AeroSafety world
Rough Ice Airfoil risks misjudged Familiar Airport Invalid SOPs wreck bizjet State Police Crash 2009 Accident HEMS pilot too low Rest in Place rate plateau Cockpit napping debate new decade’s global challenges
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Unnecessary Slide ’ve been in the newspapers a lot again. This them. Have we spent years implementing some- time, the discussion revolved around the late thing people don’t actually intend to use? December American Airlines Boeing 737-800 Another interesting part of this accident is runway excursion at Kingston, Jamaica. As the airport. Much has been made of the fact that Iusual, I got to try to comprehensively explain a the runway wasn’t grooved. Grooved pavement is complex set of interacting factors in a 10-word common in the United States but it isn’t required quote, a four-second sound bite. No matter how by International Civil Aviation Organization hard I try, I never get it quite right. Let me see if I (ICAO) standards. It is worth noting that the run- can do better with 500 words. ways were not grooved in the Air France accident The preliminary report shows that the airplane in Toronto, or the TAM accident in São Paulo, landed 4,000 ft (1,220 m) down a wet runway with Brazil. Maybe it is time for ICAO to tighten up a substantial tailwind. The tendency is to shrug off compliance with that standard? that approach as a dumb mistake in the cockpit, but Something that worries me even more is the that would be a real disservice. First, let’s consider the runway end safety area (RESA) in Kingston. It environment during the approach. There were lots of doesn’t even come close to meeting ICAO stan- bumps and lots of rain. The flight crew was offered a dards. Many airports in the region have the same chance to circle to Runway 30 for a better wind angle, problem. This has been known and documented but considering that it was dark and rainy with clouds for years. It would be nice if somebody asked, around 1,000 ft above ground level, it is easy to under- why does this requirement seem to be so widely stand why the crew passed on that option. ignored? There also are proven arrestor pavement Logically they chose to land straight in, with technologies that could have turned this accident a significant tail wind that was on the margins into a non-event. Where were they? of acceptability. With about 8,900 ft (2,700 m) Lots of things had to go wrong on that rainy of runway that didn’t seem to be a big deal. The night to have an outcome this bad. I hope the runway was wet, but there was plenty of it. investigators ask, as a minimum: Why wasn’t the Some tough questions should be asked. First of RNAV approach considered a viable option? Is all, why were the crew’s choices limited to a tough it time to admit that grooved pavement actually downwind landing or a risky circling maneuver? works? And when will airports start taking the There was an area navigation (RNAV) approach requirements for RESAs seriously? to Runway 30. I am not sure that option was really considered by air traffic control (ATC) or the flight crew. An RNAV approach can be a pain in the flight deck and something out of the ordinary for ATC in the control room. Global positioning system (GPS) William R. Voss approaches with vertical guidance can have huge President and CEO safety benefits, but only if we are prepared to use Flight Safety Foundation www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 1 AeroSafetyWorld
December 2009–January 2010 contents Vol 4 Issue 12 features
12 CoverStory | Major Accidents
18 CausalFactors | Bombardier Global 5000
12 22 SafetyOversight | Red Flags on SMS
26 HelicopterSafety | Fatal Descent
32 FlightOps | Rough Ice Is Bad Ice
38 HumanFactors | Rest in Place
44 FlightTraining | Executive Ability 18 departments
1 President’sMessage | Unnecessary Slide
5 EditorialPage | Deus ex Machina
6 AirMail | Letters From Our Readers
7 SafetyCalendar | Industry Events 22 9 InBrief | Safety News
2 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 26 32 44
AeroSafetyWORLD telephone: +1 703.739.6700 48 DataLink | Part 135 Accident Rates William R. Voss, publisher, FSF president and CEO [email protected] 52 InfoScan | Both Sides Now J.A. Donoghue, editor-in-chief, FSF director of publications 56 OnRecord | Control Anomaly Catches Crew Unaware [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Karen K. Ehrlich, webmaster and production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer [email protected], ext. 120 About the Cover Reducing rates of major accidents requires Susan D. Reed, production specialist daily commitment in the new decade. [email protected], ext. 123 © Newlight/Dreamstime.com Patricia Setze, librarian [email protected], ext. 103
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Deus ex Machina
or the most part, we know how to that will cost much less than $1 million to Perhaps people have no money right be safe. Much of our current safety fix, an amount that the airline’s insurance now — who does? — or are waiting for work involves promoting proven company is happily paying. the next generation aircraft, or the integra- procedures and technologies to The title of this column is, of course, tion of HGS with enhanced vision and/or preventF the same kind of accident from what it is about, for just as ancient Greek synthetic vision, with regulatory buy-in in happening over and over again. As Bill plays often end with a god being lowered the form of reduced minima to improve Voss points out in his column this month, to the stage by a mechanism – hence, the schedule regularity. Then there is the the American Airlines 737 accident in god from the machine – to resolve the next generation air traffic control system Jamaica involved, among other factors, a drama, so, too, does aviation have access transition on the horizon, also promising runway that lacked an adequate runway to salvation through the use of a variety benefits in both safety and operational end safety area. A few weeks later, on Jan. of technologies. While much of our cur- efficiency, and a flood of associated prod- 19, the pilots of a US Airways Express rent work involves the human side of the ucts leveraging the automatic dependent Bombardier CRJ-200 with 31 passengers equation and developing procedures to surveillance-broadcast technology. And and a crew of three rejected a takeoff from avoid known pitfalls, sometimes you even simple-sounding stuff, like the Air- the hilltop Yeager Airport at Charleston, really can just go out and buy enhanced bus system that tells pilots where on the West Virginia, U.S., and did not plunge safety. The most dramatic example of runway they are going to land and whether off of the side of the mountain because this is the use of terrain awareness and the space is sufficient, is becoming avail- the airport management had installed warning systems that can eliminate con- able and appears to offer great value. an engineered material arresting system trolled flight into terrain, the class of There are a lot of products either here (EMAS) at the runway’s end. accident that used to kill more people or arriving soon that can reduce the risk This compare-and-contrast exercise than any other. of an accident, and isn’t that what we are is so obvious I’m almost embarrassed Along the way, some have been re- all trying to do? Budget planning should to do so, yet I feel obligated to point out luctant to buy the latest devices, which, reflect that intention. once again the number of technologies in part, is understandable when the tech- that exist and are just waiting for use nology is new and rapidly evolving. But to either avoid incidents and accidents, some of these safety enhancements have or minimize damage and injuries when been with us for years, decades even, something bad does happen. The event at and yet many still choose not to invest. Charleston was prevented from becom- One such technology that immediately J.A. Donoghue ing a very expensive, very fatal catastro- springs to mind is the head-up guidance Editor-in-Chief phe by a few hundred feet of EMAS bed system (HGS). AeroSafety World www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 5 AirMail
Automation must not degrade fighter squadrons, well educated and discrepancies, might pass unobserved decision making skills used to handling aircraft in all axes. by the pilot. read “Topsy Turvy” and “Grappling Times have changed, however, and IFALPA AIR (Airworthiness Study with the Unexpected” (ASW, 11/09, new pilot recruits have to be trained in Group, now AGE/ADO) has always had I p. 20 and p. 26, respectively) with civil aviation schools. “Unusual posi- a high priority of merging human brain great interest. tion recovery” training might there- capacity with high-stress piloting work. As one familiar with flight opera- fore be one correct response; however, “Pilot reaction time” has for de- tions, I suggest possible new avenues to I believe this picture can be expanded cades been standard within FARs Part identify why things happen: a bit. 25 aircraft certification. Everything Incident/accident investigations Among new generation pilots a has limits and that includes how much start with the affected pilot’s ability to change might be observed: from child- instant stress even a well-trained hu- handle the unforeseen situation. Identi- hood, they have grown up with ad- man brain can take, as well as the abil- fying a possible triggering point is next vanced computer games. This new kind ity to make the correct “split-second — changes from normal to abnormal of background has, perhaps, tended decision.” conditions. These might vary through toward “autoflight complacency.” Further, AIR’s message to aircraft hidden gradual build-ups or external Observations from active pilots manufacturers was, “Do not fill up influence. They can result in the need reported back to me, as an advisor to cockpits with all kinds of warnings.” For for split-second decision making! the International Federation of Air Line example, a howling horn, with simulta- Regardless of modern well- Pilots’ Associations (IFALPA), hint of neous flashing lights for stall warning, equipped aircraft/warning systems, a complete new-pilot view that “auto- which would be more nerve-wracking human brain capacity limits must flight” from the point of flap retrac- than useful, was not acceptable. always be taken into consideration. tion after takeoff until full stop after Acceptable was: “Bell ringing, red Automation must, for instance, include landing, including autobraking, seems light = fire.” Likewise, “aural horn override systems, to enable the pilot- acceptable — worrying! signal, red light = unsafe gear.” “Stick in-command to take corrective action. Flying as a profession ought to keep shaker = stall warning,” etc. For lesser Such decision making requires human being a skilled art, since it includes priority warnings, various voice mes- skill and experience. obeying laws of nature. Actual flying by sages were OK. On the other hand, flight simulator feel, such as visual, minimum circling Nowadays, with the introduction of instruction has become an indispens- approaches, etc. is good training. all-remote-controlled aircraft, ever- able means of teaching procedures, but Initial, progressive pilot educa- increasing weight, etc., a new updated “upside down” aircraft positioning and tion is essential, followed by continu- understanding of human brain capacity feeling the actual g forces are impos- ous skill updating and training. An versus technological expansion ought sible in a simulator. engine failure will not be adjusted by to be considered. In earlier days, many pilots were the autoflight mode. Situations out- recruited from an air force milieu and side autoflight control, perhaps slight Capt. (retired) Oddvard Johnsen
6 | flight safety foundation | AerosafetyWorld | December 2009–January 2010 ➤ safetycalendar
CALL FOR PAPERS ➤ 41st Annual Seminar MARCH 1–4 ➤ Next Generation of Aviation MARCH 15–17 ➤ Human Factors — General of the International Society of Air Safety Professionals Symposium. International Civil Principles. Baines Simmons. London. Kevin Baines Investigators. Sapporo, Japan, Sept. 6–9. Bob Aviation Organization. Montreal. Nicole Barrette- or Bob Simmons,
www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 7 Serving Aviation Safety Interests for More Than 60 Years
Officers and Staff light Safety Foundation is an international membership organization dedicated to Chairman, the continuous improvement of aviation safety. Nonprofit and independent, the Board of Governors Lynn Brubaker FFoundation was launched officially in 1947 in response to the aviation industry’s need President and CEO William R. Voss for a neutral clearinghouse to disseminate objective safety information, and for a credible General Counsel and knowledgeable body that would identify threats to safety, analyze the problems and and Secretary Kenneth P. Quinn, Esq. recommend practical solutions to them. Since its beginning, the Foundation has acted in the Treasurer David J. Barger public interest to produce positive influence on aviation safety. Today, the Foundation provides leadership to more than 1,040 individuals and member organizations in 128 countries. Administrative Manager, Support Services Linda Crowley Horger MemberGuide Flight Safety Foundation Financial Headquarters: 601 Madison St., Suite 300, Alexandria, VA, 22314-1756 USA Chief Financial Officer Penny Young tel: +1 703.739.6700 fax: +1 703.739.6708 www.flightsafety.org Accountant Misty Holloway
Membership Director of Membership Ann Hill Seminar and Exhibit Coordinator Namratha Apparao Membership Services Coordinator Ahlam Wahdan
Business Development Member enrollment ext. 102 Director of Development Susan M. Lausch Ahlam Wahdan, membership services coordinator [email protected] Seminar registration ext. 101 Communications Namratha Apparao, seminar and exhibit coordinator [email protected] Seminar sponsorships/Exhibitor opportunities ext. 105 Director of Ann Hill, director of membership [email protected] Communications Emily McGee Donations/Endowments ext. 112 Susan M. Lausch, director of development [email protected] Technical FSF awards programs ext. 105 Director of Ann Hill, director of membership [email protected] Technical Programs James M. Burin Technical product orders ext. 101 Technical Namratha Apparao, seminar and exhibit coordinator [email protected] Programs Specialist Norma Fields Library services/seminar proceedings ext. 103 Manager of Patricia Setze, librarian [email protected] Aviation Safety Audits Darol V. Holsman Web site ext. 117 Karen Ehrlich, webmaster and production coordinator [email protected] Technical Specialist/ Safety Auditor Robert Feeler Regional Office: GPO Box 3026 • Melbourne, Victoria 3001 Australia Telephone: +61 1300.557.162 • Fax +61 1300.557.182
Past President Stuart Matthews Paul Fox, regional director [email protected] Amy Beveridge, event manager [email protected] Founder Jerome Lederer 1902–2004
flight safety foundation | AeroSafetyWorld | December 2009–January 2010 Safety News inBrief New Support for Anti-Criminalization Pact
he joint resolution opposing the International Federation of Air Traffic that had fallen off a Continental Airlines criminalization of aviation acci- Controllers Associations. McDonnell Douglas DC-10 that had Tdents, originally published in 2006, “We welcome these latest safety taken off earlier from the same runway. has gained new backing from the Inter- professionals joining in our statement As the tire broke apart, one piece struck national Society of Air Safety Investiga- of principles, and urge judges, jurors one of the Concorde’s fuel tanks, the fuel tors (ISASI), which added its signature to and prosecutors, like those involved in ignited, and the burning airplane struck the document in January. the unfortunate Concorde criminal case the ground. All 109 people in the air- “The current trend of criminalizing soon going to trial in France, to pay close plane were killed, along with four on the aviation accidents has a deleterious effect attention,” said Flight Safety Foundation ground. The airplane was destroyed. on the appropriate investigation of said President and CEO William R. Voss. “We French prosecutors plan to try occurrences, the finding of contribut- cannot afford to let the desire by some Continental and two of its maintenance ing factors and probable causation, and for vengeance or publicity to come at the employees on involuntary manslaugh- the formulation of recommendations to expense of safety for all. We need to learn ter charges, as well as former officials prevent recurrence,” said ISASI President from accidents to prevent them, not crim- of the French airline regulator and the Frank Del Gandio. inally punish well-meaning professionals Concorde division at Aerospatiale, which The resolution originally was devel- and thereby risk a repeat of a tragedy.” built the airplane. oped by Flight Safety Foundation, the The Concorde trial, scheduled for Civil Air Navigation Services Organisa- February, stems from the July 25, 2000, tion, the Royal Aeronautical Society crash of an Air France Concorde during and the Académie Nationale de l’Air et takeoff from Paris Charles de Gaulle de l’Espace. Subsequently, it also was Airport. The French Bureau d’Enquêtes signed by the European Regions Airline et d’Analyses said the probable cause of Association, the Professional Avia- the crash involved the passage of one of tion Maintenance Association and the the Concorde’s tires over a titanium strip Wikimedia
Aviation Policy Statement Incident Reporting
he Australian government has issued a new national aviation policy statement, he General Civil Aviation Au- outlining more than 130 policy initiatives and pledging that safety and security thority (GCAA) of the United Twill remain the no. 1 priority. TArab Emirates has begun an The policy calls for modernizing air traffic management with increased use of incident reporting program as part of satellite technology and providing additional funding to the Civil Aviation Safety an effort to centralize the reporting Authority (CASA) for safety surveillance and oversight. The additional funds allocated of aviation accidents and incidents for the current fiscal year will be used to hire specialized technical staff in such areas as throughout the federation. surveillance of helicopter operations and foreign operators that fly into Australia, and “We recognize the need to con- increased oversight of low-cost operations and offshore maintenance, CASA said. stantly improve processes and systems The policy statement also identified seven emerging safety issues, including for managing risks effectively,” said monitoring the effectiveness of safety management systems, aging aircraft, regula- Ismaeil Mohammed Al Balooshi, tion of dangerous goods, shortages of pilots and maintenance personnel, and the GCAA director of aviation safety. regulation of unmanned aircraft systems. “Centralized reporting will ensure ef- In implementing the new policies, the government will “ensure Australia’s fective communication and coordina- safety regulatory and investigatory agencies remain world-leading and have the tion necessary for higher records of skills and capabilities to maintain safety and successful incident management.” facilitate the industry’s growth; regulation of The GCAA said that introduction safety will take account of best international of the centralized reporting system is a practice … ; [and] Australian safety agencies “milestone achievement in raising air will explore opportunities to adopt tech- safety standards” in the region, where nologies that improve safety and work with growth is forecast in the aviation industry to implement them.” industry.
© Adrian Matthiassen/iStockphoto
www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 9 inBrief
Advent of ADS-B
ir traffic controllers have begun officially as the Next Generation Air using automatic dependent Transportation System. He said ADS-B Asurveillance–broadcast (ADS- is “not only more accurate than radar B) to manage air traffic over the Gulf but comes with significant safety and of Mexico — an area without radar efficiency benefits.” coverage. In addition to providing for track- U.S. Federal Aviation Administra- ing aircraft by their satellite-based tor Randy Babbitt described the advent position reports, ADS-B will provide of ADS-B as “a significant early step for more efficient routing of aircraft, toward NextGen” — the satellite-based and provide pilots with more accu- transformation of the National Airspace rate weather information and other
System, including airports, known benefits. Administration Aviation Federal U.S.
Black Box Recommendations Threats, Errors and Safety
he French Bureau d’Enquêtes that are substantiated by the facts,” dverse weather is the most com- et d’Analyses (BEA), citing its the BEA said in its second interim mon specific threat to aviation Tcontinuing investigation of the report on the crash. “It also brings Asafety reported by Australian June 1, 2009, accident in which an to light the difficulties that can be pilots engaged in low capacity air Air France Airbus A330 plunged encountered in [locating], recovering transport operations — those involv- into the Atlantic Ocean during a and reading out the recorders after an ing no more than 38 passenger seats flight from Rio de Janeiro to Paris, accident in the sea.” and maximum payloads smaller than is recommending steps to aid in the In the accident’s aftermath, the 4,200 kg (9,259 lb), according to a post-accident recovery of aircraft BEA formed an international work- report by the Australian Transport flight recorders. ing group to review techniques that Safety Bureau (ATSB). The crash killed all 228 people in might be used to safeguard flight data The report was based on responses the A330, which has not been located. “and/or to facilitate localization of the from 167 participants in a threat and er- Searchers also have been unable to find wreckage and recovery of the flight ror management course; of that number, the airplane’s flight data recorder and recorders.” 55 pilots worked in air transport opera- cockpit voice recorder, both of which Citing the working group’s find- tions and 112 were involved in flight were equipped with regulation under- ings, the BEA recommended that the training and other types of aerial work. water locator beacons (ULBs), which European Aviation Safety Agency All 167 pilots were asked to identify “the stopped transmitting a little more than (EASA) and the International Civil five most common threats to operations 30 days after activation. Aviation Organization (ICAO) extend and errors made by pilots in their indus- to 90 days the current 30-day transmis- try in the preceding 12 months.” sion requirement for data recorder In both flight categories, depar- ULBs installed in airplanes conducting ture/arrival threats were the most overwater public transport flights. common, but the most common spe- The BEA’s additional recommen- cific threat was bad weather, including dations included a call for EASA and turbulence, fog, crosswinds and high ICAO to study requiring airplanes temperatures, the report said. involved in public transport flights to “Communication issues” involving regularly transmit position, altitude air traffic control (ATC) or the pilots of U.S. National Transportation Safety Board Safety Transportation National U.S. and other basic flight parameters. other aircraft also was among the top “The investigation … confirms Another recommendation asked that five threats identified by pilots in both the importance of data from the flight an ICAO panel establish proposals on groups. The report said, “Examples in- recorders in order to establish the “conditions for implementing deploy- cluded pilot language difficulties, ATC circumstances and causes of an ac- able recorders” on public transport command (e.g., difficult clearance, late cident and to propose safety measures flights. changes) and ATC instructions.”
10 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 inBrief
Cushioning the Fall
esearchers at the U.S. National Aeronautics and Space Administration (NASA) are looking for ways to reduce the Rdestructive forces of aviation crashes. Recent efforts have focused on determining whether a “deployable energy absorber” — an expandable honeycomb cushion attached to the belly of a helicopter — can ward off damage to a helicopter in a crash. In a recent experiment, they dropped an MD-500 — donat- ed by the U.S. Army — from a height of 35 ft (11 m) to deter- mine whether the destruction was lessened by the honeycomb cushion beneath the fuselage. Before researchers can reach a conclusion, they must analyze data gathered by instruments U.S. National Aeronautics and Space Administration National Aeronautics U.S. that had been installed in the helicopter for the event. “I’d like to think the research we’re doing is going to end up NASA said the drop test “imitated what would be a rela- in airframes and will potentially save lives,” said Karen Jackson, tively severe helicopter crash,” with a flight path angle of about an aerospace engineer who oversaw the test at the NASA Lang- 33 degrees and combined forward and vertical speeds of about ley Research Center in Hampton, Virginia, U.S. 48 ft (15 m) per second, or 30 mph (48 kph). The honeycomb cushion, developed by Sotiris Kellas, a Lan- The MD-500 survived the crash “relatively intact,” NASA gley engineer, is made of Kevlar and includes a flexible hinge that said. In a future experiment, the helicopter will be dropped enables the cushion to be packaged and lie flat until it is needed. again, without the deployable energy absorber.
he Association of Air Medical Services and the International TSociety of Aeromedical Services (Australasia) have agreed to collabo- rate on initiatives to enhance air medical transport throughout the world. … Earl F. Weener, a Foundation Fellow of Flight Safety Foundation and a former chief engineer with The Boeing Co., has been nominated by President Barack Obama as a member of the U.S. National Transportation Safety Board. Weener was the co- leader of the FSF Runway Safety Initia- tive and the FSF Ground Accident Prevention Program and the initial leader of the FSF Controlled Flight Into Terrain and Approach and Land- ing Accident Reduction task forces. © Yeager Airport Yeager © … Eurocontrol says it is moving to enhance civil-military cooperation Emergency vehicles surround a US Airways Express CRJ200 that stopped in the engineered in European air traffic management material arresting system (EMAS) area of a runway at Yeager Airport in Charleston, West by establishing a new military liaison Virginia, U.S., following a rejected takeoff. No one in the airplane was injured. The U.S. function within the Eurocontrol Cen- Federal Aviation Administration said the Jan. 19 incident was the fifth incident in the tral Flow Management Unit. United States in which EMAS stopped an airplane after a runway overrun.
Compiled and edited by Linda Werfelman.
www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 11 Coverstory Disappointing Level-Off The decade just ended averaged 0.57 major accidents per million departures of Western-built commercial jets.
By James M. Burin
verage” is the best that can be said number of accidents; the rate for the entire year about the 2009 overall safety perfor- was 0.52 major accidents per million departures mance of the largest segments of profes- of Western-built commercial jets. This was about sional civil aviation, the operation of the average of the previous five years and below “commercialA and corporate jets, and commercial average for the decade just ended. The total turboprop airplanes. The year started poorly for fatalities for major accidents in all three industry A Boeing 737 was operators of commercial jets, and by mid-year, it segments was 745 in 2009, up from 688 in 2008 destroyed in a loss looked like their rate of major accidents might and 763 in 2007, but lower than 903 in 2006. of control accident regress to the level seen 10 to 15 years ago (see The corporate jet fleet, which normally during approach to “Accident Classification,” p. 17). averages about 10 major accidents a year, had a Amsterdam Airport However, the second half of the year was significantly better year with six major accidents Schiphol. much safer than the first half, as measured by and 12 fatalities, compared with higher numbers © Bas Czerwinski/Associated Press
12 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 coverStory
in the rest of the decade. The commercial turbo- prop fleet’s year was a bit better than average, as measured by the number of major accidents, but controlled flight into terrain (CFIT) accidents Press © Associated remained prominent in this segment’s accident and fatality numbers. Last year, the commercial jet fleet grew approximately 1 percent from its 2008 size. By year’s end, there were more than 21,000 com- mercial jets in the world, 7 percent Eastern-built. The commercial turboprop fleet decreased approximately 3 percent from 2008 with more than 6,000 commercial turboprops registered, one quarter of which were Eastern-built. The corporate jet fleet grew approximately 6 percent to almost 16,000 aircraft. However, the active fleets, the aircraft actually in service, A Boeing 737 overran the runway landing at Kingston, Jamaica. are smaller than the total fleets. About 10 Major Accidents, Worldwide Commercial Jets percent of the total January 1, 2009–December 31, 2009 commercial jet fleet was inactive, a grow- Date Operator Aircraft Location Phase Fatalities ing percentage. About Jan. 15, 2009 US Airways A320 New York, USA Climb 0 13 percent of the total Feb. 25, 2009 Turkish Airlines 737 Amsterdam, Netherlands Approach 9 turboprop fleet was March 9, 2009 Aerolift IL-76 Entebbe, Uganda Climb 11 inactive. For the first March 9, 2009 Lion Air 737 Jakarta, Indonesia Landing 0 time, there were inac- March 23, 2009 FedEx Express MD-11 Tokyo, Japan Landing 2 tive corporate jets, ap- April 9, 2009 Aviastar Mandiri BAE-146 Wamena, Indonesia Approach 6 proximately 3 percent of the total fleet. April 29, 2009 Bako Air 737 Massamba, DRC En route 7 Major accidents May 31, 2009 Air France A330 Atlantic Ocean En route 228 involving commercial June 6, 2009 Myanma Airways F-28 Sittwe, Myanmar Landing 0 jets totaled 17, killing June 30, 2009 Yemenia A310 Comoros Approach 152 609 people, in the July 15, 2009 Caspian Airlines TU-154 Qazvin, Iran Climb 168 data for major acci- dents in all scheduled July 24, 2009 Aria Air IL-62 Mashhad, Iran Landing 16 and unscheduled Oct. 21, 2009 Azza Transport 707 Sharjah, UAE Takeoff 6 passenger and Nov. 12, 2009 RwandAir CRJ-100 Kigali, Rwanda Taxi 1 cargo operations for Nov. 19, 2009 Compagnie Africaine MD-82 Goma, DRC Landing 0 Western-built and d’Aviation Eastern-built types Nov. 28, 2009 Avient Aviation MD-11 Shanghai, China Takeoff 3 (Table 1), and 14 in- Dec. 22, 2009 American Airlines 737 Kingston, Jamaica Landing 0 volved Western-built Loss of control accident Possible loss of control accident CFIT accident aircraft. Approach and landing accident Runway excursion
Nine of the 17 Source: Ascend, Aviation Safety Network were approach and landing accidents, Table 1 www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 13 Coverstory
and one was a CFIT accident. There were only does not have reliable worldwide exposure data to two confirmed loss of control (LOC) accidents, calculate the rate of accidents. although three others could receive this classifi- Even though 2008 and 2009 have been cation, pending final accident reports. Six of the roughly average years for commercial jet major 17 commercial jet major accidents were runway accidents, the accident rate for the decade, as excursions. noted above, was impressive, although there was The major-accident rates for commercial jets both good news and bad news. The good news since 2000 and the five-year running average is that in the decade ending in 2009, the com- both have virtually leveled off (Figure 1). The mercial aviation industry basically halved the accident rate is only for Western-built aircraft be- rate from the previous decade — an outstand- cause even though the number of major accidents ing accomplishment. The bad news is that most for Eastern-built aircraft is known, the industry of the improvement was in the first half of the decade, the second half of the decade failing to continue the decade’s early trend. Western-Built Commercial Jet Major-Accident Rates, 1997–2008 There were six major accidents involving corporate jet aircraft in 2009 (Table 2), killing 12 1.2 Major-accident rate people, the lowest number of corporate jet major 5-year running average 1.0 accidents since 2000 (Figure 2). The numbers highlight the fact that operators of corporate jets 0.8 had an outstandingly safe year. Although reliable 0.6 worldwide exposure data are not available for cor- porate jets, the number of aircraft and the number 0.4 of departures increased steadily throughout the 0.2 decade, so the corresponding accident rates with Accidents per million departures 0.0 confidence can be assumed to be decreasing. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 The 2009 data include 21 major accidents Year involving Western- and Eastern-built com- Note: Total departure data are not available for Eastern-built aircraft. mercial turboprop aircraft with more than 14
Source: Ascend seats (Table 3, p. 16). These accidents caused 124 deaths, compared with 29 accidents and 292 Figure 1 deaths in 2008, the lowest number of the decade and less than the de- Major Accidents, Worldwide Corporate Jets cade’s annual average January 1, 2009–December 31, 2009 of approximately 28
Date Operator Aircraft Location Phase Fatalities major accidents. Jan. 3, 2009 Aero Jet Services Lear 45 Telluride, Colorado, U.S. Landing 0 The most signifi- cant safety challenge Feb. 7, 2009 Air One Executive Citation III Trigoria, Italy Climb 2 for commercial tur- Feb. 12, 2009 Laret Aviation Falcon 100 St. Moritz, Switzerland Landing 2 boprops remains the Oct. 26, 2009 S-Air Hawker 125 Minsk, Belarus Approach 6 prevention of CFIT Nov. 19, 2009 Pel-Air IAI Westwind Norfolk Island, Australia Approach 0 accidents. Although Dec. 17, 2009 FL Aviation Group Falcon 20 Great Inagua Island, En route 2 progress has been Bahamas made in reducing the
Loss of control accident CFIT accident Runway excursion risk of CFIT for com-
Source: Ascend, Aviation Safety Network mercial jets, as illus- trated by the fact that Table 2 one CFIT accident
14 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 coverStory
occurred in 2009, it is not the same positive story Major Accidents, Business Jets, 2000–2009 for turboprops. In 2008, seven of the 29 turbo-
prop major accidents were CFIT, almost one of 20 every four. In 2009, seven of the 21 turboprop major accidents were CFIT, one in every three. 15 15 As has been the case for the past 20 years, 14 14 CFIT, approach and landing, and loss of control classifications continued to represent the major- 10 11 11 9 ity of accidents and to cause the majority of 8 8 8 5 6 fatalities in all three industry segments. Trends Number of accidents in the number of CFIT accidents involving commercial jet aircraft since 1997 show the slow, 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 but positive, progress the industry has made in Year reducing this risk. In the most recent five-year period, more Source: Ascend than 90 percent of the aircraft in the commer- Figure 2 cial jet fleet had terrain awareness and warning system (TAWS) equipment installed. The com- International Civil Aviation Organization mercial jet segment in this period experienced (ICAO) standard for states to require operators 11 CFIT accidents; none involved an airplane to install TAWS in turbine-engine airplanes with with a functional TAWS. maximum certificated takeoff weight greater In contrast, as noted, a substantial propor- than 5,700 kg /12,500 lb or authorized to carry tion of turboprop major accidents continued to more than nine passengers. be CFIT accidents, and none of those aircraft By 2008, LOC accidents had surpassed CFIT had a TAWS installed, according to prelimi- as the leading killer among commercial jet ac- nary information. This calls into question why cidents. In 2009, there were only two confirmed some countries have yet to implement the LOC accidents, although three others — an
A Bombardier Q400 crashed during approach to Buffalo, New York, U.S. © Dave Sherman/Associated Press Sherman/Associated © Dave
www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 15 Coverstory
Ilyushin Il-76 accident at Entebbe, Uganda; an It has been eight years since the Foundation Airbus A330 accident over the Atlantic Ocean; released its original safety product for approach and a Tupolev Tu-154 accident in Iran — may and landing accident reduction (ALAR) — the be classifiable as LOC accidents. The aviation ALAR Tool Kit. More than 40,000 copies of community awaits the final accident reports to the ALAR Tool Kit have been distributed as of confirm the accident class. January 2010, and since 2000, the Foundation’s Eleven years ago, Flight Safety Founda- CFIT and Approach and Landing Action Group tion released, in a special issue of Flight Safety (CAAG) has conducted 32 ALAR workshops Digest, the report “Killers in Aviation,” which around the world. focused on solutions to the global challenge The Foundation is completing an update of approach and landing accidents, including of the original ALAR Tool Kit, which had been those involving CFIT. based on an international task force study of fatal approach and Major Accidents, Worldwide Commercial Turboprops landing accidents January 1, 2009–December 31, 2009 from 1985 to 1996.
Date Operator Aircraft Location Phase Fatalities The upcoming new Jan. 11, 2009 Zest Airways MA60 Caticlan, Philippines Landing 0 ALAR Tool Kit, a Jan. 27, 2009 FedEx Express ATR-42 Lubbock, Texas, U.S. Landing 0 more comprehensive Feb. 7, 2009 Manaus Aerotáxi EMB-110 Santo Antônio, Brazil Landing 24 product compared Feb. 12, 2009 Colgan Air Q400 Buffalo, New York, U.S. Approach 49 with the original, pro- vides data from 1995 Feb. 20, 2009 Aerolift AN-12 Luxor, Egypt Takeoff 5 through 2007 and April 1, 2009 Aberdair EMB-110 Locbokh, Ethiopia Takeoff 0 looks at all approach May 26, 2009 Service Air AN-26 Isiro-Matari, DRC Approach 3 and landing acci- June 2, 2009 Maldivian Air Taxi DHC-6 Halavelhi, Maldives Landing 0 dents, not just fatal June 26, 2009 TAC Transporte LET-410 Capurganá, Colombia Landing 0 accidents. Aéreo de Colombia The new data June 29, 2009 Aviastar Mandiri DHC-6 Wamena, Indonesia En route 3 show improvement in July 6, 2009 El Magal Aviation AN-28 Saraf Omra, Sudan Landing 0 areas such as installa- Aug. 2, 2009 Merpati Nusantara DHC-6 Oksibil, Indonesia En route 15 tion of safety equip- Airlines ment and reduction Aug. 4, 2009 Bangkok Airways ATR-72 Koh Samui, Thailand Landing 1 of nonprecision Aug. 11, 2009 Airlines PNG DHC-6 Kokoda, Papua New Approach 13 approaches. The data Guinea also show that the Aug. 14, 2009 Skydive Portugal Beech 99 Évora, Portugal Landing 2 major causal fac- Aug. 26, 2009 Aero Fret Business AN-12 Brazzaville, DRC Approach 6 tors in approach and Sept. 24, 2009 SA Airlink Jetstream 41 Durban, South Africa Takeoff 1 landing accidents Oct. 15, 2009 Blue Wing Airlines AN-28 Kwamalasamutu Landing 0 identified in the Airfield, Suriname original ALAR study Nov. 9, 2009 Blue Bird Aviation Beech 1900 Nairobi, Kenya Approach 2 are still present (e.g., Nov. 10, 2009 Kingfisher Airlines ATR-72 Mumbai, India Landing 0 omission of action, Nov. 19, 2009 Win Win Services DHC-8 Tarakigne, Mali Landing 0 poor professional judgment/airmanship Loss of control accident CFIT accident Runway excursion Note: Data comprise turboprop airplanes with more than 14 seats. and inadequate crew
Source: Ascend, Aviation Safety Network resource management [CRM]). The best Table 3 news from the latest
16 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 coverStory
landing accident rate have decreased since the Approach and Landing Accidents, 1995–2007 Foundation launched the initiative. In 2009, the Foundation also released the 100 Total = 1,007 accidents 30 Departures report of its Runway Safety Initiative, titled 90 93 89 Accident trend line 25 90 Millions of departures “Reducing the Risk of Runway Excursions.” 81 80 81 76 81 20 Runway excursions are the most common type 76 78 72 70 15 of accident for commercial aircraft, accounting for almost one of every three major accidents. 65 64 60 61 10 The report details the conclusions and recom- Number of accidents 50 5 mendations of more than two years of work by a Foundation-led, international multi- 40 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 disciplinary team that addressed the challenge Year of runway excursions. Source: Ascend A recent product published jointly by the Foundation and the International Air Figure 3 Transport Association (IATA) — the Runway ALAR study is that the Foundation’s efforts have Excursion Risk Reduction Tool Kit — contains achieved some success. the runway safety report and related informa- In a graphical presentation of approach and tion. The runway excursion report also is being landing accidents (Figure 3) from 1995 through incorporated, along with references to the 2007, the red line is updated ALAR report, in the updated ALAR the best fit for the Tool Kit. Accident Classification trend, and it shows It is unfortunate, but true, that a significant that the annual num- gap persists between creating safety interven- ince 2007, Flight Safety Foundation ber of these accidents tions to reduce risk and actually implementing has used “major accident” as its has been decreasing. these interventions. The U.S. Commercial Avia- Sprimary accident criterion in place of The yellow line shows tion Safety Team (CAST), the Foundation, IATA “hull loss.” A major accident is defined as the increasing trend and ICAO, as well as other concerned organiza- an accident in which any of three condi- for the number of tions and individual safety professionals, have tions is met. The first condition is that the aircraft is destroyed or sustains major departures over the generated effective interventions for the civil damage. Major damage is defined by the same period. So, not aviation community that will prevent at least Ascend Damage Index (ADI), a measure only did the aviation 90 percent of the accidents that occur each year. developed by Paul Hayes of Ascend. The community reduce However, those interventions do no good unless ADI is the ratio of the cost of repairs to the the number of ap- they are implemented. projected value of the aircraft had it been proach and landing The Foundation’s goal is to make aviation brand new at the time of the accident. If the ADI is over 50 percent, the damage is accidents — which is safer by reducing the risk of an accident. The considered major. The second condition good — but it also ac- global aviation community has achieved great defining a major accident is that there are complished this while successes while advancing toward that goal, multiple fatalities. The third condition is the number of flights but as can be seen from last year’s safety record, that there is one fatality and the aircraft is steadily increased. there are still many risks yet to be mitigated. substantially damaged. The major accident The 2009 data analy- Moreover, in an industry in which risk will classification criteria ensure that an acci- dent is not determined by an aircraft’s age sis for the FSF ALAR never be zero, we all face in 2010 and beyond or by its insurance coverage, and it gives program update also a constant challenge of meeting the public’s a more accurate reflection of the high-risk shows that both the expectation of perfection as the minimum ac- areas that need to be addressed. approach and landing ceptable standard. — JB accident rate and the fatal approach and James M. Burin is FSF director of technical programs. www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 17 Causalfactors
Something Changed BY MARK LACAGNINA The short runway was familiar, but the big new bizjet was not.
he pilots had flown into Fox Harbour In the afternoon of Nov. 11, 2007, the pilots Aerodrome in Nova Scotia many times. The employed this familiar procedure in an unfa- runway is short, and the customary proce- miliar aircraft, a Bombardier Global 5000 that dure was to drop below the visual glide path had been acquired by their company only three Tindication on short final approach to maximize the weeks earlier. Accustomed to flying smaller jets,
available roll-out distance after touchdown. they had not adjusted fully to the new aircraft, of Canada Board Safety Transportation
18 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 Causalfactors
according to the Transportation Safety Board of more hours in the aircraft. He had conducted two Canada (TSB). approaches to Fox Harbour in the Global 5000 — The glide path was too shallow for the big- one with the Bombardier pilot on Oct. 21 and one ger aircraft, and the captain held an inordinate with the first officer four days before the accident. right-wing-low crosswind correction on short The first officer had 6,426 flight hours, in- final approach. The aircraft began to sink, and cluding 2,540 hours as captain of the company’s the captain corrected by increasing angle-of- 604 and G100. After transition training for attack. He left the throttles at idle, however. the Global 5000, he had flown the Challenger The aircraft continued to sink, and the right exclusively for more than three months. He had main landing gear collapsed when it struck the flown three segments in the new aircraft during edge of the runway threshold. After traveling a the five days preceding the accident. short distance with the right wing dragging on “Had the crewmembers operated more flights the runway, the aircraft veered off the pavement, and been exposed to more landings, they would struck mounds of dirt and came to a stop near a have had the opportunity to become more famil- housing complex. iar with the aircraft size, its handling characteris- The aircraft was substantially damaged, but tics and performance,” the report said. there was no fire. The first officer and a passen- ger were seriously injured; the captain and the New Plane, Old SOPs other seven passengers sustained minor injuries. The company, Jetport, had an operations refer-
This airplane veered In its final report on the accident, the TSB ence manual (ORM) for the Global 5000 but off the runway and goes beyond accounting the contributing fac- did not use it to develop standard operating came to a stop near tors and explores other issues revealed by the procedures (SOPs) for the new aircraft. a housing complex. investigation, such as a general lack of knowl- Instead, the company adapted its Challenger edge about the safety margins provided by visual 604 SOPs to the new aircraft. “The Jetport glide path indicators and how these margins are Global 5000 SOPs contained a lot of good infor- affected by the sheer size of an aircraft. mation,” the report said. “They also contained The report also presents the board’s concerns some procedures applicable to the CL604 which about maintaining adequate oversight of Cana- were not suitable for the Global 5000.” dian business aircraft operators as they transi- For example, the SOPs required pilots to use tion from the traditional regulatory scheme to visual glide slope indicator (VGSI) guidance on the modern concept of the safety management approach and to plan to touch down about 1,000 system (see “Red Flags on SMS,” p. 22). ft (305 m) from the runway threshold. A note advised that descending below the VGSI glide Stepping Up path “is not a recommended technique and is Although the Global 5000 was new to them, the not normally an accepted practice.” pilots had extensive experience in a variety of Nevertheless, the SOPs included this excep- business aircraft. The captain had 9,188 flight tion: “When operating on short runways or when hours, including 3,196 hours in jets. He had braking action is reduced by contamination on flown into Fox Harbour 75 times in the com- the runway, landing as early as conditions permit pany’s Challenger 604 and Gulfstream G100. is generally considered to be good airmanship.” The captain and the first officer had com- pleted Global 5000 ground and simulator Short and Damp instruction at the manufacturer’s training center. The pilots, who were conducting a corporate The captain also had flown the aircraft for 43 flight from Jetport’s home base in Hamilton, hours accompanied by a Bombardier pilot. Ontario, did indeed plan to “land early” at Fox After the transition training and familiar- Harbour. The runway, 15/33, was 4,885 ft (1,489
© Martin Eadie/Airliners.net ization flights, the captain had logged about 20 m) long and 75 ft (23 m) wide, and it was damp.
www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 19 20 | Causalfactors
© Bombardier Bombardier 5000 Global Source: Jane’s AlltheWorld’s Aircraft Note altitude is51,000ft. Maximum cruising speedis0.85Mach. normal cruisingspeedis0.89 Mach; 78,600 lb(35,653kg).Maximum weight of87,700lb(39,781kg)andamaximumlandingweight of at 65.6kN(14,751lbthrust). The Global5000hasamaximumtakeoff are powered by Rolls-Royce BR710A2-20engines Deutschland rated larger aircraft. maximum range, however, 1,200nmlessthanthe is4,800nm,nearly (244m)shorter. (1,524m),more than800ft field lengthof5,000ft Its T and operation on shorter runways.and operation onshorter weights are lower, allowing better takeoffandlandingperformance, 1. Both airplanes have airplanes Both accommodations for upto 19passengersand Compared withtheGlobalExpress, theGlobal5000hasabalanced fuselage is 6 ft (2m)shorter,fuselage is6ft andoperating andfuelcapacity sion oftheGlobalExpress, whichpredated itby sixyears. The he Global5000was introduced in2004asaslightly smallerver aircraft was manufactured. Operating weights were increased in2008,two years theaccident after east, was reporting winds from 360degrees at 21 direction information,” report the said. ment available to give accurate and wind speed thresholdthe of Runway 33,there is no equip- “Asideservices. from located near wind sock the report said. m] of runway was required for landing,” the estimated that, for conditions, the [1,310 4,300ft The nearest station, north- 28nm(52km) didnotThe airport have weather-reporting “Using performance charts, captain the had 1 - flight safety foundation as aircraft the descended. component was 18kt at point this but decreased forrudder crosswind correction. The crosswind from runway the and right aileron used and left disengaged autopilot the about 1.4nm(2.6km) system approach to Runway 33.The captain ing approach. the would 113kt, be with 5kt for added gusts dur increased the pitchincreased the attitude to 10.6 degrees. The captain felt aircraft the and sinking rapidly airspeed decreased to 102ktairspeed decreased —11kt below V erable aileron and input,” rudder report the said. had to dwindled 8kt, using he was still “consid- ground. Although crosswind the component captain flare beganthe about above 50ft the precision approach path indicator (APAPI). The indication provided by runway’s the abbreviated intentionally was below flown on-path the approach angle,” report the said. due to combination the of gusty winds and alow [the captain’s] workload, which was already high the aircraft more difficult to control, increasing spoilers “resulted in which a made in decrease lift, wing that is held being low. that deploys multifunction the spoilers on the 5000hasGlobal an automatic roll-assist feature runway centerline,” report the said. fuselage with the parallel the to align is used flare is commenced, gentle application of rudder tion to runway track the centerline and, as the that, on approach, pilot the apply correc adrift - approach.crabbed to ORM’s the recommendation of awings-level, technique for crosswind correction was contrary The captain’s of use wing-low, the or sideslip, Wrong Technique cided thatcided reference their landing (V speed light rain; and overcast. a900-ft kt, gusting to 33kt; visibility 7mi(11 km) with They conductedThey positioning global the The autothrottles reduced power to idle, and From about out, 0.5nm(0.9km) aircraft the The sideslip and the extra drag created by the The crab technique is preferred the because [recommended]“This technique requires As neared they Fox Harbour, pilots the de- |
World AeroSafety |
December 2009–January 2010 REF REF. ) -
Causalfactors
The aircraft touched down 7.5 ft (2.3 Short Touchdown vs. Glide Path Guidance m) from — and 18 in (46 cm) below — the runway. The right main gear col- lapsed, and “the aircraft continued down the runway with the right wing drag- ging,” the report said. It veered off the 3.0° 58 ft VPTH runway about 640 ft (195 m) from the threshold and traveled about 360 ft (110 m) before coming to a stop about 200 ft (61 m) from a condominium. 3.3° 3.0° Eye-to-Wheel Height APAPI 2.7° 29 ft The report said that interviews during the investigation with several pilots holding airline transport pilot licenses revealed a general lack of knowledge about eye-to-wheel height (EWH) and Runway how it applies to different types of Road VGSIs. Ground impact EWH is “the vertical distance from a pilot’s eyes to the lowest portion of the VPTH = vertical flight path generated by the flight management system APAPI = abbreviated precision approach path indicator aircraft in the landing attitude,” the report Source: Transportation Safety Board of Canada said. “This distance varies from less than 4 ft to 45 ft [1.2 to 13.7 m] for some wide- Figure 1 body aircraft, such as the Boeing 747.” Nav Canada’s Canada Air Pilot which is about 5 ft (1.5 m) greater than assurance that they are on a safe glide shows that EWH is the differentiation the height for the Challenger 604. path. among four types of PAPI installations. The report said that although the “This false assumption can lead
Those with the symbol P1 are appropri- APAPI installation at Fox Harbour was pilots to rely on VGSI guidance that is ate for aircraft with EWHs up to 10 ft not appropriate for the Global 5000, if the unsuitable for the aircraft type they are
(3 m). The symbols P2 and P3 designate crew had followed its guidance to touch- operating,” the report said. “Vertical installations appropriate for EWHs up down, the main gear would have cleared guidance should only be used after con- to 25 ft (7.6 m) and 45 ft, respectively. the runway threshold by about 8 ft and firmation that the VGSI type is appro- APAPI installations — which have the aircraft would have touched down priate for the aircraft type operated.” two, rather than four, lamps in their light about 500 ft (152 m) from the threshold. Among the recommendations gener- bars — are designated with the symbol AP Moreover, if they had followed the ated by the investigation, TSB called on and, like P1 installations, are appropriate vertical guidance provided by the on- Transport Canada to ensure that EWH for aircraft with EWHs up to 10 ft. board flight management system, the information is available to transport However, EWH information is not aircraft would have crossed the thresh- aircraft pilots and that comprehensive readily available to pilots. The Global old at 58 ft and touched down 1,000 ft training on VGSIs is provided to pilots, 5000 aircraft flight manual, for exam- from the threshold (Figure 1). “so they can determine if the system in ple, does not include this information. use is appropriate for their aircraft.” “The manufacturer had to complete ‘False Assumption’ This article is based on TSB Aviation calculations to determine [the aircraft’s] Based on the interviews conducted Investigation Report A07A0134, “Touchdown EWH,” the report said. during the investigation, the report Short of Runway; Jetport Inc.; Bombardier BD- Bombardier determined that the concluded that most pilots believe an 700-1A11 (Global 5000), C-GXPR; Fox Harbour Global 5000’s EWH is 17.2 ft (5.2 m), on-path indication from a VGSI is Aerodrome, Nova Scotia; 11 November 2007.” www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 21 SAFETYOVERSIGHT Red Flags on SMS Friction builds in Canada’s push for safety management systems.
BY MARK LACAGNINA
ost aviation safety special- Slunder contends that safety actu- that operators have a functioning SMS ists worldwide have hailed ally may suffer as self-regulating opera- in place. the safety management tors create a deluge of SMS paperwork system (SMS) as a key to that can conceal less-than-sterling ‘Sugarcoating’ furtherM reduction of aircraft accidents. practices. Slunder says that, under SMS, operators However, cautions recently have been “Transport Canada describes SMS provide reams of data to show that they expressed about overextension of the as a partnership: Industry agrees to take are operating safely; consequently, data concept and about the risks of relax- on more responsibility for ensuring analysis has taken the place of direct over- ing government oversight of opera- compliance with safety requirements sight through inspections and audits. tors as they struggle toward full SMS in exchange for less direct oversight by “The trouble is, all these data are implementation. government inspectors,” Slunder said in unverified,” he said. “In other words, It is not surprising that most of the a CFPA news release issued in July 2009. the door is open to airlines to sugar- red flags have been raised in Canada, “As SMS has been introduced, how- coat their reports in order to keep their which is leading most of the world in ever, key safety audit programs have planes in the sky, earning money. aggressively pushing for SMS imple- been canceled,” he said. “In fact, Trans- “Transport Canada inspectors have mentation by all aviation certificate port Canada recently canceled its prac- become deskbound, relying on the pa- holders in the country. tice of requiring a specific frequency perwork assurances of the airlines that Hoisting one of the red flags is Dan- of audits and inspection and replaced everything is OK instead of inspecting iel Slunder, national chair of the Cana- it with a program of SMS assessments airplanes and crews.” dian Federal Pilots Association (CFPA), and program validations.” Slunder says that civil aviation a union representing about 470 pilots The result, contends Slunder, is that authorities (CAAs) worldwide must employed by Transport Canada, Nav few audits and inspections are being maintain adequate oversight by directly Canada and the Transportation Safety conducted to ensure compliance with conducting inspections and audits.
Board of Canada. regulations; the focus now is to ensure “Such functions cannot be delegated,” Tsagaris/Airliners.net © Peter
22 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 SAFETYOVERSIGHT
he warned. “Otherwise, aviation personnel, also measures how well industry safety manage- maintenance organizations, general aviation, ment systems are working.” commercial operators, aviation service provid- The rail industry and the international ers, aerodrome operators, etc., will in effect be maritime industry were the first transportation regulating themselves and will not be effectively modes targeted for SMS implementation. When monitored by CAA inspectors.” the concept was extended to the aviation indus- try, Transport Canada established a four-phase ‘Sadly Misguided System’ process for SMS implementation. Criticism of SMS also has been expressed by Canadian air carriers and their associated an organization based in the United States — maintenance organizations have completed all the Aircraft Electronics Association (AEA), four phases of SMS implementation, and inter- which represents more than 1,300 businesses national airports and air traffic service providers specializing in general aviation avionics and are entering the third phase. electronics equipment. The target for SMS implementation by all In the January issue of Avionics News, AEA remaining aviation certificate holders is 2015. They board chairman Barry Aylward dubbed SMS the include commuter operators governed by Canadi- “sadly misguided system” and an “unproven theo- an Aviation Regulations (CARs) Subpart 704 and retical model based on the faulty premise that if air taxi operators governed by Subpart 703. the paperwork is good, the aircraft is good.” Among the deadlines established by the He contends that SMS never was intended International Civil Aviation Organization for SMS to be applied beyond the airlines. “Yet, aviation implementation were January 2009 for commercial regulatory authorities are embracing this con- aircraft operators and November 2010 for private, cept with zeal and forcing broad-brush imple- or business, operators of large turbine airplanes. mentation across all sectors.” However, SMS implementation worldwide is Aylward said that SMS “imposes an enormous proceeding at a slow pace, with much confusion and very costly administrative burden on an remaining among some operators and regulators aviation business, and it does so with no evidence about how to proceed (ASW, 1/08, p. 14). Trans- whatsoever that it will improve aviation safety or port Canada has conceded that implementa- compliance with existing aviation regulations. tion has been far more complex than originally “The fact is, SMS has not been successful in envisioned. improving the safety record of the rail industry in Canada,” which introduced SMS in 2001. ‘Tendency to Stay on Course’ ‘Aviation regulatory In a presentation at Flight Safety Foundation’s ‘Extra Layer of Protection’ authorities are 2009 International Air Safety Seminar in Bei- Transport Canada steadfastly dismisses any jing, Robert Dodd, general manager of Qantas forcing broad-brush suggestion that introducing SMS clears the Airways, posed a question that is on the minds path to deregulation (ASW, 1/09, p. 24). On of many safety specialists and aviation operators: implementation the contrary, the regulator characterizes SMS Has SMS been oversold? as a proactive tool that complements govern- His answer: “I don’t believe so, but I do feel across all sectors.’ ment oversight of operators in all segments of that in many ways the performance improvement aviation — “an extra layer of protection to help to be gained from SMS implementation will be save lives.” much tougher to get than previous gains. In part, “Transport Canada inspects aviation opera- this is just the obvious effect of trying to improve tions to make sure they meet safety regulations an already extremely impressive accident rate.” and enforces the law when they don’t,” says a In his discussion about gauging the effective- statement on the organization’s Web site. “Trans- ness of an SMS, Dodd said, “In all probability, the port Canada’s role now goes even further, as it system won’t be right when it starts up. … In large
www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 23 SAFETYOVERSIGHT
part, this is because existing, presumably success- Chief among them was tacit consent to duck fully functioning organizations have a natural below the visual glide path on approach to a tendency to stay on course and keep doing what short and/or contaminated runway. This, along they were doing and how they were doing it before with the flight crew’s use of an inappropriate ‘Organizations they installed the brand new SMS.” crosswind technique and inadequate response These comments unintentionally cut to the to an excessive sink rate on short final, was have a natural core of concerns about SMS implementation that among the factors that led to the collapse of the were generated by the investigation of a business right main landing gear when the big airplane tendency to stay airplane accident in Canada. The accident involved touched down short of the runway. Damage was a company that purportedly had been operating substantial, and two of the 10 people aboard the on course.’ under an SMS for three years but actually was do- airplane were seriously injured. ing what it was doing before installing the SMS. In its final report, the Transportation Safety Board of Canada (TSB) said that the accident ‘Evolving Environment’ “needs to be considered in the context of a The accident occurred on Nov. 11, 2007, at Fox relatively new and evolving safety regulatory Harbour Aerodrome in Nova Scotia (see “Some- environment.” thing Changed,” p. 18). It involved a Bombardier The environment is unique and complex. Canada is alone in requiring business aviation operators, under CARs Subpart 604, to obtain a private operator certificate (POC) for any air- plane that is pressurized and turbine-powered, and weighs more than 5,700 kg/12,500 lb.
Self-Regulation Transport Canada and the Canadian Business Aviation Association (CBAA) began discussions in the late 1990s about the possibility of self- regulation of business aircraft operators. At the time, Transport Canada had 16 inspectors responsible for the oversight of 121 POC holders operating 193 aircraft and em- ploying 672 pilots. The inspectors “carried out routine regulatory audits, conducted PPCs [pilot proficiency checks], performed safety visits, monitored, and carried out follow-ups on inci- dents,” the TSB report said. © Bo Kim/Airliners.net The discussions between Transport Canada and the CBAA led to a joint feasibility study Global 5000 that had recently been acquired by concluding that self-regulation was possible. A Jetport, which specializes in air taxi operations follow-up study in 2001 generated the recom- and aircraft management. mendation that business aircraft operators For operation of the Global 5000, Jetport had implement SMS based on performance-based adapted standard operating procedures devel- rules and standards developed by the CBAA. oped for its Challenger 604, a much smaller air- The studies also concluded that, to mitigate plane. Some of the procedures did not conform the risks of self-regulation, continued oversight in with the manufacturer’s recommendations and the form of CBAA audits of POC holders would were not suitable for the new airplane. be required and that any deficiencies in CBAA’s
24 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 SAFETYOVERSIGHT
oversight must be identified and cor- an SMS infrastructure in place; if so, a formal assessment of the risks involved rected by Transport Canada. Because of POC is issued. During the second audit, in operating the Global 5000 at Fox the cost of hiring auditors, it was agreed the POC holder must show that the Harbour Aerodrome, the report said. that the audits would be performed by SMS is functioning. Finally, the opera- TSB concluded that these findings independent contractors accredited and tor must show that SMS activities have point to the absence of effective quality monitored by the CBAA. been fully integrated and that a positive assurance of the CBAA’s POC program. In January 2003, the CBAA issued safety culture is being maintained. “As with the transition to any new business aviation operational safety No firm deadlines for SMS imple- system, the introduction of SMS in the standards (BA-OSS) and SMS-audit mentation have been set. “CBAA Canadian aviation industry is facing guidelines to auditors and POC ap- plicants. Notably, the guidelines advise Canadian Business Aviation Oversight that “the implementation and operation 2000 of an SMS take time, even for mature 1999 (plan) 2008 aviation departments; therefore, the au- Transport Canada Transport Canada Transport Canada ditor must determine a reasonable level 16 inspectors of performance that can be expected Audits Audits when evaluating the SMS.” × CBAA CBAA ‘Twice Removed’ 3 sta No audits No audits During its investigation of the Fox Audits Audits Harbour accident, TSB found that the × business aviation regulatory environ- CBAA CBAA accredited auditors accredited auditors ment has not evolved as planned. 14 14 ×
Figure 1 shows that, as of 2008, × Audits three CBAA staff members were as- signed to the POC program, and 14 Private operators Private operators Private operators accredited independent contractors 121 121 320 were conducting audits of 320 business aviation operators. However, no audits CBAA = Canadian Business Aviation Association of the auditors or the operators were Source: Transportation Safety Board of Canada being conducted by the association. Figure 1 In effect, business aviation opera- tors had been “twice removed” from indicated that very few POC holders challenges,” the report said. “Many Transport Canada’s scrutiny, the TSB have advanced beyond level one and operators, although willing to progress report said. “This is a significant suggested that, in some cases, it could to SMS, still do not possess a good departure from the feasibility studies. be many years before they do,” the TSB understanding of how to do it. … The The current model consists of informal report said. confusion is not limited to the opera- communications between the CBAA The accident investigation revealed tors, as some of the people tasked with and its accredited auditors and op- that, after receiving a POC for its assessing SMS programs misinterpret erators during liaison visits and trade Challenger in 2004, Jetport presented performance indicators expected from shows. … Transport Canada has not basically the same SMS documentation a functioning SMS. ensured that the CBAA is fulfilling its during three subsequent audits, none “With time and experience, op- responsibilities for oversight.” of which found that it did not meet the erator and assessor knowledge should The plan called for CBAA audits of BA-OSS standards. improve and eventually provide the business aviation operators to be con- Moreover, the company had a “tra- level of protection expected of a mature ducted at three levels. The first audit ditional, reactive safety management SMS. … During this transition, it is es- determines whether an applicant has process in place” and did not conduct a sential that oversight not be relaxed.” www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 25 helicopterSAFETY Fatal Descent BY LINDA WERFELMAN © Mark Carlisle/Airliners.net
Inadequate weather assessment and weak risk management helped set the stage for a HEMS crash in a cloud-covered, wooded area.
he pilot of a Maryland State Camp Springs, Maryland, U.S., on occurred in the United States in 2008, Police Aerospatiale SA 365N1 Sept. 27, 2008. prompting government hearings and in- on a medical evacuation flight Four of the five people in the he- dustry review boards to examine reasons was descending to avoid low licopter were killed, the fifth suffered for the surge in accidents and recom- cloudsT when the helicopter struck the serious injuries, and the helicopter was mend actions to prevent similar events. ground during a late-night instru- substantially damaged in the crash, one The U.S. National Transportation ment landing system approach to in a cluster of fatal helicopter emergency Safety Board (NTSB), in its final report Andrews Air Force Base (ADW) in medical services (HEMS) accidents that on the accident, said that the probable
26 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 www in awoodedpark. helicopter crashed conditions whenthe meteorological to returnvisual 365N1 wastrying Aerospatiale SA The pilotofthe .flightsafety.org |
World World AeroSafety Radar ApproachRadar Control] controllers.” Tower and PCT[Potomac Consolidated Terminal handling by the Ronald Reagan National Airport Aviationeral Administration] control air traffic workload of because “inadequate FAA [U.S. Fed- mation for ADW and the increase in the pilot’s to provide pilot the with current weather infor citedreport also failure the by control air traffic to led which his decision to accept flight.” the The the pilot’s “inadequate assessment of the weather, cedures” by MarylandState the Police (MSP) and of adherence to risk management effective pro- ited recent instrument flight experience, the “lack descent altitude during anonprecision approach.” his failure to arrest the descent at the minimum conditions by performing arapid descent and cause was “the pilot’s attempt to regain visual car accident to Prince George’s Hospital Center that —to flight the transport of two victims a and pilot the notified of accident the helicopter that initiated about flight time the 2302local tions Center (SYSCOM) received request the A duty at officer MSP the System Communica- ‘We’re Goingto Try’ Contributing factors included pilot’s the lim- |
December 2009–January 2010 - that another emergency medical services that another services emergency medical had reported ceiling.Then he a1,200-ft said Reagan Washington National (DCA) Airport ceiling at Park College and noted that Ronald up to you. you Do you think it?” can fly youthem go, will want they you to go. …That’s ain’tThey going to change mind; their ifyou tell changewill mind.” their zone coordinates, pilot the said, “Maybe they hospital.the After abrief discussion of landing ParkCollege about Airport, from 1nm(2km) commented on reported ceiling the at 800-ft mission,the you can’t make mission.” the replied,ficer “Well, that’s fine.If you can’t make if we can get to hospital,” the and duty the of- two hours.weather every “call by call” basis, with pilots required to review forecast to deteriorate, were flights accepted on a only slightly better than MSP minimums and of an elementary schoolinWaldorf. property the on originate would — Cheverly in The pilot again commented on 800-ft the The duty said, then “Well, officer hold on. Their conversation continued, and pilot the The pilot told duty the officer, “I don’t know weatherBecause conditions at were time the HelicopterSafety |
27 © Jose Luis Magana/Associated Press helicopterSAFETY
emergency medical technician who boarded the Track of Accident Flight helicopter with the patients, a flight paramedic and the pilot (Figure 1). The pilot contacted the DCA tower at 2337:45 to report departing from Waldorf en 495 College Park route to Prince George’s Hospital Center. The he- Airport licopter entered Class B controlled airspace east Prince George’s of the airport at 2341, headed north at 1,000 ft. Hospital Center During initial contact, the DCA tower con- troller told the pilot that he had received a re- Walker Mill Regional port from another helicopter pilot — the pilot of Park District of Columbia 295 the same helicopter that the pilot had discussed in his earlier conversation with the SYSCOM duty officer — 30 minutes earlier that described
Accident cloud bases at 900 ft and lower to the north. Virginia 395 site About 2344, the accident pilot said, “We just Ronald Reagan ran into some heavy stuff. I don’t think we’re Washington National Airport 95 Andrews going to be able to make it all the way to the Air Force Base hospital. I’d like to continue on about three more miles and see what happens, and if I don’t see a
Maryland hole, I’ll have to go IFR (instrument flight rules) back to Andrews.” The pilot continued north at about 900 ft
210 until the helicopter was about 0.25 nm (0.46 Fort Belvoir km) east of the hospital. Then, at 2347, he began a 180-degree turn and told the controller that he wanted to climb to 2,000 ft for an instrument approach to ADW. The controller approved the
plan and handed the pilot off to PCT.© Nastar Center At 2348, the pilot twice repeated the request to a PCT controller, and the controller began provid- Patient pick-up ing vectors for the instrument landing system (ILS) approach to Runway 01R. At the time, ADW was
Source: U.S. National Transportation Safety Board reported to have a broken ceiling at 1,800 ft. At 2353, the controller told the pilot to turn Figure 1 right to a heading of 170 degrees to intercept the ILS localizer for Runway 19R. That heading, helicopter operated by a private company had however, would not have resulted in a successful completed an interhospital transfer flight in the localizer intercept, the report said. area, adding, “If they can do it, we can do it.” The pilot continued the turn to 210 degrees The duty officer responded, “OK. It is up to and intercepted the localizer 1 nm (2 km) from you,” and the pilot said, “Yeah, we ought to be the final approach fix. About 2355, he told an able to do it. … We’re going to try it.” ADW tower controller that he had no glideslope The accident helicopter took off from ADW indication. At 2357, he requested an airport at 2310 for the Waldorf elementary school surveillance radar approach, but the controller pickup site, landed there at 2319 and departed said she was not current and could not provide about 2337, carrying the two patients, a local that service.
28 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 HelicopterSafety
There were no further radio com- a flight, or conduct a VIP (very impor- accident flight. The helicopter also munications. The last radar contact tant person) transport,” the report said. had a radio altimeter, and an autopilot occurred about 2357:50 when the heli- The pilot also completed a subse- that could be fully coupled to an ILS; copter was at 800 ft above Walker Mill quent instrument proficiency check it did not have a terrain awareness and Regional Park, and the last automatic on May 13, 2008, conducting an ILS warning system (TAWS). dependent surveillance-broadcast approach, a nonprecision approach The helicopter was maintained in (ADS-B) target was at 2358:04 at 325 and a global positioning system (GPS) accordance with the manufacturer’s ft, near the site where the wreckage was approach in Leonardtown, Maryland. recommendations under an approved found, in a heavily wooded area of the The instructor said that the pilot “did inspection program. Its most recent park at an elevation of 200 ft. pretty well” and had no difficulty with 100-hour airframe and engine inspec- the approaches and that his perfor- tion was performed on Sept. 22, about State Trooper Since 1970 mance was “above average” compared 3.2 flight hours before the accident. The The pilot had a commercial pilot with other pilots. no. 1 (left) engine had 7,077 hours total certificate for helicopters and an In the year before the accident, he time and 1,120 hours since overhaul; instrument rating, as well as a flight recorded 2.1 hours of instrument time the no. 2 engine had 7,427 hours total instructor certificate with ratings for and four instrument approaches. During time and 575 hours since overhaul. helicopters and instrument helicop- the two years preceding the accident, he The helicopter was within weight ters and a private pilot certificate for completed 25 instrument approaches and balance limits throughout the acci- single-engine land airplanes. at ADW, including four nonprecision dent flight. Instrument approach charts He was hired by the MSP in 1970 approaches; three GPS approaches at were readily accessible to the pilot, State as a state trooper and began working other airports; and two approaches in a Police aviation authorities said. in the State Police aviation division in simulator. Before the accident flight, his 1981. He had 5,225 flight hours, all ac- last recorded night flight was on Sept. ‘Below the Clouds’ cumulated during his State Police em- 16, 2008, and his last recorded flight in Weather at ADW three minutes before ployment. Of his total flight time, 2,770 night IMC was Oct. 29, 2006. the accident included visibility of 4 mi hours were flown in the same make The pilot held a second-class medi- (6 km) in mist, scattered clouds at 200 and model as the accident helicopter, cal certificate. Records from his most ft and broken clouds at 500 ft. The fire and 1,920 hours were flown at night. recent airman’s physical examination on chief at ADW said that visibility at the Investigators could not determine his Sept. 26, 2008, showed that he was 6 ft time of the accident was about ¼ mi total instrument flight time. 3 in (191 cm) tall, weighed 293 lb (133 (0.4 km). A man who lived 1.8 mi (2.9 His most recent annual flight evalu- kg), and had a body mass index of 36.6, km) southwest of the accident site said ation was conducted Oct. 27, 2007, and which is considered obese. His obesity that he saw a helicopter flying over his included an instrument proficiency — and the loud snoring for which the house “below the clouds in a descending check in which he flew one ILS ap- report said he was notorious among his attitude” and estimated that the clouds proach and one nonprecision approach colleagues — are both common among were 100 to 150 ft above the trees. to Runway 01L at ADW. The instructor people with sleep apnea, a disorder The pilot had obtained a weather conducting the evaluation described that can disrupt breathing hundreds briefing about 1851 from the FAA the accident pilot’s instrument skills as of times during a typical eight-hour direct user access terminal (DUAT) “slightly above average.” During the eval- sleep period (ASW, 9/09, p. 24). The service, including weather radar data, uation, the pilot was approved to “act as pilot had not been diagnosed with sleep terminal forecasts and winds aloft fore- single pilot PIC [pilot-in-command] for apnea, however. casts. The ADW terminal forecast valid IFR operations, which allowed him to The accident helicopter was manu- from 1800 through 0100 the following file a flight plan and fly in IMC [instru- factured in 1988 and had accumulated morning called for visibility of 7 mi (11 ment meteorological conditions], if 8,869 total flight hours and 34,575 km) and scattered clouds at 2,000 ft. By necessary, to fly a patient to a trauma total landings. It had a night vision 0200, however, the forecast was for vis- center, reposition the helicopter to a imaging system for law enforcement ibility of 3 mi (5 km) in mist, a broken maintenance facility, return to base from flights, but it was not used during the ceiling at 500 ft and overcast at 1,000 ft. www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 29 helicopterSAFETY
of the state and that all State Police aviation bas- Aerospatiale SA 365N Dauphin es were operating “call by call” — an indication that weather was near the agency’s minimums. Current surface weather observations for ADW and nearby Fort Belvoir were not avail- able at 2300 because of a technical problem affecting U.S. Defense Department weather dissemination. As a result, the ADW weather being reported on non-Defense Department weather outlets was from 1855, about five hours before the accident. “It appears that the pilot based his decision to launch solely on the weather observations at College Park and DCA and the suitable condi-
© Fred Johnston/Airliners.net © Fred tions implied by the other medevac helicop- ter’s completed flight,” the report said. “Other he Aerospatiale (now Eurocopter) SA 365N, first flown in 1979, pertinent weather data — the low temperature/ is a twin-engine helicopter designed to carry two pilots and up Tto eight passengers. The accident helicopter had two front seats dew point spreads at ADW and College Park, with dual controls and an aeromedical interior with four seats and two the AIRMET for IFR conditions encompassing litters. the route of flight and the continuing deteriora- The SA 365N1 is equipped with Turbomeca Arriel 1C1 engines, tion of the weather conditions as the evening each rated at 540 kW (724 shp) for takeoff. progressed — were either discounted by the Empty weight is 4,764 lb (2,161 kg) and maximum takeoff weight pilot or not obtained. If the pilot had thoroughly is 9,039 lb (4,100 kg). Maximum cruising speed at sea level is 153 kt, maximum rate of climb is 1,300 fpm and service ceiling is 11,810 ft. obtained and reviewed all of the available Maximum range, with standard fuel at sea level, is 460 nm (852 km). weather information, it is likely he would have
Sources: Jane’s All the World’s Aircraft, U.S. National Transportation Safety Board realized that there was a high probability of encountering weather conditions less than MSP minimums on this flight and this would have The pilot did not request information on prompted him to decline the flight.” weather hazards; if he had, the DUAT briefing The report quoted the MSP Aviation Com- would have included an airman’s meteorological mand safety officer as saying that, at the time information (AIRMET) for IFR conditions in an of the accident, MSP did not have a formal risk area north and east of ADW, and including the management program but instead provided hospital’s landing area, valid until 2300. optional guidance with a “risk assessment This apparently was the pilot’s last use of matrix” that said pilots should consider a flight DUAT, the report said. to be of medium risk if it was conducted with a Subsequent weather information, issued later temperature/dew point spread of less than 2 de- the night of the accident, contained forecasts of grees C. However, the matrix provided no guid- visibilities less than 3 mi (5 km) for the entire ance about pilot actions concerning medium route of the accident flight. Another pilot saw, risk flights, the report said, adding that there when he arrived at the hangar at 0310 the morning was no indication that the pilot had consulted after the accident, that the pilots’ computer was the matrix before the flight. turned on and an experimental HEMS weather “Even if he had referred to it, the pilot might tool — authorized for use only in visual meteoro- not have changed his decision to accept the flight, logical conditions (VMC) — was on the screen. since the matrix did not provide clear guidance The duty officer said that the weather tool on medium risk flights,” the report said. If the indicated that marginal VMC prevailed in most MSP had used a formal risk evaluation program,
30 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 HelicopterSafety
however, it might have led to cancella- flight and fatigue “may have contributed unresponsiveness, inattention and poor tion of the flight, the report said. to his deficient decision making.” radar vectoring. These deficiencies were The report said that the pilot might a distraction to the pilot and increased Confusing Information have been encouraged to “deviate below his workload by requiring him to com- Almost immediately after loss of the glideslope and attempt to duck pensate for the poor services provided.” radar contact, the ADW airport traffic under the cloud ceiling” because of In addition, the approach controller controller began trying to contact the his “expectation that he could descend did not give the pilot current weather pilot. At 2359:50, she notified the ADW below the cloud ceiling at an altitude information for ADW, an omission that fire department chief, who contacted above the minimum descent altitude “likely led the pilot to expect that he the State Police and the Prince George’s for the approach, his familiarity with could descend below the cloud ceiling County communications center. [ADW] and the reduction in workload and establish visual contact with the The SYSCOM duty officer mistak- a return to visual conditions would ground at an altitude well above the enly believed that the helicopter had have provided.” minimum descent altitude for the ap- landed at ADW. The report quoted the Nevertheless, he “failed to adhere to proach,” the report said. State Police as saying that the equip- instrument approach procedures when The report also challenged the FAA’s ment installed on their helicopters for he did not arrest the helicopter’s de- classification of all medical evacuation ADS-B tracking “does not function well scent at the minimum descent altitude,” flights involving government-owned at low levels” and that police personnel the report said, adding that the pilot aircraft as public operations,1 noting had been conditioned to assume that probably did not monitor cockpit in- that the classification “creates a discrep- when an ADS-B signal was lost, the struments because he was preoccupied ancy in the level of FAA safety oversight helicopter had landed safely. with looking for the ground. of [HEMS] aircraft operations carrying Confusion surrounded informa- The report said that the pilot’s passengers and is contrary to the intent tion exchanged by the State Police, workload had increased “substantially of [the law that] states that aircraft the ADW controller and the Prince and unexpectedly” after the helicopter carrying passengers are excluded from George’s County Police about the last entered IMC and that, although he met operating as public aircraft.” reported location of the helicopter. The the recent-experience requirements Six months after the accident, the wreckage was found after the pilot and to serve as PIC under IFR, he was MSP told NTSB accident investigators of medic assigned to another State Police “not proficient in instrument flight.” a number of changes, including develop- helicopter talked by phone with the Changes in the MSP instrument train- ment of a new mission-specific flight risk ADW controller, who said radar contact ing program about 10 months before assessment tool; implementation of new was lost when the helicopter was “about the accident — eliminating the require- pilot training requirements, including 2 miles out on approach to Runway ment for six instrument approaches completion of at least two instrument 19R.” The pilot drew a line on a map to every six months and replacing it with approaches per month; and training all correspond with the extended runway two instrument proficiency checks aviation command personnel and MSP centerline; the line intersected the spot every year — “did not promote instru- field personnel in the use and interpreta- where they had plotted the original ment proficiency,” the report said. tion of geographic coordinates. coordinates for the last contact. The If the helicopter had been equipped This article is based on NTSB Aircraft two drove to the area and then walked with a TAWS, the device would have Accident Report No. AAR-09/07, Crash toward the spot, where they located the generated a “glideslope” aural alert During Approach to Landing of Maryland State wreckage and the survivor at 0158. about 24 seconds before the initial im- Police Aerospatiale SA 365N1, N92MD, District pact, followed by terrain warnings that Heights, Maryland, September 27, 2008. Fatigue would have begun seven seconds before Note The report said that, considering the impact, the report said. 1. Aircraft used in public operations — in- time of day, the pilot’s risk factors for The report cited air traffic services cluding those operated by state govern- sleep apnea and his decision to deviate provided by the DCA airport traffic ments for non-commercial purposes from published approach procedures, he control tower and the PCT for “numer- — generally are exempt from U.S. Federal probably was “less than alert” during the ous procedural deficiencies, including Aviation Regulations. www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 31 FlightOPS
A new concept in understanding in-flight icing gathers believers. Rough Ice
By John P. Dow Sr. and John Marwitz
n the early days of aviation, at the While common usage simplifies the lesser thickness that may be far more advent of thermal ice protection character of the in-flight ice to two de- adverse. Icing severity as often forecast system development, aircraft design- scriptors — glaze ice and rime ice — the and reported by pilots does not always ers believed that in fighting in-flight shape, location, thickness and distribu- equate with severity of effect. icing,I the critical variables were the mass tion of ice features, including roughness, Further, the UW observations of supercooled water that an airplane are the true discriminators of the effect expanded awareness of the critical would transit and the temperature. The of ice on aircraft aerodynamics. factors influencing in-flight icing be- measure of mass is liquid water content Large ice shapes may be problem- yond high LWC to include an under- (LWC). Droplet size of supercooled atic, but research is showing that thin, standing of atmospheric temperature water, which influences potential icing rough ice can have a much greater and the largest droplets, particularly severity, is measured by the median effect on aircraft performance. These when considering the performance of effective diameter. Droplet size also new findings call for a reconsideration deicing systems. There tends to be an determines how far back on the airfoil of aircraft certification. “optimum bad” value for each of these the ice collects. Temperature, mass This new way to consider icing and parameters: For the flight conditions and location of the ice on the airfoil its effects began to evolve in 1967 when of the research airplane static air tem- determine the amount of heat required the University of Wyoming (UW) start- perature, it is around minus 8 degrees and the extent of ice protection needed ed operating a variety of state-of-the-art C (18 degrees F). Conditions warming for thermal systems to prevent phase aircraft outfitted for cloud physics work. to temperatures well above 0 degrees change of water to ice. For the past 40-plus years, UW research- C (32 degrees F) result in run-back Out of the extensive airborne ers participated in various weather ice — water freezing as it flows — or sampling of icing conditions starting modification projects, beginning with no ice; at colder temperatures there is in the late 1940s, U.S. Federal Aviation a search for supercooled liquid water1, mostly ice, no water. Run-back ice can Regulations (FARs) Part 25 Appendix without which there is no weather modi- also form ridges aft of ice-protected C was developed and defined most of fication potential. areas, which can create adverse effects. the icing envelope used for certifica- Data and experience collected in The largest “optimum bad” droplet tion. While well suited to anti-icing this process inadvertently produced size seems to be around 100 microns in systems, Appendix C does not define a new concept of in-flight icing: The diameter, approximately 2.5 times the the environment adequately to prevent shape and distribution of the accreted thickness of a human hair. These drop- all hazards to deicing systems. Ves- ice, and primarily the roughness, are lets collect on the airfoil in the area of tiges of this concept of calculating more significant in terms of perfor- 5 percent to 15 percent of chord. They the potential for threats from the mance degradation, by an order of result in the formation of ice resem- development of icing by relying on the magnitude, than the mass of ice. Pilots bling small, pointed “shark’s teeth” with measure of mass alone have been slow often comment on how much ice they the teeth oriented into the local airflow. to be revised, even in the face of icing are able to handle, creating a misplaced Smaller droplets collect on the lead- events to the contrary. sense of confidence about accretion of ing edge of the airfoil and cause little
32 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 FlightOPS Is Bad Ice
performance degradation. Larger droplets with unlike other key milestones in the understanding higher mass inertia and thermal inertia2 cover of icing risk. the airfoil with a relatively smooth coating of ice, Evolution of the regulatory icing envelope de- which does not usually significantly degrade the fined in Appendix C occurred from 1920 to 1950. Two views of performance of the airfoil. There were important milestones in that period. distributed-roughness The “optimum bad” value for LWC is around In 1928, the National Advisory Committee for icing, showing the 0.4 g per cu m. At smaller values of LWC, the Aeronautics (NACA) reported “the ice forms in thin layers involved. rate of ice accretion and rate of performance degradation are low. At high values of LWC, thermal inertia is dominant and, therefore, run-back ice, ice horns and smooth ice occur. And importantly, these droplet sizes can occur either in conditions defined by Appendix C or outside them. However, it was found that specific combinations of droplet size and liquid water content produce the most rapid change in aircraft performance. Despite a high degree of confidence about the concept, there existed no significant theo- retical or icing tunnel data suitable for guidance in the selection and combination of specific, measurable icing parameters. A value was selected — 80VD3 — as a new parameter to rep- resent the largest droplets, and LWC as the best parameter for cloud composition. The effect of the combined parameters was expressed as sim- ply the first parameter times the second, and the resulting value showed a remarkable correlation to adverse affect on aerodynamic performance. The ice accretion that creates the most adverse conditions is not large. The massive changes in U.S. icing regulations spawned by the ATR 72 accident at Roselawn, Indiana, on Oct. 31, 1994, finally will be incorpo- rated into an operational airplane 20 years after the event, yet ice roughness in this context has
yet to be fully defined or addressed in the FARs, Wyoming University of
www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 33 FlightOPS
dangerous amounts only within a small respectively, and the regulations for range of temperature below 32 degrees F aircraft were codified in the FARs. [0 degrees C].” In 1965, FARs Part 25.1419 set forth Not long after this report, a fatal more comprehensive regulations for accident attracted wide attention in the transport airplanes and icing condition United States. On March 31, 1931, a definitions with no discrimination be- Fokker F-10 departed Kansas City, Mis- tween thermal systems and mechanical souri, with an en route stop at Wichita, systems; the requirements defined how Kansas, and encountered severe icing. the applicant would show compliance. The airplane suffered an in-flight In 1971, FAA Advisory Circular structural wing failure resulting in fatal (AC) 20-73 was published. It discussed injuries to all eight occupants, includ- acceptable means of showing compli- ing legendary Notre Dame University ance with the icing regulations. For Svetlana Bakavets/iStockphoto, Screammm/Dreamstime and Susan Reed Bakavets/iStockphoto, Screammm/Dreamstime Svetlana football coach Knute Rockne. ice protection systems, the concept of The icing aspect of the accident impingement limit — or how far back received inadequate attention as a causal droplets would strike the airfoil surface factor that forced the airplane into an — was addressed, and the suggested attitude that resulted in structural failure, means of designing a compliant system the failure becoming the public focus. ones.” Johnson’s conclusion on scale was to use a simple scheme to deter- Nonetheless, it was the first high profile was later quantified as the ice thick- mine impingement in various flight occurrence involving in-flight icing. ness (k) to chord (c) ratio or “k/c.” The conditions. The limit of the ice pro- After the Fokker accident, and be- effects of a certain thickness of ice were tection system was typically based on fore the natural icing environment was less severe for a larger chord (smaller how far aft 20-micron and 40-micron measured or quantified, wind tunnel k/c) than a smaller chord (larger k/c). diameter droplets would impact the testing by Eastman Jacobs and Albert E. Researcher J.K. Hardy in 1944 may surface. The importance of roughness Sherman demonstrated that the degree have been the first to comment on the effects was not recognized or addressed. of in-flight icing hazard was primarily need for an icing envelope definition, Thermal anti-ice protection systems a function of the location and shape obviously referring to thermal systems: predominated in jet transport design. of the accreted ice, and secondarily “This [lack] has retarded development, Groundbreaking research in the its mass or thickness. The logic is still since it has not been possible to analyze academic community started in early sound and its method effective against the performance of the system under 1982 with UW’s work using a Beech the shape and/or ridge icing threat. conditions of icing.” King Air 200T. During one notable It wasn’t until 1930 that the “Ice Immediately after World War II, a flight, the drag resulting from in-flight Removing Overshoe,” a predecessor number of military aircraft gathered icing reduced the aircraft’s climb capa- of the pneumatic deicing boot used data used to form the basis of Appen- bility at maximum power to approxi- today, was introduced by B.F. Goodrich, dix C icing condition envelopes still in mately zero in less than 15 minutes, and mechanical systems entered the use. Regulations developed in the early with airframe buffet indicating stall on- discussion. 1950s addressed only pneumatic ice set approximately 30 kt above normal In December 1940, famed Lockheed protection systems, however. It was not uncontaminated stall speed. Aircraft designer Clarence L. (Kelly) until 1955 that Amendment 4b-2 to the While gathering icing data was not Johnson wrote about his wind tunnel Civil Aviation Regulations introduced part of the UW effort, the airplane research using artificial ice shapes to the icing envelopes we have today. performance degradation was so severe estimate aerodynamic degradation of In 1958, the U.S. Federal Aviation that the researchers began an immedi- stability, control, stall angle and drag. Administration (FAA) and the National ate in-depth examination of the re- One of Johnson’s conclusions was this: Aeronautics and Space Administra- corded cloud physics data and aircraft “The icing problem is relatively less tion came into existence, replacing the performance data to understand the severe on large airplanes than on small Civil Aeronautics Authority and NACA, cloud characteristics. This was a unique
34 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 FlightOPS
effort to determine a cause and effect experiences in which they had occasion- but formed into the shape of shark’s relationship. Further, unlike contempo- ally landed in freezing rain, taxied up to teeth, similar to 10–20 grit, or grain per rary studies, they recognized the icing the hangar, and needed assistance from inch (2.5 cm), sandpaper. variables and associated consequences. ground personnel to open a cabin door This implied that the thermal Two potentially hazardous in-flight sealed shut by a coating of glaze ice. inertia of SCDD is small. The smaller icing encounters were evaluated. The Freezing raindrops are large, SCDDs, therefore, freeze on contact. performance degradation was far greater than 500 microns. This size The obvious deduction was that as the greater than was predicted on the basis droplet has large inertial mass and droplets get larger and/or the LWC of LWC or another cloud composition thermal inertia, compared with other increases, the thermal inertia will parameter called MVD.4 The per- droplets. Freezing raindrops, therefore, prevent freezing on contact and the formance degradation comprised an penetrate the airflow surrounding ice will tend to be relatively smooth, increase in stall speed, a decrease in the the airfoil to hit the wing, but do not glaze ice. coefficient of lift (CL) and a decrease freeze on contact. Rather, they strike The problem was to identify a spe- in climb capability. Both encoun- the airfoil, spread downwind and coat cific environment that would represent ters involved substantial numbers of the entire aircraft with glaze ice.5 The these mass and thermal inertial regulat- supercooled drizzle droplets (SCDD) coating of ice is rather smooth, and ing processes. The parameter selected in the range of 40–300 microns; the the airfoil is just slightly larger and was the product of 80VD and total maximum theoretical droplet size in slightly heavier. The airfoil is still fairly LWC. This product was abbreviated Appendix C’s “Intermittent Maximum” efficient, and the weight of the ice as 80VD*LWC and the accompanying envelope is 135.5 microns. coating is not a significant factor. graph was produced (Figure 1). Notably, In 1997 and 1998, Ashenden and The UW researchers found that as the peak in the curve near 40 would be Marwitz presented additional detailed the largest droplets increased in size the same if 80VD on the Y axis was 400 data from 13 flights in the UW King above approximately 30 microns in microns and LWC on the X axis was 0.1 Air. They presented analysis of perfor- diameter, the accreted ice from SCDD g per cu m, or if the Y axis was 100 mi- mance degradation in conditions of was not a solid or monolithic formation crons and the X axis was 0.4 g per cu m. freezing drizzle, freezing rain, warm rain, SCDD, SCDD with high LWC, Drag Rate vs. 80VD*LWC mixed phase clouds of ice and water, 0.035 and ice-only clouds. (MVD<25µm) SLD (MVD>50µm) 2 Change in drag rate, or how quickly 0.030 drag increased, was selected as the best ZR (80VD>200µm) 0.025 3 measure of one aerodynamic hazard –1 because a dramatic increase in drag 0.020 4 /dt, min /dt, occurred when the MVD was between D 0.015 5 10 and 200 microns. The increase in 7 0.010 drag was sometimes large and some- (min) descend to Time 10 times small. That is, for a given MVD = dC rate Drag 0.005 there was a large range in how rapidly 20 drag increased, but flight experience 0.000 ZC SCDD ZR indicated that the largest droplets −0.005 combined with the LWC had the most 1 63 10 30 60 100 300 3 adverse effect on aircraft. 80VD*LWC (µm g/m )
Analyzing flight data, it became CD = coefficient of drag; LWC = liquid water content ; min = minutes; µm = micron; MVD = median volumetric diameter; SCDD = supercooled drizzle droplets; clear that the UW pilots inadvertently SLD = supercooled large droplets; ZC = freezing cloud drops; ZR = freezing rain drops had flown through freezing rain four Source: John P. Dow Sr. and John Marwitz times without incident. A number of other experienced pilots related similar Figure 1 www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 35 FlightOPS
The figure’s vertical axis has a second scale From 1991 to 1994, the FAA focused on the showing the time until descent was required to hazards and remedies for ice-contaminated tail-
prevent a stall. The CD for a clean aircraft is ap- plane stalls. One recommendation was to expand proximately 0.045, based on clean aircraft tests, research into conditions beyond Appendix C
and the CD when the aircraft has no more climb into freezing rain and drizzle. One reason for the capability is 0.12. Therefore, the time to a forced research was that pilots had no means to identify descent is inversely related to drag rate. when the icing conditions were beyond the certi- The worst case shows that the aircraft would fication envelope and so, beyond the capabilities be forced to descend in two minutes. These of the ice protection system. infrequent but consistent conditions contrasted Initially, the FAA concluded that, in consid- with more common in-flight icing encounters, eration of resources available, “This does not those involving supercooled cloud droplets and appear to be a program that should be supported encounters with freezing rain, in which the pilot at this time.” However, a little more than a month had roughly 20 minutes to recognize the threat later, the Roselawn ATR 72 crash occurred. The and respond. The major counterintuitive find- airplane was in a holding pattern at an altitude ing has been that this most-adverse condition above the freezing level. The flaps were extended in SCDD conditions. The crew operated the ice protection system, Stylized Representation of ‘Shark’s Teeth’ Distributed Ice Elements but the reduced angle of attack associated with the
Side view flap extension and the large droplets impinging aft of the deicing boots allowed ice growth from drop- Free stream flow lets running back from the leading edge. This re- Airfoil sulted in a sharp-edged ice ridge forming aft of the boots, where it could not be removed, and forward of the ailerons. This ice ridge eventually caused Local flow (flat face forward the ailerons to self-deflect to the right-wing-down 4 mm height x 2 mm width) position; the crew could not regain control, and the crash killed all the occupants. As a result of this accident, researchers launched an icing tanker test focused on SCDD large droplet conditions. The work by ATR, the U.S. Bottom view National Transportation Safety Board, FAA, UW
Source: John P. Dow Sr. and John Marwitz and the U.S. Air Force rapidly identified the princi- pal causal factor of the accident. The drag increase Figure 2 — with this form of ice on this airplane in these conditions — was untypically low at 5 percent, plus is not related to the thickness of the ice forma- or minus 5 percent. The industry was then focused tion. Therefore, the practice of associating icing again on the size, location and shape of the ice. severity and threat with only the thickness of ice The FAA required a quarter-round piece of accumulation is seriously flawed. wood, flat side forward, to be tested just in front of Atmospheric conditions that form a shape the ailerons. This was termed the “stick test” and are better understood by viewing the shape employed the principle of the same kind of “protu- itself. Specifically, a stylized drawing (Figure 2) berance” used six decades earlier, but applied this can depict critical parameters of these distrib- time for identifying control issues rather than just uted elements on the order of only 2 to 4 mm lift degradation. (0.08 to 0.16 in) in length covering 15 to 30 As a result of the post-accident research, percent of the airfoil surface area. the FAA issued airworthiness directives that
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brought attention to the visual cues mechanism for distributed-roughness recommended for operation of deicing associated with the droplets of the icing formation seems to involve a depo- boots. Moreover, distributed-roughness Roselawn icing conditions. The larger sition of droplets ranging in size greater icing is not effectively removed even droplets in the test provided distinc- than the larger size droplets of the 40 to if the deicing boots are operated, or if tive visual cues. However, distributed 109 micron range in Appendix C. This thermal anti-icing use is delayed. roughness elements from smaller, yet deposition process must be long enough More work needs to be done to fully hazardous-sized, droplets may not to form a grid or matrix of distributed define this problem, but it is impera- present the same visual cues, nor elements and subsequent ice shape tive that flight crews realize that a major would they form large ice shapes. formation, but not so long as to allow performance degradation can be caused During the Roselawn accident the distributed elements to merge into a in a fairly short time by a relatively small investigation, the phrase “supercooled monolithic shape. amount of ice that cannot be countered large drop” (SLD) was coined. SLD was Accordingly, the LWC of the larger by most deicing systems, with smaller defined to refer to drop sizes where droplets can be low. The matrix elements airfoils being more susceptible to severe MVD exceeded 50 microns, i.e., outside are close but do not touch, and the initial effects than larger airfoils. And, finally, the Appendix C envelope. The prob- effect of this formation is neither visually aircraft certification standards and guid- lem with this phrase is it includes both extraordinary nor of noticeable aerody- ance must be reconsidered.
SCDD and freezing rain. namic consequence. The mechanism of John P. Dow Sr. is a consultant in aircraft On Jan. 7, 1997, an Embraer formation is not totally understood, but certification and icing with more than 25 years EMB-120 crashed in Monroe, Michi- the data describing the results have been of experience in airplane icing issues relating to gan, U.S., near Detroit, with fatal observed and documented. airplane certification and accident investigation. injuries to all 29 occupants. Neither The visual appearance of distribut- John Marwitz is professor emeritus, University of droplets outside the definitions in ed-roughness icing formation may be Wyoming and president, Wyoming Weather Inc. Appendix C nor a long exposure were innocuous, with a thickness or element likely. The most probable ice present height less than 1/8 in (0.32 cm). If this Notes was thin and rough and not a ridge, occurs on a black deicing boot, part of 1. Supercooled liquid water can exist in the as in the Roselawn accident. this formation may appear gray. There liquid phase at temperatures as cold as In addition to the Monroe accident, may be other ice formed at the leading minus 40 degrees C (minus 40 degrees F). there have been a disturbing number of edge as well. While this icing forms 2. Water at a temperature slightly below freez- other accidents paradoxically involving quickly and usually is not effectively ing must reject approximately 80 calories thin ice or small amounts of roughness removed by deicing boots, once outside per gram to change state from liquid to on airplanes equipped with deicing the cloud, the adverse effects of the solid (ice). This takes a discrete amount boots, and not all of these have been small elements, disproportionate to of time for the heat transfer process and is referred to as “thermal inertia.” in the droplet size region beyond the their size, tend to diminish as quickly certification requirements. as they occurred. 3. The proposal was to begin with the com- On Aug. 16, 2006, the FAA issued Precise effects of ice roughness ele- mon cloud measurement called the “droplet AC 20-73A. It introduced a revised ment shape remain to be determined. spectrum cumulative mass 80th percentile diameter, in microns,” abbreviated as 80VD. concept of assessing ice protection Common types of solid geometric shapes that suggests some of these issues be are used in icing effects research, but the 4. The measurement is called the “droplet addressed during certification. While rapid onset of degradation of aerody- spectrum cumulative mass 50th percentile diameter, in microns,” abbreviated as MVD. distributed-roughness effects are namic characteristics in distributed discussed, the shapes are derived from roughness — without change in location 5. Freezing rain has a low freezing fraction, the icing tunnel, which is not typically of the ice on the airfoil or the forma- a measure of the fraction of water that representative of natural SCDD condi- tion of large sizes — strongly suggests freezes on the surface area it strikes. A freezing fraction of 1.00 means all the tions and resulting shapes. sharp-edge features and shape play an water that impacts a surface freezes on Distributed-roughness icing can form essential role. This infrequent condition that area. A freezing fraction of 0.0 means within or outside the icing conditions can result in a hazardous ice shape that is none of the water impacting an area on described in Appendix C. The primary two to five times thinner than even that the surface freezes there. www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 37 humanfactors
BY LINDA WERFELMAN, CLARENCE E. RASH AND in SHARON D. MANNING Place Rest © Douglas Freer/iStockphoto
38 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 HUMANFactors
Some aviation officials and aeromedical specialists recommend controlled napping to help keep pilots alert; others say naps aren’t the answer.
ontrolled in-seat napping on the flight undertaking,” Gilligan said during a Decem- deck has been recommended for years as ber 2009 hearing on pilot fatigue before the one element of an effective plan to help aviation subcommittee of the U.S. Senate pilots ward off fatigue. Most recently, Committee on Commerce, Science and Trans- Cthe Aerospace Medical Association (AsMA) portation. “We believe that we can manage said that the aviation industry should end its and mitigate their fatigue through the new prohibition against in-seat napping — a practice regulations sufficiently that they should be the organization characterizes as a safe and ef- alert throughout the flight.” fective risk-management tool that could greatly John Prater, president of the Air Line Pilots improve pilot alertness.1 Association, International (ALPA), told the “Taking a nap when it is convenient is subcommittee that napping should only be used better than trying to stay alert and productive as a “last-ditch effort” to help pilots stay alert for hours on end without sleep,” says J. Lynn during critical phases of flight. Caldwell, a crew rest expert at the U.S. Air Prater said, however, that he fears that Force Research Laboratory and a member of the sanctioned napping could become a means for AsMA fatigue countermeasures subcommittee, “somehow keeping pilots on duty even longer.” which drafted the recommendations endorsed He said he envisions conversations in which in 2009 by the organization. “A nap can make a a pilot tells a scheduler that he or she must de- noticeable difference in performance, alertness cline a flight because of fatigue, and the sched- and mood.” uler responds, “Don’t worry — you can catch a Although in-seat napping is sanctioned by nap en route.” some civil aviation authorities — only in ac- “That’s not a sound strategy for being alert cordance with guidelines to ensure operational on the other end,” Prater said. safety — and used by the pilots of some inter- Supporters of controlled napping, includ- national air carriers, not everyone considers ing Flight Safety Foundation President and napping a solution to the fatigue problem. CEO William R. Voss, told the subcom- For example, the U.S. Federal mittee that an in-seat nap would be Aviation Administration (FAA) does not permit napping by on-duty flight crewmem- bers. An upcoming revision of the agency’s rules for pilot rest will not change that policy, says Margaret Gilligan, FAA associate administrator for aviation safety. “The crew needs to come to work prepared for the schedule that they are © Edward Westmacott/Dreamstime www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 39 humanfactors
“an exception, not the rule,” a tactic to be 26 minutes and, after awakening, displayed used as “one last layer of defense” against crew “improved physiological alertness and per- fatigue. formance,” compared with colleagues in the This “last layer,” which also includes such no-rest group, according to the researchers’ fatigue countermeasures as the “timely intake” report. of caffeine, “recognizes the inevitable fact “The benefits of the nap were observed ‘It’s ... a smarter that crews sometimes experience significant through the critical descent and landing phases fatigue despite their — and the operator’s of flight,” the report said. “The nap did not af- approach than — best efforts to prevent it,” Voss said. “It fect layover sleep or the cumulative sleep debt includes those actions that can be invoked displayed by the majority of crewmembers. The to run the risk to manage the risk until the flight is safely nap procedures were implemented with mini- of both pilots concluded.” mal disruption to usual flight operations, and Basil J. Barimo, Air Transport Association there were no reported or identified concerns falling asleep.’ of America vice president of operations and regarding safety.” safety, agreed, calling on the FAA to endorse The NASA sleep researchers and others controlled cockpit napping “conducted in believe that properly planned napping strategies accordance with FAA-approved procedures to can be effective against fatigue, preventing many facilitate alertness during the critical phases of the attention lapses and microsleeps — peri- of flight.” ods of sleep that last only several seconds and “We don’t view napping as a silver bullet for often are not recognized — encountered during fatigue,” Barimo said. “Airlines would not build long-range flight operations. schedules that incorporate napping as a require- In addition to its benefits, napping also has a ment to complete a trip. … It’s a way to man- negative aspect. “Practically everyone,” Caldwell age fatigue as it arises on a real-time basis — a said, “experiences post-nap grogginess.” smarter approach … than to run the risk of both This grogginess also is referred to as “sleep pilots falling asleep.” inertia,” which manifests itself in degraded Controlled napping should be one of the fa- vigilance, increased drowsiness and dimin- tigue-fighting tools incorporated into the FAA’s ished performance3 for one to 35 minutes after new rules, Barimo said, citing studies showing awakening.4 that scheduled in-flight naps can improve alert- Sleep inertia is an important consider- ness and performance, especially when pilots ation in the scheduling of cockpit naps, sleep do not obtain the recommended eight hours of researchers have said. ALPA’s Prater agreed, add- sleep in each 24-hour period. ing, “Trying to come up out of a nap to make a snap decision … is difficult.” NASA Research Those who favor in-seat napping agree that One such study, conducted in 1994 by the U.S. planning must take into consideration several National Aeronautics and Space Administra- factors. AsMA’s recommendations call for no tion (NASA), divided 21 participating pilots more than 40 minutes to be set aside for an — each a member of a three-person flight on-duty, in-seat nap. The time limit was derived crew — into a “rest” group whose members from the NASA studies and other sleep research were allowed a 40-minute controlled rest that has shown that a sleep period of less than period during the cruise portion of flight and 30 minutes is less likely to be followed by exces- a “no-rest” group whose members contin- sive sleep inertia. ued their usual flight activities during that In the 1994 NASA study, only 8 percent of 40-minute period.2 participants entered “slow-wave sleep” — also Pilots in the rest group typically fell asleep called deep sleep or non-rapid eye movement quickly, slept “efficiently” for an average of (NREM) sleep — the stage of sleep conducive to
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subsequent sleep inertia. NREM sleep typically begins about 30 minutes after a person falls asleep; REM sleep, the stage of sleep associ- ated with dreaming, typically begins 60 to 100 minutes after the start of a regular eight-hour sleep period.5 When a pilot is planning an off-duty nap, however, the strategies differ. An off-duty nap should be scheduled in proper relation to the sleep loss period and the natural circadian rhythm. Also, most studies indicate that a nap of at least one hour improves performance and alertness; as might be expected, the longer the nap length, the better. Finally, the quality of the nap is determined by the amount of time spent in deep sleep.6
No Adverse Effects A number of international carriers, including Air Canada, Air New Zealand, British Airways, Emirates and Qantas, allow one pilot to nap in his or her seat during routine cruise segments of long-range flights. The 2009 AsMA report said that these naps have been taken “without producing adverse effects.”7 The AsMA report also cited a 1999 NASA report on a survey of U.S. commercial pilots, noting that, despite the FAA’s prohibition, 56 percent of flight crewmembers who respond- to take a nap if another qualified pilot is awake ed to a regional airline operations survey said and can take over during the nap.”11 they had been on a flight during which one Nevertheless, Voss noted in his testimony that pilot arranged to sleep in the cockpit.8 Of in the United States, “the idea of controlled rest in those pilots responding to a related corporate/ the cockpit is unfortunately colored by well-pub- executive pilot survey, 39 percent said that licized episodes of uncontrolled rest.” He referred, they had been on flights in which similar ar- in part, to a February 2008 incident in which a rangements were made, according to a 2001 go! Airlines Bombardier CL-600-2B19 overflew NASA report.9 its destination in Hilo, Hawaii, because both Several years earlier, in a 1991 NASA study pilots had unintentionally fallen asleep (ASW, of long-range flight crews, pilots were observed 9/09, p. 24). The pilots awakened and returned to napping 11 percent of the available time, with Hilo for an uneventful landing. The U.S. National naps that lasted an average of 46 minutes.10 Transportation Safety Board said the timing of In addition, the AsMA report cited a 2002 the incident in the mid-morning was an indica- opinion poll conducted by the U.S. National tion that the pilots were fatigued. Sleep Foundation, in which 86 percent of re- “We hope that the FAA will consider the spondents said that they completely or mostly science and the successful experiences in agree with this statement: “An airline pilot who many other countries to guide them … rather becomes drowsy while flying should be allowed than alarmist concerns from individuals who www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 41 humanfactors
have not studied this issue,” said Voss, safer to have a procedure in place to 6. Caldwell, J. Lynn. “Napping: Power or although he acknowledged that the allow the fatigued pilot to sleep for a Poison?” Flying Safety. October 2002. 16–17. idea of planning a nap for a pilot prescribed amount of time with the full might seem “counterintuitive to folks knowledge of the copilot and the rest of 7. Caldwell, John A. et al. in the back of the plane. the crew.” 8. Co, E.L.; Gregory, K.B.; Johnson, J.M.; “Many countries and airlines Clarence E. Rash is a research physicist with 30 Rosekind, M.R. Crew Factors in Flight allow for controlled napping, includ- years experience in military aviation research Operations XI: A Survey of Fatigue Factors ing France, Australia, Singapore and and development. He has authored more than in Regional Airline Operations. Moffett Canada. The aviation safety records of 200 papers on aviation display, human factors Field, California, U.S.: NASA Ames Research Center, Report No. NASA/TM- those countries speak for themselves,” and protection topics. 1999-208799. 1999. he said. Sharon D. Manning is Garrison Safety and Canadian Aviation Regulations Occupational Health Director at the Aviation 9. Rosekind, M.R.; Co, E.L.; Gregory, K.B.; Miller, D.L. Crew Factors in Flight (CARs) Part 720.23, “Controlled Rest Branch Safety Office (ABSO), Fort Rucker, Operations XIII: A Survey of Fatigue on the Flight Deck,” spells out the Alabama, U.S. She has 15 years experience in Army aviation and privately owned vehicle Factors in Corporate/Executive Aviation requirements for Canadian opera- safety. Operations. Moffett Field, California, U.S.: tors whose pilots participate in in-seat NASA Ames Research Center, NASA Technical Memorandum No. 2001- napping programs. Training in general Notes principles of fatigue and fatigue coun- 211385. 2001. termeasures is required, along with 1. Caldwell, John A.; Mallis, Melissa M.; 10. Gander, P.H.; Graeber, R.C.; Connell, training in the specifics of the opera- Caldwell, J. Lynn; Paul, Michel A.; L.J.; Gregory, K.B. Crew Factors in Flight Miller, James C.; Nerei, David F.; AsMA tor’s program. Operations VIII: Factors Influencing Fatigue Countermeasures Subcommittee Sleep Timing and Subjective Sleep Quality According to the CARs, rest pe- of the Human Factors Committee. in Commercial Long-Haul Flight Crews. riods are planned during a pre-flight “Fatigue Countermeasures in Aviation.” Moffett Field, California, U.S.: NASA. briefing “to enable them to anticipate Aviation, Space and Environmental Technical Memorandum No. 103852. and maximize the sleep opportunity Medicine Volume 80 (January 2009): 1991. and to manage their alertness”; some- 29–39. 11. National Sleep Foundation. 2002 Sleep in times, however, the briefing may be 2. Rosekind, Mark R.; Graeber, R. Curtis; America Poll.
42 | flight safety foundation | AeroSafetyWorld | December 2009–January 2010 Aviation— It’s a Small World Pricing forat 20092010 rates!is being held at the 21st International Women in Aviation Conference February 25-27, 2010 Disney’s Coronado Springs Resort Orlando, Florida
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WAI_ASW_Conf_010710.indd 1 1/12/10 10:35:50 AM FlightTRAINING Executive China Southern Airlines prepares flight crews to optimize Ability operational safety and profit. By Wayne Rosenkrans | From Beijing
simple drawing of a circle overlap- model, this visual aid to risk assessment ping a square can help clarify how and management also has been an instruc- airline captains simultaneously must tional tool to improve the executive ability be safety professionals and line man- — analytical skills that can be taught and agersA of their companies, says Zhou Yizhi, improved — of flight crews. The model helps an Airbus A330 captain instructor for China in adequately considering company profit Southern Airlines. Called the square‑circle in relation to operational risk assessment, © Jorgen Syversen/AirTeamImages.com © Jorgen
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especially in abnormal or emergency to depend largely on consistent ap- beyond the boundaries of the square — situations, he said. plication of executive ability. the crew’s decision exceeds their ability In crew debriefings, for example, — an unsafe event would occur.” the model has been used to address Square-Circle Model decisions made impulsively without sci- In the model, a square signifies execu- Model Applications entific analysis of the actual margin of tive ability, with a larger size signifying One case study looked at risk fac- safety. “Profit yield will be significantly better executive ability. The perimeter tors during a final approach at sunset less if the crew’s improper decisions of a circle signifies the actual risk or after an asymmetric trailing edge flaps lead to unnecessary diversion or the the crew’s assessed risk (Figure 1). The malfunction on a China Southern cancellation of flights,” he said. area of the circle signifies the effect Boeing 757 operating from Chengdu to Zhou, who also is a crew resource on company profit of one decision Jiuzhaigou. This uneventful flight was management instructor for the Inter- compared with others. By superimpos- flagged for safety analysis. national Air Transport Association ing the “assessed risk,” “actual risk” “Jiuzhaigou is a most challenging (IATA) and a member of the IATA Safe- or both circles on the square, parts of airport to fly into,” Zhou said. “They ty Group, presented three case studies the square covered or revealed can be just cut off the top of a mountain and during the joint meeting of the 62nd interpreted. set up the runway. The airport eleva- annual Flight Safety Foundation In- “The non-overlapping area rep- tion is 11,311 ft, and only Runway 20 ternational Air Safety Seminar (IASS), resents the safety margin,” Zhou said. may be used due to terrain limitations. IATA and International Federation of “We want both a safety margin and The flaps seized between positions 20 Airworthiness 39th International Con- a greater company profit; they can and 25 at about 2,000 ft above ground ference, held here in November. vary from big to small. In different level [AGL] roughly 7 nm [13 km] from When an airline flight concludes risk assessments, we will have differ- touchdown, or two minutes to go. In safely, this does not necessarily validate ent company profits. If the circle is normal conditions, the Boeing 757 air- that the flight crew’s decisions were too small, the safety margin appears craft lands at this airport with flaps set logical or reasonable — or that the larger, but the company’s profit will be at 25. In this case, there was a tail wind margin of safety was adequate, he said. the inverse [that is, decreased]. Some at 3 to 4 mps [6 to 8 kt], a wet runway China Southern teaches that “decision circles are just inside the square, so the with partial standing water, no braking making primarily shall be based on square covers the circle. Then executive action reports and time pressure.” safety factors,” Zhou said. ability can cover the decision making Pilots with the desired executive “Within the safety margin, required. If the size of the circle extends ability consistently recognize that timely however, the crew must consider the company profit. A Square-Circle Model and Landing at Jiuzhaigou low profit of the company could be Executive ability Executive ability caused by improper (entire square) risk assessment and Risk Actual and assessed (assessed or actual) risk (coincide) excessively conser- vative decisions, Decision outcome Decision outcome (pro t) (pro t) while the potential threats could be Safety margin Safety margin (non-overlapping area) (inadequate) increased as a result of unchallenged bold Notes: The left drawing identifies common elements used in square-circle model analysis. The right drawing shows risk for an actual landing with an asymmetric trailing edge flap malfunction on approach to this high-altitude airport. Risk factors decisions.” In his included tail wind, wet runway with partial standing water, nonadherence to procedures and no braking action report. experience, favorable Source: Zhou Yizhi, China Southern Airlines outcomes of flight crew decisions tend Figure 1 www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 45 FlightTRAINING
decisions to go around are essential when increased landing distance and selected braking — and less with the maximum critical tasks cannot be completed before maximum autobrakes. Finally, the aircraft autobrakes used. landing. “[In this 757 approach] at the landed safely.” The square-circle model (Figure edge of night, some of the crew did not The risk of this landing was 1) showed the perimeter of the “actual think in that way,” he said. “On the actual analyzed retrospectively. If braking risk” circle coinciding with the “as- flight, both pilots had captain qualifica- action on the 3,000-m (9,843-ft) wet sessed risk” circle. Overlaying both tion per company policy. The copilot on runway had been good, the required circles on the “executive ability” square the observer’s seat carried the quick refer- landing distance for this non-normal left some safety margin visible. “Prob- ence handbook [QRH, and one minute configuration of flaps setting 20 and ably, they did not have enough safety
elapsed as the non-normal checklist was VREF20 (landing reference speed) of 144 margin, so I can say that even with a performed]. Immediately after comple- kt would have been 1,584 m (5,197 ft), safe flight, the decision to land probably tion of the non-normal checklist and providing an adequate safety margin. was not reasonable,” he said. normal checklist, the height of the aircraft If braking action had been medium, Another case study looked at the was 500 ft AGL, so the crew mostly could the distance would have been 2,465 m decision by a captain operating a 757 see the runway. The captain could see the (8,087 ft) and if poor, 3,253 m (10,673 from Guangzhou to Urumqi (Figure 2); ft), he said. the crew had returned to the departure For all these landing dis- airport. “Just as the crew lifted off and Incorrect Risk Assessment tances in the QRH, however, during the process of aircraft accelera- Near Guangzhou the aircraft must be 50 ft over tion and flap retraction, the message
Executive ability the runway threshold and land ‘TRAILING EDGE FLAPS DISAGREE’ Actual risk at the touchdown point, and appeared,” Zhou said. The crew com- (non-normal event) the crew must apply maximum plied with standard operating proce- Decision outcome manual braking and select dures, engaging the autopilot, reducing (pro t if ight continues to destination) maximum thrust reversers. airspeed to flap maneuvering speed, Safety margin Zhou analyzed the crew’s climbing to a safety altitude of 1,200 m (adequate) decision to land with medium (3,900 ft), notifying air traffic control braking action assumed, and conducting the corresponding leaving a safety margin of 535 non-normal checklist. Assessed risk m (1,755 ft) and touchdown “One of the last items was ‘Alternate (over-estimated) groundspeed of 190 kt (98 Flaps Selector — Set. Extend or retract mps). “Clearly, the threat on flap as required.’” Zhou said. Executive that day was significant,” he ability influenced the decision. “The Safety margin said. “This crew did not con- actual situation was ‘flaps extension (incorrect assumption about reduced safety sider properly the non-normal and retraction [are] normal in alternate margin if ight continues landing distance [or the need] mode,’” he added. The crew had told to destination) to apply maximum braking safety investigators, “Possible problems and maximum reverse thrust. after flap retraction were considered at Decision outcome Their groundspeed was almost the time, and there was no guarantee (pro t reduced by returning to 100 mps [328 fps].” Thus, that problems wouldn’t occur during departure airport) every second of flight before the remaining [five-hour] flight.” Safety margin flare reduced the runway avail- The square-circle model showed (unnecessarily large) able for deceleration by 100 m that the crew had created an “un- Note : The flight crew observed a “trailing edge flaps (328 ft) so just a two-second necessary safety margin,” he said. “By disagree” message after takeoff from Guangzhou on a five- hour flight to Urumqi. They returned to Guangzhou. aircraft handling error would correctly assessing the threat, within
Source: Zhou Yizhi, China Southern Airlines have reduced the distance the safety margin, the crew’s decision safety margin to 339 m (1,112 should minimize operational cost as Figure 2 ft) with maximum manual much as possible,” Zhou said.
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Another case Flight Crew Decisions With Different Executive Abilities: Kunming Arrival study interpreted actual and hypotheti- Crew A Crew B Crew C Crew D cal crew responses to a dual malfunc- tion of the automatic cabin pressurization systems. The ac- tual flight cited was Unsafe Unsafe Unsafe Safe from Guangzhou to Kunming, which has Note: In these hypothetical scenarios, the flight crew is alerted soon after takeoff that both aircraft systems for automatic control of cabin altitude are inoperative. Perimeters of circles signify almost the same initial risk in continuing the flight using an airport elevation manual control. Squares signify different executive abilities demonstrated by these crews (bigger size means greater ability) of 6,220 ft. “After de- while continuing to the destination. parture, the crew was Source: Zhou Yizhi, China Southern Airlines instructed to climb Figure 3 to Flight Level 197 [6,000 m, approxi- “Suppose that at the cruise altitude ear pain for occupants, possible ear mately 19,700 ft],” he said. “While to Kunming — which was 8,400 m or injury and a cabin altitude warning. climbing through 6,000 ft, a malfunc- 27,600 ft — the cabin altitude is 3,000 ft Crew D manually sets landing alti- tion occurred with the annunciation and after about two hours, the aircraft tude before descent, gradually increases ‘CABIN AUTO INOPERATIVE 1 will descend,” he said. “Also suppose we cabin altitude from 7,000 to about 9,000 AND 2.’” The crew correctly lev- have four crews [Crew A, Crew B, Crew ft, then on final approach below 10,000 eled off above the safety altitude, but C and Crew D of different executive ft performs the deferred checklist item to below 10,000 ft, and conducted the abilities].” open the aft floor valve. This action safely non-normal checklist as they were Crew A forgets to select the pres- maintains comfortable cabin altitude, and trained. surization setting item in the normal there is no cabin altitude warning. “If the cabin altitude cannot be checklist and the non-normal checklist “For these crews, the decisions in the controlled manually, the crew obviously items, so the cabin door cannot be circles [Figure 3] were almost the same will return to the departure airport,” opened safely. but the result varied due to the difference Zhou said. “[When it can be controlled Crew B forgets during descent the in their executive abilities,” Zhou said. manually,] the choice the crew must landing-altitude setting on the normal “Crew D’s executive ability covered the make is to continue or return to the de- checklist but remembers to conduct decision making required. Executive abil- parture airport, considering the safety the deferred item on the non-normal ity of Crew A, Crew B and Crew C could margin and company profit.” checklist. At the pattern altitude of 10,200 not. So only Crew D was safe; Crew A, If the decision is to continue to the ft, the crew fully opens the aft floor valve Crew B and Crew C were unsafe.” destination, the crew implicitly accepts and cabin altitude rapidly rises from Regardless of executive ability, how- responsibility to comply with a deferred 3,000 to 10,200 ft. This causes severe ear- ever, altering one variable would mask item — select landing altitude — on the drum discomfort and possible ear injury, any difference in performance among normal checklist; a procedure for man- and triggers a cabin altitude warning. these crews. “Suppose the destina- ually adjusting cabin altitude during Crew C manually sets landing alti- tion is Shanghai, airport elevation 9 ft, descent based on the specific change tude to 6,220 ft before descent and con- instead of Kunming,” Zhou said. “Both of altitude; and a deferred item on the ducts the deferred items but fully opens pattern altitude and the cabin pressure non-normal checklist for which the the aft floor valve at pattern altitude. then would be 3,000 ft, and even if all QRH says, “When at pattern altitude: The consequences are less severe than crews continued to the destination, the CABIN ALTITUDE MANUAL CON- for Crew B because the cabin altitude threats discussed for Kunming would TROL — CLIMB. Position to CLIMB only rises from 6,220 to 10,200 ft, but have been much smaller, so all would until outflow valve [is] fully open.” the effects are similar: uncomfortable have the same safe outcome.” www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 47 DataLink
BY RICK DARBY Part 135 Sightseeing Flight Accident Rates Improve Air medical flights had lower rates than other categories.
he numbers of fatal accidents and fatali- For example, the report says, no accident ties in U.S. Federal Aviation Regula- rates could be determined for cargo versus pas- tions (FARs) Part 135 revenue flights senger flights because the FAA does not make increased in 2008 compared with 2007,T according to data published by the Air FARs Part 135 Accident Rates, 2004–2007 Charter Safety Foundation (ACSF).1,2 A year- to-year increase was also found in Part 135 Accidents/100,000 Hours 2004 2005 2006 2007 non-revenue flights. Air medical 1.69 0.50 0.57 0.98 The ACSF analyzed accident and incident Cargo/passenger 2.09 1.86 1.42 1.54 data obtained from the U.S. National Trans- Sightseeing 2.23 2.56 2.37 1.18 portation Safety Board (NTSB) and flight Other/unknown N/A N/A activity data obtained from the U.S. Federal Total 2.04 1.70 1.39 1.54
Aviation Administration (FAA). The orga- FARs = U.S. Federal Aviation Regulations nization says that the study is “a critical step Note: Cargo and passenger flights are combined because the U.S. Federal Aviation toward identifying trends in Part 135–related Administration does not distinguish between them in compiling flight hours for Part 135 operations. Activity data for 2008 is not yet available. accidents” but was “limited in its analysis due Source: Air Charter Safety Foundation to limitations on the data currently collected by the NTSB and FAA.” Table 1
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that distinction in recording flight hours of Part FARs Part 135 Revenue Flight Fatal Accidents, 2004–2008 135 operators. Therefore, cargo and passenger flights were grouped together in calculating ac- 2004 2005 2006 2007 2008 cident rates (Table 1). Fatal accidents 23 11 10 14 19 Although U.S. helicopter emergency Non-fatal accidents 43 54 42 48 38 medical services flights during 2009 were the Total accidents 66 65 52 62 57 subject of comprehensive risk-reduction initia- Fatalities 64 18 16 43 66 tives by government and industry, the ACSF FARs = U.S. Federal Aviation Regulations found that in every year from 2004 through Source: Air Charter Safety Foundation 2007, revenue air medical flights — not necessarily emergency or helicopter opera- Table 2 tions — had lower accident rates than the other categories.3 In 2007, for example, this FARs Part 135 Revenue Flight Accidents, category had 0.98 accidents per 100,000 hours. by Purpose of Flight, 2004–2008 That was 36 percent lower than the combined cargo/passenger category, and 17 percent 2004 2005 2006 2007 2008 lower than for sightseeing flights. Air medical 8 3 4 9 6 Sightseeing flights had the highest accident Cargo 26 25 16 24 21 rate of any category throughout 2004–2006 Passenger 27 28 23 24 26 but showed a significant improvement in 2007. Sightseeing 5 9 7 6 4 The 2007 rate, 1.18 accidents per 100,000 flight Other/unknown 0 0 2 1 1 hours, was about half the 2006 rate of 2.37. Total 66 65 52 64 58 The rates for non-revenue flights were not FARs = U.S. Federal Aviation Regulations determined, and all other data compared only Note: One air medical accident in 2008 involved two aircraft. Therefore, although the total numbers of accidents and fatalities. number of accidents in 2008 is 57, this and the following data reflect 58 aircraft and flights. More fatal revenue flight accidents occurred Two separate cargo-related accidents in 2007 involved two aircraft. Therefore, although the total number of accidents in 2007 is 62, this and the following data reflect 64 aircraft and in 2008 than in any year since 2004, and the flights. number of fatalities was highest in the five-year Source: Air Charter Safety Foundation period (Table 2). Total accidents, however, were Table 3 down 8 percent in 2008 from the previous year as well as from the average for the previous four years. One-third of the total accidents in 2008 FARs Part 135 Revenue Flight Accidents, were fatal. by Flight Conditions, 2004–2008
Cargo and passenger revenue flight acci- 2004 2005 2006 2007 2008 dent numbers were tallied separately (Table 3). VMC 36 49 36 41 37 The 21 cargo flight accidents in 2008 com- IMC 11 3 3 5 5 pared with an average annual of 23 in the four IMC/VMC 1 1 2 1 1 previous years. For passenger flights, the 26 NVMC 10 8 7 12 9 accidents in 2008 matched the average in the NIMC 8 4 4 4 4 previous four-year period. Sightseeing flights in 2008 had fewer accidents than in any year Unknown 0 0 0 1 2 going back to 2004. Total 66 65 52 64 58 The percentages of oil rig–related flight ac- FARs = U.S. Federal Aviation Regulations; VMC = visual meteorological conditions; IMC = instrument meteorological conditions; IMC/VMC = mixed conditions; cidents among total passenger aircraft accidents NVMC = night VMC; NIMC = night IMC varied widely, from a high of 30 percent in 2004 Source: Air Charter Safety Foundation to a low of 8 percent in 2008. On average for the five-year period, transportation to and from Table 4 www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 49 DataLink
oil rigs represented 18 percent of revenue flight in visual meteorological conditions (VMC; accidents. Table 4, p. 49). Accidents in instrument me- In every year of the study period, the ma- teorological conditions — as a percentage of jority of accidents in revenue flights occurred all accidents where the flight conditions were reported — ranged from 5 percent in FARs Part 135 Revenue Flight Accidents, by Phase of Flight, 2004–2008 2005 to 17 percent in 2004. 20 2004 2005 2006 2007 2008 Takeoff, cruise 18 and landing were the 16 most common phases 14 of flight reported in 12 revenue flight acci- 10 dents throughout the 8 study period (Figure 6 Number of accidents 1). Accidents in these 4 phases totaled 64, 2 72 and 67, respec- 0 Approach Climb Descent Landing Missed Takeo Other/ tively. The number unknown Circling Cruise Hover Maneuvering Standing Taxi of takeoff accidents, Phase of ight which had averaged 15 from 2004 through FARs = U.S. Federal Aviation Regulations 2007, dropped to six Source: Air Charter Safety Foundation in 2008. Figure 1 The report includes the distribu- tion of revenue flight FARs Part 135 Revenue Flight Accidents, by Aircraft Type, 2004–2008 accidents by aircraft type (Figure 2). There 20 was good news about 2004 2005 2006 2007 2008 18 helicopter accidents. 16 Nine accidents in 14 2008 involved single- 12 engine helicopters, 10 compared with an 8 average of 16 for the 6 four prior years in the Number of accidents 4 study period. The two 2 accidents involving 0 twin-engine helicop- Turbojet Rotorcraft Rotorcraft Single engine Single engine Twin engine Twin engine single engine twin engine piston turboprop piston turboprop ters were an improve- ment over the annual Aircraft Type average of four in the
FARs = U.S. Federal Aviation Regulations four previous years.
Source: Air Charter Safety Foundation The report also includes data for Figure 2 non-revenue flights
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flown by Part 135 certificate holders under FARs Part 135 Non-Revenue Flight FARs Part 91. Those include positioning, Fatal Accidents and Fatalities, 2004–2008 maintenance ferrying, instructional flights and miscellaneous others. 2004 2005 2006 2007 2008 Jacqueline Rosser, ACSF executive di- Fatal accidents 13 9 6 2 4 rector, told ASW, “Basically, we wanted to Non-fatal accidents 25 22 18 9 15 capture the ‘lost’ accidents. There are many Total accidents 38 31 24 11 19 accidents that occur while deadheading/po- Fatalities 24 15 11 5 11 sitioning, but because those are not labeled FARs = U.S. Federal Aviation Regulations as Part 135 operations by NTSB, they become lost in the general aviation accident data, Source: Air Charter Safety Foundation when really those flights were the respon- Table 5 sibility of the [Part 135] certificate holder. Until now, the number of Part 135 certificate holder–controlled and Part 91–flown ac- FARs Part 135 Non-Revenue Flight Accidents, by Purpose of Flight, 2004–2008 cidents was an unknown. Identifying those events allows us to help operators better 2004 2005 2006 2007 2008 understand the risks for those flights and, Air medical 13 9 11 4 7 hopefully, we can mitigate those risks.” Cargo 2 2 3 1 0 Fatal non-revenue accidents increased to Passenger 14 15 4 2 3 four in 2008 from two in 2007, but the 2008 Sightseeing 2 0 0 0 0 number was lower than the average of eight in Other/unknown 7 5 6 4 9 the four previous years (Table 5). Total non- revenue accidents, tabulated at 19 for 2008, were Total 38 31 24 11 19 also higher than the previous year and lower FARs = U.S. Federal Aviation Regulations than the annualized 26 in 2004 through 2007. Source: Air Charter Safety Foundation The number of fatalities increased in 2008 Table 6 to 11, compared with five in 2007. The previ- ous four-year average was 14. Fatal accidents represented 34 of 123, or 28 percent, of all 2. Air Charter Safety Foundation. “Part 135 non-revenue flight accidents during the five Accident/Incident Review, 2004–2008.” Released Dec. 10, 2009. Free to members; nonmembers years studied. can order a copy for $25 from Jacqueline Rosser, Air medical operations contributed the 888.723.3135 (U.S.). largest number of non-revenue accidents 3. Air medical flights “are typically conducted in during the study period, 44 (Table 6). Non- airplanes and are frequently not emergency- or revenue passenger flight accidents, which trauma-related flights. Helicopter emergency numbered 14 in 2004 and 15 the following medical services operations could be of an year, were reduced to two in 2007 and three emergency nature or might be hospital or medical in 2008. facility transfers.” Among non-revenue flights during the 4. Other than rates available in 2004–2007, the study period, 76, or 62 percent, occurred in annual numbers give only a general idea of the VMC. significance of changes for safety because of the lack of information about risk exposure, such as Notes flight hours or departures in a given period. Small numbers particularly may reflect random varia- 1. FARs Part 135 is titled Operating Requirements: tion. Numbers have been rounded off to the near- Commuter and On Demand Operations and Rules est whole number, including when they involve a Governing Persons On Board Such Aircraft. fraction of exactly 0.5. www.flightsafety.org | AeroSafetyWorld | December 2009–January 2010 | 51 InfoScan
Both Sides Now Studying skilled performance is one way of understanding human error.
BOOKS the pilot further out of the system by adding another layer of automation. “Some of the most Ambiguity and the Need for Human Decisions crucial tasks pilots perform cannot be handled Human Error in Aviation by computers,” he says. “Most of the time, hu- Dismukes, R. Key (editor). Farnham, Surrey, England and Burlington, mans — but not computers — are able to make Vermont, U.S. Ashgate, 2009. 604 pp. Figures, tables, references, index. reasonable decisions in novel situations; when killed human performance is the product available information is incomplete, ambiguous of the most complicated and sophisticated or conflicting; and when value judgments are “S information-processing system known in required.” the universe: the human brain,” says Dismukes As an example of the latter situation, Dis- in his introduction to this anthology of articles mukes presents a scenario in which a passenger from scientific and academic sources. “The is having a heart attack while the aircraft is essays reprinted in this book provide a cross- on approach to an airport with deteriorating section of operational challenges, research weather. Can a computer balance the need to accomplishments and issues that remain to be get medical help for the passenger as quickly as addressed. … possible with trying to land where the weather “Both correct performance and errors must conditions might pose a high risk? be understood in the context of the experience, He believes that studying the skilled perfor- training and goals of the individual; character- mance and errors of aviation personnel other istics of the tasks performed; human-machine than pilots has not received enough attention, interfaces; events — routine and unanticipated; compared with studies of pilots’ performance, interactions with other humans in the system; possibly because there is a bias in accident inves- and organizational aspects. Those aspects tigations to focus on the person who performed include the organization’s explicit and implicit the final actions before the accident. “Equip- goals, reward structures, policies and proce- ment failures leading to accidents can often be dures. Explicit and implicit aspects sometimes traced to inadequate maintenance, so we should diverge; for example, the norms for how tasks be equally concerned with mechanics’ errors, are actually performed on the line may not be which, like pilot errors, should be considered consistent with formal guidance.” manifestations of weaknesses and flaws in the Although pilots make errors from time to overall system,” he says. “Similarly, we should time, he says, it is often a mistake to design be concerned with the skilled performance
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and errors of air traffic controllers, dispatchers, stress, age, experience and organizational instructors, managers, equipment designers and influences. The fourth section broadens the all others in the aviation system whose work af- scope to include maintenance and air traffic fects safety and production.” control. Although Dismukes was able to find “Crews as Groups: Their Formation and worthwhile essays on particular dimensions Their Leadership,” by Robert Ginnett, is one of performance and on factors that affect the example of the type of material in the book. In quality of performance in those dimensions, he CRM, he says, a group — not individuals — is was disappointed at how few essays he reviewed the basic unit, which does not come naturally for possible inclusion in the book were pub- in an individualistic culture where personal lished in peer-reviewed journals and provided achievement is stressed. He examines how a a “thoughtful, critical overview of a domain of group most effectively becomes a coherent skilled performance in aviation.” team. He suggests two reasons why more research “Groups are something more than merely a is not being conducted on skilled performance collection of the individuals comprising them,” and human error. The first is that it is hard to he says. “Some groups do remarkably well with design controlled, laboratory experiments in no particularly outstanding individuals. Other this field. Cognitive processing and behavior are groups, made up almost exclusively of high- relatively easy to study, he says, but it is a differ- performing individuals, do not do at all well as ent story when scientists try to design replicable a team.” experiments concerned with flying aircraft. The optimal crew, he says, is not an “all- These involve “multiple, dynamically shifting star team” but people who can integrate their tasks, incomplete and ambiguous information experiences and strengths, particularly when the and competing goals.” unexpected arises. “In many accidents in today’s The second reason, he believes, is lack complex systems and environment, it is com- of funding. “A handful of full-mission flight mon to find that some aspect of the environ- simulator facilities dedicated to research on ment or situation created ambiguity which, by aircrew performance exist around the world,” he definition, eliminates a structured solution,” The optimal crew, says. “However, the cost of such facilities runs he says. “After all, if you do not know what the is not an ‘all-star into the tens of millions of dollars, and running problem is, it is unlikely that you know what enough experimental subjects (pilots) through the solution is! But if you can get two or three team’ but people a simulation to answer a given research ques- independent critical thinkers involved, you will tion requires a very long and expensive study. have a better chance of ruling out individual who can integrate … Fortunately, some research questions can be biases and will be on the road to a more effective their experiences answered using lower fidelity simulators that are solution.” much cheaper.” One key to a well-functioning crew is the and strengths, The book is divided into four sections, each quality of the leader. In the cockpit, that is the beginning with a brief introduction to set the captain. Ginnett quotes from an earlier study of particularly when the stage for its essays. The first section is devoted his when he interviewed subordinate pilots and to conceptual frameworks for thinking about asked, “Are all the captains you fly with pretty unexpected arises. skilled performance and error; the next offers much the same?” selections that address specific aspects of perfor- One response was, “Oh, no. Some guys are mance such as workload, automation manage- just the greatest in the world to fly with. … ment, situation awareness, risk assessment and When you fly with them, you feel like you want crew resource management (CRM). to do everything you can to work together to The next section comprises essays about get the job done. Some other guys are just the factors affecting performance, such as fatigue, opposite. You just can’t stand to work with them. www.flightsafety.org | AEROSafetyWorld | December 2009–January 2010 | 53 InfoScan
That doesn’t mean you’ll do anything that’s however, did they move all the way to the unsafe, but you won’t go out of your way to keep laissez-faire pole. him out of trouble either.” Ginnett says that the HI-E captains used Ginnett discusses some of the characteristics three methods to build an effective leader-team of captains who, prior to observation in a study, relationship. were assessed by check pilots as being especially The first was establishing their competence. skilled at creating highly effective teams. He They demonstrated the legitimacy of their calls them HI-E captains. authority by means such as logical organization “Contrary to expectations, the HI-E captains of their briefing, using the language of aviation hardly discussed tasks at all,” Ginnett says. “Even precisely and showing comfort in the group when tasks were mentioned — closing the cabin setting. door, retracting the aft air stairs or keeping the Second was disavowing perfection. The HI-E cockpit door open prior to pushback — they captains made it clear that the other crewmem- were more about boundary issues than about bers were expected to take responsibility for the the tasks themselves.” work of the group. One said, “I just want you Boundary issues are essentially a question guys to understand that they assign the [cock- of who is included in the group. “The HI-E cap- pit] seats in this airplane based on seniority. So tains … worked to create a larger vision of the anything you can see or do that will help out, I’d relevant work group — one that exceeded the sure appreciate it.” bounds of the aircraft,” Ginnett says. “They took The third behavior was engaging the crew. pains to include, at least psychologically, gate Instead of giving a completely standardized personnel, maintenance and air traffic control- briefing that might as well have been a record- lers as part of the group trying to help them — ing, they were interactive. “By dealing in real not as an outside hostile group trying to thwart time with the people who were filling the roles, their objectives.” they conveyed important normative information The HI-E captain The Zeus-like authoritarian captain is sup- about themselves and the value of the individu- can communicate posed to be a thing of the past. Instead, the als who made up this particular group,” Ginnett HI-E captain can communicate standards and says. standards and expectations both through formal briefings and — Rick Darby by modeling the desired norms. “For example, expectations both a captain may quite subtly transmit the impor- WEB SITES tance of exchanging information as the group through formal goes about its work by merely taking the time Boeing Firefighting Aid briefings and by to exchange information (two-way communica- Boeing Commercial Airplanes, Airport Technology,
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Instruction sheets Law Group Offers Safety News include detailed Nolan Law Group,
Control Anomaly Catches Crew Unaware The Citation pilots did not know what went wrong or how to deal with it.
BY MARK LACAGNINA
The following information provides an aware- Citation 500/550 type rating. He was a business- ness of problems in the hope that they can be man who flew part-time for the charter company. avoided in the future. The information is based Marginal visual meteorological conditions on final reports by official investigative authori- (VMC) prevailed when the airplane lifted off ties on aircraft accidents and incidents. from Runway 01L. The departure clearance called for a climb on runway heading to 2,000 JETS ft, followed by a right turn to 050 degrees. Soon after starting the turn, the captain asked the first High Airspeed Intensified the Problem officer, “Why am I fighting the controls here?” Cessna Citation 550. Destroyed. Six fatalities. The first officer replied, “How’s your trim he flight crew’s “lack of coordination” and set? Is that the way you want it?” “mismanagement of an abnormal flight con- The captain said, “It wants to turn hard left. Ttrol situation” were the probable causes of … Something is wrong with the trim … the the crash of a Citation II into Lake Michigan on rudder trim. … Something is wrong with our June 4, 2007, said the U.S. National Transporta- rudders, and I don’t know what.” tion Safety Board (NTSB) in its final report on He told the first officer to inform air traf- the accident. fic control (ATC) that they were returning to The board was not able to determine con- land at Mitchell. Shortly thereafter, the sound clusively what caused the flight control problem, of a grunt was recorded by the cockpit voice however. recorder (CVR), and the captain said, “She’s roll- The pilots had flown a medical transplant ing on me. Help me. Help me.” team from Ypsilanti, Michigan, U.S., to Milwau- “I am,” the first officer said. kee to harvest an organ. After about four hours The captain asked the first officer to pull on the ground, the Citation departed from the autopilot circuit breakers. The first officer Milwaukee’s General Mitchell International — who was known to have deficient systems Airport at 1557 local time for the return flight to knowledge, according to the report — asked Ypsilanti. where they were located. The captain, 59, had about 14,000 flight The captain did not answer the first officer’s hours, including 12,000 hours in a variety of question. He declared an emergency, telling transport category airplanes, with 300 hours in ATC that he had a control problem. “I don’t the Citation 500/550 series. He was the charter know what’s wrong,” he said. company’s chief pilot and check airman. He told the first officer, “You hold it, I’m go- The first officer, 65, had about 9,200 flight ing to try to pull circuit breakers.” He then said, hours, including 420 hours in type, and held a “We’re not … holding it.”
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“I’m pulling,” the first officer said. Five sec- coordinated. CVR data indicates that the first onds later, at 1600:45, the CVR recording ended. officer adjusted the trim settings without con- The Citation was in a 42-degree nose-down sulting the captain. attitude and in a 115-degree left bank when it Moreover, the report said, “The first officer’s struck the water at about 243 kt. The fragmented trim inputs aggravated, rather than ameliorated, wreckage was recovered by divers. the situation.” For example, a performance study Investigators determined that the control indicated that after the first officer said, “How’s problem might have been related either to that? Any better?” about a minute before im- inadvertent engagement of the autopilot or to pact, the airplane banked steeply and the CVR an electric pitch trim anomaly. “Without an recorded the sound of the captain grunting. FDR [flight data recorder] or image recorder on The report said the accident illustrates that board, it was not possible to determine the exact when pilots encounter abnormal flight control cause of the initiating event or the pilots’ actions forces, “they should prioritize airplane control ‘At reduced during the accident sequence,” the report said. (airspeed, attitude and configuration) before airspeeds, the Noting that the autopilot and yaw damper attempting to identify and eliminate the cause of push buttons are identical and close together on the flight control problem.” pilots should have the center pedestal, the report said that if the Among recommendations based on the autopilot had inadvertently been engaged by the findings of the investigation, NTSB called on the been able to first officer when he attempted to select the yaw U.S. Federal Aviation Administration to require damper on initial climb, the autopilot would on-demand operators and fractional ownership maintain control.’ have tried to maintain the climb pitch attitude operators to provide their pilots with recurrent and the runway heading when the captain lev- upset recovery training (ASW, 11/09, p. 22). eled off at 2,000 ft and initiated the right turn to the assigned heading. Speed Brakes Neglected on Go-Around If the initiating event was a nose-down pitch Boeing 757-200. No damage. No injuries. trim runaway, the pilots would have had to place he 757 was inbound with 78 passengers and as much as 140 lb (64 kg) of back pressure on eight crewmembers from Innsbruck, Aus- their control columns to counter it. “Although Ttria, to London Gatwick Airport, where sur- the airplane would have been controllable … it face winds the morning of Dec. 13, 2008, were would have required a significant physical effort from the southeast at 14 kt, gusting to 26 kt. by both pilots working together to keep the “Runway 08R was in use, and aircraft were airplane upright,” the report said. being radar-vectored to intercept the ILS [in- When investigators explored these scenarios strument landing system] from the south,” said in a Citation flight simulator, the participating the U.K. Air Accidents Investigation Branch pilots were able to recover only after reducing (AAIB) report. “The wind at 2,000 ft was 50 kt power and airspeed to reduce the control forces. from the south.” “Regardless of the initiating event, if the [ac- Groundspeed was 190 kt and the aircraft was cident] pilots had simply maintained a reduced high as it neared the final approach course, so airspeed while they responded to the situation, the the commander, who was flying with the autopi- aerodynamic forces on the airplane would not have lot and the autothrottles engaged, deployed the increased significantly,” the report concluded. “At speed brakes. reduced airspeeds, the pilots should have been able The autopilot localizer mode was armed to maintain control of the airplane long enough too late to capture the localizer from the south, to either successfully troubleshoot and resolve the so the commander disengaged the autoflight problem or return safely to the airport.” systems and hand-flew the aircraft onto the The report also said that the pilots’ actions final approach course. He then re-engaged the in response to the control problem were not autopilot but not the autothrottles. www.flightsafety.org | AEROSafetyWorld | December 2009–January 2010 | 57 OnRecord
The landing gear was extended — and the is reference landing speed (VREF) plus 20 kt, or 135 speed brakes were still deployed — when the kt at the aircraft’s landing weight. Airspeed on crew selected the flap 20 setting. Shortly there- short final approach, however, was 149 kt. after, the stick shaker activated and the autopilot “At about 20 to 30 ft above the ground, the automatically disengaged. pilot stated [that the aircraft] experienced a sudden “The commander immediately lowered the downdraft [and then] touched down heavily on aircraft’s nose and increased engine thrust,” the the runway,” the report said. “The touchdown was The stick shaker report said. “The airspeed increased and the on the centerline, just before the touchdown zone.” stick shaker stopped, but the crew decided that The crew applied heavy wheel braking but activated and the best [course] of action was to go around.” did not extend the spoilers. Both main land- The aircraft was descending through 1,000 ing gear tires burst, and the aircraft veered off the autopilot ft when the go-around was initiated. The com- the right side of the 7,500-ft (2,286-m) run- automatically mander selected the takeoff/go-around mode, way about 2,200 ft (671 m) from the approach but neither pilot checked to ensure that the speed threshold and struck the airport boundary wall. disengaged. brakes were retracted, as required for a go-around. The copilot sustained minor injuries; the pilot The commander became confused and and five passengers were not hurt. disoriented because the aircraft’s attitude and The report did not provide information on the performance did not appear normal, the report likely causes of the flap-extension system failure. said. Moreover, the flight director pitch bars had inexplicably disappeared from the primary flight Ninety-Tonne Takeoff Error displays. The commander transferred control Airbus A330-243. No damage. No injuries. to the copilot, who appeared to have better situ- hile preparing for a flight from Montego ational awareness, and subsequently noticed that Bay, Jamaica, to an undisclosed location the speed brakes were deployed. He retracted Win the United Kingdom the night of Oct. them, and the crew completed the go-around 28, 2008, the A330 flight crew was unable to and a second approach to a landing without locate the aircraft’s performance manual, which further incident. had been improperly stowed among navigation The report noted that the 757 training charts, the AAIB report said. manual recommends that the pilot flying “keep The commander used a mobile telephone his hand on the speed brake lever whenever the to call the airline’s dispatch office in the United speed brakes are used in flight; this will preclude Kingdom and to request takeoff performance leaving the speed brake extended.” data calculations. According to airline procedure, such calcula- Tires Burst Under Heavy Braking tions must be derived independently by both Raytheon 390 Premier I. Substantial damage. One minor injury. flight crewmembers working with different dis- he aircraft encountered continuous turbulence patchers. The pilots provide information includ- during a charter flight from Jodhpur, India, ing the aircraft’s takeoff weight, airport weather Tto Udaipur the morning of March 19, 2008. conditions and runway data. The dispatchers en- Surface winds at the destination were from 230 de- ter the information into an Airbus computer sys-
grees at 10 kt. During a visual approach to Runway tem, which calculates takeoff speeds (V1, VR and
26, the “FLAP FAIL” annunciator illuminated, and V2), permitted takeoff thrust reduction and the the pilots were unable to extend the flaps. “green dot speed” — that is, the target airspeed to “Subsequently, the pilots carried out the check- be used if the takeoff is continued after an engine list for a flap-less landing,” said the report by India’s failure. The pilots then compare and cross-check Directorate General of Civil Aviation (DGAC). the data received from the dispatchers. “However, the pilot approached with a higher The report noted that pilots of Airbus air- speed.” The airspeed recommended by the checklist craft typically perform a “gross error check” by
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comparing the green dot speed calculated by the that the aircraft ‘did not feel right’ and instinctively manufacturer’s computer system with the value selected TOGA [takeoff/go-around] power. independently calculated by the on-board flight “The aircraft then became airborne and management guidance system (FMGS). climbed away. … By 50 ft radio altitude, the However, the incident pilots were not given a aircraft had covered an estimated distance of green dot speed; for unknown reasons, the com- approximately 2,500 m [8,202 ft] since the start puter function that enables this calculation had of the takeoff roll.” been disabled at the airline’s dispatch office. The flight continued to the destination with- Moreover, although two dispatchers were on out further incident. duty, only one was in the dispatch office when Citing the findings of the investigation of the commander called. “Only he processed the this incident and those of other incidents and data,” the report said. “He did, however, speak accidents involving erroneous takeoff perfor- with both pilots and confirmed the input data mance calculations (ASW, 10/06, p. 16, and and performance data with each.” ASW, 9/08, p. 28), the AAIB recommended that Nevertheless, a substantial discrepancy the European Aviation Safety Agency develop went unnoticed: The A330’s load sheet showed specifications for takeoff performance moni- a takeoff weight of 210,183 kg (463,369 lb), but toring systems and require installation of the the performance calculations were based on an systems aboard transport category aircraft. The flight crew erroneous takeoff weight of 120,800 kg (266,316 lb). Investigators were unable to determine how Deicing Fluid Fouls Cabin saw a ‘gray cloud’ the mistake was made, in part because the tele- Boeing 737-800. No damage. No injuries. in the cockpit. phone conversations between the pilots and the he flight crew had not configured the 737 dispatcher were not recorded, and the CVR data for deicing before ground crewmembers subsequently were overwritten. Tbegan deicing operations after the airplane The calculations provided to the pilots was pushed back from the gate at Seattle-Tacoma included 114 kt for both V1 and VR (the correct International Airport the morning of Dec. 24, figures were 136 kt and 140 kt, respectively) and 2008. The auxiliary power unit was operating and an FMGS data entry — an artificial outside air the engine bleed air valves were open, allowing temperature — that resulted in a reduced takeoff deicing fluid to enter the air supply lines for the thrust setting that was lower than the correct cabin and cockpit, the NTSB report said. setting for the autothrottle system. The cabin crew reported fumes in the cabin, Although the takeoff speeds and the thrust and the flight crew saw a “gray cloud” in the setting were lower than normal, “the crew were cockpit, the report said. After telling the ground unable to explain why they did not recognize crew to discontinue deicing operations, the that the figures they used were outside the ex- flight crew completed the smoke removal check- pected range,” the report said. list, started the engines and taxied the 737 back There were 318 passengers and 13 crewmem- to the gate, where the 135 passengers and six bers aboard the A330 when the pilots began the crewmembers disembarked via the airbridge. takeoff from Sangster International Airport’s “The captain reported that he did not clear 2,663-m (8,737-ft) Runway 07 at 2326 local time. the ground deicing crew to start their deicing “The aircraft appeared to accelerate normally, operations,” the report said. “The driver of the and the copilot made the standard calls as the primary deicing vehicle reported that he in- aircraft passed through 100 kt and then V1/VR,” formed the flight crew of the fluid types, freeze the report said. “The commander was surprised by points and concentrations. He added that there how close the calls had followed on from each oth- was a lot of ‘radio chatter’ and the bucket opera- er. … He pulled back on his sidestick and pitched tor began deicing operations ‘after we received the aircraft to about 10 degrees nose-up but stated no objections’ from the flight crew.” www.flightsafety.org | AEROSafetyWorld | December 2009–January 2010 | 59 OnRecord
Tow Bar Snaps During Pushback ATC the current weather conditions at the two British Aerospace RJ85. Substantial damage. No injuries. closest weather-reporting stations. ll four engines were operating at idle Akron, Colorado, which is 52 nm (96 km) power while the aircraft was pushed back west of Wray, had 4 mi (6 km) visibility in mist Afrom the stand at Dublin (Ireland) Airport and a 100-ft overcast ceiling. Imperial, Kansas, the evening of March 2, 2009. The tug driver 42 nm (78 km) northeast, had 3 mi (4,800 m) stopped the pushback on a taxiway and then visibility in light snow and a 1,600-ft overcast. began to pull the aircraft forward. The pilot requested and received clearance “This pull forward was not in a straight line from ATC to conduct the global positioning sys- but in an arc,” said the report by Ireland’s Air tem (GPS) area navigation approach to Runway Accident Investigation Unit. “This was carried 17 at Wray. out on his [the tug driver’s] own initiative with Several witnesses saw the Commander the probable intention of a minor realignment of emerge from low clouds north-northeast of the the aircraft nosewheel back onto the taxi line.” airport. “Shortly thereafter, the airplane pitched The tug driver perceived that the aircraft, down to a near-vertical attitude and began to which weighed 34,300 kg (75,618 lb), was rotate,” the NTSB report said. “The airplane im- pushing the tug on the wet taxiway, which had pacted the ground nose-first, and a fire erupted.” a slight downhill slope. “He braked, but the air- Investigators determined that the airplane craft continued forward,” the report said. “The was 560 lb (254 kg) over gross weight and that tug jackknifed, and the tow bar broke (the shear the center of gravity was at or just forward of the pins did not shear). The aircraft continued for- forward limit. ward under its own inertia and struck the tug.” NTSB determined that the probable cause of The 48 passengers and five crewmembers the accident was an aerodynamic stall result- disembarked through the aft cabin door. Exami- ing from “the pilot’s failure to maintain aircraft nation of the aircraft revealed substantial dam- control during the approach” and that icing age to the fuselage skin, frames and substructure conditions were a contributing factor. on the lower right side of the nose. Near the time of the accident, a Beech King The report noted that the tug, which weighed Air pilot reported that, despite frequent op- 5,750 kg (12,676 lb), had markings indicating that eration of the deicing boots, his airplane had it was to be used “for pushback only.” accumulated a significant amount of ice while Among postaccident revisions to the airline’s flying in the area. “In a follow-up telephone ground-handling procedures was a requirement conversation with the pilot, he characterized the that only one engine can be started at the stand ice that day as ‘sticky’ and hard to get rid of,” the and that the other engines can be started only report said. after the pushback operation is completed and the aircraft’s brakes are set. Control Lost in Low Visibility Beech King Air C90. Destroyed. Two fatalities. TURBOPROPS oss of control during a sudden maneuver to avoid an obstruction likely caused the King Icing Suspected in Approach Stall LAir to strike terrain during a visual ap- Gulfstream Commander 690C. Destroyed. Three fatalities. proach in low visibility the morning of Oct. 29, oderate icing conditions were forecast 2008, said the report by India’s DGAC. along the business airplane’s route of flight The aircraft was operated by the Punjab state Mfrom Denver to Wray, Colorado, U.S., the government. The pilots were conducting a short morning of Jan. 15, 2009. Wray Municipal Airport positioning flight from Chandigarh to Ludhiana. is uncontrolled and has no weather-reporting The report said that neither pilot had previously facilities. While en route, the pilot received from flown to Ludhiana or had proper endorsement
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to fly the King Air. The pilot-in-command, who relaxant for back pain. “He had heart disease was in the right seat during the flight, had not identified during the autopsy that may have received required familiarization training; and increased his risk of sudden cardiac death,” the there was no record to verify the copilot’s claim report said. “However, the investigation could not of 50 flight hours in type. conclusively identify that the pilot was impaired.” Visibility was 1,500 m (less than 1 mi) in NTSB concluded that spatial disorientation haze and smoke, and the flight crew was given was the probable cause of the accident. a special visual flight rules clearance to the airport, which had no instrument approach Turbulence Triggers Breakup procedure. “They were estimating their position Rockwell Aero Commander 500S. Destroyed. Two fatalities. based on GPS,” the report said. ight instrument meteorological condi- The crew spotted Ludhiana’s Runway 12 too tions prevailed for the business flight from late to land during the first visual approach and NEssendon to Shepparton, both in Victoria, initiated a go-around. However, instead of com- Australia, on July 31, 2007. ATC radar and radio plying with procedure requiring an initial climb contact with the aircraft were lost when it was to 1,000 ft above ground level (AGL), they leveled about 25 nm (46 km) north-northwest of Essen- at about 300 ft AGL and then descended while don at 7,000 ft over the Great Dividing Range. circling to the right of the runway in an apparent “The wreckage was found in the area of the effort to maintain visual contact with the runway. last radar position, and both occupants had The report said that the aircraft was at about been fatally injured,” said the report by the Aus- 100 ft AGL when the crew likely saw an un- tralian Transport Safety Bureau. “At the time, marked tower ahead and lost control while try- special weather reports for severe turbulence ing to avoid it. The King Air was banked steeply and severe mountain waves were current for left when it struck terrain and burned. that area.” Local residents said that surface wind velocity was 50 kt. PISTON AIRPLANES Investigators calculated that the Command- er’s true airspeed was about 165 kt when radio Disorientation Leads to Control Loss and radar contact were lost; the aircraft’s weight- Beech 58 Baron. Substantial damage. One fatality. adjusted maneuvering speed was about 131 kt. ight VMC prevailed when the pilot de- “Flight through an area of severe turbulence at parted from Cleveland’s Burke Lakefront speeds at or above the aircraft’s maneuvering NAirport for a positioning flight on Jan. 16, speed increases the risk of aircraft structural 2008. After taking off to the southwest, the pilot failure,” the report said. initiated a right climbing turn over Lake Erie. Examination of the wreckage indicated that the “The moon and city associated with the Commander likely broke up while it was in level airport were south of his flight path,” the NTSB cruise flight. “The breakup most likely resulted report said. “The maneuvering of the aircraft from an encounter with localized and intense tur- and lack of outside visual references soon after bulence or from an elevator control input, or from takeoff made the situation conducive to spatial a combination of both,” the report said. disorientation.” The airport traffic controller saw the Baron Leak Prevents Gear Extension descend during the right turn and strike the water. Cessna 421C. Substantial damage. No injuries. Examination of the aircraft revealed no pre-impact t the conclusion of a business flight the anomalies and verified that both engines were night of Oct. 29, 2008, the pilot received no producing high power when the crash occurred. Aindication that the left main landing gear Investigators found that the 68-year-old pilot was down and locked on approach to Falcon had been using a potentially sedating muscle Field in Mesa, Arizona, U.S. He made several www.flightsafety.org | AEROSafetyWorld | December 2009–January 2010 | 61 OnRecord
unsuccessful attempts to extend the gear using The helicopter had received a lightning the normal procedure. strike in August 2004, but “no evidence of “The pilot attempted to extend the gear lightning strike damage was found in any of the using the emergency procedure, and he was wiring” during the investigation of the air tour similarly unsuccessful,” said the NTSB report. accident, the report said. The pilot landed the airplane with the left main gear partially extended. The 421 veered Tarpaulin Fouls Main Rotors off the runway and slid to a stop. “Belly skin was Aerospatiale SA 315B. Substantial damage. No injuries. punctured, and several ribs were bent upward,” he helicopter was carrying construction the report said. None of the five people aboard materials for a television relay antenna to the airplane was injured. Ta temporary helibase in Obonai, Japan, the Examination of the 421 revealed that an alumi- afternoon of Oct. 23, 2008. The pilot said that num hydraulic line had ruptured beneath a clamp, during initial approach, he saw a pile of folded allowing hydraulic fluid to leak. The report noted blue tarpaulins about 4 m (13 ft) from the that the airplane had 4,113 airframe hours. helipad and, before continuing the approach, visually confirmed that timber had been placed HELICOPTERS on the tarpaulins to secure them. The report by the Japan Transport Safety Board Short Causes Engine Deceleration said that the timber placed on the tarpaulins was Eurocopter EC 130B4. Substantial damage. No injuries. not heavy enough to secure them properly. oon after slowing the helicopter to 30 kt to As the pilot brought the helicopter to a hover give his air tour passengers a view of water- slightly above the helipad, several tarpaulins were Sfalls, the pilot heard the main rotor low speed blown into the air by its downwash, and one tar- warning horn and saw instrument indications paulin was “sucked into its rotor disc,” the report confirming that main rotor speed was decreasing. said. The pilot felt the helicopter begin to vibrate “He entered into an autorotation to make a and yaw left as it touched down. He shut down forced landing and tried to regain engine torque the engine and applied the rotor brake. and rotor speed but was unsuccessful, and the None of the three people aboard the heli- low rotor horn sounded again,” the NTSB report copter was hurt. Examination of the aircraft said. “The helicopter came down in trees, with revealed that one of the three main rotor blades the main rotor blades contacting the treetops.” was damaged, some tail boom truss tubes were None of the six people aboard the helicopter broken, the tail boom and tail rotor drive shaft was hurt in the accident, which occurred in La- were bent, and the left shock strut was broken. haina, Hawaii, U.S., the morning of Jan. 5, 2006. Initial examination of the helicopter revealed Control Lost in Clouds damaged insulation and electrical shorts in the Robinson R44. Substantial damage. Two serious injuries. wiring harness for the digital engine control he commercial pilot and his flight instructor unit and the ancillary control unit. “Further discontinued an instrument training flight examination and testing revealed the insulation Tbecause of turbulence the night of Jan. 8, breakdown was a result of wire damage due to a 2009. The commercial pilot was flying the R44 tight bend in the harness,” the report said. back to Bountiful, Utah, U.S., under visual flight The wiring harness was longer than nec- rules when the helicopter entered clouds. essary and had been bent tightly to facilitate The pilot became spatially disoriented and lost its installation during the manufacture of the control of the helicopter. “The flight instructor helicopter, the report said. The helicopter — the took the controls and attempted to regain control first EC 130B4 delivered to a customer — had but was unable to do so before the helicopter im- been in service more than 4,800 hours. pacted the ground,” said the NTSB report.
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Preliminary Reports, October–November 2009 Date Location Aircraft Type Aircraft Damage Injuries Oct. 1 Lacco Yavero, Peru Aerospatiale AS 350B3 destroyed 3 fatal The helicopter crashed in the jungle during a survey flight. Oct. 6 Aurora, Texas, U.S. Beech King Air B100 destroyed 4 serious The King Air crashed in a field after both engines lost power. Oct. 15 San José de Ocoa, Dominican Republic Eurocopter EC 120B destroyed 3 fatal The helicopter was being flown in heavy rain when it crashed into a mountain. Oct. 16 Kangerlussuaq, Greenland Piaggio P180 Avanti substantial 1 serious The pilot made a forced landing on an ice sheet following fuel exhaustion during a ferry flight from Keflavik, Iceland. Oct. 16. Weert, Netherlands Pilatus PC-12NG destroyed 2 fatal Witnesses saw smoke coming from the engine on takeoff from Budel Airport. The PC-12 then descended and crashed in a field. Oct. 17 Manila, Philippines Douglas DC-3C destroyed 4 fatal The DC-3 struck an abandoned warehouse soon after the pilot reported engine problems during takeoff for a cargo flight. Oct. 21 Sharjah, United Arab Emirates Boeing 707-300C destroyed 6 fatal Witnesses saw the freighter enter a steep right bank after takeoff and descend into an open field. Oct. 22 Bonaire, Netherlands Antilles Britten-Norman Islander destroyed 1 fatal, 9 none The pilot was not able to exit the airplane after ditching it following an engine failure on approach. The passengers were rescued by boaters. Oct. 26 Minsk, Belarus Raytheon Hawker 800 destroyed 3 fatal The Hawker crashed in a wooded area during the crew’s second night approach with 2,000 m (1 1/4 mi) visibility and a 200-ft ceiling. The airport’s instrument approach systems reportedly were not in service. Oct. 26 Benavides, Texas, U.S. Beech King Air B100 destroyed 4 fatal Radio and radar contact were lost soon after the pilot reported difficulty maintaining control in severe turbulence at 25,000 ft. The wreckage later was found in a rural area. Nov. 1 Mirnyj, Russia Ilyushin 76M destroyed 11 fatal The aircraft crashed shortly after taking off for a positioning flight to Irkutsk. Nov. 2 Mulia, Indonesia Antonov An-28 destroyed 4 fatal The An-28 crashed into a mountain while descending during a police-supply flight. Nov. 5 Fort Pierce, Florida, U.S. Grumman Albatross substantial 1 minor, 2 none The airplane struck terrain while returning to the airport after the left engine failed on takeoff. Nov. 6 Cat Lake, Ontario, Canada Cessna 310R destroyed 3 fatal The 310 struck terrain during a night charter flight. Nov. 9 Nairobi, Kenya Beech 1900D destroyed 2 fatal The airplane struck the perimeter fence and crashed while returning to the airport after the crew reported a problem on departure for a cargo flight. Nov. 9 Greer, South Carolina, U.S. Beech King Air B200 substantial 3 serious The King Air struck terrain on approach after both engines flamed out due to fuel exhaustion during a post-maintenance test flight. Nov. 12 Kigali, Rwanda Canadair CRJ100ER destroyed NA After returning to the airport due to a problem on takeoff, one or both engines accelerated at the stand, and the airplane struck the terminal building. One of the 10 passengers was killed; another passenger and both pilots were injured. Nov. 14 Doyle, California, U.S. Aerospatiale AS 350BA destroyed 3 fatal Night visual meteorological conditions prevailed when the emergency medical services (EMS) helicopter struck terrain while returning to its base after transporting a medical patient to Reno, Nevada. Nov. 19 Norfolk Island, Australia Israel Industries 1124A destroyed 6 none After fuel ran low during three unsuccessful approaches in adverse weather, the EMS flight crew ditched the Westwind in the ocean. Nov. 28 Shanghai, China McDonnell Douglas MD-11F destroyed 3 fatal, 4 NA The tail struck the runway shortly before the freighter stalled and crashed on takeoff. Nov. 29 Lyall Harbour, British Columbia, Canada de Havilland Beaver destroyed 6 fatal, 2 NA The floatplane crashed while taking off in adverse weather conditions for a scheduled flight to Vancouver. 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.
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Smoke, Fire and Fumes Events in the United States, September–October 2009
Date Flight Phase Airport Classification Sub-Classification Aircraft Model Operator
Sept. 9 Cruise Atlanta, Georgia (ATL) Unscheduled landing Smoke in cockpit Embraer EMB- Continental 145XR Express Airlines “The crew reported an electrical burning odor in the cockpit and forward cabin during cruise, with a bleed 2 overheat warning on the EICAS. The aircraft was landed at ATL without incident.” Sept. 13 Descent Dallas/Fort Worth, Texas Emergency landing, return Smoke in cabin Canadair CL-600 American Eagle (DFW) to airport Airlines In icing conditions at 20,000 ft, the crew reported receiving an ant-icing message. The crew was descending the airplane to 11,000 ft when a bleed duct warning came on. The crew then ran an emergency checklist for the bleed duct warning. The first officer reported a noxious odor with fumes in the cabin. The crew declared an emergency and elected to return to DFW. Sept. 23 Cruise Cincinnati/Northern Return to airport, Sparking windshield Canadair CL-600 Sky West Airlines Kentucky (CVG) unscheduled landing En route at Flight Level 350, the crew noticed windshield sparking. They turned off windshield heat. A couple of seconds later the outer ply of the windshield shattered. They consulted the quick reference handbook and landed normally at CVG. Sept. 24 Takeoff NA Aborted takeoff Smoke in cockpit, Embraer EMB-145 American Eagle smoke in cabin Airlines During the takeoff at about 40 kt, the crew reported grayish-white smoke in the cockpit that increased rapidly. The crew elected to abort the takeoff. Smoke removal procedures were applied with the auxiliary power unit and packs, and the smoke cleared to 84 percent. A flight attendant confirmed smoke in the cabin but not in the lavatory. Oct. 1 Climb Dallas/Fort Worth, Texas Return to airport Smoke in cockpit, McDonnell Douglas American Airlines (DFW) smoke in cabin DC-9 Approaching Flight Level 180, the crew started smelling fumes in the cockpit and flight attendants reported a burning odor getting stronger at the back of the cabin. The flight crew turned off the recirculation fan and returned to DFW. Oct. 1 Takeoff Port Columbus, Ohio Emergency landing, return Smoke in cabin Cessna 500 Corporate (CMH) to airport Just after rotation, the cabin filled with smoke with an oily odor. The crew deployed passenger oxygen masks and conducted an emergency return to the airport. Oct. 3 Takeoff White Plains, New York Continued to destination Smoke in cockpit Embraer EMB-190 JetBlue Airways (HPN) On takeoff from Orlando, Florida (MCO), there was a “pack 1 fail” EICAS message, an odor of smoke and a rumbling noise with the pack on. The crew consulted the quick reference handbook and the odor and noise ceased. The flight was continued to its destination. Oct. 6 Climb Sitka, Alaska (KSIT) Return to airport, Smoke in cockpit, Boeing 737 Alaska Airlines unscheduled landing smoke in cabin On takeoff, the crew smelled smoke on the flight deck. Within two seconds, a flight attendant reported a smell of smoke throughout the cabin. The crew diverted back to the origination airport and accomplished the quick reference handbook ”Smoke/Fumes or Fire in Flight Deck or Passenger Cabin” checklist. Oct. 9 Descent NA Emergency landing, return Smoke in cabin Boeing 767 Delta Air Lines to airport A strong electrical burning odor was noticed at the top of descent, but it dissipated in five minutes. The odor returned and an emergency was declared. The crew found the left recirculation fan circuit breaker tripped and reset the circuit breaker. Oct. 13 Climb NA Emergency landing, Smoke in cockpit Boeing 767 Delta Air Lines diversion On climbout, the crew observed a right automatic direction finder flag and fumes in the cockpit. The first officer’s horizontal situation indicator also lost color and flickered. The crew also received a ”cabin auto inop 1 and 2” message. Oct. 15 Cruise NA Unscheduled landing Smoke in cockpit, Boeing 777 United Air Lines smoke alert Smoke was noted in the cockpit, and smoke alarms activated at Flight Level 320. Oct. 23 Descent NA Diversion, unscheduled Smoke in cockpit, Embraer EMB-145 Continental landing smoke in cabin Express Airlines The crew reported a strong odor of smoke on the flight deck and in the cabin as soon as descent was started at Flight Level 250. The odor was described as acrid, like electrical smoke. The aircraft was landed without incident. NA = not available Source: Safety Operating Systems
64 | flight safety foundation | AEROSafetyWorld | December 2009–January 2010 “Me m b e r s h i p i n Fl i g h t Sa f e t y Fo u n d a t i o n i s a s o u n d i n v e s t m e n t , n o t a n e x p e n s e .” dave barger, ceo, jetblue airways
For Eurocontrol, FSF is a partner in safety. In these times of economic restraint, it makes excellent sense to combine scarce resources and share best practices.
— David McMillan, President
FSF membership has made a real difference for the Johnson Controls aviation team. Having access to the Foundation’s expert staff and its global research network has provided us with an in-depth understanding of contemporary safety issues and the ability to employ state-of-the-art safety management tools, such as C-FOQA and TEM. All of which has been vital to fostering a positive safety culture.
— Peter Stein, Chief Pilot
JetBlue Airways considers that membership in Flight Safety Foundation is a sound investment, not an expense. Membership brings value, not just to our organization, but to our industry as a whole.
— Dave Barger, Chief Executive Officer
Cessna has worked with FSF for a number of years on safety issues and we especially appreciate that it is a non-profit, non-aligned foundation. Its stellar reputation helps draw members and enlist the assistance of airlines, manufacturers, regulators and others. We supply the Aviation Department Toolkit to customers purchasing new Citations and it’s been very well received. Our association with FSF has been valuable to Cessna.
— Will Dirks, Vice President, Flight Operations
At Embry-Riddle Aeronautical University, we view FSF as a vital partner in safety education. Together, we share goals and ideals that help keep the environment safe for the entire flying public.
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Flight Safety Foundation is the foremost aviation safety organization committed to reducing accident rates, particularly in the developing economies. To all civil aviation authorities, aviation service providers, airlines and other stakeholders interested in promoting aviation safety, this is a club you must join.
— Dr. Harold Demuren, Director General, Nigerian Civil Aviation Authority
For membership information, contact Ann Hill, director of membership, +1 703.739.6700, ext. 105, or [email protected]. 22nd annual European Aviation Safety Seminar EASS March 15–17, 2010
For seminar registration and exhibit information, contact Lisbon,Namratha Apparao, tel: +1 703.739.6700, Portugal ext. 101; e-mail: [email protected]. To sponsor an event at the seminar, contact Ann Hill, ext.105; e-mail: [email protected].
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