AeroSafety WORLD
787 CLEARED TO FLY Battery solution OK’d GO-AROUND RESEARCH Part 3: Inspiring pilots’ choices FIRST 1,000 MPL HOLDERS ICAO’s initiative marks five years
HIGH-CONSEQUENCE BEHAVIORAL ECONOMICS DEMANDING DECISIONS
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AeroSafty World full-page.indd 1 02/05/2013 14:10:36 PRESIDENT’SMESSAGE
AVIATION SAFETY in India
uch has been reported over the past two to not allow aircraft to land or take off on runways months concerning aviation issues in In- that will not support their size or performance. dia. Safety, security and cost reductions More air service will mean more air traffic, have dominated the stories. The director which means that the infrastructure will have to generalM of the International Air Transport Associa- be updated to meet demand. Air traffic control tion, Tony Tyler, this year has spoken about Indian systems will need to be designed and control tow- aviation in three major speeches. His remarks have ers built; in addition, qualified personnel will be focused on the great potential of the market, and needed to run the system. Revenue from airport how we must overcome some of the major issues charges must be allocated to help improve the faced by the aviation community in India. infrastructure and lessen the risk. A number of safety issues remain daunting Commercial and business aircraft operators challenges for the country and its civil aviation will need to exercise caution when they operate authority. India’s fiercely competitive aviation into areas of the country in which airports are not sector will have to become more stable to support as well developed as some of the major cities. Fuel a quickly growing domestic demand for air trans- quality also could be an issue. portation. There are more than 1.2 billion people The government of India is working hard in India, but only a very small percentage fly. As to ensure that the International Civil Aviation the demand for air travel increases, India will face Organization’s standards and recommended growing pains related to the country’s poor airport practices are being followed. However, if there is and air traffic infrastructure. Take these two issues poor oversight due to a lack of qualified personnel, and add to them rapidly expanding air carriers and then the infrastructure will not improve and the you potentially have the components for a very inherent high safety risk will still be there. There high operating risk. are some measures that are being worked on at As you know, the Foundation is very proactive this time, and hopefully they will help in resolving in supporting runway safety. Basic items associ- the major issues. ated with runways such as adequate markings, signage and lighting need to be standardized and installed at all airports in India that support com- mercial and business air traffic. Incorrect runway rubber removal procedures exist at certain air- ports, which will make the runways slippery after Capt. Kevin L. Hiatt rain. Correct classifications of runway length and President and CEO clear areas need to be conducted and verified so as Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2013 | 1 AeroSafetyWORLD
contents June 2013 Vol 8 Issue 5 12 features
12 CoverStory | High-Level Decision Making
18 FlightTraining | Multi-Crew Pilot License
23 MaintenanceMatters | LOSA Data Prospecting
28 FlightOps | Go-Around Reasoning
34 SeminarsBASS | FOQA Lessons in Business Aviation
38 SafetyRegulation | 787 Fleet Resumes Flying 18 43 CabinSafety | Emotional Awareness 23 departments
1 President’sMessage | Aviation Safety in India
5 EditorialPage | Positive Focus
6 LeadersLog | What Isn’t Happening
8 SafetyCalendar | Industry Events
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2013 34 43
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AeroSafetyWORLD telephone: +1 703.739.6700 9 InBrief | Safety News Capt. Kevin L. Hiatt, publisher, FSF president and CEO 50 DataLink | Analysis of 2012 SMS Audits [email protected] Frank Jackman, editor-in-chief, FSF director of publications 52 InfoScan | Harmonized Accident Data [email protected], ext. 116
Wayne Rosenkrans, senior editor 57 OnRecord | Overrun at Khartoum [email protected], ext. 115
Linda Werfelman, senior editor [email protected], ext. 122
Rick Darby, associate editor [email protected], ext. 113
Jennifer Moore, art director [email protected]
About the Cover Ultimately, the final result of a high-consequence Susan D. Reed, production specialist decision may depend on one aviation leader’s [email protected], ext. 123 ability to objectively weigh salient facts. © Andreus | Dreamstime.com Editorial Advisory Board
David North, EAB chairman, consultant
We Encourage Reprints (For permissions, go to
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2013 | 3 Serving Aviation Safety Interests for More Than 65 Years OFFICERS AND STAFF ince 1947, Flight Safety Foundation has helped save lives around the world. The Chairman Board of Governors David McMillan Foundation is an international non-profit organization whose sole purpose is to President and CEO Capt. Kevin L. Hiatt Sprovide impartial, independent, expert safety guidance and resources for the General Counsel aviation and aerospace industry. The Foundation is in a unique position to identify and Secretary Kenneth P. Quinn, Esq. global safety issues, set priorities and serve as a catalyst to address the issues through Treasurer David J. Barger data collection and information sharing, education, advocacy and communications. The
ADMINISTRATIVE Foundation’s effectiveness in bridging cultural and political differences in the common Manager of cause of safety has earned worldwide respect. Today, membership includes more than Support Services and 1,000 organizations and individuals in 150 countries. Executive Assistant Stephanie Mack FINANCIAL MemberGuide Financial Operations Manager Jaime Northington Flight Safety Foundation 801 N. Fairfax St., Suite 400, Alexandria VA 22314-1774 USA tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org MEMBERSHIP AND BUSINESS DEVELOPMENT Member enrollment ext. 102 Senior Director of Ahlam Wahdan, membership services coordinator [email protected] Membership and Seminar registration ext. 101 Business Development Susan M. Lausch Namratha Apparao, seminar and exhibit coordinator [email protected] Director of Events Seminar sponsorships/Exhibitor opportunities ext. 105 and Seminars Kelcey Mitchell Kelcey Mitchell, director of events and seminars [email protected] Seminar and Donations/Endowments ext. 112 Exhibit Coordinator Namratha Apparao Susan M. Lausch, senior director of membership and development [email protected] Membership FSF awards programs ext. 105 Services Coordinator Ahlam Wahdan Kelcey Mitchell, director of events and seminars [email protected] Consultant, Student Technical product orders ext. 101 Chapters and Projects Caren Waddell Namratha Apparao, seminar and exhibit coordinator [email protected] Seminar proceedings ext. 101 COMMUNICATIONS Namratha Apparao, seminar and exhibit coordinator [email protected] Director of Website ext. 126 Communications Emily McGee Emily McGee, director of communications [email protected] Basic Aviation Risk Standard GLOBAL PROGRAMS Greg Marshall, BARS managing director [email protected] BARS Program Office: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia Director of Global Programs Rudy Quevedo tel +61 1300.557.162 fax +61 1300.557.182 Foundation Fellow James M. Burin
BASIC AVIATION RISK STANDARD BARS Managing Director Greg Marshall
facebook.com/flightsafetyfoundation Past President William R. Voss @flightsafety Founder Jerome Lederer 1902–2004 www.linkedin.com/groups?gid=1804478
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2013 EDITORIALPAGE
POSITIVE Focus
uring my 30 years in journalism, I have been Report (see InfoScan, p. 52), and amid all the asked numerous times why the news me- charts and graphs and verbiage about accident dia tend to focus on the negative. “Report rates, safety issues and volcanic activity, there the good news for a change,” I have been were a few paragraphs and some numbers about Dadmonished more than once by friends, rela- Africa. The region accounted for only 5 percent of tives, sources and strangers on the street. When total accidents, as defined by ICAO, in 2012, but I was younger, I’m sure I had a standard reply 22 percent of all fatal accidents and 45 percent of that involved an eye roll (learned from my father, all fatalities. Neither of those last two numbers is a career newspaperman) and a snide comment good news, and the first one is more of function about how no one cares that something worked of market size than anything else. as it was designed, or that good news versus bad But deeper into the report, there is some news is like beauty — it resides in the eye of the positive news that is worth sharing. According to beholder. What is bad news to one side of an argu- ICAO, Mali, Mozambique, Rwanda, Seychelles, ment is euphoria for the other side (try searching Sudan and Zambia have successfully resolved “elections, presidential, U.S., 2012”). previously identified, significant safety concerns. But in the world of aviation, particularly in Additionally, Mauritania and Sudan have met flight operations, that relativity seldom exists. If the Universal Safety Oversight Audit Programme a component malfunctions, or a process fails or a (USOAP) target of 60 percent effective imple- human makes an error, the results can be tragic. mentation of safety-related ICAO Standards and I was stopped in my tracks a few years ago when Recommended Practices, and “significant im- I heard someone describe aviation as “low prob- provements” also were noted by the USOAP in ability, high consequence.” The likelihood of an Benin and Madagascar. accident occurring is extremely low, but when one Much remains to be done in Africa, but prog- does, people sometimes are killed. ress is being made, and it is up to all stakeholders to Over the years, I’ve mellowed, and I now continue to aid in the region’s safety development. see a need to report the good news along with the not-so-good, particularly in aviation safety. When progress is made, it should be highlighted so others can learn and recognize what works and what does not. Frank Jackman Recently, the International Civil Aviation Editor-in-Chief Organization (ICAO) released its 2013 Safety AeroSafety World
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2013 | 5 LEADERSLOG What Isn’t Happening Let’s expand predictive technology.
BY JOHN M. COX
n a clear winter night, the jet- commercial aviation. A new technol- This potential wind shear accident liner begins a normal descent ogy, the ground-proximity warning did not happen. for landing. The descent profile system, which arrived in 1995, could A third example of commonly used is loaded into the flight man- predict the threat and warn the crew predictive technology is the traffic-alert Oagement computer. Air traffic control in time to react. Other types of acci- and collision avoidance system (TCAS). (ATC) asks the crew, “Airport and traf- dents were reduced by predictive tech- TCAS monitors the altitude and direc- fic in sight?” Visibility seems assured. nology. Predicting a wind shear before tion of other aircraft for any threat. If a “Cleared for the visual to Runway 26, the airplane encountered it became threat is predicted (based on projected follow company traffic 5 miles ahead,” possible, and fewer accidents resulted, trajectory), then a climb or descent the controller directs. The first officer as in this example: instruction is issued to the flight crew responds, “Cleared for the visual; we The jetliner is slowed in anticipa- to avoid the oncoming aircraft. will follow company.” As long as they tion of possible turbulence. Numerous Thanks to TCAS, many potential monitor the speed and do not overrun thunderstorms are in the area, but other midair collisions do not happen. the company flight, this will be routine. flights are successfully landing. On Imagine predicting the impending As expected, the altimeter smoothly the weather radar, the intended flight failure of components prior to failure. unwinds and the crew comments on the path looks clear. The captain and first In that case, the catastrophic clearness of the desert sky. Suddenly … officer have seen days like this many engine failure of Qantas Flight 32, where did the runway go? It was there a times before, but they are cautious. ATC an Airbus A380, near Singapore in moment ago. “CAUTION TERRAIN,” carefully threads the flight between the November 2010, could have been pre- the synthetic voice calls out. Terrain? storms. The final approach course is dicted. Technology is rapidly develop- The crew is certain their airplane is well clear. “Turn right heading two one zero, ing that will be able to make such a above the ground. This must be a nui- maintain two thousand five hundred prediction. Its cost may be justified by sance alert. “TERRAIN AHEAD, PULL until established, cleared for the ILS improvement in reliability and opera- UP!” Quickly the captain disengages the [instrument landing system approach tional efficiency. Safety and economics autopilot, increases thrust and begins to to] Runway one eight right,” the control- can mutually benefit. climb. Only then do both pilots realize ler directs. The crew acknowledges the Along with crew resource manage- how close to the ground they were. The clearance and listens carefully for any ment, upset recovery training and fatigue mountains recede and the airport again comment from the preceding corporate management, we should expand predic- becomes visible. The mountains were jet. Suddenly, “WINDSHEAR AHEAD, tive technology to increase the number of between the jetliner and the airport but WINDSHEAR AHEAD,” the synthetic accidents that do not happen. completely dark. voice calls, and the weather radar now Capt. John Cox is the chief executive officer This controlled flight into terrain displays a large red danger area. Both of Safety Operating Systems. He is a 42-year (CFIT) accident did not happen. pilots recognize that weather is radically aviation veteran with experience as a corporate For many years, CFIT accidents changing. They climb the jet and turn it pilot, airline pilot, instructor, test pilot and were the leading cause of fatalities in away from the developing wind shear. safety professional.
6 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2013 CASSIOPÉE PUT YOUR FLIGHT DATA TO WORK © Service Sécurité Sagem Défense communication
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cassiopée_215,9-279,4_2013-02-14.indd 1 15/02/13 15:09 ➤ SAFETYCALENDAR
JUNE 2–13 ➤ Aviation Safety Management JUNE 21–23 ➤ Flight Attendants/Flight AUG. 19–22 ➤ ISASI 2013: Preparing the Systems. University of Southern California Technicians Conference. National Business Next Generation of Investigators. International Aviation Safety and Security Program. Los Aviation Association. Washington, D.C. Jay Evans, Society of Air Safety Investigators. Vancouver, Angeles. Raquel Delgadillo,
8 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2013 INBRIEF Safety News Reversing Overruns
anadian airports need the longer runways being pro- Under a TC proposal, many runways at Canadian airports posed by Transport Canada (TC) as a defense against would be required to install 150-m RESAs. Some airports Crunway overruns, which occur about once a month, already have installed longer RESAs, including the Macdonald- Wendy Tadros, head of the Transportation Safety Board of Cartier International Airport in Ottawa, which installed 300-m Canada (TSB), says. RESAs at both ends of one runway in 2012 and plans similar Tadros said, in an article in the Canadian Skies e-newsletter, work at another runway this year. that Canada’s current regulatory standards are “disappoint- “While the TSB understands that solutions to overruns can ing” in that they lag behind international standards and best be expensive, doing nothing may ultimately cost even more,” practices. Tadros said, citing a Flight Safety Foundation study that found The current Canadian requirement calls for a 60-m (197-ft) that, between 2005 and 2007, runway overruns cost the aviation buffer at the end of any runway that is 800 m (2,625 ft) or lon- industry $506 million a year in damage, delays associated with ger and recommends an additional 90-m (295-ft) runway end down time and litigation costs. safety area (RESA) for runways that are 1,200 m (3,937 ft) or She said that reducing runway overruns across Canada “will longer. The International Civil Aviation Organization requires take numerous lines of defence,” including improved measure- buffer strips of at least 150 m (492 ft) but suggests that 300-m ment and reporting of runway surface friction, or installation of (984-ft) buffer areas would be better. longer RESAs or arrestor beds.
Repair Station Oversight
he U.S. Federal Aviation Administration (FAA) lacks “effective standardized processes for identifying deficiencies” at aircraft repair stations and for verifying that the deficiencies have been addressed, according to a report by a government watchdog Tagency. The Department of Transportation’s Office of Inspector General (OIG) said, in a report released in early May, that because of the lack of standardization, its inspectors found “numerous systemic discrep- ancies” at repair stations visited during its review of the FAA’s repair station oversight. The FAA oversees operations at 4,800 aircraft repair stations used around the world by U.S. air carriers. “We found that while FAA developed a risk assessment process to aid repair station inspectors in identifying areas of greatest concern, its oversight continues to emphasize completing mandatory inspections instead of targeting resources where they are needed, based on risk,” the OIG report said. “Less than half of its inspection elements are evaluated based on risk, and foreign repair stations are not inspected using a risk-based system.” The report also said that the FAA has not followed through on a promise made five years ago to give inspectors national data analyses that would improve their ability to evaluate repair stations. In addition, inspectors sometimes overlooked repair station problems and failed to check on whether previously identified problems had been addressed through corrective actions, the report said. “For example, an FAA inspector determined that a repair station failed to maintain a current list of required mechanic training three years in a row, yet the inspector accepted the repair station’s corrective actions each time,” the report said. The OIG issued nine recommendations for improvement, including implementation of a risk-based system for oversight of foreign repair stations, development of a standardized checklist, and enhanced training for inspectors. The FAA concurred with all nine recommendations and said that it plans to implement a new oversight system in the fiscal year beginning Oct. 1, 2014.
© poco_bw|istockphoto.com
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2013 | 9 INBRIEF
Laser-Strike Protection Sought
ore than 12,000 aircraft laser strikes were reported in the United States between 1980 and 2011, with 88 Mpercent involving airplanes, according to a report by the U.S. Federal Aviation Administration’s Civil Aerospace Medical Institute (CAMI). About 18 percent of the laser strikes (also called illumina- tions) involving airplanes occurred in the so-called Laser-Free Zone of 2,000 ft or below, while 70 percent of helicopter strikes occurred in that zone, the CAMI report said. Helicopter crewmembers were more likely than their coun- U.S. Department of Transportation terparts in airplanes to report adverse effects stemming from laser strikes within the Laser-Free Zone, the report said. This in ways that could warrant policy changes to better protect may be, in part, because the large bubble canopies on helicop- pilots, the report said. ters can allow more light to enter and reflect throughout the The report’s authors said that because of their findings, as cockpit, the report said. well as the nature of helicopter operations, “special protective The report’s authors said that because of their findings, as and preventative measures may be needed for helicopters and well as the nature of helicopter operations, “special protective other low-flying aircraft outside of designated airport flight and preventative measures may be needed for helicopters and hazard zones due to the higher percentage of illuminations other low-flying aircraft outside of designated airport flight reported and the increased rate of adverse effects associated hazard zones due to the higher percentage of illuminations with these events.” reported and the increased rate of adverse effects associated Their recommendations also suggested that authorities with these events.” consider equipping helicopters, especially those operated by law Their recommendations also suggested that authorities enforcement personnel, with laser-detection and laser-tracking consider equipping helicopters, especially those operated by law equipment “to improve the possibility of apprehending perpe- enforcement personnel, with laser-detection and laser-tracking trators of these offenses.” equipment “to improve the possibility of apprehending perpe- Continued monitoring of laser strikes will provide informa- trators of these offenses.” tion to help determine whether laser technologies are changing Continued monitoring of laser strikes will provide informa- in ways that could warrant policy changes to better protect tion to help determine whether laser technologies are changing pilots, the report said.
Autorotation Aid aft cyclic and down collective to achieve a successful autorotation entry at cruise airspeeds.” he U.S. National Transportation Safety Board (NTSB), citing The accident occurred about 1 nm (2 km) short of the the Aug. 26, 2011, crash of a Eurocopter AS350 B2 that lost Midwest National Air Center in Mosby, Missouri, U.S., when the engine power because of fuel exhaustion, says pilots should T engines lost power “and the pilot of the emergency medical ser- be given more information about successful autorotations. vices helicopter did not make the flight control inputs necessary The NTSB issued nine safety recommendations as a result of to enter an autorotation, which resulted in a rapid decay in rotor its investigation of the accident, including several dealing with rpm,” the NTSB said. mitigating pilot distractions and others that discussed the best The patient, flight nurse, flight paramedic and pilot were killed way of entering an autorotation. in the crash. The NTSB said the probable causes, in addition to One recommendation called on the U.S. Federal Aviation the pilot’s failure to successfully enter an autorotation, were his Administration (FAA) to “inform pilots of helicopters with low- “failure to confirm that the helicopter had adequate fuel on board inertia rotor systems about the circumstances of this accident … to complete the mission before making the first departure [and] and advise them of the importance of simultaneously applying his improper decision to continue the mission and make a second departure after he became aware of a critically low fuel level.” The NTSB also recommended that the FAA revise its Helicopter Flying Handbook “to include a discussion of the entry phase of autorotations that explains the factors affecting rotor rpm decay and informs pilots that immediate and simultaneous control inputs may be required to enter an autorotation.” Fletcher6|Wikimedia Commons
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2013 INBRIEF
Proposed Penalties
he U.S. Federal Aviation Administration (FAA) says it has proposed $4 million in civil penalties Tagainst United Parcel Service (UPS) for failing to properly maintain four cargo airplanes and oper- ating them while they were out of compliance with Federal Aviation Regulations. UPS is accused of failing to comply with FAA- approved procedures for making structural repairs SteveCof00/Wikimedia Commons to two Douglas DC-8s and two McDonnell Douglas DC-11s. The four airplanes then were operated on more than 400 flights between October 2008 and June 2009, the FAA said. “These violations stem from UPS’s failure to fully comply with the terms of a consent agreement in which the carrier agreed to inspect all aircraft in its fleet and compare actual repairs with maintenance records,” the FAA said. “This would have ensured the four aircraft were in compliance with the regulations.” UPS has 30 days after it receives official notice of the proposed penalties to respond.
Weather Worries SESAR Deployment
ustralian pilots and air traffic controllers are he European Commission has taken steps to encourage the “effec- concerned about thunderstorm forecasting tive and timely” transition to the Single European Sky Air Traffic Aand “untimely fog forecasts” at Australia’s Management Research (SESAR) program designed to upgrade the major airports, the Bureau of Meteorology says. T air traffic management (ATM) system in Europe. Nevertheless, the bureau says that an online The commission adopted a regulation specifying four broad areas survey, conducted in late 2012, found that 78 where action must be taken to support SESAR’s deployment. Among percent of respondents considered the agency’s the four are common projects “to ensure the deployment of ATM func- forecasts “mostly or always accurate,” and 80 per- tionalities,” government mechanisms for timely deployment of SESAR, cent believed that they were timely. Terminal area deployment programs to “translate common projects into detailed forecasts and trend forecasts were the most widely deployment activities” and targeted incentives for the coordination and used services, and 80 percent of respondents said implementation of those projects. they also used airport weather briefings. The commission also revised regulations associated with imple- The bureau says it is taking steps to improve menting the SES performance scheme, which establishes a framework thunderstorm forecasting through scientific for determining targets for the delivery of better air navigation services. research into enhancing short-range forecasts, as “Now that the framework is set, we will focus our efforts on the well as increased cooperation with the aviation adoption, by the end of this year, of realistic and ambitious targets to en- industry to “improve the aircraft meteorological able real progress … in particular in terms of cost reduction,” said Siim data relay sensors fitted to aircraft.” Kallas, European Commission vice president responsible for transport. In addition, a five-year program is under way to improve the accuracy of fog forecasts, the bureau says. In Other News …
The U.S. Federal Aviation Administration has ended the furloughs of air traffic controllers whose work schedules had been curtailed because of cuts in the federal budget. Transportation Secretary Ray LaHood said a transfer of government funds made it possible to end the furloughs and to keep open — at least through September — 149 air traffic control tow- ers that had been scheduled to close in June. … The International Civil Aviation Organization and The International Air Cargo Association have signed an agreement to bolster their cooperation in several technical areas, including efforts to improve air cargo safety.
© Robert Hackett|istockphoto.com
Compiled and edited by Linda Werfelman.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2013 | 11 12 NASA | and Bowties and Trees Decision COVERSTORY to enhancedecisionmaking. Sophisticated analyticaltoolsare available M line operations, ever-existing the threat of decisions, tools the matter. and, as insenior executives’ pilot-in-command responsibility deck, the flight lieswith the ing an management effective system. Onthe requirements establishing while and maintain- outcarried inaccordance with applicable the ensuring that financed and can activities be all accountable manager has who authority the for The high-consequence nature of air management the team, inparticular decisionthe making lieswith the shots.the In an airline organization, anagement ultimately means calling BY MARIOPIEROBON - ing factor. The O-ring failure caused abreach in atfailed liftoff, and cold weather was acontribut- shuttle’sin the right rocket solid (SRB) booster craft disintegrated over Atlantic the Ocean. deathsthe of its crewmembers. seven The space - broke apart 73seconds into its leading to flight, 1986, but never made it into space. The shuttle Kennedy Space Center inFlorida on Jan. 28, disaster. Flight STS-51L was launched from the safetyflight is 1986Space the Shuttle Challenger sensitive process. catastrophic failure, makes decision making a The accident occurred because an O-ring seal The accident an because O-ring seal occurred decision-makingA tragic failure related to FLIGHT FOUNDATION SAFETY |
WORLD AEROSAFETY | JUNE 2013 JUNE COVERSTORY
the SRB joint it sealed, allowing pressur- that people are motivated by impulses Common decision-making biases ized hot gas from within the solid rocket that are measurable and predictable, are numerous, and counterstrategies motor to reach the outside and impinge and often irrational.”1 exist for many of them. We have elected on the adjacent SRB attachment hard- Although the first research activi- to analyze three biases that are evident ware and external fuel tank. This led to ties in the field of behavioral econom- in aviation — non-systematic consider- the separation of the right-hand SRB’s ics date back to the 1970s, until ation of all options available; the avail- aft attachment and the structural failure recently the discipline was limited to ability heuristic; and groupthink. We of the external tank. Aerodynamic forces the academic world. However, since also will outline strategies for encourag- rapidly broke up the orbiter. the 2008 global financial crisis, behav- ing sophisticated safety-related decision ioral economics has started to receive making in aviation organizations. Flawed Decision Making more attention from policy makers According to the Rogers Commission and developers of risk models. Non-Systematic Consideration Report, produced by a U.S. presidential About the contribution of behav- Aviation organizations often require commission charged with investigating ioral economics to driving efficiencies multiple management systems (in- the Challenger disaster, there also was in decision making, Iris Bohnet, a be- cluding several trans-organizational a serious flaw in the decision-making havioral economist and academic dean systems), have dispersed operations, process leading up to the launch of and professor of public policy at the have many technical functions requir- flight 51L: “A well-structured and Harvard Kennedy School, said, “Theo- ing skilled employees, and are highly -managed system emphasizing safety ries assuming rationality — such as the regulated and characterized by over- would have flagged the rising doubts rational actor model used in economics lapping state jurisdiction.2 Within about the solid rocket booster joint seal. — prescribe what is optimal but do not this operational complexity, there is Had these matters been clearly stated do a good job at describing how people considerable room for inefficiencies in and emphasized in the flight readi- really behave.” decision making due to the difficulty of ness process …, it seems likely that the Critical analyses of decision-making accessing the full spectrum of options. launch of 51-L might not have occurred styles, as enabled by the consider- Counterstrategies include graphic when it did.” The commission report able amount of research produced by techniques — such as fault tree also said that “the waiving of launch behavioral economists, can reduce the analysis, decision trees and bowtie risk constraints appears to have been at probability of flight safety failures like analysis — that are helpful in organiz- the expense of flight safety. There was that of the Challenger. Bringing sophis- ing thinking, and therefore decision no system which made it imperative ticated — that is, as far as possible free making, systematically. that launch constraints and waivers of from biases — decision making into Fault tree analysis (FTA) was launch constraints be considered by all risk management optimizes the results developed at the Bell Laboratories in levels of management.” of the risk analyses and provides a more the early 1960s and later was adopted targeted treatment of risks. and refined by, among others, the Behavioral Economics The alternative to flawed decision Boeing Co. FTA is a graphical tool for The Challenger accident became a case making suggested by behavioral eco- analyzing complex systems to deter- study in academic fields such as engi- nomics is sophisticated decision making, mine potential failure modes and their neering safety, safety communication which assumes that individuals are probabilities of occurrence. FTA uses and, most importantly, decision making. biased and biases are systematic. “Biases, a logic block diagram with symbols to In behavioral economics, the however, can be dealt with systematical- indicate various states. It is built from Challenger disaster is used as a case ly,” Bohnet said. “There are theories built the top down, beginning with a poten- study in trying to boost efficiency in on these behavioral regularities which tial failure mode. Pathways are used the way humans make decisions indi- describe and predict how people actually to interconnect events that contribute vidually and collectively. Behavioral behave. Sophisticated (although not to the failure. These pathways use economics is a discipline derived from fully rational) decision making implies standard logic symbols. If the prob- studies in economics as well as in understanding how to overcome biases ability of failure of each component is psychology, and it “has demonstrated to make quasi-optimal decisions.” known, a quantitative analysis can be
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2013 | 13 COVERSTORY
The symbols used in decision trees differ Example of a Fault Tree from, and are fewer than, those utilized in FTA (Figure 2). Decisions to be made are represented Airplane crash by squares. Chance events are represented by circles. Options available to the decision maker are represented by branches emanating from a decision node (square). Branches from deci-
Engine fails Insu cient sion nodes must guarantee that one alternative airspeed can be chosen. Outcomes of a chance event are represented by branches emanating from a chance node (circle). Outcomes must be mutually exclusive and collectively exhaustive (no other Improper Insu cient pilot control altitude possibilities exist; probabilities have to sum to 1). Consequences are specified at the ends of the branches.”4 Using bowtie risk analysis (Figure 3) is an Failure effective way of understanding risk analysis Poor Unavoidable occurred Flying into training distractions after rising terrain and managing threats (called hazards in this takeo method). The analysis, already being used in the aviation industry, consists of a simple methodol- Source: Stolzer, Halford and Goglia, 2008 ogy to frame an undesired event within a stan- Figure 1 dardized scheme with the following principal components: triggering events, avoidance barri- Example of a Decision Tree ers, hazards, hazardous events, recovery barriers and outcomes. All chance events Bowtie risk analysis makes visible what es- are represented All consequences by a circle (c) must be listed sential controls should be in place and which p c1 need to be provided and maintained. Bowties can support safety investigations, aid audit 1-p c2 teams in tracking controls and enable staff to Alternative 1 All decisions report when additional controls are needed.5 are represented Probabilities must by a square add up to one Alternative 2 Availability Bias c3 The availability heuristic makes us evaluate the All alternatives must be shown likelihood of an event based on things we can easily call to mind. Source: Adapted from Bohnet, 2002 The decision-making process leading to the Figure 2 Challenger disaster is valuable in understanding how availability bias works. The Rogers Com- performed.3 Figure 1 contains an example of a mission reported that “the managers compared fault tree. as a function of temperature the flights for which Decision trees conceptually are very similar thermal distress of O-rings had been observed, to fault trees. The main difference is that decision not the frequency of occurrence based on all trees are not developed with strict regard to failure flights. In such a comparison, there is nothing ir- events, but more generally to allow for decisions regular in the distribution of O-ring ‘distress’ over to be made in a more systematic way, representing the spectrum of joint temperatures at launch be- all paths that a decision maker might follow. tween 53 degrees and 75 degrees F [11.7 degrees
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to 23.9 degrees C; the forecasted range of In the air transport industry, avail- had developed into an ‘unwanted’ temperatures for the launch]. When the ability bias is common because aircraft decision by the members of the Shuttle entire history of flight experience is con- accidents are particularly easy to recall. team. In other words, suggestions sidered, including ‘normal’ flights with While there are invaluable post-accident made by any group member that would no erosion or blow-by, the comparison is lessons to be learned, the decision maker ultimately support a scheduled launch substantially different.” The commission should, however, also appreciate that an were met with positive support by the also reported that “if the decision mak- accident’s circumstances are peculiar to group. Any suggestion that would lead ers had known all the facts, it is highly the given occurrence. Doing otherwise to a delay was rejected by the group.”10 unlikely that they would have decided can lead to ignoring variables worth The self-censorship of deviations to launch 51-L.” For risk management to consideration and, when qualitative from group consensus was another produce information in support of flight judgment is required, to over- or under- manifestation of groupthink before safety decision making, it is essential to assess probabilities related to possible the Challenger disaster: “All members invest in data quality, with a well-defined outcomes of hazardous events under of the group decision support system taxonomy (ASW, 5/13, p. 12). consideration. Additional techniques felt that they should live up to the One of the downfalls of a classifica- to avoid availability bias are developing ‘norms’ of the group. Although the tion scheme, however, is that it narrows an exhaustive list of possible options Thiokol [a NASA supplier] engineers the observer’s identification scope and, and outcomes; comparing the actual were firm on their recommendation to with the availability bias, can lead to the frequencies of various events and putting scrub the launch, they soon changed inability to identify new issues.6 them in perspective; and publicizing their presentation of objections once Availability can also influence these actual frequencies in order to edu- threatened with the possibility of threat identification, especially in cate the decision makers involved. being expelled from the program (as an aviation organization with a very suggested by a NASA administrator basic risk management system. To Groupthink who was ‘appalled’ at a company that speed up the process, an immature Groupthink is “a deterioration of men- would make such a recommendation organization might use checklists (or tal efficiency, reality testing, and moral based on the data available).”11 other predetermined lists of risks) judgment that results from in-group As counterstrategies against group- during, or in lieu of, risk-identification pressures.”9 think, it is possible to adopt different brainstorming.7 Groupthink is another decision- decision-making procedures, namely A counterstrategy to “win” despite making bias that played a part in the those widely known as devil’s advocacy the availability bias at the time of hazard decisions leading up to the loss of the and dialectical inquiry. identification is to avoid the use of Challenger. One of the ways groupthink In an emergency or in other checklists until after brainstorming. It manifested itself at NASA was through decision-making situations, it can be is also very important that subject mat- pressure on dissenting group members: advisable for the group leader not to ter experts involved in system design/ “The decision to delay a Shuttle launch attend all the meetings in order to keep analysis — as well as employees report- ing occurrences — feel empowered to Bowtie Interpretation Schematic think analytically, or as one specialist said: “Experience and knowledge will Hazard always form a valuable part of the risk identification process. The way that the process is managed must ensure that Triggering Hazardous Accident this historical information does not event event outcome block out a creative assessment of the Avoidance Avoidance future, where matters which have never barrier barrier been seen before might arise, and the Source: Mario Pierobon, Great Circle Services balance between familiar risks might shift dramatically.”8 Figure 3
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the discussions from being inhibited. Interestingly, devil’s advocacy and thank Professor Iris Bohnet of the Harvard Ken- Personal recommendations may change dialectical inquiry can be classified as nedy School for inspiring this article. when the leader is present, and even decision-making procedures. The term Notes participants with strong contrary procedure is stressed because the avia- personal views can alter recommenda- tion industry has a history of focus on 1. Tritch, Theresa. “Helping People Help tions based on what they believe the procedural compliance. Themselves.” The New York Times. Feb. leader wishes to hear. The leader should Both applicable aviation safety 14, 2007. instruct the decision-making group regulations and industry standards 2. Lonsbury, Sandra. “Integrated Aviation to come forward with recommenda- such as International Air Transport Management Systems (IAMS).” Presenta- tions for one course or possibly several Association (IATA) Operational Safety tion at City University London on May 28, 2010. alternative courses of action. During Audits, the IATA Safety Audit for deliberations, all participants need to Ground Operations and the Interna- 3. Stolzer, A., Halford, C. and Goglia, J. speak as equals.12 tional Standard for Business Aircraft (2008) Safety Management Systems in Aviation. Aldershot, Hampshire, England, The decision-making group needs Operations mandate management United Kingdom: Ashgate Publishing. to be split into subgroups to write the system requirements — among which recommendations, trying to anticipate devil’s advocacy and dialectical inquiry 4. Bohnet, Iris (2002) Individual and Collec- tive Decision Making. Course presentations all possible contingencies and recom- as decision-making styles would most at Harvard Kennedy School. mendations as to how to react to them. certainly fit. Aviation organizations Each subgroup should then review already are implementing such generic 5. Edwards, C. Active Safety Management. what the others have come up with, requirements, and they are also being From notes to the Active Safety Manage- ment module at City University London. dissecting and considering the other audited against them. London, England, United Kingdom: City subgroups’ findings. Further exchang- The Rogers Commission also issued University London. May 23, 2011. es should then enable the subgroups recommendations on such manage- 6. Stolzer, Halford and Goglia. to develop further answers. From this, ment system areas as management the outline of definitive plans should structure, the Shuttle safety panel, criti- 7. Broadleaf Capital International (2007). come gradually.13 cality review and hazard analysis, safety Tutorial Notes: The Australian and New Zealand Standard on Risk Management, For dialectical inquiry or devil’s organization and improved communi- AS/NZS 4360:2004. Pymble, New South advocacy, emphasis should be put on: cations. Typically, aerospace accident Wales, Australia. investigations issue recommendations • Evolving the mode of thinking, 8. Broadleaf Capital International. dealing not only with technicalities but from one-dimensional to multi- also with higher-level safety manage- 9. Janis, Irvin L. (1982) Groupthink: Psycholog- dimensional, with the creation of ment issues. This is how civil aviation ical studies of policy decisions and fiascoes. alternatives; has evolved to proactive and predictive 10. Forrest, Jeff. “The Space Shuttle Chal- • Evolving the mode of discussing, safety management. lenger Disaster — A failure in decision from a person/position/rank ori- Given the aviation industry’s support system and human factors entation to a problem/task/issues mindset favoring procedural compli- management.”
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18 | Pilot Project Pilot BY HEATHER BALDWIN with thenewICAOlicense. More than1,000pilotsare nowflying FLIGHTTRAINING MPL license holders are worldwide. flying test programs commenced, more than 1,000 dures throughout training the program. and standard airline-specific operating proce- and error management, human factors awareness embedding multi-crew the environment, threat students to right the seat of an advanced airliner, multi-crew pilot license, or MPL, zero-time takes I for pilots of commercial transport The jets. licenseinmore first new the than 40years Aviation Organization (ICAO) introduced n November International 2006,the Civil Today, roughly five years after beta- initial al programsal outdated, such as emphasis the on changes had rendered many of tradition aspects - ous 30years. that determined The review these environment that had evolved over previ the - and increased complexities the of pilot the work light of significant the advances intechnology pathsthose were and effective still relevant in airliner to understanding with aview whether established training paths to right the seat of an Licensing. From panel 2002–2005,the examined (FCLTP) of review ICAO Annex 1—Personnel Flight Crew Licensing and Training Panel The MPL came about following an ICAO FLIGHT FOUNDATION SAFETY |
WORLD AEROSAFETY | JUNE 2013 JUNE
© Duncan Walker/iStockphoto FLIGHTTRAINING
solo operations, individual skills and time-building (Volume 1, July/August 2011): “In a competency- in single-engine aircraft. As ICAO told AeroSafety based approach for an MPL, performance World, “Ab initio cadet training approaches for air- benchmarks are developed against a detailed job line programs were becoming out of date and no task analysis, partially specific to each air carrier. longer applicable to the quality and skill sets that Continuous assessment of the trainees against airlines were striving to see in their pilot recruits.” these established baselines moves them in a di- In response, the FCLTP created the MPL rect line towards the end goal: the right-seat job. program to focus on building competency in a It bypasses other, traditional skill assessments multi-crew environment, leveraging advanced such as those of a private pilot or a commercial training devices to develop the technical pilot in single-crew operations.” proficiency to safely operate new-generation So rather than a single, end-of-course exam, passenger jets in high-altitude operations. competency measurement is continuous. For As of April 2013, ICAO figures show that instance, CAE, a global provider of integrated approximately 50 states have implemented training solutions for civil aviation and defense an MPL approach, with 14 having current forces, uses 37 “testing gates” throughout its MPL training programs. Those 14 include Austria, programs, said Gary Morrison, CAE’s head of China (mainland and Hong Kong), Denmark, U.S. Federal Aviation Regulations Part 121, MPL Ethiopia, Germany, Malaysia, Philippines, Singa- and ab initio initiatives for the Americas. “To pore, Sweden, Switzerland, Thailand, UAE and pass from one phase to the next, a level of com- the U.K. There now are 20 approved training petency is defined and when the student meets organizations (ATO) conducting MPL courses it, he or she is passed on to the next phase,” he globally. To date, roughly 1,100 students have said. “We track every individual’s performance graduated from the MPL program and about on all elements of each task.” 1,500 students are enrolled worldwide. “MPL is designed in such a way as to The new license encapsulates ICAO’s move get continual feedback on the validity of the from a prescriptive flight-hour requirement to instructors and students. It’s like a good ISO competency-based training. This is a massive [International Organization for Standardization] shift in training philosophy: Where traditional system,” said Rudy Toering, vice president busi- training is measured in units of time, competen- ness development at FlightPath International, a cy-based training is measured in achievement of global training firm for flight, cabin and aircraft learning objectives. maintenance personnel. “Because of all the quiz- ICAO Doc 9868 (Procedures for Air Naviga- zes, exams and other testing, both academic and tion Services — Training) defines competency flight, students have many milestones they must as the combination of knowledge, skills and atti- continually pass to move on.” tudes required to perform a task to a prescribed standard. Therefore, MPL training does not Key Differentiators measure training hours as the primary criterion, In addition to the competency-based training but uses measurable, defined performance approach, there are several other fundamental criteria. This approach requires targeted compe- differences between the MPL and a traditional tencies to be continuously measured throughout commercial pilot license (CPL) training program. the course — a dramatic departure from tradi- For starters, the MPL includes a rigorous candi- tional programs in which the determination of date selection process aimed at identifying those competence rests on oral, written and flight tests most likely to complete the program with a high at the end of a fixed amount of training time. degree of success. These candidates are sponsored Nick Taylor, member of the ATO/MPL by a collaborating airline. Unlike CPL programs, Implementation Team at Transport Canada, there are no “independent” MPL courses, as the
© Anil Yanik | istockphoto.com Yanik © Anil Illustration Moore modification: Jennifer explained in ICAO’s inaugural Training Report advanced training phase is done in accordance
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with a participating airline’s operating proce- FlightPath International is working with Ethi- dures. The airline mentors the student and hires opian Airlines to train the carrier’s future copilots him or her upon successful graduation. in an MPL program. The program launched in The MPL additionally acknowledges the late 2011 with 48 students beginning on multiple increasing significance of human factors in dates. As of April 2013, an initial group of 14 were aviation safety and wraps these concepts into on track to receive their MPLs at the end of that training from start to finish. In a document month and from there proceed to base training released in September 2011, “Guidance Material and initial operating experience (IOE). Through and Best Practices for MPL Implementation,” its agreement with the carrier, FlightPath will the International Air Transport Association gradually transfer the program to the airline; by (IATA) observed, “The majority of incidents and the end of 2013, Ethiopian Airlines will manage accidents in civil aviation are still caused by hu- and run its MPL program and FlightPath will man factors such as a lack of interpersonal skills step into a quality-management role. Toering said (communication, leadership and teamwork), his company is talking with several other African workload management, situational awareness, carriers about creating similar programs that and structured decision making. MPL requires would ultimately transition operation of MPL full-time embedded (rather than add-on) crew training to the airline. resource management (CRM) and threat and A final difference: The MPL makes far more error management (TEM) training.” extensive use of simulators than traditional CPL Another major difference between the programs, which tend to build time in progres- MPL and CPL is the qualification and relevant sively more complex aircraft. Peter Wolfe, execu- experience requirements of MPL instructors. tive director of the Professional Aviation Board FlightPath International’s Toering points to of Certification (PABC), said that simulation, instructor quality as a distinguishing ele- in his opinion, is the biggest difference between ment of the MPL. “In a normal CPL program, the MPL and other ab initio training programs. your better students become instructors so “MPL is designed to make maximum use of you’ve got a younger pilot building time in the simulation and training devices because they instructor position,” said Toering. “That is not provide the ideal teaching and learning environ- the case in the MPL. All our instructors hold ment,” said Wolfe. “They provide a high degree multiple ratings, are Boeing 737NG-qualified of control and predictability, efficiency and Countries labeled commercial pilots, they all have had exten- exposure to malfunctions and threats you can’t have current MPL sive careers in the airline business, and they risk encountering in an airplane.” training programs. understand the requirements.” As of January 2013, MPL program flying training averaged 284 hours, according to IATA figures. The vast majority of that time — 185 hours, average — was completed in flight simu- lation training devices (FSTDs). Singapore provides a typical example. At Germany the first meeting of the Regional Aviation Safety Group — Asia and Pacific Regions, held in Octo- ber 2011, the government of Singapore presented an overview of its implementation of the MPL in Singapore. Under the oversight of an MPL Work- ing Group chaired by the Civil Aviation Authority of Singapore and comprising representatives from ST Aerospace Academy, the ATO, and participat- Illustration: Moore Jennifer ing operator Tiger Airways Singapore Pte. Ltd., an
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MPL trial began in December 2009 and con- cluded in August 2011. After phase 1 training in a single-engine airplane, the next time students came in contact with an actual airplane was toward the end of phase 4, when they conducted six takeoffs and landings. “This approach was consistent with the MPL philosophy of empha- sizing training in FSTDs, given that training in high fidelity simulators would provide the same benefit as flying actual aircraft for training multi-
crew operations,” Singapore officials reported. © CAE MPL trainees in the Singapore test completed, on average, 86 hours in actual aircraft and 219 hours Professional Pilot Certification exam, currently AirAsia cadets in FSTDs for a total of 305 hours. in development, “will assess pilots’ recollec- in CAE’s MPL tion of expected information and their ability program were Is It Working? to apply it in dealing with a variety of generic rated at ICAO Like any radical new initiative, particularly in operational situations,” Wolfe said. Level 6 (Expert) the slow-to-change world of aviation, the MPL Regulatory resistance is another roadblock at the end of their has its skeptics, with the majority of the world for MPL. National aviation authorities strongly intermediate phase taking a wait-and-see approach. As of today, just protect their regulations, as they follow exhaus- of training. 7 percent of the 190 ICAO contracting states tive study and extensive investments of time and have current MPL training programs. money. For instance, the U.S. Federal Aviation Detractors argue there are too few train- Administration told AeroSafety World that while ing hours in light aircraft (proponents counter it has been involved in discussions with ICAO that there are more airline-focused, multi-crew and the international community about MPL, it is environment, advanced-airliner training hours not actively pursuing development of an MPL be- in the MPL than in a CPL); that the license is cause it would require significant changes in the too limiting as it only permits the bearer to fly as training and hiring practices of U.S. air carriers. copilot of a multi-engine, turbine-powered, pres- Finally, there is a sense in the industry that surized airplane certified to be operated by two current programs are working, so it makes no or more pilots; and that the MPL was created to sense to undergo the massive investment needed fast-track zero-time students into the right seat of to change them. Australia’s Civil Aviation Safety an airliner to address the looming pilot shortage Authority (CASA), for instance, established an (it was not; work on the MPL began in 2002, in industry project team in 2007 to advise on the the post-9/11 days of widespread pilot furloughs). implementation of the MPL. It conducted a proof Observers also note that most airline trans- of concept trial in Brisbane with six airline cadets port pilot (ATP)-level exams fail to ensure that who began the MPL course in March 2007 and graduates understand and have retained the completed it in December 2008. All cadets are knowledge they are expected to have acquired currently flying as Boeing 737 first officers with from MPL courses — a gap PABC is working to their sponsoring airlines. While the program was close. “With the exception of Transport Canada, successful and CASA has the rules and training there are no ATP-level exams that fully and ef- standards in place for training organizations to fectively test the knowledge of MPL candidates,” run an MPL program, no organizations have PABC’s Wolfe explained. “Industry wants a good yet implemented it. “We were keen,” observed a ATP-level test, but most of the exams in use to- CASA spokesman, “but the industry was not.” day have failed to keep up with industry changes Still, initial results on MPL are encouraging. and are badly compromised.” PABC’s Global Dieter Harms, chief executive officer of Harms
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Aviation Training Consulting Associates, has Aviation Malaysia, ran a test program for 12 cadets worked for IATA since 2007 as a senior adviser in to become first officers on the Airbus A320 for the IATA Training and Qualification Initiative and AirAsia. At the end of the intermediate phase, as a consultant for international training provid- in March 2011, CAE announced that each of the ers and airlines on MPL implementation. He also 12 cadets tested to ICAO Level 6 (Expert) standard serves as a member of the European Aviation in an exam administered by Canadian examin- Safety Agency MPL Advisory Board. In these roles, ers at CAE SimuFlite in Dallas. ICAO minimum Harms is in contact with airlines that are applying guidelines require a Level 4 competency. the MPL. He says that while no scientific evalu- All 12 cadets graduated on schedule in May ation of feedback from IOE has been conducted, 2011 and proceeded to AirAsia for base training operators tell him “the performance of the MPL and IOE. A second class of 12 students gradu- graduates is throughout positive, compared to ated in summer 2012. students of traditional CPL programs,” said Harms. In February 2012, announcing a five-year con- In its October 2011 report, Singapore tract with CAE to train more than 200 additional concluded, “The fundamentals underpinning new AirAsia A320 first officers in an MPL program, the MPL are sound and robust. The training AirAsia Group CEO Tony Fernandes observed, “We approach leverages the use of modern training have seen firsthand in our flight operations that [the devices and is purpose-oriented toward the end CAE MPL program] is producing the next genera- objective of having the pilots operate in multi- tion of pilots who will fly safely and efficiently.” crew airline operations. It also offers the potential In addition to AirAsia, CAE currently has to reduce the duration and cost of pilot training MPL programs with Dragonair, easyJet and in the long term through more airline-type train- flybe. More than 30 students are enrolled today ing. Singapore is therefore supportive of the MPL in CAE MPL programs. To date, its MPL course as a way forward to train future airline pilots in a completion rate is 100 percent, compared to more effective and efficient manner.” an approximately 97 percent completion rate AirAsia expressed similar views. In February through its traditional CPL programs. 2010, training firm CAE, under the regulatory The MPL program remains under intense guidance of Transport Canada and in coopera- scrutiny — perhaps most of all by those who have tion with AirAsia and the Department of Civil created it. When it was launched in 2006, ICAO committed to a review of concept once the pro- Four Phases of Training gram was under way. As a follow-up, ICAO will be holding an MPL Symposium on Dec. 10–12, 2013, with topics including global status of MPL he multi-crew pilot license training program takes place in four implementation as well as MPL successes and phases. It requires a minimum of 240 hours of training, including challenges. The intended outcome is the initial pilot flying (PF) and pilot not flying (PNF), although those hours T identification of a work program to improve on are not the primary measure of success. MPL course lengths range from 14 to 36 months, with a 21.5-month average, according to IATA. the existing ICAO standards and MPL guid- The basic four-phase framework includes: ance. During the symposium, ICAO will pres- Phase 1 (Core): Basic single-engine pilot training. ent the results of a new proof-of-concept study. Phase 2 (Basic): Introduction of multi-crew operations and instru- The symposium will also provide an important ment flight. experience-sharing opportunity for rulemaking Phase 3 (Intermediate): Application of multi-crew operations in a authorities, airline training organizations, inter- high-performance, multi-engine turbine aircraft. national organizations and other stakeholders. Phase 4 (Advanced): Type rating training within an airline-oriented Heather Baldwin is a Phoenix, Arizona-based freelance environment. writer. A pilot and former U.S. Army officer, she writes — HB regularly about aviation, military issues and topics related to management and workplace performance.
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Reports offer ‘how to’ guide to implementing LOSA in maintenance shops and on the ramp. MINING
Maintenance Data BY LINDA WERFELMAN © Nikolaas Boden/iStockphoto
nalysis of the findings of a maintenance to the report by Marie Langer and Graham line operations safety assessment1 (M- Braithwaite of Cranfield University and to a LOSA) at a U.K. facility has identified presentation by Langer at the 2012 seminar in errors — largely procedural errors associ- Baltimore of the International Society of Air Aated with non-compliance — in 86 percent of Safety Investigators (ISASI). observations, British researchers say.2 Nevertheless, their report said, 34 percent Most of the errors discovered through of observations involved errors that “resulted in the maintenance operations safety survey undesired states mainly associated with aircraft (MOSS) — as the assessment was called — areas not checked for damage at any point during were classified as inconsequential, according the check, APU [auxiliary power unit] left running
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unattended or failure to complete all adding, “The inadequate fastening had a document presenting guidelines for checklist items before certification.” apparently occurred during a routine implementation of an M-LOSA program Although the undesired states did maintenance check due to a deviation or a ramp line operations safety assess- not contribute to accidents or incidents, from standard procedures — a practice ment (R-LOSA).4 Similar documents they still must be addressed, the report that reportedly had been fostered by were published by Boeing5 and Airlines said, noting the potential for an acci- features of the maintenance system and for America, formerly known as the Air dent or incident to result from occur- may have been commonplace.” Transport Association of America.6 rence of a similar undesired state. The Langer-Braithwaite report said The CAMI document — developed For example, the report cited an that, had a MOSS program been in through a four-year effort to extend incident in which a large access door place where the 777 was being serviced, LOSA methodology to aviation main- separated from a Boeing 777 after observations could have identified “spe- tenance and ramp operations — pre- takeoff from Gatwick Airport, dam- cific threats contributing to the failed sented an 11-step process for program aging cabin windows, the fuselage and systemic defence (e.g., walk-around implementation (“11 Steps,” p. 26). the fin. Some pieces of the access door inspection) and opportunities for errors “The goal was to capitalize on the penetrated the 777’s cabin while oth- with the potential to result in similar successes of flight deck LOSA,” the ers landed near a couple who had been incidents so these can be addressed and CAMI report said. To accomplish that walking near a wooded area. reoccurrence prevented.” goal, the FAA’s researchers consulted The U.K. Air Accidents Investiga- Although the principles underly- with airline safety representatives tion Branch (AAIB), in its final report ing the LOSA that is commonly used worldwide who were involved in M- on the June 26, 2003, event, attributed to assess flight crews can be applied LOSA and R-LOSA efforts. the door’s separation to a deviation in aviation maintenance and on the Threat and error management from standard operating procedures ramp, difficulties abound in transfer- (TEM) is the underlying framework during routine maintenance, and said it ring LOSA to work environments that for LOSA data collection, the report was “likely that only one of the 13 door bear little resemblance to the flight line, said, adding, “The TEM model is aimed catches had been fastened.”3 Langer said. at understanding error management Despite 11 subsequent walk-around Release of Langer’s report coincided (i.e., detection and response) rather inspections, conducted by nine people, with the issuance by the U.S. Federal than solely focusing on error causal- no one noticed that the door catches Aviation Administration’s (FAA’s) Civil ity (i.e., causation and commission).
were unfastened, the report said, Aerospace Medical Institute (CAMI) of Regardless of the error type, its effect on © JangSu Lee/AirTeamImages
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safety depends on technicians’ and ramp participation, use of observers who are service, catering, cleaning service, fuel employees’ detection and response to “trusted and trained,” sponsorship by service, uploading, departure, deice and avoid an undesired operational state and both management and labor, a “systemat- anti-ice, and pilot walk-around. prevent a potentially unsafe outcome.” ic observation instrument based on TEM Under the TEM framework, safety model,” a secure repository for collected Measuring Readiness observers can detect threats and errors data, “data-verification roundtables,” The CAMI report said that, before be- that might go unnoticed by mainte- “data-derived targets for enhancement” ginning to implement an M-LOSA or R- nance personnel and ramp employees, and feedback to workers. LOSA program, organizations must have the report said. In the report published by Boeing, support for the idea from senior manage- Despite different opinions about the procedures used in M-LOSA and ment, labor unions and other employee what the “A” in LOSA stands for, the R-LOSA were described as being very groups, and the workforce itself. CAMI report said the program is an different from those used in flight In addition, if the organization “assessment” process and “should not be crew LOSA. does not have at least some additional represented or used as an audit program. “Flight LOSA relies on trained recommended items — familiarity It focuses on observing normal opera- pilots using open-ended text to record with the LOSA concept and with safety tions by peers in a non-punitive envi- observations,” the Boeing report said. management systems, other non- ronment to identify ‘at-risk’ behaviors to “Ramp LOSA and maintenance LOSA punitive safety programs such as an implement changes to get employees to have structured observation checklists aviation safety action program, at work more safely, as well as capture in- that are used by an airline’s own staff. least one formal safety data collection formation on effective countermeasures The tools developed for ramp LOSA and program, a human factors program and currently in place. LOSA samples activi- maintenance LOSA include a ready-to- organizational support for a just culture ties in normal operations — the vast use database and data analysis software — an M-LOSA or R-LOSA program is majority of these are well-managed and that are kept with the operator. There unlikely to succeed, the report said. successful operations. Confidential data is no need for outside data storage and “Address any issues you identify collection and non-jeopardy assurance analysis. This ensures that company data first, and then come back to prepare for for frontline employees are fundamental are secure and that analysis does not a LOSA implementation,” the docu- to the process.” require external consultants.” ment added. LOSA’s data-derived safety informa- An M-LOSA observation form In the beginning phases of pro- tion is intended to lead to “continuous contains nine specific items: planning, gram implementation, the main tasks quality improvement over time,” the prepare for removal, removal, prepare for the implementation team should report said, likening a LOSA experience to install, install, installation test, include publicizing LOSA within the to a person’s annual physical examination. close-up and complete restore, fault organization — and especially among “People have comprehensive check- isolation/troubleshooting/deferral, the employees who will be the focus of ups in the hope of detecting serious and servicing. M-LOSA observations LOSA observers, the report said. The health issues before they become con- generally are conducted by one trained team also must decide on the focus of sequential,” the report said. “LOSA is maintenance peer observer, but two the LOSA — whether it will involve built upon the same proactive and pre- observers may be required if an espe- observations of a sample of the entire dictive notion. It provides a diagnostic cially complex task such as an engine operation or of specific areas — as well snapshot of strengths and weaknesses change is being performed. as the timing of the observations. that an aviation organization can use to An R-LOSA form — for obser- The subsequent marketing of LOSA bolster the health of its safety margins vations to be carried out during an should involve multi-level, multi-strategy and prevent degradation.” airplane turnaround by a team of two marketing plans, using face-to-face meet- The report cited 10 “essential char- or three trained ramp peer observers ings, printed material and websites to tar- acteristics” for the success of LOSA, — can contain a varied umber of items, get employee groups, frontline employees, including peer observations during depending on the organization’s choices. managers and business partners. normal operations, “confidential and Among the possibilities are arrival, “Organizations are naturally non-punitive data collection,” voluntary downloading, lavatory and potable water resistant to change,” the report said.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2013 | 25 MAINTENANCEMATTERS
safety programs and a return-on-invest- 11 Steps ment analysis of the effects of LOSA and the resulting safety interventions. Ultimately, information gathered uidelines for implementing a maintenance line operations safety assessment through various LOSA programs should program (M-LOSA) or a ramp line operations safety assessment (R-LOSA) Gprogram begin with (1) obtaining buy-in from senior management.1 be made more widely available, the re- Assuming that management approves, the next steps call for (2) forming port said. “As more organizations imple- an implementation team, (3) marketing the M-LOSA and/or R-LOSA programs ment LOSA programs, an industry-wide and (4) integrating those programs with existing safety programs, as well as the LOSA information-sharing meeting safety management system. may be held biannually to exchange Next, the guidelines prescribe (5) developing LOSA infrastructure, “including best practices and lessons learned, in three parallel activities: adapt/customize LOSA database, conduct train-the- trainer training, [and] establish and maintain a virtual LOSA website.” The next addition to zooming in on fleet-wide step is (6) to customize and conduct training for LOSA observers. problems. It is a priority to involve more After that, the guidelines call for (7) collecting data, (8) validating data, (9) airlines in the M-LOSA and/or R-LOSA populating and maintaining a database, (10) analyzing data and compiling a initiative, as well as participants from the report and (11) providing feedback to employees. regional airlines and maintenance repair —LW Note and overhaul communities.” Notes 1. Ma, Maggie J.; Rankin, William L. Implementation Guideline for Maintenance Line Operations Safety Assessment (M-LOSA) and Ramp LOSA (R-LOSA) Program, Report No. 1. LOSA was previously widely known as a DOT/FAA/AM-12/9. August 2012. line operations safety audit. The FAA and other supporters of the new terminol- ogy say the word “assessment” later was “A good marketing plan should clearly After all data have been collected, selected because of a desire to make clear define the safety value and benefits of a validated and analyzed, the recommend- that LOSA is distinct from the traditional LOSA program.” ed procedures call for providing feedback airline safety audit process. Later in the process, when the ob- — first to managers and labor leaders 2. Langer, Marie; Braithwaite, Graham. servations are about to begin, frontline and then to frontline employees — about “The Development of the Maintenance employees should be reminded about “what has been learned and action items Operations Safety Survey: Challenges in Transferring a Predictive Safety Tool From the plan and the purpose of the LOSA derived from the initial round of LOSA Flight Operations to Aircraft Maintenance.” and be given an opportunity to decline observations.” Various departments with- Paper presented at ISASI 2012 Annual to be observed. in the operation may want to investigate Seminar, Baltimore, August 2012. “Plan a reasonable number of further, and if so, data should be made 3. AAIB. Accident Report EW/C2003/06/04, observations per observer per day to available to them, the report said. published in AAIB Bulletin No 3/2005. allow sufficient time to complete the Later, the report added, “it is criti- 4. Ma, Maggie J.; Rankin, William observation coding and write detailed cal to continuously monitor the safety L. Implementation Guideline for comments,” the report advised. “Build change process through implementing Maintenance Line Operations Safety some flexibility into the schedule to allow and monitoring actions resulting from Assessment (M-LOSA) and Ramp LOSA for the unexpected. Finally, do not let the LOSA observations. Historically, (R-LOSA) Program, Report No. DOT/ the observations continue indefinitely — organizational safety changes within FAA/AM-12/9. August 2012. schedule a set of observations within a aviation organizations have been driven 5. Rankin, William; Carlyon, Bill. “Assessing one- to three-month period, if possible. by accident/incident investigation and the Safety of Ramp and Maintenance Operations.” Boeing Aero Quarterly The data need to be assessed and actions intuition. Today, organizations must (Quarter 2 2012): 10–15. implemented in a timely fashion. This is deal proactively with accident and inci- 6. Airlines for America. Implementation not to preclude using LOSA observations dent precursors.” Guideline for Maintenance Line as part of the overall SMS set of tools Additional actions beyond the Operations Safety Assessment (M-LOSA) and conducting [the observations] if and 11-step plan call for the integration of and Ramp LOSA (R-LOSA) Programs. when needed in your operations.” LOSA data with data derived from other Washington. 2012.
26 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2013 ESCO-ZA ASW Ad June 2013 .pdf 1 5/8/2013 10:35:30 AM
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he first two articles in this series The second article described a “situated likely is the immediate “cause” that (ASW, 2/13, p. 22; ASW, 4/13, recall” survey experiment in which we explains why they failed to go around. p. 24) described our attempt to asked more than 2,300 pilots worldwide But backing up from these risk assess- begin to understand the psychol- to describe in detail their experiences ments to psychological and psychoso- Togy of why 97 percent of the time, (thoughts, feelings, actions) in the cial factors, we saw that pilots failing to when flying an unstable approach (UA), moments leading up to their last deci- fly GAs reported that they had signifi- pilots do not call a go-around (GA) as sion between continuing to fly a UA or cantly degraded representations and a preventative mitigation against ap- calling a GA maneuver. A comparison awareness of the situation in terms of proach and landing accidents.1 of the psychology preceding decision all nine of the DSAM dimensions. So, Part of Flight Safety Foundation’s making in these two scenarios provided above and beyond the objective aircraft 2011 “Go-Around Decision Making a look at what factors may be implicat- and environmental factors, pilots’ ac- and Execution Project” effort, the first ed in causing a near-complete avoid- counts of their experiences revealed article presented a new description ance in the industry to call a GA. that many surprising aspects of the of the various facets of this decision The results showed that the dif- situation were the main drivers of their making psychology in terms of what ferences were stark: Pilots continuing judgments about the manageability of we have called the Presage “Dynamic to fly UAs perceived far less risk than the risk, including social and organiza- Situational Awareness Model (DSAM).” pilots deciding to go around, and this tional norms and expectations.
Inspiring the Decision to Go Around BY J. MARTIN SMITH, DAVID W. JAMIESON AND WILLIAM F. CURTIS
28 | FLIGHTFLIGHT SAFETY SAFETY FOUNDATIONFOUNDATION || AEROSAFETYWORLD || JUNEJUNE 2013 © Ismael Jorda/AirTeamImages * UA =unstableapproach; ATC GA=go-around; =airtraffic control Top Given 10Reasons for Conducting GAs Top Given 10Reasons for Continuing UAs inHindsight Reported Influences onDecision Table 1 Source: The Presage Group 10 10
of amaximumscore of4.0 9 8 7 6 5 4 3 2 1 9 8 7 6 5 4 3 2 1 Peer/professional pressures to land Communication withATC Fatigue Crew communication Crew coordination Crew competency Aircraft configuration Weather Experience Aircraft instabilities Aircraft instabilities associated withago-around Personal resistance to managing thedemands Fatigue Aircraft configuration Peer/professional pressures to land Weather Crew communication Crew coordination Crew competency Experience combat psychology of the non-compliance with list ofliminary recommendations about how to summarize ofwe all findings will the inapre- thresholds standards. with industry align Finally, UA risk ,to compare how closely pilots’ personal pilots personal their to describe we inwhich conducted asked within survey the report results the also of asecond experiment we after makingchoices the did. And they we will anysion experienced —and they whether regret any company response —approval or repercus- eventsthe inhindsight), there whether had been were inlanding successful safely view (as they sions We had been. examine pilots will whether what thought they pilotsthe provided us inhindsight to explain results of study, this describing judgments that FLIGHTSAFETY.ORG In article, continue this we will to report the |
WORLD AEROSAFETY the main the drivers of- deci their | JUNE 2013 JUNE Influence Score*Influence Score*Influence thresholds for Average Average 1.39 1.56 1.72 1.79 1.83 1.96 2.01 2.28 2.51 2.92 1.55 1.62 1.73 1.73 1.86 1.88 2.01 2.11 2.24 2.75 and decisions, either initiating a GAin“bright” how pilots lived respective their approaches Instead, alignment close between avery we see sions, we saw little of evidence rationalization. statedthe-fact reasons accounting for- deci their datarecall and compared with them pilots’ after- justification. However, we when examined those without filter the of conscious interpretation or re-live thoughts, their feelings and perceptions situations and had have experienced they them to place pilotsdeveloped: to back into try the why event guided the procedure recall was and escaping problem this is one of reasons the rationalization of pilots’ respective decisions, influences mayported indicate apost hoc decision than by UA pilots). as strongertion seen (both influences on their pilots), and weather the and aircraft configura- (judgedrience astrong but factor lesser by UA instabilities were they - with dealing per, expe se est influences on decision their were aircraft the to managing demands the of aGA. pressurepeer to land and resistance apersonal admitted also They to moderate the influenceof and presence the of crew. ahigh-functioning to compensate. included These experience their were associated with ability all their as acrew UA pilots stated continued they approach the groups is revealing. The top four reasons why encers.” The rank order of factors the between common ineach of average their “top- 10influ pilots groups inboth named nine causes in decision.their The results (Table 1)reveal that to report degree the of influence eachhad on pilots groups scenario inboth and asked them decision,their what would pilots these say? But ifasked, inhindsight, about reasons the for pilotsthose choosing to continue aUA. to fly “dimmed” situational awareness exists with We know from our event results recall that Analysis Scenario Versus HindsightJudgments have discovered inour research to date. andGA policies procedures giventhat all we While informative, patterns these of re - GA pilots, on other the hand, said great the - We alist of 16possible posed influences to FLIGHTOPS
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situational awareness or continuing a and executed. UA pilots agreed, with Pilots were presented with a hypo- UA in a “dimmed” DSAM condition, the exception that they reported long thetical flight scenario in which they and how, in hindsight, they reported landings. However, when asked whether were randomly assigned to different having made those decisions. they had made the right decision under experimental conditions in which they In accordance with our DSAM the circumstances, UA pilots doubted received variations in the severity of the model, with relatively high situational themselves in retrospect: They were risk associated with wind conditions, awareness comes the following: a pilot’s less likely to say that they had done the runway conditions/braking action and expert ability to see the threat (an- right thing, and more likely to say they runway length, on a visual meteorologi- ticipatory awareness) such as aircraft had engaged in needless risk and should cal conditions approach. They were instability, configuration and weather have called a GA. More than twice as then asked at what degree of aircraft well in advance of intercepting it; natu- many pilots flying UAs also reported instability they would call a GA. Pilots rally defaulting to his or her experience having changed their views of flying were instructed to report on the insta- (critical awareness) as a means to vali- UAs and GAs as a result of experiencing bility thresholds for calling a GA based date the perceived threat(s); accurately the event they described. on their own personal risk criteria. assessing the crew dynamics (relational There also is evidence here for the This allowed us to infer where on the awareness) for confidence and support; “normalization of deviance” to help flight path different risk factors become and finally, expertly adjusting (compen- explain pilot noncompliance with GA personally salient and important as satory awareness) for external threats, policies. Pilots flying UAs reported that drivers of pilots’ judgments. The overall such as fatigue and pressures to land. their companies had responded with objective was to determine whether GA pilots had higher awareness of neither clear, consistent criticism nor there was basic alignment between pi- the situation, and, when their attention support for their decisions. When com- lots’ perceptions about when there is a was drawn to aircraft and instability panies fail to manage noncompliant need to call a GA and general industry factors, they became salient in attention behavior in this area, this lack of feed- policies about when these instabilities and memory as the likely top influences back implicitly allows such behaviors necessitate such a decision. Our goal on their decision. Meanwhile, because to flourish, as it sends a signal that such was to then use these data to guide re- their situational awareness competen- risk taking is “the new normal.” In our alistic recommendations about changes cies were dimmed, UA pilots naturally last article, we saw the manifestations of to policy that might bring them into experienced the following: not seeing this implicit approval: In the moments alignment, without compromising certain threats (anticipatory awareness) leading up to their decisions, pilots re- safety. To the extent that pilots do not such as aircraft instabilities, weather porting a UA experience said they were see current policies as constituting a and aircraft configuration; selectively in less agreement with their companies’ set of legitimately unsafe conditions, leveraging their “stick and rudder” expe- GA policies and procedures, and more they are likely to ignore such standard riences (critical awareness) as permis- tolerant of deviations from them. operating procedures (SOPs) and en- sion to continue; and finally, perceiving gage in potentially riskier, noncompli- or assuming crew dynamics (relational Pilots’ Personal Thresholds ant behaviors. While the experiment’s awareness) to support non-compliant To more fully understand why pilots design and many findings are complex, behavior. In the end, these respective do not call GAs, we conducted a small the overall results are fairly clear and profiles of what pilots reported had experiment within the survey in which are depicted simply in Figure 1. shaped their decision making adds fur- 1,754 (79 percent) of our pilots took Across the entire experiment, a ther explanatory power to the negative part. This experiment was designed to large percentage of pilots had personal effects of dimmed situational awareness. uncover the environmental and physi- judgments about the threshold at which cal instability parameters that have the they would call a GA that were less Perceptions of Flight Outcomes most influence on pilots’ perceptions of conservative than industry standards. We also asked pilots to report on the the risks inherent in flying UAs, and to In other words, these pilots told us that success and other outcomes of their UA examine when their attention to these they would not judge that a GA was or GA episodes. GA pilots reported that parameters affects their judgments warranted within the industry’s limits their maneuvers were well coordinated about calling GAs. on these instability parameters. This
30 | FLIGHTFLIGHT SAFETY SAFETY FOUNDATIONFOUNDATION || AEROSAFETYWORLD || JUNEJUNE 2013 FLIGHTOPS
and unacceptable decision. Moreover, Percent of Pilots With Less Conservative UA pilots clearly used their unstable Personal GA Thresholds Than Industry Thresholds approach experience as a teachable mo- 90 ment, inasmuch as they reported that 1,000 ft AGL 80 500 ft AGL they had changed their views somewhat 70 200 ft AGL of both UA and GA policies. 60 50 ft AGL The results of the experiment 50 40 showed pilots are, in general, comfort-
Percentage 30 able with lowering the GA thresholds 20 under certain in-flight conditions. The 10 question now becomes to what extent 0 Lateral ight Vertical ight VREF+ > 10 kts VREF+ > –5 kt Sink rate > the former is driven by the normaliza- path deviation path deviation 1,000 fpm > 1 dot >1 dot tion of deviance, and to what degree Threshold flight department management and
AGL = above ground level regulators play a role in this.
Source: The Presage Group Recommended Strategies Figure 1 As the FSF Go-Around Decision Making and Execution Project is ongoing, the was especially true at 1,000 ft for all of To the extent that these personal following recommendations are prelimi- the five instability measures examined, thresholds for risk differ from pub- nary and based only upon the results of but even at 500 ft for some of them. lished limits, we can expect pilots to this portion of Phase 1 work. We offer the Among the five, pilots perceived the psychologically downplay industry following recommendations with three least necessity to call a GA when their compliance standards and procedures essential strategies (S1 to S3) in mind. airspeed exceeded VREF by 10 kt: At surrounding an unstabilized approach. S1 Enhance situational awareness (psy- 1,000 ft above ground level (AGL), more The challenge in amending industry chosocial awareness) through policy than 80 percent of pilots did not yet a policies to better honor pilots’ judg- and procedural enhancements and see a need to call a GA, and even at 50 ft ment and experience in managing such communication improvements, to AGL, nearly one in five pilots said their unstable aircraft states, and inspire bet- heighten flight crews’ situational personal thresholds for safety had not ter overall compliance with go-around awareness throughout the approach been breached. At 500 ft, we can see that policies, is to do so without inadver- — through the stabilized approach personal exceedances beyond published tently lowering overall safety. height and beyond — until landing. limits were present for more than 50 S2 Optimize the stable approach definition percent of the pilots reporting. Inadequate Situational Awareness and height to maximize its relevance The story was somewhat different The results of the pilots’ reflection on to flight crews and its manageability for pilots’ thresholds for vertical and their experience of flying a UA provides by flight managers/supervisors. horizontal flight path deviation, how- even further empirical evidence to sup- ever. At 1,000 ft, between 30 percent and port the idea that pilots who continued S3 Minimize the subjectivity of UA versus 40 percent of pilots felt that deviations in a UA did not have adequate situational GA decision making for the decision excess of 1 dot were not yet beyond their awareness to accurately assess the risk. maker (e.g., pilot flying, captain as per personal thresholds for manageability. Arguably, the most salient finding in company policy) to mitigate specific But between 1,000 ft and 500 ft, their support of this assertion is the UA pilots’ components of situational awareness thresholds came quickly into align- experiences of post-decisional regret. that directly compromise the pilot’s ment with industry limits, for by 500 ft, Regret is every pilot’s moral compass, risk assessment and decision making only 10 percent of pilots said that their and in this case, it points in the direc- ability, so that he or she will be able personal envelope was less conservative tion of “dimmed situational awareness,” to more accurately assess operational than the industry’s published standards. pointing out what was a perhaps willful risk and remain compliant.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2013 | 31 FLIGHTOPS
It should be stressed that the above Preliminary Recommendations strategies cannot be addressed in isolation. Doing so could increase the Recommendations Strategies Constructs relative risk level of an unstable ap- R1 Re-define the stable approach criteria and stable approach S2 C4, C9 proach. For example, lowering a stable height(s). In redefinition there is a valid argument to separate the profile (vertical and lateral) from the other stable approach approach decision altitude (S2) without criteria. Additionally, separation should be established increasing the flight crew’s situational between the desired SAH and GA decision critical point. awareness (S1), expertise and vigilance R2 Develop SOPs to discuss instability threat factors during S1 C1, C2, C7, approach briefings prior to descent. C8 may actually increase risk. Moreover, particular attention will be paid to the R3 Develop SOPs to (briefly) state critical instability factors S1, S3 C2, C4, C6, strategically throughout the approach, for example each C7 types of communication recommended time the ATIS or new wind is reviewed. (passive, active, progressive, informa- R4 Develop “active” communications procedures for each S1, S3 C2, C7, C8 tive and instructive). Strategic place- approach that are “objective,” “progressive” and “sequential,” similar in concept to EGPWS or TCAS systems, e.g., at 1,000 ment of mandatory communication of ft: “On profile/off profile”; at 500 ft: “Stable/unstable”; and at the right type throughout the approach SAH; “Stable/unstable.” is important in achieving consistent R5 Separate the active “objective” communications from the S3 C3, C8 and reliable compliance. Similarly, “decision” communications, e.g., the PNF would verbalize the objective call, and the PF verbalize the decision call. This is strategically placed SOPs designed particularly important for the case of a junior PNF first officer to have crews discuss and identify paired with a senior PF captain. Avoid the junior PNF pilot having to make a directive call, e.g., “go around.” instability factors prior to and during R6 Ensure UA and GA policies are clear, concise and unambiguous, S1 C3, C8, C9 the approach will naturally enrich the including follow-up procedures for non-compliance. flight crew’s relational, anticipatory and R7 Develop automated stable approach monitor and alerting S3 C1, C2, C5, compensatory awareness. systems. C9 Table 2 offers preliminary recom- R8 Avoid directive or suggestive calls that may compromise S1, S3 C2, C3, C4, mendations, links them to our strategic ongoing decision making, e.g., announcing, “Landing” at C8 minimums. intents and lists the psychosocial DSAM R9 Provide ongoing training to enhance psychosocial S1 C1, C2, C3, constructs they explicitly address. awareness and management, their components and their C4, C5, C6, This research and analysis set out contribution to non-compliance during the approach phase. C7, C8, C9
to help determine if there exists, from a ATIS = automatic terminal information service; EGPWS = enhanced ground-proximity warning system; psychological point of view, an answer GA = go around; PF = pilot flying; PNF = pilot not flying; SAH = stable approach height; SOP = standard operating procedure; TCAS = traffic alert and collision avoidance system; UA = unstable approach to the question “Why are GA decisions Constructs that policy states should be made, actu- C1 = affective awareness; C2 = anticipatory awareness; C3 = critical awareness; C4 = task-empirical ally not being made during so many awareness; C5 = functional awareness; C6 = compensatory awareness; C7 = hierachical awareness; C8 = relational awareness; C9 = environmental awareness unstable approaches?” and to then Source: The Presage Group make preliminary recommendations based on the findings. Table 2 The results to date demonstrate there are clear differences in situ- mitigations that can be instituted to referred to a more comprehensive report ational awareness, crew interaction, better ensure GA decision making — “Why are go-around policies ineffective? The psychology of decision making during risk assessment and decision mak- compliance. unstable approach” — available on our ing between flight crews who elect to website,
32 | FLIGHTFLIGHT SAFETY SAFETY FOUNDATIONFOUNDATION || AEROSAFETYWORLD || JUNEJUNE 2013 TEL12537-1_LaunchAd_fullpg_FS.pdf 1 5/10/13 12:30 PM Intelligence in flight.
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K Taking data to new heights. At Teledyne Controls, we built our name on intelligent solutions that collect, manage and deliver aircraft data with the most advanced technologies available. But, intelligence for us has come to signify an even deeper meaning. Intelligence means we support our clients with critical thinking and cutting-edge technology. Intelligence means helping our partners to exceed their goals in safety, performance and efficiency. Intelligence means connecting with our clients’ needs in a way that surpasses normal business transactions and uncovers actionable truths in real time. 1.310.765.3600 teledynecontrols.com 34 | Greater Leverage SEMINARSBASS tors out …running to adebris field, sifting largelywas based upon having investiga - would integrate simulator flight data into SMS. —even one methods these concept that also ing familiar but intractable safety issues through intrigued by prospect the of voluntarily resolv- and United the States. Yet many attendees were operators during April conferences inCanada BY WAYNE ROSENKRANS to ameliorateriskssuchasunstableapproaches. Flight andsimulatordataanalysesseek R “Forty years ago …accident prevention comments from some business aircraft routine operations flight was obvious in systems (SMS) and analyzing data from esistance to requiring safety management technology to throughtechnology sift that data to collect are privileged and fortunate enough through airplanes represents that debris field, and we data. “Today, data the that on we collect our operationalflight quality assurance (C-FOQA) andcollects analyzes corporate de-identified C-FOQA Centerline, initiative an industry that and chairman of steering the committee for manager of training and standards, Altria, accident,”the said Steve Charbonneau, senior together chain …the of events, what caused broken and parts to pieceslink [to] literally try through wreckage the the and all collecting FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE2013
© Anton Balazh - Fotolia.com © mechanik|VectorStock this isthis agrassroots organic program.” programthe is from user’s the group, so mittee …management and leadership of coming on board. …The steering com- nearly doubled insizewith key operators program. that During time, program the to aleap, take and achance take with the fied operatorsfied compliant operators and IS-BAO-certi- had a growing community of [SMS]– really to began accelerate,” he said. “We “InAmerica. 2010and program 2011,the venture for business aviation inNorth Safety Committee, is an in 2003by Foundation the and NBAA the tools are working effectively.” ing, standards and risk communication assurance tool to ensure that your train- in hand with your SMS as asafety- data monitoring programs work hand agreement to reinforce that point. Flight of [voluntary the participants’] service such is written ause] into language the regard.in this …In [prohibiting fact, of data gathering or monitoring system notdoes promote or support any kind clear that very [C-FOQAbe Centerline] or not performing,” he said. “I want to pilots perhaps [who] are not compliant years as atool to single out individual toring stigmatized over has been the (BASS) inMontreal. “Flight data moni - tion’s Business Aviation Safety Seminar presenter during Flight Safety Founda- tion (NBAA) Safety Committee, was a Nationalthe Business Aviation Associa- accidents happen.” that links the risks before the identify FLIGHTSAFETY.ORG p. 47).“We 17aircraft added in2012, bypublished AeroSafety World (2/13, analysis, updating previous findings its 2012aggregate-data report and The program inApril published Latest Findings The program, initially co- Charbonneau, chairman vice also of | AEROSAFETYWORLD 1 out there that were willing indu | JUNE2013 stry-led stry-led spo nsored adherence to guidelines. the “[The for participants, monitoring then developing safe landing guidelines collaborated with Foundation the in stability, from to 1,000 ft 500ft.” ance, gateway the to achieve approach we even when reducecase] toler the in instrument conditions. This is [the happen than [unstable approaches] conditions are more 20times likely to said. “Unstable approaches invisual … achallenge for pilots,” Charbonneau “It’s clear that approaches visual remain in North to seems contribute. America stable approach rates, and weather the months to seems explain un- higher munication to crews flight insummer a “disconnected” flowof safety com- key roles as asteering committee.” robust mentoring, and is this one of our ing into program the from benefit will from …that this operators new com- approach–event rates. We can deduce anwe obvious see reduction inunstable operationalthe of experience operators, consider years the of enrollment and Charbonneau said. “However, we when ashallowwe see decline inrates,” year since launch the of program, the nual unstable approach rates year-over- excursions. “When we at look an the - closely related concerns over runway ing insights into segment’s industry this trends inunstable approaches, includ- programs into our aggregate data set.” ing strategies to recruit other [FOQA] out there, and we are actively pursu- of operations the all that are going on This data really is only set slice asmall littleto speedy Citations. [Cessna] … from Boeings airframe types wide-body represents cross of agood section flights,” Charbonneau fleet said. “The and we recorded more than 13,000 C-FOQA Centerline recently The latest data analysis found that His presentation mainly on focused - really good jobofreally good achieving 700 [the] that [participants’ crews] are doing a at look closer rates the of descent shows proach events,” Charbonneau said. “A descent indicated unstable in the ap- correlatewhich rates with high the of system ‘GLIDESLOPE’ aural messages], [enhanced ground proximity warning events …are dominated by EGPWS threshold,” he said. approachare carrying to the speeds tions indicate that [participants’ crews] threshold[-crossing] distribu- speed 2012 C-FOQA data showed that “the aboveft runway the threshold. But for crews at flight to be V procedures, participants typically call on slow the sideof V the ure 1,p. 36).There is asteep drop-off or onto be fast speed on approach (Fig- ticipants’ crews] show astrong tendency descent. It’s interesting to note that [par late gear extensions and rates high of on approach, [astate] developing into “[Some crews were] either or high fast states,” energy high Charbonneau said. unstable approach events are related to four of top the five [causal] factors of about implications. practical “Firstly, steeringthe committee’s curiosity significant changes have noted. been an unstabilized- rollout. Any single event trigger will threshold crossing, touchdown and monitored phases: inthree critical to safety,” he said. “Performance is of landing performance with regard stability and understand effects the at look to adeeper take landing that [C-FOQA Centerline] decided 2012was first year the latter of] part flown wellflown into [V the on fastview the side, we approaches find landing When speed]. we expand the “Our operations [2012]flight In own their standard operating Nevertheless, data from 2012piqued lan ding caution.” No REF SEMINARSBASS REF ]+20 kt range.” REF [reference at 50 - |
35 SEMINARSBASS
to 900 fpm rate of descent below 200 ft above Excessive Airspeed Prevails in ground [level]. However, there are still numer- C-FOQA Runway Threshold Crossings, 2012 ous C-FOQA data plots of 1,000 fpm rate of descent close to the ground — a clear indicator 20 5.62 of a high energy condition.” C-FOQA C-FOQA average deviation (kt) Most of the aircraft monitored by C-FOQA 15 Centerline are certified with a 3-degree ap- proach slope angle, that is, for touchdown points near the 1,000-ft (305-m) distance marker from 10 the threshold. “Our average touchdown point in 2012 was about 1,700 ft [518 m] from the Percent of flights Percent threshold, which is really not that bad,” he said. 5 The data also revealed a “large number of land- ings” beyond 2,000 ft (607 m) and some beyond 3,000 ft (914 m) from the threshold. 0 One issue in steering committee discussion 10 –8– –6–4–20 2 4 6 8 10 12 14 16 2624222018 is an apparent trait of business aviation pilot Deviation from VREF at threshold (kt CAS) culture: tailoring landing technique foremost CAS = calibrated airspeed; C-FOQA = corporate flight operational quality assurance; to impress passengers. “It has been commonly VREF = reference landing speed accepted [for these pilots] to shallow landing Note: The value 0 on the horizontal axis indicates runway threshold crossing at VREF. De- identified data were aggregated from program participants. flares to achieve a smooth or roll-on landing, Source: C-FOQA Centerline thereby trading built-in safety margins for finesse,” Charbonneau said. “It really doesn’t Figure 1 make any sense.” Runway length per se did not correlate with C-FOQA Results for ‘Short Remaining Runway unstable approaches, but could be part of a com- While Fast’ Events, 2012 bination of factors. “A strong indicator of runway 4,688 15 excursions [risk] is a short runway while [the C-FOQA aircraft is] fast — [by C-FOQA definition, an] C-FOQA average (ft) event that measured 80 kt of speed with 2,000 ft 12 remaining,” Charbonneau said. “We’re beginning to see a trend (Figure 2) that when the runway is 9 longer, pilots are willing to accept more [devia- tion from] precise landing performance … 2
Percent of flights Percent 6 percent of the flights … a big number.’’ Willingness to override the established criteria for stable approach is like one side 3 of a coin, and reluctance to go around when unstable is the other side. “We can deduce 0 0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 5,500 6,000 6,500 7,000 … that we have a strong culture of not going Runway remaining (ft) when airplane slowed to 80 kt around,” Charbonneau said (see “Inspiring the Decision to Go Around,” p. 28). “In the end it C-FOQA = corporate flight operational quality assurance comes down to a culture of normalized devia- Note: Speeds greater than 80 kt with less than 2,000 ft of runway remaining strongly indicate risk of a runway excursion. De-identified data were aggregated from program participants. tion, or accepted noncompliance, or accepted
Source: C-FOQA Centerline nonperformance, or perhaps even a planned- continuation bias — regardless of what you Figure 2 call it, it is what it is. … This is exactly why
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programs such as C-FOQA Centerline of construction, as] out of service. But Pilots’ exceedances of established are critical and needed more than ever.” because there were about three pages flight parameters became measurable Some BASS attendees described of NOTAMs for this particular airport, by collecting in advance the details of a their own mitigations. One practice is we missed it.’ [They flew] an unstable specific operator’s SOPs on a standard- to avoid planned-continuation bias by approach because they weren’t ready for ized Microsoft Excel worksheet. “The conducting in-flight briefings for every [the non-precision approach] ahead of SOQA algorithm looks at the Excel approach and landing. The crew pre- time. … [The operator could] put out [worksheet,] then looks at the [simula- sumes a go-around will occur regard- a communication [to] raise everyone’s tor] data and compares it,” he said. The less of whether the flight is scheduled awareness. … That’s proactive.” resulting report to the operator draws to conclude in visual or instrument me- Imagine finally the operator work- attention to exceedances/SOP devia- teorological conditions. They said this ing with the predictive mindset. “The tions assessed as meaningful by the encourages vigilance, builds in a safety company has the reports of unstable algorithm, how long they lasted and margin and reduces the trepidation and approaches at XYZ due to ‘glideslope how they affected overall risk. alarm that pilots may experience from inoperative’ because the runway was “The most frequent deviation from lack of familiarity or recent go-around undergoing some type of construction,” standard operating practice was a late practice. “If we happen to see the run- he said. “[They also know] that airport extension of approach flaps [and] late way, if we happen to be stable … then ABC is about to have one of the runways gear extension,” he said. One bar graph, we’re going to land,” one attendee said. go under construction. Do you really for example, showed that instead of need to wait for crews to submit reports? nominal 1-g touchdowns (that is, one Consistent With SMS Do you need to wait for your FOQA times the standard acceleration of As an integral tool in the typical airline data to show a negative trend of unstable gravity), some accelerations in the 5-g SMS, FOQA also supports today’s approaches?” So they also could use even to 6-g range were reported. In training, emphasis on predictive identification wider communication as their mitigation. this threat surprisingly could be over- of risks, said J.R. Russell, chairman and looked. “First of all, you’re not going CEO of Proactive Safety Systems and Simulator Data Concepts to feel that in the simulator because we a United Airlines captain. “I’ll just say Recent experimental research for can’t replicate this [acceleration] in a this about the predictive [method]: It’s two U.S. military services concluded hexapod system for a sustained period quicker to the punch than proactive that both FOQA data and simulator of time,” Németh said. “So you rely on [or reactive methods],” Russell said. operational quality assurance (SOQA) the data to tell you whether or not it He described the methods in terms of data could be integrated in novel ways was a good landing. But 5 g is twice the practical issues in unstable approaches. relevant to business aviation, said Lou limit of the airplane. That airplane [ac- “[Imagine that] an unstable ap- Németh, chief safety officer for CAE. tually would have] broken into several proach into airport XYZ has led to a The Air Force and Navy asked CAE, pieces on landing.” runway excursion,” Russell said. “An “Is there value in the simulator data Moreover, unloading inputs by a investigation is done. Lessons are and, more importantly, is there value in pilot to achieve an exceptionally soft learned to prevent a similar incident. correlating what we see in the FOQA touchdown — flagged by the algorithm [The operator would] really want to be data [taken] off the airplane to the data as events with acceleration of less than looking for latent failures that contrib- that we see in the simulator?” A study 1 g — can be discussed with crews with uted to it. So that’s reactive safety.” concluded that this was “a success- the same objectives as Charbonneau’s Imagine instead that, based on ful demonstration. … The ability to warnings about the inherent yet under- FOQA, the company had discovered an automatically detect deviations from estimated risk of runway excursions. increasing rate of unstable approaches standard operating practice is a major Note at XYZ. “Say they received a report innovation, and the objectivity was a 1. The International Standard for Business from a pilot that said, ‘[We] were fly- major benefit.” In practical terms, it Aircraft Operations (IS-BAO) is used by ing an approach at XYZ the other day, convinced him that data from a simula- auditors trained and authorized by the and the glideslope was [reported in tor can validate the efficacy of the International Business Aviation Council notices to airmen (NOTAMs), because entire flight training system.
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BY LINDA WERFELMAN
With a battery fix approved, Boeing 787s return to the air.
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ven as accident investigators pushed to find to land at Takamatsu Airport, where the crew the cause of a January fire in the battery ordered an emergency evacuation after they system of a Japan Airlines Boeing 787, the saw smoke coming from the forward fuselage. entire fleet of 787s — equipped with new Four of the 137 people in the airplane received Elithium-ion battery systems — began returning minor injuries during the evacuation. Published to service after a three-month grounding. reports quoted investigators from the Japan The modified battery systems were required Transport Safety Board (JTSB) as saying that the under an airworthiness directive (AD) issued airplane’s main battery had overheated and that by the U.S. Federal Aviation Administration they found a slight swelling in the APU battery.1 (FAA) in late April. The AD mandates the Civil aviation authorities worldwide cited replacement of the main battery, the auxiliary both events in their orders grounding all 787s. power unit (APU) battery and their chargers, and the installation of main and APU battery Finding a Solution enclosures (see “787 Batteries,” p. 41). The FAA The events prompted an intensive effort by directive applies only to U.S. operators of 787s, Boeing — aided by more than a dozen battery but other civil aviation authorities worldwide experts from industry, government, academia have issued similar orders to operators of 787s and the consumer safety field — to develop a under their jurisdictions. solution. The FAA said its action was intended “to The result of their work was a collection of minimize the occurrence of battery cell failures modifications to the original lithium-ion battery and propagation of such failures to other cells system, including “design changes to both pre- and to contain any flammable electrolytes, heat vent and isolate a fault, should it occur,” Boeing and smoke released during a battery thermal said, adding that production, operating and event in order to prevent damage to critical testing processes also were improved. systems and structures and the potential for fire The modifications include redesigned in- in the electronics equipment bays.” ternal battery components to minimize chances The worldwide fleet of 50 787s was ground- of a short circuit, better insulation of battery ed in January after two events that occurred cells and installation of a new containment and within days of each other involving lithium-ion venting system for both main batteries and APU batteries on the new airplanes. batteries. The first event was a Jan. 7 fire aboard the Boeing said that the new steel-enclosure Japan Airlines 787 about 15 minutes after it containment system was designed to “keep any had been parked at a gate at Boston Logan level of battery overheating from affecting the International Airport after a flight from Narita airplane, or even being noticed by passengers.” International Airport in Japan. Maintenance Ray Conner, president and CEO of Boeing and cleaning personnel saw smoke coming from Commercial Airplanes, added, “This is a the aft electronics bay and summoned aircraft comprehensive and permanent solution with rescue and fire fighting personnel, who extin- multiple layers of protection. The ultimate layer guished a fire in the APU battery. No passengers of protection is the new enclosure, which will or crewmembers were in the airplane at the ensure that even if a battery fails, there is no time, but one firefighter received minor injuries impact to the airplane and no possibility of fire.” during the event. The modifications — developed through The second event, on Jan. 15, involved an more than 100,000 hours of preparing and per- odor and a battery-overheat indication on the forming tests and analyzing their results — were flight deck of an All Nippon Airways 787 dur- approved by the FAA after the agency’s review of ing a domestic flight in Japan. The flight crew certification tests that Boeing said were designed conducted an emergency descent and diverted to “validate that individual components of the
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battery, as well as its integration with said that, despite the interruption of battery failures following a design the charging system and a new enclo- deliveries of new airplanes, all planned program led by one of the world’s sure, all performed as expected during 2013 deliveries of 787s should be com- leading manufacturers and a certifi- normal operation and under failure pleted by the end of the year. cation process that is well-respected conditions.” throughout the international aviation As the FAA approved Boeing’s Looking for Answers community,” NTSB Chairman Debo- solution, the company deployed teams The modifications were ordered as the rah Hersman said at the start of the around the world to install the replace- U.S. National Transportation Safety two-day hearing. ment battery systems. The first of the Board (NTSB) and the JTSB continued Hersman said that although the 787s to be equipped with the replace- their investigations of the two battery- NTSB has not determined the cause of ment systems were back in the air in related events. the fire, its investigators have pinpoint- late April, with installations expected to As part of its investigation of the ed the event’s origin — “short circuits in continue throughout May for all 787s Boston incident, the NTSB held a pub- [APU battery] cell no. 6 that cascaded, in the order that the airplanes originally lic hearing that focused on the battery’s in a thermal runaway, to the other cells. were delivered. original design and the certification The temperature inside the battery case The modified battery systems also process. exceeded 500 degrees F [260 degrees were being installed on new airplanes “We are here to understand why C].” The NTSB expects to issue its final at Boeing assembly plants, and Boeing the 787 experienced unexpected report on the fire, including the prob- able cause, before the one-year anniver- sary of the event, Hersman said.
Continuing Investigation While seeking the cause of the fire, the NTSB also is reviewing the cer- tification and testing of the 787 and its lithium-ion battery system — a feature that, in regulatory terminol- ogy, incorporated “novel or unusual design features” that were subject to nine special conditions imposed by the FAA. Those conditions were intended to “ensure that this new The Japan Airlines technology would not pose a greater incident in Boston safety risk than other technologies destroyed an APU battery, addressed in existing airworthiness above, in a parked regulations,” the NTSB said in its 2 Boeing 787. At right, an interim report. electrical schematic of In 2007, when the FAA’s notice the main and APU battery. of proposed special conditions was published in the Federal Register, the agency explained its reasons for the proposal, noting that the aviation industry had limited experience with lithium-ion batteries and that other users of the batteries, in cell phones and electric vehicles, had experi-
U.S. National Transportation Safety Board U.S. National Transportation enced “safety problems, including
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overcharging, over-discharging and flammabil- generated by the battery, and with smoke, hot ity of cell components.” gas and electrolyte discharged from the battery. In addition, the FAA said at the time that lithium-ion batteries were “significantly more Procedures, Past and Future susceptible to internal failures that can result During the NTSB’s public hearing, Mike Sinnett, in self-sustaining increases in temperature and 787 vice president and chief project engineer at pressure” than other types of batteries that had Boeing Commercial Airplanes, described the been used in transport-category airplanes. certification process for the 787 and its battery The special conditions emphasized FAA system as the most extensive in Boeing history. requirements that the battery installation Boeing initially had chosen lithium-ion bat- must maintain safe temperatures and pres- teries rather than other battery types for the 787 sures, and that it must include a method to because of their low weight, charging charac- “control the charging rate of the battery auto- teristics, power capability and safety, among matically, so as to prevent battery overheating other characteristics, Sinnett said, noting that or overcharging.” The FAA also required an over-temperature warning system, including 787 Batteries a method of automatically disconnecting the battery in case of an over-temperature event or a battery failure. he original main battery in the Boeing 787 and the auxiliary power During the certification process, Boeing unit battery are unique to the airplane. conducted a safety assessment to identify “po- T Both are lithium-ion batteries consisting of eight battery cells, connected in series and assembled in two rows, each made up of four tential hazards that various failure conditions of cells. Insulation sheets separate the cells from each other and from the electrical system components could introduce to electrically grounded aluminum battery case.1 the airplane and its occupants,” the NTSB report The U.S. National Transportation Safety Board (NTSB) said, in its inter- said. Among the potential failure conditions im factual report on the Jan. 7 battery fire in Boston, that the cells have a were those identified as “battery vents smoke/ lithium cobalt oxide compound chemistry, that they contain a flammable fire,” which was classified as “catastrophic” and electrolyte liquid and that they have “nominal voltage” of 3.7 volts. Each cell contains a vent disc, defined by the NTSB as “a plate that “battery vent and/or smoke (without fire),” clas- ruptures when the internal pressure in a cell reaches a predetermined 3 sified as “hazardous.” level,” and the vent discs are oriented toward the battery’s exterior. Tests determined that the probability was Each cell also has three internal electrode winding assemblies, one in 10 million flight hours that one of a 787’s described this way by the NTSB: batteries could “vent” — a process in which a Each winding assembly is about 33 ft [10 m] in length and is build-up of pressure inside a battery cell causes configured with an electrode, then a separator, then another the rupture of a plate on the cell known as a electrode and then another separator. One electrode (the “vent disc.” When the 787s were grounded on anode) is a copper foil coated in carbon; the other electrode (the cathode) is an aluminum foil coated in a lithium cobalt Jan. 16, however, two smoke events had oc- compound. Lithium-ion batteries have primarily nonflam- curred in a fleet that had accumulated fewer mable components, but the electrolyte is flammable, and than 52,000 flight hours. active material coatings on the negative (anode) and positive Examination of the APU battery on the (cathode) electrodes contain chemically reactive components. Japan Airlines 787 showed that, of the eight The battery case also contains the battery monitoring unit, which battery cells, vent discs on three were slightly monitors for overcharging, over-discharging, overheating, imbalance open, vent discs on four “had opened more and high current, and signals the battery charger unit to stop charging completely, leaving a ruptured appearance,” if any battery-monitoring thresholds are exceeded. — LW and the disc on one cell remained intact, the NTSB report said. The area where the APU Note battery was installed had been damaged in ways 1. NTSB. Interim Factual Report, Accident Number DCA13IA037. March 7, 2013. that the report said were consistent with heat
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the lithium-ion main and APU batteries, where the current safety standards were not adequate or appropriate to address the novel or unusual design features. At the time, there was no avia- tion industry standard for rechargeable lithium- ion batteries.” The special conditions were developed in reference to existing knowledge of lithium-ion batteries and knowledge of other types of batter- ies that traditionally have been used in large air- craft, with the goal of ensuring a level of safety
© Reuters/Yuya Shino © Reuters/Yuya for lithium-ion batteries that was equivalent to The redesigned lithium-ion technology was considered “a better that required for other battery types. lithium-ion battery for technology” for the 787. Hersman said the NTSB’s goals in the in- the Boeing 787 and When tests were conducted as part of the vestigation are to understand not only why the its battery charger certification process, he added, it was believed events occurred but also how the design and are displayed at an that even if one battery cell overheated and certification process functioned. All Nippon Airways vented, other cells would be unaffected. “We are looking … for knowledge that maintenance center in Boeing — as well as the FAA — has contin- can be applied to emerging technologies going Tokyo. ued to review circumstances surrounding the forward,” she said. two January events to fully understand what “The U.S. aviation community is using the happened and why, Sinnett said. same approach to certification that was created Throughout the certification process, he to certify our grandparents’ aircraft, and by most added, “Boeing worked closely with its suppli- accounts, it has served us very well. But perhaps it ers and the FAA to demonstrate that the battery is time to ask if any changes are needed to update complied with all applicable Boeing and regula- the system that will be used to oversee the devel- tory requirements.” opment of new and beneficial technologies on The FAA provided “rigorous oversight” of our children’s and our grandchildren’s aircraft.” the development process, he said. Hersman said, however, that the FAA would Notes
need a considerably larger staff if it were expect- 1. Karp, Aaron. “Swelling Found in ANA 787’s APU ed to oversee every detail of the operation, and Battery.” ATWOnline, Feb. 19, 2013. A subsequent she noted the difficulty in determining precisely report (Karp, Aaron. “JTSB: Incorrect Wiring Found how detail-oriented the agency should be. in ANA 787.” ATWOnline, Feb. 21, 2013) said that Dorenda Baker, director of the FAA Aircraft JTSB investigators had found “incorrect” wiring in the airplane but that the wiring — which involved the con- Certification Service, characterized the FAA’s nection between the main battery and the APU battery oversight process as a “robust” procedure that — likely was not related to the battery problem. has functioned well for 50 years. Part of the process allows for the development 2. NTSB. Interim Factual Report, Accident Number DCA13IA037. March 7, 2013. of project-specific special conditions — such as those approved for the 787’s lithium batteries — 3. TheInterim Factual Report cited the FAA’s definitions of when current standards are not appropriate for a catastrophic event as one typically involving a hull loss specific new technologies, Baker said. The inten- with multiple fatalities. A hazardous event is defined as one typically involving “a large reduction in functional tion of special conditions, she added, is to “allow capability or safety margins of the airplane with serious innovation while maintaining safety.” or fatal injury to a small number of passengers or cabin In the case of the 787, she said, “We identi- crew along with physical distress or excessive workload fied a number of design features … including impairing the ability of the flight crew.”
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light attendants are far more likely today for long-lasting feelings of personal guilt without to handle in-flight medical emergencies reasonable cause, she said. (IFMEs) than to conduct an evacuation, “In talking with flight attendants who fight an in-flight fire or experience other have been involved in serious emergencies, Fcabin safety events that require specialized train- and particularly in [responding to] passenger ing, says Helen Zienkievicz, president of Health deaths, my experience has been that often Leaders Promoting Safety, cardiac critical care they may view themselves as [having] failed,” and hospice nurse practitioner, and former she said. “When I talked to [one] flight atten- manager of in-flight safety for United Airlines. dant … she was so devastated … totally blown BY WAYNE ROSENKRANS BY WAYNE Even so — based on admittedly sparse data away, until I started to talk to her about some and research findings — real-world experi- of the statistics. ence among cabin crewmembers in handling “I tried to remind her that… many of these an IFME tends to be rare to non-existent, she illnesses … are progressive in nature [and symp- told one of the April cabin safety sessions at the toms in flight actually may not be sudden or World Aviation Training Conference and Trade- new]. … Studies have shown that for somebody show (WATS 2013) in Orlando, Florida, U.S. who has a cardiac arrest [without rapid access The quality of “pre-event” training and “post- to advanced life support] … a fatal arrhythmia, event” support deserve thoughtful, thorough their survival rate is somewhere between 23 and anticipation by airlines, Zienkievicz said. Espe- 31 percent. … It’s important that we remind our cially in cases when an IFME has an unfavorable crews of that so that they don’t walk away with outcome, including the death of a passenger or feelings of failure, with feelings of depression, colleague, the cabin crewmembers involved (not of insomnia [from thoughts like] ‘If only I had to mention pilots and ground staff) can be at risk done this, or if only I hadn’t taken that flight.’ …
Appreciation for unspoken needs of flight attendants and passengers reshapes cabin safety training. © Alexander Podshivalov | Dreamstime.com © Alexander Podshivalov
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what we are finding via [Apple] iPads and [other devices to] the ground.” More attention to the emotional dimensions of being first responders could help make flight attendants even more effective. “Even if you have dealt with [IFMEs] 10 times, it’s still go- ing to be a stressful situation,” she said. “While they have the training, they [also] are ‘on stage’ … trying to deal with this medical event and still dealing with maybe 200 other passengers.” There can be strong desire to convey to passen- gers, “No problem, we do this all the time.” What can be most helpful — yet the aspect
© Delta Air Lines most difficult to teach via computer-based training/distance learning — is participating in a realistic simulation of how a real IFME might unfold, including including the possible range of outcomes and their probability. Cardiac failure, A new tablet-based [An IFME] is a critical incident [as] traumatic as heart attack, respiratory emergencies and neu- in-flight entertainment fighting the fire on board, dealing with a bomb rological events such as strokes make good case (IFE) system trainer, threat, dealing with an evacuation.” studies. described by Delta The rate of occurrence of IFMEs “by all ac- Realism means teaching unvarnished medical Air Lines at WATS counts, seems to be on the rise,” she said. Many facts with data that will support the theoretical 2013, supplements well-documented problems still surround the and skills training, and the emotional well-being. computer-based subject of consistently counting and adequately This includes coming to terms with the possibil- and instructor-led explaining IFME-related on-board deaths (Cab- ity of supporting and sustaining life by compe- training, enabling in Crew Safety, July–August 1999). For example, tently performing the skills from training, but flight attendants the cabin crew is not qualified to pronounce realizing that “ultimately, they don’t necessarily to simulate normal someone dead, and beyond providing appropri- have the power” over the outcome, she said. IFE operations, ate care and comfort for passengers who may She added that airlines should be prepared build confidence become aware of the event, there could be risks to routinely take action within one to four hours through hands-on of an aircraft being impounded by authorities in to support the entire affected crew, such as by troubleshooting, and some situations. providing a quiet private place to talk with each explore safety-related One observable factor has been a higher other, to have something to drink and make scenarios. proportion of passengers traveling with acute phone calls. health problems or terminal diseases, she said. “[This is not a debriefing but to defuse,] Consequently, the cabin has become a place help them sort of calm down from the event,” where the likelihood of IFMEs has increased Zienkievicz said. “The other thing, if pos- but passengers’ likelihood of survival also has sible, is to demobilize, to help facilitate them increased. “Our flight attendants are much bet- coming from a very highly stressful, high- ter trained than they were, say, 30 to 40 years adrenaline state to a more relaxed state. You ago … so certainly we’ve seen better outcomes,” may not always be able to pull the crew out of Zienkievicz said. “We have enhanced medical service, but there may be times when it is to kits. We have companies such as MedAire that the benefit of everyone … to give them time can provide support and expertise in how to to adjust.” Formal critical incident debriefing manage the emergency. And we also have … and long-term follow-up, as needed, typically telemedicine, where we actually can transmit are scheduled later.
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Face Mask Revelations The issue was correct retrieval, assembly and In a separate presentation, Paul Caldwell, man- use of the onboard CPR face mask, for which ager, in-flight advanced qualification program a flexible plastic face shield formerly had been (AQP), SkyWest Airlines, said his company’s substituted in training. Used correctly on a child AQP program currently has approval from the or adult mannequin, the CPR face mask enables U.S. Federal Aviation Administration (FAA) first responders to create an air seal around solely for continued qualification (CQ) flight the victim’s nose and mouth and to give rescue attendant training but anticipates approval for breaths without direct mouth-to-mouth contact. initial new hire training within approximately “Prior to 2012, we were using the CPR face a year. Meanwhile, the airline has shared with shield when we conducted CPR training,” he other airlines “real world numbers” and lessons said. “It’s disposable [so] it’s cost-effective [un- learned about a few ways to improve CQ, he like] sanitizing [the face masks].” He focused on said. SkyWest, with roughly 2,400 flight atten- changes discovered in the associated AQP data dants, has eight cabin safety instructors qualified when the airline changed from using the face to teach under AQP. shield to an actual CPR face mask. “One of the big things about AQP is that it “Basically, the scenario [studied was] a preg- has encouraged innovation in the way that we can nant passenger on board who experiences chest train,” he said. “The goal is always to achieve the pains and eventually goes into cardiac arrest,” Analysis of student highest possible standard for our flight attendants Caldwell said. “Health precautions — that’s basi- performance data … a more realistic training environment. … cally wear gloves, use the face [mask] — [was] in 2012 inspired There is a heavy emphasis on crew performance one of the things that we were evaluating. So in SkyWest Airlines and TEM [threat and error management], and our first quarter [2012], we had roughly 75 flight to add these the biggest component is data collection.” attendant classes come through.” photographs, and The airline also is modifying its grading scale “[In] the first quarter, we recognized pretty a demonstration for flight attendant performance in safety train- early on that we had an issue with our flight video, that clarify ing, refining what was presented at WATS 2012 attendants either wearing gloves or utiliz- correct use of (ASW, 5/12, p. 42). A score of 4 (excellent) on ing the CPR face [mask] or utilizing the CPR cardiopulmonary the four-point scale currently means no errors, a face [mask] properly. … Roughly 60 percent resuscitation face standard requiring the trainee to perform almost of our flight attendants made an error that was masks. perfectly, correcting right away even minor er- rors. Unsatisfactory performance, a score of 1, creates the most concern for instructors. “Those are … an instance where they made a mistake, it affected safety, and they never corrected it — or maybe it was too late to correct it,” he said. After the modifications are complete, what will be considered acceptable (3) or standard (2) performance basically is “they made an error, but it didn’t affect safety … and how we bring them up to standard is during the debrief,” Caldwell said. “We [also] make sure they have the knowledge required for that task.” Data from this scoring system drew atten- tion during 2012 to instances of unsatisfactory performance on one aspect of cardiopulmonary resuscitation (CPR) first aid training, prompting changes in both the training and the scoring. Airlines © SkjyWest
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never corrected or recognized. … This how they’re doing. Nobody knows if the people [who] take these flight at- was an instance where, as a training they made it. Did they make it to the tendants out on their first operating ex- department, we just were not provid- airplane the first time? Nobody knew.” perience,” she said. “[Air transportation ing the proper training. … We had 23 She said that the airline’s training supervisors] don’t fall under training, [face mask omission] instances and 20 specialists also had “started to wonder but they’re not in-flight supervisors — instances where they weren’t using gloves. ‘Are we losing people because we’re not so they’re kind of neutral.” Essentially, My guess is they probably didn’t do either doing something, or [is it] the demo- most activities are repeated at intervals the majority of the time.” graphic … the type of person? We don’t during the flight attendant’s first year. In view of the analysis, the FAA know. So we need to do all we have to For purposes of formally evaluat- certificate management office worked do to make sure we are holding up our ing new flight attendants’ performance with the airline under AQP procedures end of the bargain.” within the first six months of beginning for adding pictures of the devices after Changes developed with input flying, the in-flight supervisor conducts the first quarter, and use of a demon- from line flight attendants were FAA- one quality assurance ride — essentially stration video after the second quarter. approved in April. They include a similar to the check ride, with possible Problems in presentation of factual new hire–focused, quality assurance punitive consequences, collecting information in the flight attendant component and a six-month guided 68-question–data points, coding every manual also were addressed. probationary period designed primarily observation (safety-related only) and From first to second quarter, the to smooth new flight attendants’ transi- inserting comments. The air transporta- CPR face mask performance errors tion to line operations and to enhance tion supervisor, flying as a passenger, con- “went from 23 to 14, and the gloves their confidence, LaTour said. ducts one separate safety and procedures went from 20 to 14,” Caldwell said. By Part of the solution was to leverage ride with a brief safety-related checklist, the third quarter, mask errors dropped communication technology for cabin all solely for support and coaching. to five and glove errors dropped to three, safety training and provide in-flight All of these changes have been accom- exemplifying relatively quick modifi- supervisors with tablets and wireless panied by correspondingly upgraded cation of cabin safety training under connectivity. In addition to classroom training for the in-flight supervisors, AQP rather than waiting for a year-end modules and scenario-based modules including self-awareness of leadership analysis of performance. in cabin simulators, more time is spent styles and validating that quality assur- in IQT aboard aircraft, and airline ance rides and coaching are consistent Unexplainable Resignations base stations have become partners in among different supervisors, LaTour said. Any unusual increase in resignations training activities. by newly qualified flight attendants She said that the probationary Cabin TEM Focus requires consideration not only of program focuses on conducting formal JetBlue Airways has taken steps to external reasons, but also of how cabin group meetings with participating supersede crew resource management safety training itself may contribute, supervisors at each base to discover (CRM) with TEM designed for cabin said Tiffany LaTour, manager, training from new flight attendants and others crews and has U.S. regulatory approval curriculum program development, US what seems to have been done well in under its AQP, said Steve Guillian, a Airways. “We need to keep these people training versus what has not been done captain and TEM project coordinator in so we’re creating a seamless transi- so well. This includes time with a new Inflight Training Program Development, tion to the operation,” she said. “It all supervisor, in which the supervisor asks and Jennifer Carlson, TEM curriculum starts with new-hire … indoctrination questions such as “How are you feeling? developer for the College of Inflight at qualification training (IQT), [and] we What can I do for you?” JetBlue University. are now the second airline to bring our To enhance lead (formerly called “The difference is that TEM is new-hire program under AQP. initial) operational experience under more operationalized. … TEM involves “In the past … they would graduate AQP, even though it requires only five developing the actions, the tools, that we as new hires … and then go on the line. hours of flying on one airplane type, the provide to our crewmembers that enable [In that system, training staff would not] company incorporated an air transpor- them to achieve the goals of CRM,” Carl- see them again for a year. Nobody knows tation supervisor program. “These are son said. “At JetBlue we are developing
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TEM to replace the CRM curriculum” to potential for distraction. Not just in After “healthy discussion,” the identify, track and mitigate errors. that moment, but also in the emotional checklist-minded evaluators shifted In TEM philosophy, individuals afterglow of a difficult encounter.” their position. “Eventually, one by one, constantly need to prevent normally the ‘Aha!’ moment came to fruition minor problems or errors from “snow- Informed Evaluators — the evaluators began respecting the balling into undesired or disastrous JetBlue in late 2012 implemented a value of other decision-making styles outcomes.” No single defense will new concept called informed evaluators and saw the benefits of meeting more be perfect. “Instead, we use as many — an element of its larger Insight IQ in the middle,” Ferricks said. “Raising [defenses] as possible to create a series program designed to help all employees their awareness … we empower them of layers that prevent our threat from grasp the benefits of high quality op- to push back on each other a little bit. getting past,” she said. “As situations erational data, said Christina Ferricks, … We didn’t approach … calibration become more complicated, we need to College of Inflight training analyst, with the idea that we were going to use more defenses.” JetBlue University. Evaluators of flight bring generations [together in their Guillian said that the cabin crew attendants play a critical and integral thinking] but, really, we tried to appeal version of TEM involves “identifying, role in the data that the airline collects to all.” documenting and training natural be- on student performance, in turn influ- haviors that maximize error resilience” encing cabin crew performance while Leveraging Face Time by drawing lessons from scientific flying, and shaping high-level decisions Every minute of face-to-face training literature review and the knowledge of about changes in training. interaction with a flight attendant has exceptionally skilled crewmembers. “Insight IQ is the ability to find and become an extremely valuable but also The specific TEM skills can be analyze relevant information to drive costly commodity, said Larry Parrigan, summarized as: Plan ahead, use extra actions and decisions effectively,” she manager, curriculum development for caution, communicate effectively, work said, and ties into cabin safety instructor flight attendant training, Southwest as part of a team and manage the cus- calibration. “[Calibration] allowed us to Airlines. “The conversation that we’re tomer climate. have some standardization as it relates having at Southwest Airlines right now “We’ve essentially drilled down to measuring student performance, and is … very similar … to what’s going to the level of tactical actions that it lets you evaluate performance based on across the industry,” Parrigan said. can be taken to achieve the defenses,” on objective standards. … We grade “[We’re asking] ‘How can we leverage Carlson said. “The unique feature of [our entire] crew, not crewmembers … the presence of the flight attendants? [our TEM] toolkit … is that it includes while they perform so calibration truly How are we getting the most [from the practices for enhancing the overall allows [us] to incorporate that. … One training time] of our flight attendants, customer experience. … There is an of the most impactful moments of our and what can we do just by them being entire defense category dedicated to calibration was on the simulators.” The present in the classroom at a training managing the customer climate. The process revealed that some “checklist- facility that we can’t do with them at tools in this category are aligned with minded” instructors had difficulty home?’” the research [on using] service and eti- grading crews. The “essential stuff” that flight at- quette to create a relational advantage.” “If the student didn’t get everything tendants perform breaks down as flight For example, the emergency-related [done] on the checklist, [one such operations tasks, including communi- tools in the TEM toolkit include situ- evaluator] felt that the student was cation; emergency duties; and customer ational assertiveness that builds on the not successful,” Ferricks said. “We had service. Instead of spending a lot of foundation of continually managing another evaluator, at the same time, time delivering fact-based information the customer climate. who watched the exact same [student’s] during initial training, the industry “We seek to create a calm, relaxed performance [and] felt that ‘a couple of has been proposing changes to regula- cabin climate for the purpose of de- little mistakes’ … didn’t mean that [the tors. “Let’s lecture to them at home creasing the complexity of safety tasks,” student] didn’t know it.” She noted that and just ‘do stuff’ in the classroom,” he Guillian said. “When crewmembers a generational/experience difference said. “Our regulators have got to get have difficulties with customers, there’s typically was involved. on board with this.” Resistance in the
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the [airport] concourse … they would [reply], ‘Take oxygen.’ … But we put them in the opera- tional environment, and they consistently fail to perform that motor function.”
Optimizing Class Time In a similar vein in Sweden, economic pressures in 2012 forced reconsideration of how best to use the relatively costly time spent bringing experienced flight attendants into classroom- based recurrent training, said Anna Mellberg Karlsson, chief cabin safety and CRM instructor, Novair. “First of all, we wanted another solution to get more time for practical training,” Karlsson said. Specifically, test-taking in the classroom consumes at least 1.5 hours that could be spent © Novair and Inflight© Novair Institute on assessing the actual performance of skills; it engages students in superfluous discussions of Online testing, United States recently was in evidence when test scores and “thoughts of why he or she failed coursework and he proposed content-rich (that is, interactive this test” — seriously distracting attention from refresher materials multimedia) computer-based training as part of learning. developed for Novair a proposed curriculum on life rafts to be taught After switching in 2013 to online tests, by Inflight Institute before flight attendants arrive for their practical which flight attendants and pilots complete any- enabled the airline training. time in the 30 days prior to coming, instructors to implement a Parrigan said that the FAA cabin safety found that “students were not half as nervous prequalification inspector who reviewed this proposal told him, as they used to be when they showed up in the certificate for flight “‘I will not sign off on a program that has a morning and the first thing that they needed to attendant applicants computer-based element for a subject that is do was take the test.” She said the change, devel- — and to focus more new to flight attendants.’ I asked ‘Why?’ and oped by Inflight Institute, also boosted partici- on hands-on safety the response was ‘This is too new. They still pants’ confidence and performance of hands-on skills during limited have questions that will require an instructor to skills. Presenting in class an aggregation of the classroom time. answer.’ … We were told that we couldn’t ensure de-identified test scores of the specific class also that our students were engaged, and that with enables efficient, non-threatening corrective an online training course, we couldn’t guarantee instruction and group discussions of the practi- that our flight attendants are paying attention. cal significance. [But] we could actually utilize that class time To deal with its growing problem of stu- performing the tasks that the flight attendants dent flight attendants quitting before program are required to do.” completion, Novair in late 2012 also required A classic example of classroom-lecture successful completion of the Inflight Institute’s content becoming disconnected with what online, prequalification-certificate course as part flight attendants actually must be able to do is a of a revised hiring process, Karlsson said. “What frequently failed event-management scenario for we experienced was a prepared and a more mo- cabin decompression, Parrigan said. tivated student [and] a 100-percent success rate. “In the classroom, we drill into our flight … Thirty-six students graduated in November. attendants over and over again ‘What’s the first … With the prequalification and better use of thing you do in a decompression?’ Take oxy- time, we are looking [to make training of] our gen. … If you walk up to any flight attendant in cabin crew as real as it gets.”
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DATALINK
BY FRANK JACKMAN Deficiencies in SMS Audits
he most common problem areas found in The objective of the PRISM report is to high- safety management system (SMS) imple- light the recurring problem areas found in SMS mentation by commercial air transport implementation, the companies said. “Although and general aviation flight operations in the audit report portrays a number of positive T2012 involved risk assessment and general oper- trends, the value of this report is its ability to al- ating manuals, according to a recently released low operators around the world to evaluate their audit analysis report from PRISM Solutions and own safety programs, identify where gaps exist, sister company Argus PROS (Figure 1). and seek to reduce risk exposure,” they said. PRISM analyzed 73 audits conducted by According to the report, 58 percent of the Argus PROS from Jan. 1 through Dec. 31, 2012 audit findings point to deficiencies in 2012, and compiled the results from all of the risk assessment. Risk assessments, according audits into a single report that is available at to PRISM, help identify, evaluate, mitigate and
General operating manuals 45% to PRISM, a GOM “must be accurate, up-to-date, and consistent with other manuals in order to Safety training 38% prevent miscommunication and confusion.” SMS training and internal evaluation programs Internal evaluation program 36% were cited as deficiency areas with 38 percent and Safety committee 26% 36 percent of the operators, respectively. Sample audit recommendations for SMS training included Policy 23% “The safety manager should receive formal train- SMS manual 21% ing for the development and implementation of an SMS.” For internal evaluation programs, a sample Hazard reporting 12% recommendation was “Resolution of findings … Operator audits should include a root cause analysis and docu-
SMS = safety management system mented follow-up when appropriate.” Audit findings for 2012 differed somewhat Source: Argus PROS from the previous year. In 2011, GOM recom- Figure 1 mendations were the most common, with
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deficiencies found at 64 percent of 74 operators, Safety Management System Recommendations, 2008–2012 followed by safety training (47 percent) and deficiencies with the SMS manual (38 percent). Internal evaluation program 36% Risk assessment (36 percent) was the fourth 47% most common recommendation area in 2011, 38% SMS training 47% according to the PRISM analysis. General operating manuals 45% The PRISM report also compares 2012’s 43% recommendations from 73 audits with the results 21% SMS manual 36% of 249 audits conducted from 2008 through 2011 Risk assessment 58% (Figure 2). Results from the 2008–2011 period 30% show that the three most common recommenda- Safety committee 26% 29% tions were about internal evaluation program (47 23% Safety policy 22% percent), SMS training (47 percent) and operating 2012 (out of 73 audits) 12% manual (43 percent). Last year’s most common de- Hazard reporting 13% 2008–2011 (out of 249 audits) ficiency, risk assessment, was cited as a deficiency Operator audits in 30 percent of the audits during the 2008–2011 period, according to the PRISM report. SMS = safety management system PRISM also reviewed the audit reports of the Source: Argus PROS operators’ emergency response programs (ERPs) Figure 2 for 2012 and for the 2008–2011 period (Figure 3). The largest share of 2012 recommendations, Emergency Response Program Recommendations, 2008–2012 26 percent, involved documentation. Sample recommendations included “that on-site team 16% members be identified in the SMS manual by BBP/PPE/Hep B Inoc 36% official job position within the company and Emergency response 26% program documentation 34% all ERP documents be controlled.” Another 14% recommendation pointed out that an ERP did Go-team 27% not contain guidance for dealing with in-flight NOK noti cation/ 15% family assistance 27% incidents involving injuries or serious medical Emergency response 8% problems suffered by passengers or crew. program drills 21% The next most common area of deficiency, 7% NTSB training 20% 16 percent, was blood-borne pathogens (BBP) 0% Checklist 11% and personal protection equipment (PPE) train- 2012 (out of 73 audits) 0% ing. Sample recommendations included that the Media statement 8% 2008–2011 (out of 249 audits) on-site response team be trained in the use of Operator audits bio-hazard suits and that the team be trained for BBP exposure. Next-of-kin notification and BBP = blood-borne pathogens; Hep B Inoc = hepatitis B inoculation; NOK = next of kin; NTSB = U.S. National Transportation Safety Board; PPE = personal protection equipment family assistance was the third most common Source: Argus PROS recommendation area at 15 percent. Comparing the 2012 ERP results with the Figure 3 2011 results shows that the most common recom- mendations stayed basically the same from one percent of 73 operators in 2012), followed by BBP/ year to the next, but that the number of organiza- PPE/next-of-kin notification and by family assis- tions that had deficiencies in these areas declined tance (both found in 23 percent of 74 operators). from 2011 to last year. In 2011, the PRISM report Both PRISM Solutions and Argus PROS shows that documentation was the most frequent- are wholly owned subsidiaries of Argus ly cited area (30 percent of 74 operators versus 26 International.
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New Measures Two international aviation organizations 2013 synchronize accident rate information. Safety Report
BY LINDA WERFELMAN
REPORTS capabilities and better coordination of related 2013 Safety Report risk reduction initiatives.” International Civil Aviation Organization (ICAO). April 2013. 28 pp. The report summarized the state of the Appendixes, figures, tables. Available via the Internet at
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accident trends and a discussion of high-risk Other operations issues included a focus on accidents; an indication of the performance loss of control in flight (LOC-I), which rarely is of individual ICAO member states on ICAO’s cited as the cause of an accident. However, the Universal Safety Oversight Audit Programme report said, in the last eight years, LOC-I acci- (USOAP), and discussions of ICAO safety initia- dents have caused more fatalities than any other tives, including medical and health safety and accident type. As a result, the report said, ICAO other flight operations issues. will implement strategies in 2013 to help the Accident data are categorized according aviation community address the issues associ- to United Nations regions showing the low- ated with LOC-I. est 2012 accident rates in Oceania, with a rate
United States Government Accountability Office FAA Efforts Have Improved Safety, Testimony GAO of 0.0 accidents per million departures; Asia, Before the Committee on Commerce,
Science, and Transportation,
U.S. Senate But Challenges Remain in Key Areas For Release on Delivery with a rate of 2.7 per million departures; and Expected at 2:30 p.m. EDT Thursday, April 16, 2013 AVIATION SAFETY U.S. Government Accountability Office (GAO). GAO-13-442T. April FAA Efforts Have Improved Northern America, where the rate was 2.8 per Safety, but Challenges 2013. 17 pp. Available from GAO at
safety oversight system that are subject to Tas overseer of one of the safest airspace the audit process — legislation, organization, systems in the world — one that has gone more GAO-13-442T licensing, operations, airworthiness, accident than four years without a fatal commercial investigation, air navigation services, and aero- aviation accident. The GAO says in this report, dromes — and a list of the approximately 100 however, that, as the aviation industry evolves, states that have been found to have effective the FAA must remain diligent to ensure its implementation better than the global average continued safety. of 61 percent. The aircraft certification process presents Among ICAO’s safety initiatives is the the FAA with challenges “in terms of resourc- organization’s effort — in cooperation with the es and maintaining up-to-date knowledge of World Health Organization, the International industry practices,” the report said, adding Air Transport Association, Airports Council that both issues “may hinder FAA’s efforts International and others — to develop a har- to conduct certifications in an efficient and monized approach to dealing with public health timely manner.” events in civil aviation. The FAA is evaluating the certification “Safety, security, operations and efficiency process to identify ways it could be streamlined, are potentially affected when large numbers the report said. of personnel are not available for work due to The report recommended improved data illness and the associated impacts of epidemics,” collection and analysis in several areas, in- the report said. “Aircraft and airport operators cluding runway and ramp safety. “Additional are particularly affected.” information about surface incidents could help The report cited the 2003 outbreak of se- improve safety in the airport terminal area, as vere acute respiratory syndrome (SARS), which data collection is currently limited to certain reduced passenger travel to Hong Kong by types of incidents, notably runway incursions … 80 percent, and the H1N1 pandemic in 2009, and does not include runway overruns.” which resulted in a 40 percent reduction in Other areas that the report singled out as travel to Mexico. needing improved data collection included
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airborne operational errors, including losses of safety enhancements by identifying and address- separation; general aviation, which currently ing fatigue factors across time and changing includes potentially unreliable estimates of an- physiological and operational circumstances.” nual flight hours; and pilot training, which is The AC includes a discussion of FRMS lacking a comprehensive system for measuring as an operator-specific entity that should be performance in meeting annual pilot school developed according to each certificate holder’s inspection requirements. specific needs. “FAA has taken steps to address safety Appendix 2 provides guidance on establish- oversight issues and data challenges in many of ing an FRMS, including how to “prepare for the these areas,” the report said. “For example, FAA FRMS approval process, develop the required is planning to develop a program to collect and documentation, develop and apply fatigue risk analyze data on runway overruns, but it will be management (FRM) and safety assurance (SA) several years before FAA has obtained enough processes, collect and analyze data, develop flight information about these incidents to assess risks. crew FRMS operations procedures and a step-by- Sustained attention to these data collection and step process required for … FAA evaluation and analysis issues will be necessary to ensure that validation of the proposed FRMS application.” FAA can more comprehensively and accurately The appendix also includes a diagram of the manage risk.” fatigue risk management process and a sample fatigue report, which requests crewmember REGULATORY MATERIALS responses to dozens of questions about specific episodes of fatigue. Fatigue Risk Management U.S. Department Advisory This AC cancels its predecessor AC 120-103, of Transportation Federal Aviation Administration Circular Subject: Fatigue Risk Management Systems Date: 5/6/13 AC No: 120-103A Systems for Aviation Safety issued Aug. 3, 2010. for Aviation Safety Initiated by: AFS-220 Change:
1. PURPOSE. a. Contents. This advisory circular (AC): U.S. Federal Aviation Administration (FAA) Advisory Circular (AC) (1) Describes the basic concepts of Fatigue Risk Management Systems (FRMS), as prescribed in Title 14 of the Code of Federal Regulations (14 CFR) part 117, § 117.7, and how they relate to aviation industry employees safely performing their duties. 120-103A. May 6, 2013. 34 pp. Appendixes, figures, references. (2) Provides information on the components of an FRMS as applied to aviation, and on how to implement an FRMS within an aviation operation.
(3) Defines an FRMS as an operator-specific process; therefore, while all FRMSs will Specimen Safety Management Manual have common elements, the specifics will be tailored to a certificate holder’s particular Available from FAA via the Internet at
(4) Provides (in Appendix 2, Fatigue Risk Management System Development) the certificate holder with the necessary detailed guidance to prepare for the FRMS approval process, develop the required documentation, develop and apply fatigue risk management (FRM) and Safety Assurance (SA) processes, collect and analyze data, develop flightcrew FRMS operations procedures and a step-by-step process required for Federal Aviation Administration (FAA) evaluation and validation of the proposed FRMS application. his AC describes fatigue risk management b. Parts of an FRMS. This AC describes the essential processes and elements for an effective FRMS.
c. Not Mandatory. This AC is not mandatory and does not constitute a regulation. However, this AC provides an acceptable method for developing an FRMS application. systems (FRMS), as prescribed in U.S. 2. CANCELLATION. This AC cancels AC 120-103, Fatigue Risk Management Systems for Aviation Safety, dated August 3, 2010.
3. INTRODUCTION TO FRMS. An FRMS is an optional approach to prescriptive regulations. A certificate holder seeking to exceed a limitation in part 117 or in 14 CFR part 121 subparts Q, R, or S, would do so under an FAA authorization. An FRMS is largely developed as Federal Aviation Regulations Part 117, and an alternative method of compliance (AMOC) to prescriptive limitations based upon objective performance standards. A certificate holder may be authorized to apply an FRMS to any part or all of its operation, provided that the certificate holder demonstrates an effective AMOC that T discusses how they can be used to help workers in the aviation industry safely perform their du- ties. Compliance with the AC is not mandatory. The document defines FRMS as a “manage- ment system for a certificate holder to use to mitigate the effects of fatigue in its particular operations. An FRMS is a data-driven system, based largely upon scientific principles and operational knowledge, that allows for continu- ous monitoring and management of safety risks associated with fatigue-related error. An FRMS is a fatigue-mitigation tool that minimizes the acute and chronic sources of fatigue and man- ages the potential risks associated with fatigue. The FRMS is part of a repetitive performance Edition 2– 10 May 2013 Page 0 of 77 improvement process that leads to continuous
54 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2013 INFOSCAN
INSTRUCTIONAL GUIDES EHEST Safety Management Toolkit: Version for Complex Operators Second edition. European Helicopter Safety Team (EHEST). May 10, 2013. Appendixes, figures, tables. Available via the Internet at
his edition of the toolkit — originally is- sued in August 2012 — has been revised to Tensure alignment with regulatory material published in October 2012. Its primary audi- ence includes operators of complex aircraft with little experience running a safety management system (SMS). Major components of the toolkit are the Safety Management Manual for Complex Op- erators, the EHEST Emergency Response Plan and the EHEST Safety Management Database User Guide.
ELECTRONIC MEDIA Take a Closer Look: The Ageing Aircraft Resource Australian Civil Aviation Safety Authority (CASA). 2013.
his compact disc is intended to aid aircraft Piper Navajo Chieftain and a 1969 Cessna operators, aviation business managers, 402A, are linked to a master PDF publication. Tmaintenance personnel and others in un- derstanding how age affects aircraft airworthi- WEBSITE ness and safety. International Civil Aviation Organization (ICAO) Topics — which are discussed in original — Safety Audit Information presentations from CASA, as well as the U.S.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2013 | 55 AIRLINEAIRLINE ENGINEERING ENGINEERING ORGANISEDORGANISED BY: BY: && MAINTENANCEMAINTENANCE10TH10TH -11TH -11TH JULY JULY 2013 2013 ININ PARTNERSHIP PARTNERSHIP WITH WITH SAFETYSAFETYLONDONLONDON AA new new targeted targeted safety safety event event forfor the the MRO MRO industry industry KeyKey themes themes to to be be tackled tackled atat this this conference: conference: Safety, Safety, regulation regulation and and culture culture Safety Safety Management Management Systems Systems Fatigue Fatigue and and human human factors factors Data Data and and reporting reporting REGISTERREGISTER NOW NOW PleasePlease visit visit Communication Communication and and interfaces interfaces www.flwww.fl ightglobalevents.com/mro2013 ightglobalevents.com/mro2013 TrainingTraining toto register register today today quoting quoting code: code: ERT91960 ERT91960
CONFIRMEDCONFIRMED SPEAKERS SPEAKERS INCLUDE: INCLUDE: RudyRudy Quevedo Quevedo BrianBrian Watt Watt StaceyStacey Bechdolt Bechdolt DirectorDirector of Globalof Global Programs Programs DirectorDirector of Safety,of Safety, Quality Quality and and Compliance Compliance Director,Director, Safety Safety & Technical & Technical Affairs Affairs FlightFlight Safety Safety Foundation Foundation FlybeFlybe RegionalRegional Airline Airline Association Association RobertRobert Alway Alway FernandoFernando Val Val BillBill Rankin Rankin President,President, AEI AEI ChiefChief Operating Operating Offi Offi cer cer TechnicalTechnical Fellow Fellow VuelingVueling Airlines Airlines BoeingBoeing MartinMartin Eran-Tasker Eran-Tasker TechnicalTechnical Director Director AndyAndy Ebdon Ebdon DarrenDarren Cook Cook AssociationAssociation of Asiaof Asia Pacifi Pacifi c Airlines c Airlines Chairman,Chairman, Human Human Factors Factors Group: Group: Engineering Engineering ManagerManager Air Air Safe Safe RoyalRoyal Aeronautical Aeronautical Society Society QANTASQANTAS Engineering Engineering FergusFergus Wilson Wilson ChiefChief Operating Operating Offi Offi cer cer SimonSimon Stewart, Stewart, Group Group Director Director of Safetyof Safety KevenKeven Baines Baines AerAer Lingus Lingus AvincisAvincis Mission Mission Critical Critical Services Services ManagingManaging Director Director BainesBaines Simmons Simmons BradBrad Brugger Brugger IanIan Williams, Williams, President, President, European European Aviation Aviation InternationalInternational Coordinator Coordinator Safety Safety of of MaintenanceMaintenance Training Training Committee Committee DaveDave Ramage Ramage FlightFlight and and Compliance Compliance Capt.Capt. Bertrand Bertrand de deCourville Courville VP-TechnicalVP-Technical Operations Operations TransportTransport Workers Workers Union Union of Americaof America CorporateCorporate Safety Safety Manager, Manager, Air Air France France JetBlueJetBlue NeilNeil Williams Williams Capt.Capt. Kevin Kevin L. HiattL. Hiatt MichaelMichael Kalbow Kalbow HeadHead of Airworthinessof Airworthiness Policy Policy and and Rulemaking Rulemaking PresidentPresident and and CEO CEO HeadHead of Maintenanceof Maintenance Training Training CivilCivil Aviation Aviation Authority Authority FlightFlight Safety Safety Foundation Foundation AirbusAirbus LuisLuis Pires Pires LydiaLydia Hambour Hambour Exhibitors:Exhibitors: StandardisationStandardisation Team Team Leader, Leader, International International SeniorSenior Manager, Manager, IEP IEP & FRMS & FRMS StandardisationStandardisation Coordinator, Coordinator, EASA EASA AmericanAmerican Airlines Airlines JorgeJorge Leite Leite PaulPaul Cousins, Cousins, Federal Federal President President VP VPQuality Quality AustralianAustralian Licenced Licenced Aircraft Aircraft Engineers Engineers TAPTAP Maintenance Maintenance and and Engineering Engineering AssociationAssociation
VisitVisit www.fl www.fl ightglobalevents.com/mro2013 ightglobalevents.com/mro2013 to to register register today today ONRECORD Overrun at Khartoum A wind shift and a prolonged touchdown were among the factors that prevented a safe landing.
BY MARK LACAGNINA
The following information provides an awareness of problems that might be avoided in the future. The in- formation is based on final reports by official investigative authorities on aircraft accidents and incidents.
JETS
Thrust Reverser Inoperative The reverser was deactivated and secured in the Airbus A310-324. Destroyed. Thirty fatalities. stowed position according to the provisions of orgoing the use of autobrakes for landing the A310’s minimum equipment list pending on a wet runway, a prolonged flare and an further corrective maintenance. Finoperative thrust reverser were among the The flights to Amman and Damascus factors that led to the overrun and fire that proceeded without incident. On the last leg, killed 29 passengers and one cabin crewmember however, the flight crew was unable to land at at Khartoum the night of June 10, 2008, accord- Khartoum as scheduled because of thunder- ing to the Sudanese Air Accident Investigation storm activity at the airport. The crew diverted Central Directorate (AAICD). The directorate’s the flight to Port Sudan, where the A310 was final report, which also cited a substantial but refueled. The aircraft was on the ground about unnoticed wind shift shortly before touchdown, 75 minutes before the crew decided to complete was posted recently by the French Bureau the flight to Khartoum, where weather condi- d’Enquêtes et d’Analyses (BEA). tions reportedly were improving. The accident occurred during a trip from As the A310 neared Khartoum, the crew Cairo, Egypt, to the airline’s home base in received the latest meteorological report, which Khartoum, with stops in Amman, Jordan, and indicated that the surface winds were from 360 Damascus, Syria. The captain, 60, had 14,180 degrees at 12 kt and that runway visual range flight hours, including 3,088 hours in type. The was 6,000 m (4 mi) in heavy rain. copilot, 50, had 9,879 flight hours, with 3,347 The instrument landing systems at Khar- hours in type. Both pilots held several type rat- toum were out of service, and the crew was ings, and they had been off duty more than 24 cleared for the VOR/DME (VHF omnidirec- hours before the trip began. tional range/distance-measuring equipment) ap- Two months earlier, the thrust reverser on proach to Runway 36, which was 2,980 m (9,777 the A310’s left engine did not stow after landing, ft) long and 45 m (148 ft) wide. and the master actuator was replaced. How- “The captain was flying the aircraft,” ever, the thrust reverser again failed to stow on the report said. “He complied with the con- command the day before the accident flight. trol clearances and performed a stabilized
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approach. The CVR [cockpit voice recorder] A fuel-fed fire erupted near the right wing reading showed good coordination between root after the aircraft came to a stop. “The the captain and the copilot.” investigation revealed that the fire could not be As the crew configured the aircraft for fought by the airport fire department with the landing, the copilot “suggested the use of au- required rapidity and efficiency,” the report said. tobrake, and the captain decided not to use it,” “This was due to training as well as communica- ‘The aircraft was the report said. The reason for this decision was tions and infrastructure issues.” not specified. The evacuation was impeded by thick actually subject The captain disengaged the autopilot as the smoke that rapidly spread through the cabin aircraft descended through 800 ft. The airport and by some passengers who attempted to to a 15-kt tailwind traffic controller had advised the crew that the retrieve carry-on items. The causes of the fatali- component. The winds were from 320 degrees at 7 kt and that the ties were not specified. The survivors — 177 runway was wet. However, as the A310 neared passengers and 10 crewmembers — used the crew seemed not to the runway, the wind shifted to the south and left forward slide to exit the aircraft before it increased in velocity. was consumed by fire. have realized it.’ “Just before touchdown, the FDR [flight Based on the findings of the investigation, data recorder] recorded 140 kt for indicated air- the AAICD made several recommendations to speed and 155 kt for groundspeed,” the report the Sudanese Civil Aviation Authority, includ- said. “This means that the aircraft was actually ing improving airport firefighting and wind- subject to a 15-kt tailwind component. The reporting capabilities, and establishing means for crew seemed not to have realized it. Due to the measuring and reporting runway friction levels. tailwind, the aircraft touched down about 850 to 900 m [2,789 to 2,953 ft] from the threshold. Flight Bag Foibles A smooth landing was recorded, which might Boeing 737-300. Substantial damage. No injuries. also be a contributing explanation for such a mistake in the calculation of takeoff per- long distance.” formance data and a malfunctioning flight The ground spoilers deployed normally on Acontrol system led to a premature and touchdown, and the captain moved both thrust excessive rotation that resulted in a tail strike levers to the full-reverse position. With only on takeoff from Chambéry (France) Airport the right engine producing reverse thrust, the the morning of April 14, 2012. The accident aircraft veered right. The captain moved the caused damage to the 737’s rear fuselage skin thrust levers back to the idle position and used and frames, but there were no injuries to the 131 differential manual braking to return the aircraft passengers and five crewmembers. to the runway centerline. Investigators found that the commander had The aircraft was about 80 m (262 ft) from not revised the aircraft’s takeoff weight while the end of the runway when the captain again using a portable electronic flight bag (EFB), applied reverse thrust, “but the speed was too resulting in airspeeds and a thrust setting that low for this action to be efficient,” the report were erroneously low. said. Rubber marks on the runway indicated “The investigation also revealed wider issues that all the wheels were locked by the brakes as relating to the general design and use of EFB the aircraft neared the end of the runway, but computers to calculate performance data,” said there was no sign of hydroplaning. the report by the U.K. Air Accidents Investiga- “Thirty-six seconds after touchdown, the tion Branch (AAIB). aircraft overran Runway 36 at 76 kt,” the report The 737 had been flown with no passengers said. The A310 rolled 215 m (705 ft) on hard, aboard to Chambéry from London earlier that rough sand, struck several lights and antennas, morning. When the commander used the EFB and crossed a ditch before stopping. to calculate takeoff performance data for the
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return trip to London, he neglected crash of a 747 freighter in Halifax, cabin early and to be seated when the to enter the takeoff weight shown Nova Scotia, in October 2004, which seat belt sign illuminated. on the load sheet. The EFB reverted also involved calculations based on an The captain illuminated the seat belt to the takeoff weight that had been erroneously low takeoff weight that sign as the airplane descended through entered before the departure from had been retained in an EFB (ASW, 25,000 ft. The A319 subsequently was London, which was 6,600 kg (14,550 lb) 10/06, p. 18). descending through 12,400 ft when it lower than the actual takeoff weight at The report (EW/C2012/04/03 in encountered turbulence. The forward Chambéry. Consequently, the calcu- AAIB Bulletin 4/2013) discusses efforts flight attendant, who was securing the lated rotation speed of 127 kt was 12 kt by Australian, European and North galley, sustained serious leg injuries lower than it should have been, and the American authorities to reduce errors when she was thrown to the floor, and reduced thrust setting of 88.6 percent in performance-data calculations using two other flight attendants suffered was 4.2 percent too low. EFBs but said, “There remains … a minor injuries. None of the 138 passen- “Both pilots stated that they would continued vulnerability to the use of gers was hurt. The report noted that the normally cross-check the performance incorrect data in making these calcula- turbulence encounter occurred about figures once they had been calculated tions, a solution to which remains 20 minutes after the captain briefed the on the EFB,” the report said. “However, outstanding. This accident serves to flight attendants. on this occasion, and for reasons the pi- demonstrate that, given these circum- The seriously injured flight atten- lots could not recall, this was not done.” stances, the existence of and adherence dant was aided by medically qualified The subsequent early rotation was to robust procedures, and appropri- passengers, including a surgeon. “The exacerbated by a broken spring in the ately designed software and hardware, flight crew advised ATC [air traf- aircraft’s elevator feel and centering are essential.” fic control] that they had an injured unit, which caused “reduced resis- The investigation prompted the crewmember and requested priority tance in the flight controls in pitch, AAIB to reiterate recommendations handling and for paramedics to meet contributing to the excessive pitch for establishing means to gauge the the airplane on arrival,” the report said. attitude achieved during rotation,” the progress of a takeoff once it has begun: “The ATC approach controller did not report said. “This event once again emphasises the forward the request for paramedics. The flight crew and a flight at- need for technical solutions for takeoff The crew also attempted to contact the tendant felt a “judder” during takeoff, performance monitoring, to cater for company station agents and dispatch, but this was attributed by the pilots those occasions where current safe- but received no response. to turbulence. The remainder of the guards have failed.” “The lack of ATC coordination and flight to London Gatwick Airport was lack of company personnel to monitor uneventful. After shutting down the Turbulence Encounter communications from inbound flights engines, the pilots were informed by Airbus A319-112. No damage. One serious injury, delayed the arrival of emergency medi- two minor injuries. ground personnel that the rear fuselage cal personnel to meet the flight.” was damaged. he A319 was on initial descent The operator of the 737 told inves- to land at Fort Lauderdale the Minimum Fuel on Go-Around tigators that all company pilots had Tafternoon of May 10, 2012, when British Aerospace 146. No damage. No injuries. been trained and checked on the use of the flight crew “noticed typical Florida he aircraft was en route with 40 the EFB. “However, the investigation summertime cumulus cloud condi- passengers and four crewmembers revealed a lack of clarity in the way the tions,” said the report by the U.S. Tfrom Paris to Zurich, Switzerland, procedures were laid out and on details National Transportation Safety Board the night of June 17, 2010. However, the of how information should be checked,” (NTSB). flight crew was unable to land the 146 the report said. The captain told the flight atten- in Zurich because of thunderstorms The report cited “a number of pre- dants that he would illuminate the seat and heavy rain. vious incidents and accidents resulting belt sign early because of expected “Given the immediate forecast from incorrect calculation of takeoff turbulence and instructed them to and the absence of an estimated time performance,” including the fatal complete the initial cleanup of the for a new approach, the crew decided
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to divert to the diversion aerodrome, Basel- The 146 was about 2 nm (4 km) out and the Mulhouse-Freiburg, without holding at Zu- A319 was still on the runway when the control- rich,” said the BEA report. “The remaining fuel ler told the Airbus crew to stop and asked the quantity was about 2,170 kg [4,784 lb], which 146 crew to go around. “The latter [initially] corresponded to about 75 minutes of flight at refused because they did not have enough fuel cruising speed.” The Basel-Mulhouse-Freiburg and requested that the A319 vacate the runway,” Airport, which is jointly operated by France and the report said. Switzerland, is about 41 nm (76 km) northeast The controller then ordered the 146 crew of Zurich. to go around. The crew complied with the “While receiving vectors for the instru- instruction and said, “We are declaring a fuel ment landing system (ILS) approach to Runway emergency now. We request priority vectors 33, the crew asked for a shortened flight path, for landing.” They landed the aircraft about without giving any reason,” the report said. The eight minutes later, after receiving vectors for 146 was on final approach when the airport a visual approach. “On the ground, the quan- traffic controller cleared the crew of an Airbus tity of fuel remaining was 1,220 kg [2,690 lb],” A319 for takeoff from Runway 33. The clearance the report said. was in French and was not understood by the The report concluded that the incident was English-speaking crew of the 146. caused by “the late communication by the crew The aircraft was about 5 nm (9 km) from to ATC of their low fuel situation and their the runway when the crew saw the A319 on emergency situation.” Based on the investiga- the runway and asked the controller to confirm tion, BEA recommended that the European that they were cleared to land. The controller Aviation Safety Agency adopt the International responded “negative,” told the crew to continue Civil Aviation Organization (ICAO) provision the approach and advised that the A319 was of declaring “minimum fuel” when a flight crew departing from Runway 33. can accept little or no delay at the destination. Although the aircraft’s fuel supply was at “The notion of minimum fuel defined by the level at which the operator requires pilots ICAO allows a crew to describe to the air traffic to declare an urgency, the crew did not. Conse- services a potentially critical situation during a quently, the controller was not aware of the 146’s diversion while avoiding the declaration of a dis- fuel state. tress or emergency situation,” the report said.
TURBOPROPS
‘Confused Crew Coordination’ by the Transportation Safety Board of Canada De Havilland Twin Otter. Destroyed. Two fatalities, four serious injuries, (TSB). “The captain also advised that the three minor injuries. airspeed should be kept above 80 kt indicated he float-equipped aircraft was on left base airspeed (KIAS), which is 10 KIAS above the to land at the floatplane base in Yellowknife, normal approach speed [for a full-flap ap- TNorthwest Territories, Canada, the morning proach]. During final approach, on a track of of Sept. 22, 2011, when the traffic controller at 195 degrees, the captain cautioned the FO twice the nearby airport advised the flight crew that about the airspeed getting too low.” the winds were variable from the southwest at The Twin Otter bounced on touchdown 10 kt, gusting to 30 kt. and contacted the water again in a right-wing- The first officer (FO) was flying from the low attitude. “The [right] float dug in, and the right seat. “Due to the 2- to 3-ft waves (rollers) aircraft yawed to the right, turning towards the on the lake, the crew planned their approach shore,” the report said. “Without declaring that so as to land close to the shore,” said the report he was taking control, the captain placed his
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right hand on the power lever over the FO’s left (HSIs), the crew continued the flight without hand and initiated full power for a go-around.” further incident. The aircraft continued to turn right at low Investigators found that the crew had airspeed and in a nose-high, right-wing-low selected the directional gyro (DG) mode while attitude. The captain called for the flaps to be re- adjusting the HSIs to match the runway head- tracted shortly before the right wing struck power ing and then had selected the slaved mode lines, causing the aircraft to pitch nose-down. before takeoff. “The heading reference system The floats then struck the side of an office build- should normally be kept in its slaved mode for The crews of several ing, and the Twin Otter crashed in a parking lot. normal operations and DG mode [only should Both pilots were killed and all seven passengers be] used in case of failure of the slaved system,” other aircraft also had were injured, but no one on the ground was hurt. the report said. experienced significant The TSB concluded that the bounced landing The report noted that the crews of several had been caused by airspeed fluctuations and other aircraft also had experienced significant navigational problems. the gusty crosswind conditions, and the loss of navigational problems after taking off from control had resulted from improper go-around London City Airport (ASW, 4/08, p. 18). “It techniques. “It is possible that confused crew was established that local magnetic anomalies coordination during the attempted go-around in the area of the runway holding point could contributed to the loss of control,” the report said. adversely affect cockpit heading indications and, in some cases, lead to heading system failure Magnetic Anomalies Affect HSIs indications,” the report said. Piaggio P180 Avanti. No damage. No injuries. isual meteorological conditions (VMC) Maintenance Check Neglected prevailed when the Avanti took off from ATR 72-202. No damage. No injuries. VRunway 27 at London City Airport and outine maintenance at Edinburgh, Scotland, began a right turn to the assigned easterly head- was completed nearly five hours after the ing the evening of April 26, 2012. The aircraft Rflight crew was scheduled to depart for a po- was at 3,000 ft when the radar controller noticed sitioning flight to Paris the afternoon of March that it was heading southeast, toward the path 15, 2011. A post-maintenance functional flight of an Avro RJ-85 that was on final approach to check apparently was not conducted before the Runway 27. crew took off in night VMC. The controller told the Avanti crew to turn The crew maintained 170 kt during the climb left to a heading of 030 degrees. “This was to Flight Level 230 (approximately 23,000 ft). “As acknowledged but was apparently not complied the aircraft levelled and accelerated through about with, so a further instruction to turn left was 185 kt, the crew felt it roll to the left by about 5 to made using the phrase ‘avoiding action’ and 10 degrees, and they noticed that the slip ball was with details of the conflicting traffic,” the AAIB indicating fully right,” the AAIB report said. report said. The copilot, the pilot flying, disengaged the Suspecting that the Avanti crew had a autopilot and applied right rudder and right aile- navigation problem, the controller told them to ron to regain directional control. “He reported that climb to 4,000 ft and to turn left until advised to the rudder pedals felt unusually ‘spongy’ and that discontinue the turn. During the turn, the Avan- the aircraft did not respond to his rudder inputs,” ti came within 2.7 nm (5.0 km) laterally and 700 the report said. “He had to maintain 15 to 20 de- ft vertically of the RJ-85. The controller told the grees of right bank to hold a constant heading.” Avanti crew to stop the turn at a radar-indicated A flight control warning light illuminated, heading of 060 degrees. The crew reported that indicating a fault with the rudder travel limita- their indicated heading was northerly. After tion unit (TLU). The commander declared an resetting their horizontal situation indicators urgency and requested vectors from ATC to
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return to Edinburgh. “The copilot assessed that excessively, resulting in the uncommanded left he had very little control authority to make right roll as airspeed increased to 185 kt. turns, so the commander requested that only left “The required independent inspection of the turns be given,” the report said. Control became work and the operational test of the TLU system more difficult as airspeed decreased, but the were not carried out,” the report said. “Com- pilots were able to land the ATR at Edinburgh. mercial pressure was identified as the most Investigators found that one of the cams on significant factor which influenced the decision the rudder TLU mechanism had been reinstalled to perform unapproved and unrecorded mainte- incorrectly and had restricted rudder control nance on the TLU system.”
PISTON AIRPLANES
Stall After Engine Shutdown which resulted in an aerodynamic stall and Cessna 421C. Substantial damage. Four fatalities. impact with terrain.” A contributing factor was hortly after the 421 lifted off from Joe Foss his nonadherence to single-engine emergency Field in Sioux Falls, South Dakota, U.S., procedures that included feathering the propeller Sfor a charter flight the afternoon of Dec. 9, and retracting the landing gear and flaps. 2011, the airport tower controller told the pilot that a plume of smoke was visible behind the Engine Cylinder Separates airplane. Other witnesses saw white smoke and Britten-Norman Trislander. Substantial damage. No injuries. flames emerging from the inboard side of the he aircraft was cruising at 5,000 ft during a left engine. scheduled flight with seven passengers from The pilot did not acknowledge the controller’s TAlderney, Channel Islands, to Southampton, advisory but began a left turn, apparently in an England, the morning of March 27, 2012, when attempt to return to the runway. The smoke and the pilot heard a very loud bang and felt severe flames disappeared shortly before the 421 pitched vibration. He determined that the no. 2 (tail- nose-down and descended to the ground. mounted) engine had failed. “A postaccident examination determined “The pilot selected full power on the no. 1 that the left engine fuel selector and fuel valve and no. 3 engines, and advised ATC of his inten- were in the ‘OFF’ position, consistent with the tion to return to Alderney,” the AAIB report said. pilot shutting down that engine after takeoff,” “While carrying out the engine failure checklist, the NTSB report said. “However, the left engine the pilot was unable to operate the no. 2 propeller propeller was not feathered [and] the landing lever through its feather gate, which left the no. 2 gear and wing flaps were extended at the time propeller unfeathered and ‘windmilling.’” of impact.” Unable to maintain altitude, and with a sink Initial examination of the wreckage revealed rate of 200 fpm, the pilot declared an emergency. that the oil cap on the left engine was not se- “At some point during the descent, the propeller cured; however, the report said that this might blades on the no. 2 engine moved to the feather have resulted from the impact and subsequent position [and] stopped rotating,” the report said. fire. Investigators determined that the right “The pilot was subsequently able to control the engine was producing power on impact. Sub- rate of descent.” He landed the Trislander at sequent disassembly and inspection of the left Alderney without further incident. engine revealed nothing that would have caused Investigators found that corrosion and a loss of power. fatigue cracking had caused a cylinder mount- The report said that the probable cause of the ing stud on the no. 2 engine to fail, resulting in accident was “the pilot’s failure to maintain ade the cylinder’s separation from the crankcase. quate airspeed after shutting down one engine, The damage distorted a cable guide conduit
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that disabled the manual propeller-feathering “Therefore, he elected to keep the landing gear system; the propeller eventually feathered when retracted, and the airplane touched down on the engine oil pressure decreased due to oil leaking soft, rough terrain adjacent to the runway.” The through the hole in the crankcase. pilot and one passenger sustained minor inju- ries; the other seven passengers were not hurt. Fuel Flow Blocked Examination of the right engine revealed Cessna 402. Substantial damage. Two minor injuries. nothing that could have caused the power loss, hortly after the landing gear was retracted but three pieces of polyisoprene (synthetic rub- during departure for a skydiving flight from ber) were found in the tank supplying fuel to the SCaldwell, Idaho, U.S., the afternoon of June engine. “Each individual piece was large enough 20, 2011, the right engine lost power, and the to plug the orifice to the fuel boost pump, and it pilot decided to reject the takeoff. is likely that one or more of the pieces inter- “Because the airplane was at a very low rupted the fuel flow to the engine and resulted altitude, the pilot was not sure that all three in the loss of power,” the report said. “It was landing gear would fully extend before the not determined when or how the material had airplane touched down,” the NTSB report said. entered the fuel tank.”
HELICOPTERS
‘Focused on the Mission’ “The pilot immediately entered autorotation Bell OH-58A. Substantial damage. One minor injury. to preserve main rotor rpm,” said the report by he law enforcement helicopter had been the New Zealand Transport Accident Investiga- dispatched to aid in the search for a per- tion Commission. He attempted unsuccessfully Tson who was ejected from a motor vehicle to restore power before ditching the helicopter during a roll-over accident on a highway near in the bay. The LongRanger, which did not have Fort Pierce, Florida, U.S., the afternoon of flotation gear, rolled inverted and sank in less May 29, 2011. than 15 minutes. The pilot was maneuvering the helicopter The pilot began to swim toward the shore. at about 400 ft above the ground when an un- He was in the water more than two hours with- commanded right yaw developed. He attempt- out a life vest and suffered hypothermia and fuel ed to stop the rotation, but the Kiowa entered burns before being rescued by a helicopter crew an uncontrolled descent to the ground. that had been alerted by witnesses. “The pilot stated that he was more focused on the mission than on flying the helicopter,” Too Rich, Too High the report said. “He lost awareness of the wind Robinson R44. Substantial damage. No injuries. condition and did not recognize the possibility flight instructor and a commercial pilot of a loss of tail rotor effectiveness.” were ferrying the R44 to its new owner the Amorning of May 10, 2012. The helicopter Power Loss Leads to Ditching was at 10,000 ft over mountainous terrain near Bell 206L-3. Destroyed. One minor injury. Grants, New Mexico, U.S., when the instructor he pilot had departed from Maunga- decided to conduct a practice autorotation. karamea, in northern New Zealand, to “During the autorotation, the engine Tcheck fishing conditions in Bream Bay stopped producing power … due to an exces- the afternoon of Jan. 20, 2011. He was cruis- sively rich fuel mixture,” the NTSB report said. ing at 110 kt and about 1,000 ft above the “The instructor continued the autorotation, bay when the engine surged and rotor speed [and] during the landing, the main rotor blades began to decrease. severed the tail boom.”
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Preliminary Reports, April 2013
Date Location Aircraft Type Aircraft Damage Injuries April 1 Fort Lauderdale, Florida, U.S. Cessna 402C substantial 1 none The nose landing gear did not retract during departure for a post-maintenance positioning flight to the Turks and Caicos Islands. The pilot returned to Fort Lauderdale, where the nose gear collapsed on landing. April 3 Miami, Florida, U.S. Robinson R44 destroyed 2 fatal Witnesses heard an explosion and saw the tail separate from the R44 during a maintenance test flight associated with replacement of main rotor blades. April 4 Mayaguana, Bahamas Cessna 402C destroyed 3 fatal, 2 NA The 402 was landing to pick up a patient for a night emergency medical services flight when it struck two trucks providing illumination on the unlighted runway. Three people on the ground were killed. April 5 Hammonton, New Jersey, U.S. Cessna 414A destroyed 1 minor, 1 none The 414 veered left after touchdown, ran off the runway and struck several trees. April 6 Morelia, Mexico Cessna 421B destroyed 6 minor The 421 was en route from Cuernavaca to Guadalajara when the pilot reported problems with the right engine and that he was diverting to Morelia. Realizing he could not reach the airport, the pilot conducted an emergency landing on an open field. April 7 São Tomé and Principe Beech 1900C NA 1 NA Thunderstorms were in the area when the 1900 crashed in the Gulf of Guiana during approach to São Tomé Island. At press time, neither the wreckage nor the pilot, who was ferrying the airplane from South Africa to Mali, had been found. April 12 Santa Monica, California, U.S. Beech C55 Baron substantial 2 none While turning off the runway after landing, the left brake locked, the tire deflated and the left main landing gear collapsed. April 13 Denpasar, Bali, Indonesia Boeing 737-800 destroyed 20 minor, 88 none The 737 descended into the Indian Ocean on final approach to Runway 09. Day visual meteorological conditions prevailed, with unlimited visibility, a few cumulonimbus clouds at 1,700 ft and winds varying from 110 to 270 degrees at 6 kt. April 14 Georgetown, Guyana Piper Aztec destroyed 2 fatal The Aztec was departing for an aerial observation flight when it crashed in a residential area. No one on the ground was injured. April 16 Madrid, Spain Boeing 767-200ER substantial 250 none The 767’s tail struck the runway during takeoff for a flight to Mexico. The flight crew flew the airplane in a holding pattern for about 90 minutes before returning to Madrid-Barajas Airport for an uneventful landing. April 17 Sam Neua, Laos de Havilland Canada Twin Otter substantial 16 NA The Twin Otter struck trees at the end of the runway on takeoff and crashed in a canal. No fatalities were reported. April 17 Tripoli, Libya Boeing 737-800 minor 155 none The 737 was on approach when a bullet penetrated the cockpit and struck a water tank in the forward lavatory. April 26 Rotenburg, Germany Socata TBM-700 destroyed 4 fatal The aircraft crashed in an open field during approach about 2 km (1 nm) from the runway. April 27 Kandahar, Afghanistan Beech MC-12W destroyed 4 fatal The airplane, a military version of the King Air 350, crashed northeast of Kandahar Airport during a reconnaissance mission for the U.S. Air Force. April 29 Bagram, Afghanistan Boeing 747-400 destroyed 7 fatal The 747 was departing from Bagram Air Base for a cargo flight to Dubai when it entered a steep nose-up pitch attitude, stalled at about 1,200 ft and then descended to the ground near the end of the runway. April 30 Zacatecas, Mexico Beech King Air 300 destroyed 6 fatal The King Air, operated by the Mexican government, crashed in an open field about five minutes after departing from Zacatecas-La Calera Airport.
NA = not available This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed.
64 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2013 Save the Date Inaugural International Aviation Safety Management InfoShare August 29–30, 2013 Singapore
CAAS brandmark with descriptor lock-up Full Colour Positive
Approved by PANTONE COATED PANTONE COATED PANTONE COATED 540 C 2925 C 227 C PANTONE UNCOATED PANTONE UNCOATED PANTONE UNCOATED 541 U 2925 U 227 U CMYK CMYK CMYK Signature/Company Stamp C:100.0 M:80.0 C:85.0 M:25.0 C:0.0 M:100.0 27 May 2009 Y:20.0 K:30.0 Y:0.0 K:0.0 Y:10.0 K:20.0