commit the sarne rnistakes that the aews will commit when to rc~fiet~c~you uf your cnmrnartd." Precede "PA.C.E." nance headquarters . the crew contains domineering Captains, submissive Vernacular translation : "Captain, you, your airplane and every Both generators became inopcrative shortly after takeoff In all day to day activities on the tlight deck, not just for Copilots or other aberrant psychological characteristics . one on board are about to be dead meat. I ~hoosc not to crisis revention u cr mana ement must vi orousl ~ ro- while still in VFR conditions. The Captain elected to continue P > Pp g g y P There is a reference to this situation drawn in the plot of join you. If you don't immediately cease and desist, I will and actively support the participation of subordinate on through the frontal system on battcry power. mote '1'he Ccrinc ~1~lrrtirty (Wouk, 1951 I . ln this fictionalized take the airplane away from you. I owe it to mysclf, my fam- crew members in minimization of anomalous performance account, the Captain tivas such an emotional cripple that Step 1 : PROBING statement: ily, our passengcrs, and our company to restore an adequate without threat of reprisal . Arnerican Airlines, for more than the subordrnate olircers re)ccted hrs leadershrp. The crew ot margin of safety." thirty years, has had a formal definition ot Copilot responsi- "Captain, l need to understand why wc arc [lying like this:' the Caine saw only two options: I 1) mutinv or (2y mission bilities that undoubtedly has h~td a significant effect on P A.C.E. Survival Stcp- iatlurc by submrssrcm tu a dysfunctronal Capt~un . Thcy Example from the HS-748 Copilot : "Cctptain, l dorr't rrrrdcrstand supparting Copilots to advise (;aptains anomalies and errors. INTERI'ENTION A'~'I) TAKEOVER: chose mutiny over submissive contpliance to a Captain they why we rfon'r rnaintain VFR (Visrral Fliyht Kules), go lrcuk fo "First Officer Responsibility : The pilot occupying the vicwcd as sclf dcstruciivc . Thc post-tria) cocktail party solil- Sprin4ttiefd crrrd karrd Irc~ore the bcrrtery ~ves dearl." "Ca p tain ()uncs), I have the airI ~lane !! oquy by the defense attorney has a lot of wisdom on the First Ofticer position is charg~d with the responsibility Vernacular translat~on: "Captain, l think lhat you rnight be (Jerry), Take your hands off the controls, NUW!!" informing the Captain intmediately and ~tt any time, need to support a lradcr you do not like . '1'hcse classic and of painting yourself into a cctrner and aiming to shoot yourself should he believe the aircratt is being handled improperly eloc~uently wr~tten prrnciples and concepts, on support ot (Spoken Ioudly, slowly, and with firm authority!!) in the foot:' or placed in jeopardy. The Captain may choose to disliked leaders, shuuld be integrated into the content of current CRM programs . disregard this counsel, such is his command privilege, Step 2: ALERTTNG statement: Takin Over Control from the Ca tain but no matter to what degree or how otten such advice 1 hc need to structure lramrng methods, proccdures, and "Captain, lt appears lo me that we am on a course of action may be disregarded or ignored, the pilot occupying the A Copilot takeover of the active control of an airplanr has contents on the more operationally and organizationally that is drastically reducing our safety margins and is con- First Ofticer's position will nevertheless be held responsi- more immediate and lifr critical ramiGcations than in any basrd com oncnts of CKM breakdowns hc~s been drlined trary to both your brie(ing and to company's SOPs;' ble for always offering such advice :' (American,1983, p other complex systems operations environment. The cock- in recent years (Bescc~, 1994 ; Besco and l,ederer, 1992; and pit of an airaaft is no place to physic~tlly wrest)e over the emphasis added). Wicncr, 1993) .1'hc aviation community will bcnefit whcn Example from the HS-148 Copilot: "Cnptain, if we proceed rrlrencf, ~r0111 L'FR l'OrlGfif 10115 ir1lU t11E' f1r1E' Uf ~iCAt~y rRir1 Sf10W- controls. The operahonal etrquette or mterventtun hterar- This policy, when practiced, protects the assertive First CRh~i training programs place the main emphasis on ers, vn battc~ry power orrfy> we wi11 crash bcinuse we have nv ~hies must be clear rut as to wlten the Copilot announces Officer from official corporate reprisal initi~tted by the rrntoving the organizalional and uperational barriers to >7~ay rv ~ly instrurnerrts tvherr our bauery gves ciead, lUe should the intention to take command. There should bc no doubt Captain. Also, the Captain is denied the authority to order tff~~tivc CRh~i. not everr he f lyin~ IFR wit{r one ,~crrcrrrtor irtoperative, let as to the appropriatcness af the Copilot taking over the the First Officer to sto otferin advice. Without this tv ~e of P g ,l I'hc resuhrtiorr o~ pe~rsunrrlit~~ cfi/)t~rc~rrcc~s on tlrc /light dec'k K~ifl crfane tlhing rright 1FX 1r11U Ii~Erlrtttirr~ ctnd lrcavy rain showers controls from the Captain . organizational support, the strategies of intervention will be, at rnvst, a tcrtiar}~ issuc x~fren the opercttivrraf and vrgcrrri-  rvirh hotdr ~~iener~rttors invpercative . The "PA.C.E." stcps-Probing, Alerting, Challenging; seldom operate (h'Iager and Pipe, 198~) . corrttnunic'uticrns be~rriers nre e1/'ec-tivf~f}~ reduced ~atiorrctl or Emergency Warnrng-requrre that thc (.aptarn rnake a rnirrirrri~ecf to et rncticaf zero. "EA .C.E:' is the t r e of o era- Vernacular translation: "Captain, it is my job to protect yctur This type of policy makes it clear to both the C~tptain and P . }p P satisfactory response to the Copilot at each level of inquir,y tionallv b~tsed trarning program which will enhance crew hlind sp ots. I see ,vou are about to walk off a cliff." the Copilot that one of the prime duties ul the subordinatc and interventi~n . It should be an organizational SOP that if performance in all aviation Or~;ilrllZ~ltlOrlti, is to protect the "six a'clock position" or the blind side ot Step 3: CHALLENGING statement. the C~tptain ignores the Copilot ihrough all four steps of the leader or Captain. "PA.C.E:', the Copilot must proceed to assunte command" "Captain, you arc placing thc passengers and aircraft in "PA.C.E ." A Four Ste P Pro g ression danger. You must immediately rtnd rontrul ol the airpl,trte . "PA.C .E." Avoids Overem hasis on I irreversible and Irilmedlate p to Survival rhoose a rourse of action that will rcduce our unacceptably For the actual announcement ol change of command on Personalit Y Conflicts high risk levels." the tliglrt deck, the Copilot could use a phrase `uch a5 Probr for a better underst,rndin 7 . I htany CRM training programs have tocused on the person- "Captain (Jones), I must take over control of the airplane . Example from NS-148: "Cnptain, you Are placing t1u pns,errgcrs alitv dynamics of the tlight crew (I lclrnreich and Foushcc, Alert Ca tain of the anomalies, ( Jerry), take your hands off the controls, NOW!" The usc P irt ct pusitinn of a iertcain irvsh rvlren the bnttcr,v gves dcad. 19y3 ; Helmreich, Predmore, Irwin, Butler, Ta 7 7art, ~ti'ilhelm ot' a personal tirst name or a nickname can very effective gg Challen e stutahilit of rescnt str.tte rv. You ntrrst inrrrtedicrtef ~ rererse cvurse Urtd r;et Iraik to rri~TJrt g Y P g. ) < < break the perceptual narrowing of the Captain. ~ti'hcn a and Clothicr,1991), ~'hc ncgativc outcome of this mcntal 1'FR iotuiitinns." to health emphasis has been that many, if not most, crew Emer gencv , ~1'arnin g of critic~al and immediate dan gers . third crew member is present, they can use terminologry mcmbers will not idcntify with these personality problems such as , "Ca p tain (1 ones 1,Y ou must g ive control of the as the source of P ast CRAi breakdocvns (Helmreich and airplane to (Barry) immediatcly." lvilhelm,1989) .

18 Flight Comment No. 3,1998 ~ Flight Comment No. 3,1998 19 Helmreich, R. L., Foushec, H. C. (19931 . "1ti'hy crew resource ;Vational Transportation Safet,v Board . (1982) . Aircra/t Accidertt To Intervene or Not To Intervene? The Copilot's Catch 22 <<,~+,~~~~~,~ management? Empirical and theoretical bases of human tacrors Repart, Air Flvrida, lrrc ., Boeiub 737-???, N6?AF, Collisiort wilh training in aviation . "In E, L Wiencr, B. G, Kanki and R. L. l~?th Strect Bridge near 114uhington, Nationnl Airport, ltiashirtgton, Hclmrcich I Eds. ), Cnckpit rcsorrrce rnanagentent . (pp 3-45). DC Januarf~ 1 ~, 1932. (NTSBIAAR-82-08) . Washin g ton, DC : ~'4'hen the Copilot is already flying the airplane (PF), the References tian Die g o, CA; Academic Press. Authc,-r. "P.A.C.E." interventian stcps must be used by the Copilot r1merican Airlines, Inc . I' 1983, March) . Flight :ti1anual, Part I, lhe intention to implement a strategy not initi- Helmreich, R. L., Predmore, S. C., Irwin, C.1s1 ., Butler, R. B., National Transportation Safety Board. i 19851. Aircraft Aicide»t to annuun~c Section 3, Page 2, Paragral?h I, DF1~' Airport, TX : Author. ated by the Captain. Even though the Copilot has control Taggart,l~' . R., Wilhelm, J. A. and Clothier, C, G. (1991) . Report : Air 1lGrtvis, Inc., Hatvker Siddley HSi482A, N7~8LL rrenr "Bevond ~Rh1 : Pa ers from the NASAIt?niversitv of Texas Crew Pinckrreyn'ille,lllinois, Oc7ober 11,198?. IN"fSB/AAR-85-03), of the aircratt, the Captain still has cornmand responsibility Arbon, E. R., Mouden, L,11 ., and Feeler, R. A. (199U) . "The prac- P tice of aviation salety, ob,ervations from Flight Safety Foundation Performance Proiect :' 1n proceedinl;"s front tlre 6th Iuteruational Washington, DC: Author. for the basic flight plan and mission control. These same Syrnposiunr o1 Aviativn ColurrtGus, OH: Oluo State safrls audits ." Fli ~1rt Sa /,ett~ I>i~ ~cst , 9 (l,8 1-~t2. Psycholo~~y, four steps of progressinn to intervcntiun strategies must Unirer>ity. National 'liansportation Safety Board. (1986), .9ircratt Aa:ident be followed by the PF Cupilot to formalize the change in Besco, R. Q. (19891 . "Pitness to lead :' .SAE Techrricnf Paper Series 4 Ret? urt: Delta Airlines, Inc ., Lockheed L-lOll-3S5-1, NJ2GDA, command and return the aircratt to the pre-planned margin 1~1'arrendale, PA: SAE,'fhe Engineering 5ociety for .Advancing llelmreich, R. L. and Wilhehn, J. A . (1989) . "\Nhen training L )alla ./Ftc ' . l1c'~ rtlt lrtternational Atrpa~ r t, Te~'a~ ., Aug rcs.t )..,l 98i. . hoomerangs: negative outcontes associated with cockpit resource (NTSBIAAR-86-U~) . Washington, DC Author. of safetv. !slobility Land tiea Air and Space, management prograrn ." R. S . lensen (Ed.) ht proieedings v(the ?th Beseo, R. 0. (1990) . "Subtle incapacitation of pilots : how bttcrr~ativrral Syrnposiunr of Aviatiort I'syehofogy, Cofurnbus OH: National Transportation Safctv l3oard . (1992) . :'aircratt Accident Report, Air Transpvrt Irtterrtational, Irtc. FIiSht 8U5 Douglas Conclusion to tell if vour captain has died :' F1iS=ht Scrjery Fouudation ,qccident O)uo State Urriversiry. Prcvention, 9'(1).1-4 . DC-8-G3, NJ94A1 Lcrss of Control and Crash, Stivantott> Uhiv, t1'hen ihe Captain decides to replace the Copilot on the Hunter, D. R. and Burkc, E. F. (199? ). Meta analysis of February 1.5,1992 . (N'fSBlAAR-9? 061 . Washington, llC; Author. Besco, R. 0,1:1991) . "~1'hy pilots err and what wc can do about it" ctircralt pilot >rlecaivu rneasures. (ARI Research No . 9251), controls uf thc airplane, the time honored': ..1've got it" . A Forensic Repvrts, 9(~t), 391-416 . Alesandria, ~';1 :11.5 . ~trmv Rescarch Institute for the Behavioral National Transportation Safety Board. (1994) Sa/~ety Sttrdy; b the Ca ~tain is readil acknowled ed b cver 'one, rruajor v~ Air Carrit:rs, Y 1 Y g Y Y ,tncl ticr~i,tl ~.i~nic~s, Revtew o~ Flightcrex~-Involved, Accidertts Lr,S, Unfortunately, there is no universally accepted procedure Besco, R. 0. (19921 . "Analyi.ing knowledge deticiencies in pilot 79i~'1'lrrvus~h 199U, (NTSBISS-9410I) .Washington, DC; Author. for the Cu ~ilot to use in taking over control uf the airplane performance :' The hrterncttiorral lnurnrt( c~hariatii~u P~ychvlogy I lurd, W. L. (1987) . "Lessons learned frotn the spacecraft I Office of Technological Assessment . (1988, July). Sa/e skic's /or frum a conscious but dysfunctional Captain. 2(1 l, 53-74. (:hallenger:' lrt Proceeding> of the ~Utlr Anuuallnternarivrtal Air tvr»orrms' a com ctitii'e envirvrtnr~nt. (()TA-SET-381) . Washin ton, ticrtety Seruirrar (pp 188-1921, w'ashington, DC. Arlington, VA: 1' g myths personality 1Vhat a Copilot needs is the cummercial aviation eyuivalent Besco, R. 0. (1994, January) . "'The of pilot Flight Safety Faundation. I)(_.: rluthur, ' n. ?4-28. of a universally understoud corumunication, well aaepted stereo nI~es :' ErQvttvrnicsL in Uesi Lautmann, L, G., and Gallimore, P. L, (1987, Octoher) . Contrvl Orlady, H .1b'., Kidera, G . J., and Harper, C. Ft, (1N73) . Developrr :c:nt the life ur dc~ath teamwork of militar fi htcr ilols. in Y g P Besco, R. 0., and Lrderer, l. F. (19921 . "CRM boornerang : benefit o~ i reu'-causecl accidertts. Paper presented to the Flight 5afety o f post-rrainirr~l vhjei tivcs /or trairtinSl pilots in Itanclf inK af irr-rlight ~lrhen a lead tightcr pilot hcars the words "Blue Leader, o r b t tst° In Prvcec:din S Ts o1 ~tJre 7i~~ent ) ~-Second International Sentinrar Coundatiun 40th Internatiunal Sytnposium>'1'okyo, lapan . irrcapacitativrt. I'aper presented at the XXI International Congress Break Hard Right ; there is no doubt and no questiun as to v1 Thc° lrrtr°rnatinrtal Snciety v~Air SalEty' Investigator~. 15ASI on Aviation & Space Medicine, Munich, West Germany. receiving this message will give Forum,?~I(~t), I13-119. Ledercr, l . F. (1990; . Safety sciencc irr crviatinn, Paper presented at its meaning. The lead pilot Schwartz, D. ( t987) . "Training for situational awareness;' Irr the First World Congress on Safc;ty Sciencc, Cologne, Gcrmany. rro thuught to group dvnamics, assertiveness, personalities Bruggink, G. h~L (1989) . "li,etlection~ of air i~trrier >afctv" The Pruceedin~~s vf the ~IOth Auuuf Internativnal Air Safety S,vrrtposiunt, ur the need for more information to reassess this situation. 15AS1 forurrt ??(1), ZU-26 Mager, R. F, and Pipe, P (1989) . Analyzing per{orrnance pruhlcrns or (pp 397-4031 . Arlington, VA : Flight Safety Foundatioi~. Also, there is no hesitation on the part of the wing man to you really otr,qlrtu tivarrna, (2nd Ed.). Belmont, C,4: David S. Lake. 1, . . . x~e, learnt uver erew intervene and alert t-1c 1~hght Leader of any and all tml end- Caesar, H, (1989, September) . 1NHat have Sears, R. E (1989, February) . Preventivtr stratc;t~ies fvr the the lasi 3U year~? Paper presentcd at the 2(Ith Annual lnternational Nagel, D. C., (1988) . "Human error in aviation operations:' ln caused accident. Paper presentcd at the Secon~ Pgyptian Airrraft ing dangers . Seminar of The lnlernational Society of air Safety Investigators, E. L. ~ti'iener and D. C. Nagel, (Eds . ), Human Factors in Aviatiorr . Accident lnvestigation and Prevention Annual Serninar, Cairo, The commercial aviatiun utdustry is overdue to develop -- a 'Vluruch, Gerrnarty. (pp.?63-304) . New York: Academic I'ress . Egypt. univers National Transportalion Sufety Board. (1972) . Aircra/1 AcciderN Alcrlin - the Ca ~tain of the anomalies . l K P . g 1 2~1(2), 18-23 . Rcpvrt: Alleglreuyrlirliues,lnc . A1lison Prvp let C~nvair 34(1/~1~10, Wouk, H. (1951) . Thc~ Cainc A~futiny Garden ( ;ity, NY: lloubleday. in the suitabilitv ~resent strate v N5133', Iv'esc~ Harerr, Counecticut, /urte J,1t171 . INTSBIAAR-7l-10) . Challen g g - , of } g, . in Dolgin, D, L . 8c Gibh, G . D. I 19891. "Personality Asscssmcnt 11'ashington, DC; Author, Qab 13esco i> an intf'rnatiottally rec'ognizc~d Bc~nrd Certi/ied - ol critical and immediate dan ers. Aviator Selection :' In lensen, R. S. (Ed,1 . Aviation Psychnlvg,t~ Emer~Jenc Y Warnin g g Irrdtc;trial Ps Ydtnlo fi ist sP ecializirr ~ irt Avi~ztiott Ps )~choln S)~ c llis (pp.'88-3?0) . Brookfield,~"1': Gower. National Transportation Safety Board. (19741 . Aircra/tAcciriertt tarriclue yuaiif ictttior2s provirle. rt brvrtc~ c:xperiertce hasc with These fnur steps of intervention strategy-"PA.C.E:'- Rc~(~ort:11'vrld Airx~ays, lnc., DG,4-63F, NBUZ WA, Kirrg Core, Helmreich, R. L, (19841 . "Cockpit management attitudes" wlttch to develop htgh tntpact prnJ,=rarrts to rrrtprove fhght crew will help Alctskrr . Serrember 8, 19i? . (NTSBIAAIt-7406) . Washington, DC: Hnmr+n Factvrs, ?6(5), 583-589. ~lttthr~r . per/'ormance . tfe htts Itctd ovc~r 4U yenrc o~~extertsive, rrti+lti- "to make the world a better place in which to fly." disci lirtcrr ex eriertce rts an Air Force Fi~lrter Pi1ot; a Alnrtcr~er I lelmreich, R. L. (19901 . Studying fight ire~rti' irtteractivn: tlre P Y P National Transportation Safety Board. (1975), Aircra/t Accidcnt irr Aircrafl Irtdttstry ; Httmarr Factors Ertgineerirr~ Grnups; a interseitivrr vf ba~ic arrd applied research. Talk prrsented at , Repvrt, Trans tiYvrIdAirfutes, lnc., Boein~ J27-231, N59.3?,K, Cnptatn f or a Ma~or Cotrrrrrernal Arrhnc ; cr C~rrtt crstty the dedication of the NASA-Ames Rescarch (:enter, Human Berry~ille, Viryinin, Decerttber 1,Ia,~d. (N I tiB? .AAR-75-16) . F'rc?/c'~sor ; cin :lir~ rn.li rlc'i iciettt Ittt'e~tiSTrator ; ctttd ctc atl Performance Rcsearch Laboraton'. Me r'tfet Fielci . CA: Auth or . I Washutgton, llG: Author. Avicttion Cartsttftarti . " Helmreich, R. L. (19931 . "Future directions in crew resource ctiational Transportation Safety Board. (1979) . Aircra~t Accident management training :' 7'1te f5.~1S1 fvrurn, ?4(1 I, 14-I5, Re(~ort: Ilnited Airlirrec, lnc., MeDvnnell-Dnuglas DC-B-til, Reprinted with permission from ISA51 Forum Volume 27, NSUR?U Portland, Oregurt, Decentber?,S, 1978. ( N'I'SBIAAR-79-07). No.S, December 1994. ~~'ashington, DC : Author .

Flight Comment No. 3, 1998 21 20 Fli 9 ht Comment No. 3, 1998 TYPE: Buffalo CC115465 TYPE : Air Cadet Tow Plane C-GCDL approximately ~0 degrees af turn the left landing gear leg LOCATION: Innisfail, Alberta broke oft. The lailed le>t, E>ivuted u 1~wards causin g the tire to LOCATION: 19 Wing Comox strikc: the aircralt on the att portion of the front left wind- DATE : 7 Feb 98 DATE: 28 Jul 97 shield and sidr vv~indou~ leaving a distinct tire imprint. As CII'CUmstanCes the aircratt settled to the ground the propeller cut into the Circumstances earth stopping the engine. The left wing tip also struck thc Buffalo CC115~(,~ was scheduled for a High Power The tlight was the first tow mission of the day at thc ground .tnd wa` bent upwards, The solo pilot shut down run-up following the replacement of the right Prairie Region Gliding School. After an uneventful the aircratt, secured the switches and egressed unaided. take-off, tuw, release and circuit the to~i~ plane set up hand PFro ~eller and the left hand enr;ine Fuel Fortunatelv hr w~as nut injurtd. Control Unit. Three qualitied technicians were for landing on the grass tu the east of Runway 16 at assigned tu carry uut the engine run-ups. lnnisfail, Alherta in aaordance with standard operat- ing proccdures . After a nonnal tuuchdown on the Investigation The run-up 1?roceeded norrnally until the left grass and braking tu slow the aircraft, a slight turn to A visual inspec~tiun of the fr~ccture surface reve,rled clear engine ~~~1ax Forward to h9ax Reverse Slarn Check. the right was initiated at low speed tu pusition the air- indication of a fatigue crack on the underside of the leg just During this check fi~ll forward thrust is applied to craft on the rrmway for the next tow missiun. After inboard ol thc llat plate that secures the leg to the fu5elage. the engine being tested and, once stabiliud, thc This leg had previously been in~pected u~ing a power lever is retarded to Max Reverse within ,^~lagnetii Particle Inspectiun (A1P11 f?roiess one second. As the throttle was retardtd the during the Scout titruitural lnspection and engine exploded and a large fire engulfed the (tepair Program ISSIRP1,rpproximately 4~0 fly- left nacelle. The crew immediately initiated the ing hours prior to the failure . Red Page emergency checklist to deal with the situatiun but the engine tire extinguisher failed A Supplementary Inspection vvas initiated an t o d is c~har g e when the Fire T-Bar handle was all other Air Cadet ~~liding I'rogramme Scuut ,rircrcrft to determine if any others werc similarly pulled . Attempts to turn the handle to discharge ting through the turhine casing . ~'Vhen the turbine wheels affected . Four other legs 5howcd signs ul similar the second tire bottle were also unsuccessful . The crew were cx~rmined it w~,js noted that all blades were missing. advised the tower of the emergency as they 5hut down cracking and are undergoing further analysis at 5everal had heen ejected through the turhine casing and the right engine and abandon the aircraft . QETE. All landing gear legs wcre either changed Irad pcnctrated ~he engine nacelle ~rnd fu~elage and were or pa5seci the 1fP1 u~spection . Investigation into found inside the cabin. The majorit~~ of the blades were Several technicians working in Servicing noted the the tield conditions where the Tow Planes oprr- found forward and to the left uf the engiue . The front fire and responded to the scene after ensuring the ate at InniSfail is ongoing to determine what if Fire Hall had been notiGed. '1'hcy brought a 50-1b power turhine wheel was found over 600 feet from the anv, effeit it mav, have had in thi~ occ:urrcnie . llalon fire extinguisher with them and began fight- enginc, ing the tire. Fire trucks arrived soon afterwards Examination of the Engine Fire Extirlguishing system DFS Comments and bruught the tire under control using 160 litres revealed that the Sqrub iharges that should have tired to of foam and 3000 litrcs uf water. '1'here were no release the extingui~her were shorted out hv pie~e~ ul ~1~hile it would be ide<~1 that vve not sutfer . The aircraft sustained "C" Category damage . injuries shunt v~~ire inserted intu the firing iah, 'I'hese wires are component failures that result in damage, we installrd for transpart and stor~rgc ecl thc iharges to pre- vvere indeed fortru~ate that this cumponent Investi 9 ation vent aciidental tiring and should have heen removed failed when it ciid. As the air~raft had slowccl prior la in~tallatiun, to t~rxi speed, the ionseyuences nf the tailurc Examination of the scene afterwards revealed thal thc were not as scrious as if it had iailcd ~rt cr two power turbine wheels were fi~rcibly ejected from 1)eterminaticm of the initiatinl; event that caused this higher spec:ci . Althoul;h fhis aircratt is designecl the bottom of the engine after clestroying the power enginc lc~ lail ia ~r high priuritl~ ,It L)FS .1'he f~jilure of the for operations on rough surlacc~, llle nUnlbel' transfer shaft on which they were spinning and cut- Squih to activate thc lire extinguishing s,yslem was thc ot take-of'fs and Iandinl;s per hour iarried suhjc~t of an imn~edia~e lucal SI tc~ contirm that the Fire out in ocu oper,rtiun oi thc airirait ia unique . Rottle, in all other C( ;l 15s woulcl work whcn n~cdcd . As Hopetirlly the ,rggressive and pruactive mainte- thcse dcvices arc uscd in other fleet~ for ~imilar purposes nancc prugramnu thal all Regiuns have in as well ~s in winch cable cutters and for deplo~~ing CP1~, a place will identifi~ iomhonent, that arc likelv more widespread SI w~rs reiommendect . tu rca~h the end c~l thrir safe life bet~~r~ thc~ ~ nldnllt,l~lllrCl''1 rt~clnllllcntiatll)n . " The FItR d~rta is being currclated with the C1'R tape to -_ _ _ determine the seyuence ot events after the throttle `vas moved lrom A1ax Forward lo ;~1 .Ix Reverse . The Propeller ()verspeed tivvitch was hench tested and foun~i to be unsrrviccable . .an ancjlysis of the C~~'R will bc attenlpted to determine the r1laXlmlrm propellcr ~pced attaincJ prior to thc explosion . Failure modes of the pcnver turbine blade are being re~earche~i ic~ a,certain i( ,In~ l,rilr~i as a rrsult o1 centritug,rllo,jdinl;. "

22 Flight Comment No. 3, 1998 Flight Comment No, 3, 1998 23 . From the Investigator 'ount own lo ~saster iU1111rrNE'l~ t rcrrn > a~e3 They worked, to some extent . The !n its findings, thc board sheets ntuch safetv officer to the aviation regiment, inertia reel belts locked, and the seats of the blart~e to the inex 1~erience of in tvhich he urg ed a gainst a lax attitude ~md undercarriage absorhed some of 26-year-old Hales, acknowledging the to salctv duc to a "can-do culture' : TYPE : CH146 GRIFFON 146480 the impact.l3ut the dama~;c from Black One pilot was the product of a Failure to report and investigate LOCATION: 17 NM SSE Cold Lake AB Black One's rotors caused the cabrn highly stressed system struggling with incidents properly would eventually roof to collapse under the weight of unsenrrceable arrcratt and hrgh lo5ses DATE: 16 April 1998 catch up with them, tivarned :~lartlew thc mator and transmission . Fuel of experienced pilots to the conu»er- The crew was conducting a night Visual Flight prophetically, and "leave the regiment ignited anci a fire broke out, but cral sector~. Rule~ ( VFR) navi g ation mission without Ni g ht open to major criticism in the evertt slrtwlv, trom the rear. Vision Goggles (unaided) . Prior perrnission It is also critical of lack of supervision ofan ezternal investig~itinn intc~ an had been ohtained to conduct a confined area Some ol the nten were able to struggle bv superiors and of the poor commu- iniident". " landing on private property during the training out. Several then went back tct dra~ nication between the SAS - with its Copy~right TheArcstrcrlic~n arui reprirtted mission . An earlier daylight recee had been out their males, despite lhe cxplosiotts penchant for secrec-v - and the avia- with their kirtc~ perrrrissiorr conducted bv the Aircraft Ca p tain ( AC ) which from the ammunition and the tors who were Less practrsed rn identified two 1~ossible landin g sites on the f~ro p - strengthenmg ttre. Burke, hrs three counter-terrorrsm. The board also erty. The primary site was occupied with heavy cree~ and f~~ur S,AS escaped with picked up on a 1994 report tvritten By Mr. Roy Ecdeston equipment on the night of the sortie and the their li~c; from Black ~I'wo. by i~9,tjor lonathon ,tilartlew, a former alternate site was chosen for landing. The crew was briefed by the AC using a hand drawn map which contained detailed information but did not note the presencc of a 2~ inch high by 6 inch diameter steel fresh water well casing in the middle of thc alternate landing site. The aircraft arrived over the intended landing area low hnver re-established . The well casing was deared and and circled it at about 50D ft AGL and 60 K1AS. the aircraft IanJed and shut dow~n 30 feet to the north of Could this be you? The confined area checks were completed during the ob~ect . t was a dark and rainy midnight shift; the only thing green mule slid across the floor heading straight for a big a downwind rautrack pattern and a two-stage left to do was an cngine runup. "1'he engitte techs had tool board. No number of nh M God's, or Hail Mar 's According to the CHI~I~ Standard Manoeuvre Manual Y Y approach was started with the ~0 foot trees north finished their walk around and were waiting for Bob Bob said wcre slowing this tlting down. After his whole (SA11~1J, the procedures for night unaided iontined area of the landing site identified as the barrier to cross. to show up to ride brakcs. l le finally showed uh and career had tlashed before his eyes and the mule had landmg; are drlterent trom thc ~iaylrght and nrght aided Once successfully clear of the harrier trees, a high everyone got on hoard. Only then did Bob reaGze he had finally stopped, Bob stepped down from the saddle to procedures . The landing light shall be retracted to illu- hover was attained but frees to the right side ol the forgotten his headset on the serving desk. So, in a hurry see that he had come to a stop just inches from the tool mtnate the under arrcraft arca ancl at least two low and aircraft were a little too close to commence the verti- to get the job done and ntayhe catch a few zzz's, he board. "What if someone had been walking through slow approaches are to be tlo~~~n in order to land in a cal decent.'1'he high obstructions were cleared as the hopped on the mulc and sped off to the hangar. The here or checking the tool board ?" he thought. He qtuetly ~unfrned arca unarded .'Ihe rnvcstrgahon rs cuntrnumg AC manoeuvred the helicopter lefr. The landing light hangar doors were open as the aircraft was going to be picked up his headset, cortcealing his shakuig hands b`~ ex~tmining the procedures for night unaided tlight was deploycd to the front of the aircraft and the towed in right after the run so Bob just sped utto the and returned to the aircraft. The run-up went withoul sequcnces anJ lhc tr,ttnrng thal crcttis reccrve at the variable spot light was aimed tnwards the right to hangar without missing a beat. llntil he went to stop a hitch and all was going well until on the ride back to Operational '~rainint, l'nit and thr~~ut;h t~n 1~h illuminate thc high trees located in that area. that is. Hc didn't rtalize that the wet tires combined with the hangar one of the engine techs on the run asked 'l~raining . " the painted hanf;ar tloor had him virtually driving on a Bob, "1-Iow come you're driving so slow?" All he could attempt visually clear An to skating rink. 4ti'ell, you can just irnagine Bob's surprise say after thinking ahout what could have happened is under the lhc landing area when he ~a~ent to stop and tive tons or so of specding <`You do_rt't tvant to know " aircratt was hampered by the manner the aircraFt li g hts were deployed and by the shadows cast into the area . . from in situ lighting . The airiralt, when clear of high e- elcin ~~~~r~irtr~r~~l i;"~~rr, ~~~~~~ 5 obstades, descended vertical- ly onro lhe steel well casing 1 hacl to stup, lt was freezing out aircratt commctnder decided tve had thanked him as ;r ~rew ~tnd told ltirtt which tore an 18 inch bv there on the rantp, and thinking had too murh excitemenl for one he had dc~ne a great thing. ahc~ut mighl have c~ccurred made me night, and we called it quits. 10 inch hole in thc underside In retrospect, my only regrets is that shiver e~~en mctre. fuselage and darnaged a As the air~ralt ~omntander canceled I cannOt rentfrllher the nttlne Ot the stringer and fuel tank located After ~!D ntinutes, our crew ,tnd TA our tlight pl~tn, I started filling out young airman tvho ntust likelv saved . in that portion of the aircraft tigured out tvhat was going un . They the safetv report . I slated that the air- mv, life. lf he is readin ~ this ste~rv, I asso- Upon hearing the noise ialled for the other deice h~uck, but ntan launchin g us out had hroken the want him to know 1 will never for~ct ciated with the damage, thc it was too late .ll'e were initially "chain of events" that leads to everv the actions he toc~k th~~t ni ;;ht c~n hi~

cjescent was arrested and a . r~ . ~..5 .~l~1 . . pushing a l6 hour crew day, and aircraft accident . l ho ~e he realised tuur in lapan. " ~. S~ ~ 1 ', : - y ~ . w . now tvith another deicin~;, we were the rnontentous decision he had made . _ .r- . ~"i ~ Reprinted courtesy of Flying Safety ~~''c staring at almost 1H hours. The hv rehrsing tc~ pull our chocks, magazine October 1997

24 Flight Comment No. 3, 1998 Flight Comment No. 3, 1998 25 i Ca P tain Mike VandenBos Ca p tain Richard Walsh Second Lieutenant Jason Nelder While conductlng a cross-country Folluwing a formation trtkeoff, Captain ~1'alsh tti~as unable to fully retract the mission to Bathurst New Brunswick, speed hrakes of his Tutor aircratt .lv'ating that he had zeru hvdraulic pre~sure Second Lieutenant Nelder, an undergraduate pilot in training, was on Captain VandenBos elected to do a he broke lormation, inlurmed thz lead aircraft> ai~d declared ~~n emergencv. a solo training mission in a Tutor aircraft performing a practice forced Snowbird p~tch at the Miramichi air- lti''hile initiating the checklist actions tor an emergency gear extension, Captain landing exercise . When he attempted to retard the throttle to idle he field . When he was at one mile final ~ti'alsh noticed hydraulic tluid on the cuckpit [loor. A ruptured line had draineci noted that the engine RPIV1 indicated 81 percent instead ~f the normal approach he advanced the throttle all of the ftuid frum both the normal and emergency systems renderin~ the 63 percent . Further investi~ation by Second Lieutenant Nelder con- slightly and heard a thump . Captain landing gear, tlaps, and ;peed brakes inoperative, tirmed that full throttle movement would only vary the engine RPh-1 VandenBos imrnediately zoomed the between Sl and IOO hercent. aircraft and headed directly to low Recognizing the potential lor a post landing fire, Captain ltiralsh beg~~n reduc- key landing . ing the residual diesel fuel in the hellv tanks as he continued his ft~rpless, gear Second Lreuten~jnt position for a forced The completion of a compressor stall u a ~raach . Ca tain lti'alsh shut the en ine u1f ~rior to touch down, landed Nelder quickly p pl p K E clearing procedure gently on the rumvay centre line, and kept the aircraft straight during the slide concluded that a resulted in no engine response . by using rudder . The aircraft camc tu a halt with minintal darnage . succcs5ful landrng rec~uired an engine Captain VandenBos executed a flaw- (;aptain 1~'alsh's calm and thoroughly professional handling of a highly unusual less forced landing. After touchdown, flamc uut, f[c posi- and hazardou ; ~ittration }~rc~°cntr~l 1hc li~s~ ol a ~~alual~le ~rviatiur~ resource. tioned the aircraft as the EGT continued to nse, he L1t'll tf0llc'' " at an airspced and placed the throttle to the cutoff altitude that would position and allowed the aircraft to allow him to com- roll out onto a tax~way . Subsequent plete a dead-stick inspection revealed significant damage landing. At a dis- to a first stage compressor blade Master Cor P oral Catherine Picard tance of tive miles Captain VandenBos's timely, efficient, During the summer of 1997, 10 Field Technical Traininy Squadron held a from the aerodrome and professional reaction to a critical Hornet 30-day seat check re-qualification session Master Corporal Picard was he tlamed out the and unexpected loss of power pre- monitoring the candidates' level of comprehension in the practical phase of engine and executed vented the loss of a va~uable aviation ground egresses . She noted one candidate making a serious sequence error in a flawless engine out resource. Well done~ " the ground egress procedure by omitting a crucial step . If the omission took pattcrn and landing. place in an actual emergency the individual would be unable to escape from the aircraft. Second Lieutenant Cor P oral S. Brassard Master Corporal Picard followed up her findings and discovered that the Nclder's calmnes5 Corpural [3ra~sarci, avirrliun an squadron was omitting this step in their unit training . She immediately took and professionalism teihnician empluyed on peacekeeping action to rectlfy the problem and notified the Wing Flight Safety Officer. Her when face:d wrth an dutic, in 1 laili, was perfurminK a emergency srtuatron actions were directly responsible for the development of a Wing Seat Check nit;httime "r1" check on a Twin Huey Standardization pollcy. allowed him to helicoplcr wh~n he ubserved some- recover his aircraft thing w~usu~tl about the tail hoom Master Corporal Picard's dedication, professlonalism and immediate actions situation . Well done! " safely, tib'ell donc'! " le(t h~rnd lower mcrunt . '[i~ investig~~te resolved an unacceptable further he requested an assist~jnt to tihake the t~ril uf the aircraft, which cau~ed the crack to open and be Corporal K .H . Smit visible to, the naked eye. (,urporal Brassard imruecliatelv nutitied his Corporal Smit, an avionics technician newly qualified as a start controller, was per- crew chief and the aircratt was hlaced forming hls first unsupervised night start after a desalinization and airframe wash uns~rviccablc . Cor oral Dou las W. Dupuls on a Twin Huey helicopter . While conducting the start check on the number two p g eng~ne, Corporal Smit noticed liqu~d in the vicinity of the fuel filter which easily Further exarnination revealed that y'~'hile prep~rring to luad trei~ht on an outhuund aircraft, Curpor~rl [)upuis obscrved could have been mistaken as wash effluent . He investlgated further and concluded thr litting hacl failed thus seriously a f Irrcules aircralt backirt ~ out under its own [~o~ ;~er frc~m the emharkation t~~cilitv. that the fluid was fuel leaking from the eng~ne fuel outlet line . compromisint; the ;tructural He noticed that the ramp support had heen lclt in the luadin~ position outside the Corporal Smit alerted the pilot who in turn shut the helicopter down Detailed intct;rit~~ ul thc tail bourtr . aircraft and was in danger of being run uver. Rcalizing the dama~e the support exarY~ination revealed that the number iwo engine outlet fuel line hiad cracked . could cau;e tn the aircraft, Curporal Dupuis imrnrdiately ~ontactrd his supervi~or, The inspectic~n of the motmt is who in turn passed a stup taxi message to the ;iircraft commander . In nlqht tirne field conditions, with substantial water remaining in the engine compart- nurn~all~~ conducted onlv, on primary ment from the airframe wash, Corporal Smit's professionalism and attention to detail inspections . Despite the night fic[d The aircraft was halted just in timr tu prr~rnt has in[; its main lan~iin`, ~ear run t,~er revealed a dangerous fuel leak which undcte~-teri ~ti~~~-~ c1 ha~,~k~ ;cri~~~,sly pnd~~nnnroc~ conditions, Corporal Rrassard's hrufes- the now to 11> >led ram [~ su [[>,ort . both the crew and aircraft . Well done! " tiionalism, attentiun tu detail, and Corporal Dupuis' expeditious and professio~lal a~tic~n; pre~cntcd seriuu ; ,rn~i ~c~~tl ; ~oniprehensive knrnvledge of the ci ;tma e to ~i Hercules aircr~ift . 11'e(1 donc' " airtrame, allo~~~cd him to identify ~t dankerous structural fault.11~e11 dorre! " 26 Flight Comment No. 3, 1998 Flight Comment No. 3, 1998 27 Cor P oral Crai 9 5 . Larawa Y Cor p oral Bruce Wentzell C~rporal Laraway was carr~~ing out an acceptance check on a recently Shortly after receiving three T58 Cor P oral Leon H Y nes arrived I lornet engine. ~'~'~ule conducting his visual inspection he cn ine lube tilter ~~ssernblies trom g Durlng a perlodic inspection notiied a black object which I~oked like an o-ring cvrapped around the supply, Corporal ~4'entzell proceeded on a Hornet aircraft Corporal sump scavenge line. On closer inspection, ~s~hich included the removal of to disassemble them far further Hynes noticed that the ECS the line, he discovered that a blankin~ hlug had been inadvertently left inspection prior t0 1llsta11~1t10n . valves were covered with a on whcn the line was installtc~ . ,Although this procedure was nat red dye . Realizing that the dye mandatory, past experience had resembled that used for fuel The location ol the line is in an area diiticult to access under the engine shown that engine oil tilter wafers tank leak checks, and know- between accessory components . A detailed inspecti~n of this line is not have been inadvertently mixed up ~ng that there should be none n~rmally part of the acceptance check, as the line tittings do not reyuire with fortivard tr

28 Flight Comment No. 3, 1998 Flight Comment No. 3, 1998 29 Cor p oral Brian Mclnall & Private Chris Cilson Cor p oral Alain Poirier & 11'hilc retrieving ilight line pavs~er units, Corporal Cor p oral Frank Ber er t9chtall and Private (Jilson notiiecj a I~ool uf hvdraulic, During a turnaround on a Hornet tluid near the main landing gear zone on a Silver Star aircraft Corporal Berger noticed parking spot .'1'he airiraft, ~~~hich had been there, had that the cotter pins on a trailing recentlv been dispatched ittto hoor weather conditions edge flap aduator appeared t~tr blue vvater tli b7ht o I~erations . Realizin f; that the abnormally loose. Corporal Berger iruplications of their discovery were ~ritical, Corporal immediately brought the condltion ~lclnall and Private Gilson immediatelv intc~rmed to the attention of Cor A oral Poirier thrir su 1 ~ers'isor, ancf the Silver St~rr ts~as recallcd to an experienced AVN technician, the rantP thrc~ugh tc~wer frequency. who confirmed the abnormality Corporal Rod Allen and determined that further investi- 11'hcn thc aircralt vvas shul down Corporal h-9c1na11 During a hot turnaround and crew gation was warranted. anci Private Gilson's suspicions were contirmed as change of a Griffon hellcopter, inspedion of the trailing r hydrauli~ Iluid was rapidly being purged from an Closer Corporal Allen initiated a visual inspec- edge flap actuator assembly unservtces3ltlc shuttle v;tl>>c', t~on engine compartments of the . revealed that a bushing required to 1~'ithout lhc yui~k professional decisions madc by He ascertained that there was a fuel support the main bolt through the pressure line leak on the number two (_;orporal hlclnall and Private (iilson an aircr;ttt trailin g ed g e fla p hin 9 e was missin 9 engine. Corporal Allen immediately would havc departcd with a Potcntialh~ clisastrouy A considerable amount of damage notified the alrcraft captain and a unserviceabilitv . I1i'll dvrtc~' " to the actuator eye end, flap hinge shutdown was carried out . and attaching hardware was also Subsequent maintenance action discovered . Ca p tain Kevin.E . Mornin 9 revealed that the number two fuel There was no visible indication of pressure line fitting was loose . (;aptain Morning, a (;rilton Pilot the problem other than the loose ;rt ~I()3 ~yU;lljr(lrl (~a~,et(1W11, 11' ;iS Corporal Allen demonstrated a high cotter pins. Corporal Berger and During a cargo area ' walktng tnward an au'cratt when he level of professionalism, in~tiative, Corporal Poirier's keen attention to ins P ection Master noticed a piece of darkened ntetal and attention to detail . H~s actions detail and their rneticulous follow broke the link in a chain of events up actions higlhlighted a problem Cor P oral Tom P kins, a ' lying on the r~3ntp. loadmaster with 435 _ that could have lead to a seriou~ that could have created a cata- Squadron, noticed a !~ Captain Ivloruing immediatelv incident ar acudent Well donel " strophic event. Well done! " wooden plug handle ' - rc I~orted the f~~rei bJn ob~ect1 , which vibratrng loosely on the , ti~~as then p;tssed to servicing. ~ti'hen emer 9enc YqP e ui ment ~r_- ` it beiame ;tpParent that the piece . Further was from the " hot end " of an storage rack , insp ection revealed six enginr, the syuac3rc~n s aircrait were mare loose plugs and recalled f~r inspection . The shard Corhoral I~orster was tasked to carry out a GPti mudification cnn a one plug missiny alto- tvas founcl to br front thc rxhaust Hercules aircratt . The tti~ork reyuired the remov;il ol an access panel gethec Master Corparal stack of (~riftitn ~t4t3 . Clnse inspec- that is not normally ohenecl, After complcting his dutv in the area Tompkins recognized tion rcvc;rlccl ,tdditiort ;tl rracking Cor1 ~oral Forster comrncnccd a FUU rhrik and discctvered a sntall that the missing plug which, had it gone unnoti~ed, would Piece of metal approximately one inch lonf;. l,oncerned ahout the could cause a serious havc resultcd in picces ol rttetal tinding, ancl although it was not lr;rde rclaled, he inspecteci everv FOD hazard . A Special heinf; eiected ii~om the tail rotor com f~onent in the area in an eff~rt to determine the ori hiin of the Inspection was conducted and Master Corporal Tompkins possihly c~jusin~ signiticant damage object . Fttrther investi ~ation by ~ CorI ~oral horster revealed that the UCR in which he recomrnended securing the plug with a tc~ thc air~raft and injury to person- itent, and other.5 like it, were rollers from the co-pilot's rud~er pedal Although Master Corporal Tompkins' onginal UCR was rejected, and the ncL r1n e~haust ~taik of~ another acljustmenl arnt shalt . (~riffon was alsc~ changed as a reinstallation of loose plugs continued using adhesive, he continued to CorPc~ral Fc~rster immediately informed his supervisor of thc fault, hreixutic~n . monitor the situation . Further investigation revealed that the adhesive was C'pon cctntE~letic+n c~l another inspection it w;ts ciuiot~ered that onlv drying out during normal flight and the plugs continued to pose a FOD Captain mornins;'s E~rol~essionalism, twc~ rctller he;u'in 1 .~ in the assen~hlv, h ;~d rentained intact . hazard . The original UCR was adopted and is being implemented . initiativc°, anci attenlion t~ detail Corporal horster's protessionalism and attention to detail hit;hlightrd Master Corporal Tornpkins' professionalism, perseverance, and attention avcrtcd a scriou5 llit;ht ~al~'tti~ an unserviceabilitv that if lett undetectecl ~cnrld ha~r ~~sral,rte'~I in~c~ to detail prevented a potential serious occurrence. Well done! " occurt'ence.ll~i'flcinrtc'' ~ ;t ver y~ serious tli 7ht cc~ntrol m;rltunctirnt . 11'~~11 c~c~ne.' "

30 Flight Comment No . 3, 1998 ------Flight Comment No. 3, 1998 31 8661 'E ou 'lon ap sodo~d ZE

Ca P tain John Stirton Captain Gre 9 Carlow 11t the tinte of the incident Captain W'hile performing at the Quinte Stirton was controlling traftic on the International Airshow Captain " uoilpntis outer runwav at ~7uose )ati,~ on which Carlow, the Snowbird number three el ap tuawanouap xnaanay,l e .r Tutor was cor~ductin g sunulated inner left wing pilot, experienccd a atueu~waa~ap ata e 'satuanbasqns emergencies. Upan turning a short ~umpressor stall and a loss of thrast . sa yooadde sa I tue P uad aaansse. base leg, the student pilot requested 'fhe power lo5s occurred immediate- 1a awlea apnti~e uos e aauiqwoa a touch and go landin g ~tnd con- Iv follotving an inverted pass at tlaree ' I.ia~edde, I a P a~ua6~n .I e. a~o P e W tirmed that the gear was down and hundred feet above g round level . leaode~ np ate~pawwi uoiheaa e~ locked . L~tnding clearance was given Unable to rnaintain posilion in thc ~aaneab6e,s ap a~ua6an with a recuntirmation ot the landing formatiun and detecting a strong aun ay~adwa e inb a~ 'alqluodslp grar posiliun rcyucstcd and rc~cived . vibration, Captain Carla~, reduced atiwi. . .I tuean ~ ea n P aoeai.li a sn I d e I the throttle tn idle to clear the stall uoqesili}n,l ~ansse e lewiuiw lueanq As the aircraft ahproached the run- at which time the engine llamed out . way and commrnccd the roundout -ae> >ane sayaoadde sap aan~a~a,p tor landing (Japtain Stirton observed (;apt~ain Carlow quiikly turned alolid ne uo~tsa66ns es uoine,l ap uoqentis el ap tueano~ ne tuaie}a , ~ ~aaluan al that thc landing gear ~~~as not down . awav from the spectator vietiving saasin sauuosaad sal anb tuernsse,s ans a~tc55uaaitr un astnpuad as au anb CaE)tain Stirton rnade all 1rllnledlate area while simultaneousl Yl~erform- ua ta sawsiue6ao saani sa aalua atrna auo asrad r h nb aansatu el anb radio transmission and the QFI on ing comprcssor stall clearing and " ~stuasaad sanaletaads sap ~tiin,is rf . p I au>'ansst~ ua asnar»ad uoileuipaaoa el tuemsse 'uoilen~ls rsutt' uotarlS aureatdr,a np aan~tuatuald bo~trd tuok control ,tnd conducted forced landint; ~rocedures . The tnot anbraneuoaae ~1 e asuliew e aao e e~ode~ a -dns tao a~ta ~a~essnaaaat~ ~t~ taat~dde an overshoat. Subsequent discussion puwer plant continucd to refuse to aamossaa aun aapaad ap aatma,p srur.rad I . . . PWI I JJ ~ . ,1 .1. luu saluyiil> tuauraruaat.xa sa,uets 'inms tuo mb snpua} stuawow un,p uoilt~an~rtuo, r~l auatuallans~n with the QFl revealed that he had respond and Captain Carloss executed -uo,ara sap surp ;tiolar_~ atnt~t~d>', np sap sanoa nd ~aleuil a~noa ua aarti.r~n ap snuat sr.d tuus au auuaraae not veritied the landing gear dotti~n Cor oral Gar Madore a llawlrss forccd landrng. p Y sa~ttdoadde ta satrq»wwf saansaur sa~l awnlle tsa,s pllinoaaan uou ayane6 uoitr.lnaaia cl ap sanalgaauo, saq contirmatton and il)at the student Corporal Madore was controlling Captain (-;arlow's iorrect and immedi- uieaa tuer(on al anbsaol (ayd) aepea had failed to select the gear down. 'afyt''aadtur a_~aot ~uieat al artaos a Silverstar aircraft on a PAR ate actions under extremelv di$ictilt ne uoisuaad ap ay~oadde aun ~nod approach a~essiaaatae un atn,axa s.tult~ r ntiul.rr~ J ap situo tit~nt~ aaft~i~r'ts al anb ta it.ros Air traliic contrullers have no when it experienced circurnstances prevented thelossof a aetsaanli5 uoine un aaloatuoa ap an unsafe left main landinq aurrlrdra al ta'aaolid np suorteaiatllos ireia ur~al al anb aur .tyuoa sed trt?nr u requirement to visually verity the valuablc ~tviation rcsource while also uieat ua tieta aaopeW leaode~ a~ gear indication on short fmal . xne aapuodaa ap aasniaa t~ anurluo~ t~ ~ L~i nb~a, Lanaa , tuo ar, r enb .rnaa ~natsur. landing configur,ttiun of an rrircraft, enstu~ing the safety of the spectators .i.f During the tense moments that anatow ay ~».rol a~t~ssula>>r un p ann ua aJ0 ~w J~.l~ pJOdp -alolid al ~anr sluanbasyns suaitaatua Captain Stirton's extra effort and in attcndancc. It'c(l clonr! " P ~I followed, Corporal Madore saanpiaoad sal tuentaa}la ua ta anassaad sa (l- ~zr~ sa P asnuaa. aun aana,aIJ a ~tction prevented a wheels-up , maintained control of the situa- -uro~ ailr~rl .~o.r,ap np sr, al .ral~aa anod anod saptrrttrruua sal srad e E~aoq e landing . jl~ell cfarte' " tion, coordinating between the saansalu sap tueuaad ua lnut sanatrtaads ata .lr t~n6 anaaanaasur-aao. Lrd al ta'or.P ea various agencies and ensuring all sal urai>'nno.rt as no auoz el ap tacaa ! ard anbiununuo~ ~uauraa>'rpatuun e personnel ~nvolved were aware r aarn . taatua 1 ~rdt~a e nto 1 atr ~ aurctide,. , a `I Il ~rtaos. sed ttt~ta. , u a~essuaaate. ,P urt~aa. of the status of the aircraft. His aI anb anhartuaa, r uotar.tS , auir~, t.rd}~a ~turita ~sa s ana~our suggestion to conduct "min al `aasod as anod tpuoaaa,l tiewetua ta al ta `a~t"tl:~uaa~p ne ui{ aauaru anod fuel" approaches assured the a~Sili. I? lEa 1 tit'l. [ JOJdlir' Uoln1'. ,I atUlUO rtualt+a nr zt?~ sal irnpa.i t~ swlar~ aumt rnost effiaent use of the limited -rdt~a al `uoqr.ryr :~ at.rut aun aurauassaa ~an~aa ta fuel availabte, thus preventing ta uoqetuaoi r~l ap uias nt~ uortrsod es aapueutap ata e uieaa np troit~sod t~l ap the emergency from deteriorat- atuaaun~tu ap .~lcledr,u~ ~los np snssap-nt~ Uu1~ClUlI. .1 Uo~a.l C 1 ta `aa. P a01Jt' ata. . E' aiit'S ing into an even worse situation. spa~d saua, sroat E~ sop al ans a~r~sshd -sraaal~e p uortesraop~r auj~ ~~llrnoaaan Cor p oral Madore's immediate un saac{e tuawaleiparulur aampua~l tsa,s aa iaaos an~ta urt~aa al anb autayuo~ t~ la response to the aircraft emer- aluessnld. a p ataad rI ~a~ucssrnd. e 1Pa allonap-asod tm aant,a,ffa,p ?pururap e gency, combined with his calm, npaad e ta .inassaadwo, a~eyaoraap un ~a.rrrr~els. . aao l.id a 1 `asr y a 1' adt~ta aaanoa controlled manner during the ryns t~ `uoiaruuol r~l ap atlanr~~ anauatur ua aatn. . arune. sald, 1~ ~anbrtu~, , uot~tm~rs, . subsequent approaches, played .,atua n p stoaa. naarurtu. [~arc.l ntou,5 n E~ alol .id ap suortt~lrnuts sa p t~ aie~a,xa s aotn,L a key role in assuring the timely `MOl.re~) auirtidra al `atutn~t ap lruoit un no~'nr~ I asou ltir t~. aanaual~a. . atsid. and successful resolution of the -euaalut uaraan al~riaads np aapt~a al surp t~l ap ayt~al al an~lu.rluo, uutart~ uyol . situ~t~on Well donet ~ uaraac. , a l~,el~ads ua ltt~n. [ ona. L,r nb sao I~ ~ aurea~de, al `tuapf,ui,l ap tuatuotu nb. nno I ar'~ ~aa~ auietid~e~. uo~its u o~ auietide~

32 Flight Comment No. 3, 1998 -