AeroSafety world
UNUSUAL AIRPORT PLANNING BURNED OUT DC-8 Operations off the beaten path UPS freighter fire BURNTHROUGH RAISING THE STANDARD Rules lengthen escape time Cabin safety symposium highlights SETTING LIMITS FATIGUE IN MAINTENANCE
The Journal of Flight Safety Foundation april 2008 What can you do to improve aviation safety? Join Flight Safety Foundation. Your organization on the FSF membership list and Internet site presents your commitment to safety to the world.
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for more than 50 years Flyer photo/source: U.S. National Aeronautics and Space Administration Wright
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Send your request to: Flight Safety Foundation 601 Madison Street, Suite 300, Alexandria, VA 22314 USA Telephone: +1 703.739.6700; Fax: +1 703.739.6708 E-mail: [email protected] Visit our Internet site at www.flightsafety.org President’sMessage Beyond Competition
ast month, Flight Safety Foundation an- only organization positioned to reach across all nounced a partnership with the Interna- segments of the professional aviation industry. tional Air Transport Association (IATA) The shortage of qualified personnel must be on its personnel training and qualification addressed in a systematic way that meets the Linitiative. Since then, I have been asked how and needs of the whole industry. For the next 10 why the Foundation would get involved in the years, a new business jet will be delivered for difficult issues involved in the looming global every airliner produced, and each will create its shortage of qualified personnel. own demand for qualified operators. First, it is important that the problem be ad- If regional carriers run out of people, smaller dressed from a safety and quality perspective, communities will lose service. If the major pilot and not just from a commercial or competitive training centers run out of instructors, there standpoint which, at its most basic level, is just will be pilot supply problems around the world. making sure the other guy runs out of pilots first. If government regulators can’t retain qualified That is not the right answer for our industry or the inspectors, no one will be left to safeguard in- people we serve. The Foundation wants to keep the dustry growth. focus on the innovations and safety improvements You can bring this problem closer to home: If that the industry will have to deliver on its way to you fall ill in the Australian outback, you expect doubling in size over the next 20 years. that an experienced pilot will be there to fly you But while we begin to act on future challenges, to the hospital. If my child is in an accident, I we can’t lose focus on what is happening today. hope a talented pilot is there to fly her to the Last year, for the first time in decades, loss-of- trauma center. control accidents surpassed controlled flight into The point is simple. It is time to drop our com- terrain as the number one killer in aviation. Did petitive instincts and look for solutions that work growth pressures, lowered qualifications for hir- for everybody. IATA and the Foundation have ing, or changes in crew interactions have some- started working on this together with the hope thing to do with that? I don’t know, but I am sure that others will join in. Maybe if we take this on the question cannot be ignored. together, we will start looking like an industry that This industry spent decades implementing young people once again will want to join. crew resource management. The resulting safety gains could dissipate quickly if communication in the cockpit falls apart because of generational gaps, culture gaps or knowledge gaps. I expect a number of accident reports during the coming 12 months will make us think hard about that. One last reason that the Foundation is get- William R. Voss ting in the middle of this problem is that it President and CEO touches every part of the industry. We are the Flight Safety Foundation www.flightsafety.org | AeroSafetyWorld | April 2008 | 1 AeroSafetyWorld
14contents April2008 Vol 3 Issue 4 features
14 CoverStory | Working to the Limit
20 FlightTech | Singapore’s New Show
22 FlightOps | VFR in the Himalayas 22 28 CausalFactors | Fire in the Hold 34 ThreatAnalysis | Departure Deviations
37 FlightTech | Burnthrough Protection
42 InSight | Flawed Report
44 CabinSafety | Winning Formula 28 departments 1 President’sMessage | Beyond Competition
5 EditorialPage | Protecting Confidentially
6 AirMail | Letters From Our Readers
7 SafetyCalendar | Industry Events
9 InBrief | Safety News
2 | flight safety foundation | AeroSafetyWorld | April 2008 37 42
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AeroSafetyWORLD telephone: +1 703.739.6700 19 FoundationFocus | Honored in Singapore William R. Voss, publisher, FSF president and CEO [email protected], ext. 108 27 | Call for Nominations FoundationFocus J.A. Donoghue, editor-in-chief, FSF director of publications 49 DataLink | Maintenance Check [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 53 InfoScan | Culture Shock Wayne Rosenkrans, senior editor [email protected], ext. 115 57 OnRecord | Bogus Stall Warning Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 AeroSafety Karen K. Ehrlich, web and print W O RLD production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer [email protected], ext. 120 Susan D. Reed, production specialist UNUSUAL AIRPORT PLANNING Operations o the beaten path UPS freighter re RAISING THE STANDARD [email protected], ext. 123 Rules lengthen escape time Cabin safety conference highlights About the Cover SETTING LIMITS Patricia Setze, librarian FATIGUE IN MAINTENANCE Work limits seek to reduce maintenance errors. THE JOURNAL OF FLIGHT SAFETY FOUNDATION APRIL 2008 Photo Illustration: © Chris Sorensen Photography [email protected], ext. 103
Editorial Advisory Board We Encourage Reprints (For permissions, go to
Editorialpage Protecting Confidentially
he problem with trying to explain accident in Lexington, Kentucky, U.S. lawyers access to information about the things that we do in the avia- (ASW, 11/07, p.38). hundreds of incidents, misunderstand- tion industry is that many levels Various aviation groups tried to ex- ings and close calls will result in anything of information usually need to be plain why violating the confidentiality positive. How can an airline’s handling knownT before understanding becomes of Comair’s ASAP is a bad idea, but to of ASAP reports be defended? And with possible. That’s one of the reasons the no avail. In ordering that the informa- what standard, reasonable diligence or general news media get aviation stories tion be released, Todd said that the zero tolerance? wrong. To be sure, there are dedicated program would persist because it is so It seems that the battle against crimi- reporters who know aviation well and important. He could say something like nalizing accidents and opening up con- are very good, and most general as- that because he wasn’t aware of — or fidential reporting systems cannot be signment reporters try to get it right, couldn’t appreciate — the difficulty U.S. fought solely on a case-by-case basis, but sometimes deadlines get the better operators had in getting legal clearance although that must be part of the plan. of them. for the Federal Aviation Administration But to better protect a proven system While much of the misunderstand- to allow confidentiality protection, then against well-meaning legal actions with ing about what we do is technology- selling the idea to their employees. potentially devastating results, laws based, when it comes to explaining Todd further said, according to one must be changed to set limits, establish how we got to where we are in keeping report, that instead of companies and boundaries of what is fair game and aviation safe, the path to understanding individuals being afraid of what legal what is too important to the lives of is even more tortured. The medical in- damage ASAP disclosure might cause, countless future passengers to be subject dustry — not a group of dummies — still they should be more afraid of increased to the whims of local legal forces. That is struggling to distill our multi-layered risk and lawsuits if the program was will be a tough sell, but it is well worth risk reduction schemes into something shut down. the effort. it can intellectually accept and practi- That logic, to my eye, is how we cally adopt. used to look at safety: Try real hard That knowledge gap became a fac- not to crash because lots of bad things tor when attorneys in February asked accompany accidents. Then we discov- Magistrate Judge James B. Todd to un- ered the benefits of data-based action J.A. Donoghue lock Comair’s aviation safety action plans, protected reporting systems and Editor-in-Chief program (ASAP) records to see if the just culture, and a new level of safety AeroSafety World airline’s management knew of any unsafe was achieved. conditions that, if corrected, might have Further, there seems to be little prevented the 2006 runway confusion chance that giving a bunch of smart www.flightsafety.org | AeroSafetyWorld | April 2008 | 5 AirMail
A Challenge From Africa There are very few hank you for the invaluable African safety forums that
contribution that Flight Safety seriously look at improving to speed on TFoundation is providing to the safety of the African skies, and that is the situation and aviation world. I feel that flight safety where Flight Safety Foundation comes actively involved. We are in Africa is being neglected due to lack in. How can we pioneer a reputable working with ICAO on their plans for Africa, of information, corruption, economic African safety organization with the and trying to obtain funding from certain Middle Eastern states for improvement of the reasons and because there is lack of backing of FSF that will fight for the en- African aviation infrastructure. We have joined enforcement from the aviation authori- forcement, training, auditing, reviews, forces with the recently established AviAssist ties. The fact that the Foundation and etc. of flight safety in African countries? Foundation in Zambia. many others are available on line does Now that aviation is moving towards Last year, the Foundation presented a not directly translate to information safety management systems, how will President’s Citation for Outstanding Service being at the fingertips of those who Africa fit in without the expertise in to Maimuna Taal, the former director general earnestly need it. Flight safety in Africa this field? of the Gambia Civil Aviation Authority, who is deplorable and something needs to Sir, this is my challenge to Flight refused permission for an operator to fly be done about it. Safety Foundation. unairworthy 747s from her country. She paid the price of being dismissed and jailed, although I have been in aviation for about 20 David Muthoka she was eventually acquitted of the charges. years. I am focusing now on aviation Daallo Airlines Through this award and efforts to see that she is safety and want to make a contribution properly recognized and employed, we intend to FSF President and CEO William R. Voss replies: specifically to safety in Africa. I am a let regulators know that they are not alone when Mr. Muthoka, I am very familiar with the chal- they stand up to political pressure. Kenyan and currently work in Djibouti lenges you face in Africa, based primarily on my as an airline operations manager. I hold previous position as director of the ICAO Air Thank you for the challenge. There is a great deal a Kenyan air traffic control license. Navigation Bureau. The Foundation is also up that needs to be done, but we are on the job.
FSFSeminars Exhibit and Sponsorship Opportunities Available CASS April 29–May 1, 2008 Flight Safety Foundation and National Business Aviation Association 53rd annual Corporate Aviation Safety Seminar The Innisbrook Resort and Golf Club, Palm Harbor, Florida IASS October 27–30, 2008 A Joint Meeting of Flight Safety Foundation, International Federation of Airworthiness and International Air Transport Association
Sheraton Hotel and Resort Waikiki, Honolulu, Hawaii © iStockphoto.com
6 | flight safety foundation | AerosafetyWorld | April 2008 safetycalendar
APRIL 1–3 ➤ Aircraft Interiors Expo. MAY 11–15 ➤ 79th Annual Scientific AUG. 14–16 ➤ Latin American Business Reed Exhibitions. Hamburg, Germany.
MAY 7–8 ➤ Aircraft Maintenance JULY 14–20 ➤ Farnborough International Be sure to include a phone number and/ Outsourcing Expo–Europe. Aviation Industry Airshow. Farnborough International.
www.flightsafety.org | AeroSafetyWorld | April 2008 | 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 Amb. Edward W. Stimpson 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 Executive Vice President Robert H. Vandel and knowledgeable body that would identify threats to safety, analyze the problems and General Counsel recommend practical solutions to them. Since its beginning, the Foundation has acted in the and Secretary Kenneth P. Quinn, Esq. Treasurer David J. Barger public interest to produce positive influence on aviation safety. Today, the Foundation provides leadership to more than 1,170 individuals and member organizations in 142 countries. Administrative Manager, Support Services Linda Crowley Horger MemberGuide Financial Flight Safety Foundation Chief Financial Officer Penny Young 601 Madison Street, Suite 300, Alexandria, VA, 22314-1756 USA tel: +1 703.739.6700 fax: +1 703.739.6708 Accountant Feda Jamous www.flightsafety.org Membership Director, Membership and Development Ann Hill Membership Services Coordinator Namratha Apparao Membership Services Coordinator Ahlam Wahdan
Communications Director of Communications Emily McGee
Technical Director of Technical Programs James M. Burin Member enrollment ext. 105 Technical Ann Hill, director, membership and development [email protected] Programs Specialist Norma Fields Seminar registration ext. 101 Technical Specialist/ Namratha Apparao, membership services coordinator [email protected] Safety Auditor Robert Feeler Seminar sponsorships ext. 105 Manager of Ann Hill, director, membership and development [email protected] Aviation Safety Audits Darol V. Holsman Exhibitor opportunities ext. 105 Ann Hill, director, membership and development [email protected] Past President Stuart Matthews FSF awards programs ext. 105 Founder Jerome Lederer Ann Hill, director, membership and development [email protected] 1902–2004 Technical product orders ext. 101 Namratha Apparao, membership services coordinator [email protected] Library services/seminar proceedings ext. 103 Patricia Setze, librarian [email protected] Web Site ext. 117 Karen Ehrlich, web and print production coordinator [email protected]
8 | SINCE 1947 flight safety foundation | AeroSafetyWorld | April 2008 Safety News inBrief Fan Blade Warning
he U.S. National Transportation Safety Board (NTSB), citing failures of General Electric (GE) CF34-3B1 turbofan Tengines on two Bombardier CRJ200s, is recommending that aviation authorities in the United States and Canada take steps to remove from other GE regional jet engines any fan blades that were the products of a faulty manufacturing process. Both engine failures involved fan blades that fractured because of a material defect introduced when the blades were
forged, the NTSB said. The blades were among 28,000 manu- © Bombardier factured by Teleflex Aerospace Manufacturing Group in San Luis Potosí, Mexico. The second occurred May 24, 2007, on an Atlantic South- The NTSB said that it issued the recommendations be- east Airlines CRJ200 in cruise at 23,000 ft en route from Syra- cause of its concern that “until the fan blades with the forging cuse, New York, U.S., to Atlanta. The blade had accumulated problem are removed from service, undercowl fires are likely to 5,845 hours and 4,717 cycles since new. result from damage caused during these events.” The recommendations to the U.S. Federal Aviation Admin- No one was injured in the two incidents, both of which istration (FAA) included a call to require GE Aviation to “define ended with safe emergency landings, and there was no airplane a reasonable maximum time frame below 4,717 cycles since structural damage, the NTSB said. new for these Teleflex fan blades and require that the blades be The first incident occurred July 27, 2006, on an Air Nos- removed from service before that limit is exceeded.” A similar trum CRJ200 as it climbed through 23,000 ft after departure recommendation said that Transport Canada should require from Barcelona, Spain; the crew discharged both fire bottles af- Bombardier to redesign a portion of the engine throttle gearbox ter receiving a no. 1 engine fire warning. At the time, the blade on CRJ100s and CRJ200s “to ensure that it can withstand the had accumulated 10,896 hours and 8,899 cycles since new. loads generated by a fan blade separation or similar event.”
Voluntary Reporting at Risk?
ilots’ organizations say volun- “undoes a lot of hard work we’ve all ac- improve the safety and efficiency of tary safety reporting systems are complished in airline safety and sets us the air transport system. Because the Pjeopardized by a judge’s decision back by decades.” maintenance of such systems requires to allow reports from Comair’s aviation Comair’s ASAP — like similar individuals and organizations to be very safety action program (ASAP) to be programs at other airlines — is designed forthcoming, there has always been a scrutinized as part of a crash liability as a confidential reporting system under concern that inappropriate use of the case. which airline employees are encouraged program output could possibly have The decision by U.S. District Court to report perceived safety problems, a chilling effect on the willingness to Judge Karl Forester involves several including their own errors, without fear continue.” lawsuits filed against Comair as a result of punishment. IFALPA said that of the Aug. 27, 2006, crash of a Bom- “Our passengers get more benefits individual countries bardier CRJ100ER during an attempted from nonpunitive safety reporting need legislation takeoff in Lexington, Kentucky, U.S. programs like the one this judge is un- to safeguard the The crew had inadvertently taxied onto dermining than virtually any program safety informa- an incorrect runway — only half as long in aviation safety,” Prater said. He said tion developed by as the runway that had been assigned that if ASAP data are released, “it will ASAP and similar for takeoff. Forty-nine of the 50 people bring pre-emptive, proactive safety programs against in the airplane were killed, and one solutions in our industry to a screech- inappropriate — the first officer — received serious ing halt.” use. injuries. The International Federation of John Prater, president of the Air Air Line Pilots’ Associations (IFALPA) Line Pilots Association, International agreed, describing ASAP as “one of (ALPA), said the judge’s decision the best opportunities to continuously © Rafa Irusta/iStockphoto.com
www.flightsafety.org | AeroSafetyWorld | April 2008 | 9 inBrief
Simulated Air Traffic Towers Flight Deck ADS-B
he U.S. Federal Aviation Administration (FAA) has expanded its use of air irbus and traffic control tower simulators in the training of new air traffic controllers. ACSS have TTower simulators, which were first used in 2006, are being deployed at 19 ad- Aagreed to cer- ditional locations, the FAA said. tify ACSS’s T3CAS The simulators are intended to incorporate the latest technology into the train- — a system that
ing program, said FAA Acting Administrator Robert A. Sturgell. “Experience tells combines a traffic- ©ACSS us that real-life training scenarios make a critical difference,” Sturgell said. alert and collision avoidance system The tower simulation system includes a large graphic depiction of the airport (TCAS), terrain awareness and warning and surrounding areas, and system (TAWS) capability and a Mode S can be adjusted for different transponder in a single unit — on Airbus weather and lighting condi- single-aisle and long-range airplanes. tions. Synthetic voice response ACSS said the integrated platform and voice recognition allow for Airbus will include automatic student controllers to give dependent surveillance–broadcast and receive responses as they (ADS–B) capability. would in a control tower. The The agreement will make simulator does not involve T3CAS standard equipment on actual air traffic control A318/319/320/321 and A330/340 operations. airplanes, ACSS said. U.S. National Aeronautics and Space Administration
ADS-B Sites Proposed Penalty Proposed for Inspection Failure
irlines participating in a Eurocon- he U.S. Federal Aviation Admin- Southwest said that the proposed trol project have identified 70 air- istration (FAA) has proposed penalty concerns “one of many routine Aports in Europe where automatic Ta US$10.2 million civil penalty and redundant inspections” that in- dependent surveillance–broadcast against Southwest Airlines for operat- volved “an extremely small area in one (ADS–B) would be most useful. Under ing 46 Boeing 737s that had not under- of the many overlapping inspections” the ADS–B Pioneer Airlines Proj- gone mandatory inspections for fatigue designed to detect early indications of ect, Eurocontrol will discuss with air cracking in the fuselage. cracking. navigation service providers (ANSPs) The FAA said that Southwest did The company said that after dis- whether implementation of ADS–B at not comply with a September 2004 covering the missed inspection area, it those airports would be feasible. airworthiness directive that required disclosed the matter to the FAA and re- Many of the airports are in repetitive inspections of some fuselage inspected the airplanes in March 2007. countries where ANSPs have been par- areas to detect fatigue cracks. The vio- Safety of flight was never an issue, the ticipating with Eurocontrol in ADS–B lations occurred from June 18, 2006, airline said. trials: Austria, France, Germany, to March 14, 2007; Greece, Italy, Sweden, Turkey and the during that period, the United Kingdom. Other airports are airplanes were oper- in Norway, Moldova, Romania, Spain ated on 59,791 flights, and Ukraine. the FAA said. The FAA Most of the airports currently are said that, after South- without surveillance-based air traffic west discovered that control service and are locations where the required inspec- the introduction of radar would be dif- tions had not been in- ficult and costly, Eurocontrol said. formed, it continued to The ADS–B Pioneer Airlines Proj- operate the airplanes ect, begun in 2007, is intended to help until March 23, 2007, airlines obtain airworthiness approval on an additional 1,451 for existing ADS–B equipment. flights. © Southwest Airlines
10 | flight safety foundation | AeroSafetyWorld | April 2008
inBrief
Increasing Errors
perational errors involving reduced vertical separa- detection of any trends adverse to the safety of aircraft operat- tion minimum (RVSM) aircraft being flown at incor- ing in RVSM airspace and the development and implementa- Orect flight levels are increasing, according to a report by tion of appropriate mitigations aimed at reducing operational Eurocontrol. risk, and that all factors that contribute to the operational errors The 2007 European RVSM Safety Monitoring Report in RVSM airspace are addressed.” showed a continued increase, which was attributed to errone- ous actions by both air traffic control (ATC) and flight crews and to incorrect planning by aircraft operators. The International Federation of Air Line Pilots’ Associa- tions (IFALPA), in its analysis of the information, said that the errors included ATC issuance of clearances to incorrect flight levels or to aircraft not approved for operations in RVSM airspace and, ATC failures to detect and correct pilots’ errone- ous readback clearances, as well as flight crew failures to obtain ATC clearance for climbs or descents, or failures to climb in compliance with ATC instructions. IFALPA said that countries and air navigation service pro- viders should ensure that measures exist to “facilitate the early © Devy Masselink/iStockphoto.com
Training Initiatives In Other News …
he Civil Aviation Safety Authority “CASA has no intention of taking urocontrol has released guid- of Australia (CASA) has begun over all flight tests,” he said. “Rather, ance material to help air naviga- Timplementing new flight training these initiatives strengthen the rela- Etion service providers develop initiatives, which CASA CEO Bruce tionship between the regulator and contingency plans for dealing with Byron says are designed to “[get] the approved testing officers in support of “challenging circumstances,” includ- regulator involved in some flight tests our shared interest in safety.” ing disruption of service. … The and [work] more closely with approved The initiatives are part of an U.S. Federal Aviation Admin- testing officers.” ongoing effort to increase CASA’s istration has amended flight data The initiatives will include the emphasis on flight training and to recorder regulations to increase establishment of a national office of press for “even higher standards of the duration of some cockpit voice flight training examiners, who will performance.” recorder (CVR) recordings and oversee flight increase the recording rate for digital training and flight data recorders (ASW, 01/08, p. take over the 47). The changes are intended to im- testing of some prove the quality of recorded infor- pilots, including mation and “increase the potential flight instruc- for retaining important information tors. The new needed for accident and incident office will over- investigations,” the FAA said. see approved Correction … A story in the testing officers March 2008 issue incorrectly stated and monitor the Internet address for lithium- their profes- battery safety guidance from the U.S. sional develop- Department of Transportation; the ment, Byron correct address is
Compiled and edited by Linda Werfelman.
12 | flight safety foundation | AeroSafetyWorld | April 2008 For over 60 years, the business aviation community has looked to the National Business Aviation Association (NBAA) as its leader in enhancing safety and security, shaping public policy, providing world-renowned industry events, and advancing the goals of more than 8,000 Member Companies worldwide. Discover how NBAA Membership can help you succeed.
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Priority Code: PM08XP18 Coverstory
Slowly but surely, operators and regulators are implementing programs to prevent fatigue among aviation maintenance personnel.
BY LINDA WERFELMAN Working to the Limit
lthough aviation maintenance personnel Although fatigue among maintenance person- typically work long hours, often at night, nel has not specifically been cited as a cause of a they rarely are included in aviation major accident, on several occasions, maintenance industry programs to fight fatigue. Duty work “performed at night by staff who may have Atime limits and other efforts to address fatigue been affected by fatigue or lack of sleep” has been typically are intended for flight crews — not identified as a causal factor, ICAO said. maintenance personnel. For example, ICAO cited a June 10, 1990, Nevertheless, in recent years, some civil avia- incident in which the left windshield of a British tion authorities and operators have taken steps Airways BAC 1-11 blew out as the airplane was to ensure that maintenance personnel are climbing through 17,300 ft after departure from not pushed beyond their limits. Birmingham International Airport in England. The International Civil Avi- The commander was drawn halfway out of the ation Organization (ICAO), opening and held there by cabin crewmembers in its 2003 manual until the first officer landed the airplane in for maintenance Southampton. Investigators said that mainte- human factors, nance personnel who had replaced the wind- said that fatigue shield the night before had used bolts that were among aviation not the size specified. The U.K. Air Accidents maintenance Investigation Branch (AAIB) said in its final personnel report that several human factors issues had has resulted contributed to the incident, including “circadian from “excessive effects” — biological patterns that influence the hours of work, time of day when the body is programmed to poor planning, sleep — on maintenance personnel. insufficient Fatigue also contributes to non-reportable staff, bad shift incidents, and ICAO cited the case of one un- scheduling identified operator of a fleet of 12 aircraft that and a working experienced extensive structural damage to one environment aircraft because of incorrect jacking procedures, with no proper extensive structural damage to two aircraft be- control of tem- cause of a towing collision, and serious injuries to perature, humidity three maintenance technicians because of a traffic or noise.”1 accident that occurred as they drove home after a
© Tom McNemar/iStockphoto 14 | flight safety foundation | AeroSafetyWorld | April 2008 coverStory
© Chris Sorensen Photography
long shift at work (see “Fighting Fatigue- One study, a U.S. Federal Avia- addressed in their training programs, Related Errors,” p. 17). tion Administration (FAA) survey of however, and only 25 percent said they Studies conducted for several civil maintenance human factors programs had a fatigue management system.2 aviation authorities and accident inves- worldwide, found that of 414 survey “The discontinuity between recog- tigation bureaus have identified fatigue respondents, 82 percent said that fatigue nizing the fatigue threat and establishing as a significant problem for aviation is a safety issue in aviation maintenance. barriers is alarming,” two of the study’s maintenance personnel. Only 36 percent said that fatigue was authors said. (ASW, 3/08, p. 34–40).
www.flightsafety.org | AeroSafetyWorld | April 2008 | 15 Coverstory
Another study, conducted in 2002 for ICAO, citing various human factors guides, Transport Canada (TC), found that aviation said that although individuals are responsible maintenance engineers (AMEs) were working for “sensible” sleep habits, “management and an average of more than 50 hours a week, often local supervision … have a responsibility to Half of the 1,209 in 12-hour shifts “with very few days off for re- control shifts, breaks, duty periods and overtime covery.” A significant number of AMEs worked to minimize fatigue.” AMEs responding during their days off, either putting in overtime The most straightforward approach is a strict to questionnaires or working extra shifts for another employer, limit on the number of hours worked, said Darol the study said. In addition, the study found V. Holsman, FSF manager of aviation safety believed that that half of the 1,209 AMEs responding to audits. During evaluations of corporate opera- questionnaires believed that overtime worked tions, he always recommends a fatigue manage- overtime worked during night shifts “had a strong negative effect ment policy and always says the best policy is a on their work.”3 12-hour duty-time limit. during night shifts The U.K. Civil Aviation Authority (CAA) “This is one of the human factors issues that “had a strong also recognized the adverse effects of tiredness should be considered by every operator,” Hols- and fatigue. In an airworthiness notice discuss- man said. negative effect ing “personal responsibility when medically un- Nevertheless, his estimate is that less than 10 fit,” the CAA said that individual maintenance percent of corporate operators have duty-time on their work.” personnel “should be fully aware of the dangers limits — the limit most often is 12 hours, but of impaired performance due to these factors some operators establish 14-hour limits — or fa- and of their personal responsibilities.”4 tigue management programs. These limits have been implemented within the last three or four years, Holsman said, noting that when he began auditing in 2000, he never found a corporate operation that limited duty time for its mainte- nance personnel. The reason for the low percentage is tradi- tion, he said. “It’s always been this way,” he said. “If there’s work that needs doing, the expectation — of managers and the technicians themselves — is that they’ll be out doing it. The technicians are sometimes their own worst enemy; they will- ingly do what’s expected.” Often, the problem is complicated by spo- radic work hours; many operators tell mechan- ics that when there’s no flying activity, there’s no reason for them to report to work. “The think- ing is that if they work only a few hours one week, then the next week they should be able to work long hours if necessary,” Holsman said. “But this still doesn’t relieve the responsibility of management to limit duty hours.” Despite the willingness of most maintenance personnel to work long hours to meet those ex- pectations, some also tell stories of falling asleep © Chris Sorensen Photography while working on an airplane, he said.
16 | flight safety foundation | AeroSafetyWorld | April 2008 coverStory
A few operators and regulatory au- thorities have rejected duty-time limits Fighting Fatigue-Related Errors in favor of a fatigue risk management system (FRMS), designed to detect be- uman factors guides recommend a variety of actions to prevent aviation havior related to fatigue and, by doing maintenance errors that stem from fatigue. For example, the International so, to prevent fatigue-related incidents. HCivil Aviation Organization, in its Human Factors Guide for Aircraft Drew Dawson, director of the Cen- Maintenance Manual, recommends the following: tre for Sleep Research at the University • Because tools and parts can obstruct flight controls if they are left in an of South Australia, said that FRMS aircraft after maintenance, a box or shadow board for wrenches, screwdrivers requires consideration of five major lev- and other hand tools should bear contrasting-color outlines of each tool to provide a cue if it is not replaced; els: “sleep opportunity or average sleep obtained across the organization, actual • Hand tools that are the personal property of a maintenance technician should be marked, and checklists should be used for each technician’s sleep obtained by individual employees, toolbox before an aircraft is released for return to service; presence of fatigue-related behavior, • When maintenance personnel take possession of company-owned tools, occurrence of fatigue-related errors and a loan system using personal “tool checks” or electronic card controls occurrence of a fatigue-related accident should be used to identify the person who has possession; or incident.” In an effective FRMS, all • “Loose-object” inspections should be conducted before final panel five levels are addressed with organized closures; 5 defense systems. • To limit interruptions, people not involved with maintenance on a specific In most cases, FRMS has thus far aircraft should be excluded from the area, unless they have the permis- been applied only to flight crews, but sion of a supervisor, and only those not working on the aircraft should a Canadian initiative aims to incorpo- answer telephone calls; and, rate FRMS for both flight crews and • To avert cross-connections of wiring or plumbing, parts should be color- maintenance personnel as a manda- coded as they are disassembled; to identify cross-connections, functional testing should be conducted any time wiring or plumbing is disturbed. tory portion of an operator’s safety Any instances of cross-connection should be reported to the regulatory management system (SMS). At press body and the type certificate holder. time, the FRMS notice of proposed — LW amendments to the Canadian Aviation Regulations was being reviewed by the Department of Justice; the require- templates, training materials and other toward implementation of FRMS in ments were expected to take effect for approved methodologies for FRMS aviation maintenance. aviation maintenance organizations implementation. The topics covered in The CASA maintenance regulations (AMOs) in March 2009, said Jacque- the toolbox’s training information for project team said that, although FRMS line Booth-Bourdeau, chief of techni- employees include how to obtain suffi- is not mandatory for aviation mainte- cal and national programs for TC. cient rest, manage fatigue and recognize nance personnel, “CASA is convinced “The implementation of an FRMS fatigue symptoms in themselves and that [it] is necessary and is initiating its is an extension to this [SMS] approach others. Management materials discuss design and formulating requirements in that it requires operators to imple- the implementation process and how for implementation. ment robust management systems for to provide sufficient rest; investigate “Safety outcome-based legislation identifying fatigue-related hazards and fatigue-related errors, incidents and ac- being developed will place the onus on managing the related risks,” Booth- cidents; and conduct FRMS audits.6 an employing organization to ensure Bourdeau said. “The FRMS approach A planned implementation trial, that there are systems in place to ‘pre- clearly establishes the accountabilities using the toolbox, was canceled because clude an employee from fulfilling any at the management and employee levels of a change in management at the par- maintenance action where the employ- for fatigue-related issues.” ticipating airline, Booth-Bourdeau said. ee’s capability to do it is impaired.’” To aid the industry, TC developed In Australia, the Civil Aviation The regulation will be accompanied an FRMS toolbox, a collection of policy Safety Authority (CASA) also is moving by an Acceptable Means of Compliance, www.flightsafety.org | AeroSafetyWorld | April 2008 | 17 Coverstory
“which will describe how an organization action is not appropriate, and said that International Journal of Applied Aviation may meet the requirements of the regula- Advisory Circular 120–72, Maintenance Studies Volume 7 (No. 2): 212–231. 2007. tion, with a range of options dependent Resource Management (MRM) Training 3. Rhodes, Wayne. Assessment of Aircraft on the size of the organization and the — characterized by the FAA as a focus of Maintenance Engineers (AMEs) Hours nature of the maintenance to be conduct- its fatigue education and training efforts of Work: Phase 1. Montreal, Canada: Transportation Development Centre. 2002. ed,” the project team said. Maintenance for aviation maintenance personnel — in organizations will be required to submit fact contains “little … guidance on hu- 4. U.K. CAA. Licensed Aircraft Maintenance Engineers — Personal Responsibility When written plans explaining how they will man fatigue in maintenance crews other Medically Unfit or Under the Influence of comply with FRMS requirements. than generalized warnings that attention Drink or Drugs, Airworthiness Notice No. The team said that CASA plans to to fatigue is important and should be 47, Issue 8. Sept. 29, 2006. establish a group including representa- considered in MRM training.” 5. Dawson, Drew; McCulloch, Kirsty. tives of CASA, AMOs and employee as- However, the FAA has emphasized, “Managing Fatigue: Defenses in Depth.” In sociations to “formulate a way forward” as Deputy Associate Administrator for Enhancing Safety Worldwide: Proceedings in development of detailed FRMS Aviation Safety Peggy Gilligan told a of the 59th Annual International Air Safety Seminar. Alexandria, Virginia, U.S.: Flight policies. congressional subcommittee in June Safety Foundation, 2006. Some operators and AMOs have 2007, that fatigue research by the FAA 6. Marcil, Isabelle; Booth-Bourdeau, implemented fatigue management and others has shown that fatigue “does Jacqueline; Laurence, Mark; Dawson, programs — sometimes through labor not easily lend itself to a set of prescrip- Drew. “Fatigue Risk Management in the agreements — even without a regula- tive rules.” As a result, she said that, in Canadian Aviation Industry.” In Enhancing tory requirement to do so. the future, fatigue risk management will Safety Worldwide: Proceedings of the 59th In Canada, for example, provincial become increasingly important.8 Annual International Air Safety Seminar. governments limit hours for workers of The FAA and other proponents of Alexandria, Virginia, U.S.: Flight Safety Foundation, 2006. all types, although they also establish FRMS say that rules to limit work hours provisions that allow the limits to be are not enough to combat fatigue. 7. NTSB. Most Wanted Transportation Safety Improvements: Federal Issues, Aviation, exceeded. In addition, some operators, The University of South Australia’s Reduce Accidents and Incidents Caused usually smaller organizations, limit Dawson said that, increasingly, sleep by Human Fatigue.
18 | flight safety foundation | AeroSafetyWorld | April 2008 FoundationFocus
Honored in Joseph S. Murphy Singapore Industry Service Flight Safety Foundation
light Safety Foundation, in a ceremony And everywhere I go, I find heroes, I find people in Singapore, was presented the Joseph who know exactly what needs to be done, people S. Murphy Industry Service Award by who will do anything to try to achieve further Air Transport World (ATW), the airline improvements in safety. But they are challenged. Fmanagement magazine. The award is named in Often they are not allowed to do what they know honor of the magazine’s founder. is necessary due to problems of political will or “Tonight we honor an organization that has resources, even commercial constraints. So there’s ensured that aviation safety is at the forefront one thing we all have to do as an industry, and around the world,” said ATW Senior Editor Aar- one thing you’ll see us do at the Foundation, and on Karp. “For 60 years, the not-for-profit Flight that is to go to bat for these people to make sure Safety Foundation has served as an independent they get the opportunity and the support they voice unconstrained by geography or industry need to do what they know needs to be done.” boundaries, providing the global aviation busi- Turning to the growing shortage of trained Flight Safety ness with a neutral forum to discuss and learn personnel, Voss said, “Something very important Foundation best practices and find solutions to problems with for us as a Foundation is to have a consciousness, President and CEO only one goal: reducing the risk of accidents. an awareness paying attention to the system, so William R. Voss “ATW salutes the Foundation not just for that if at some point we go beyond what is possible (right) accepts the its laudable and lengthy list of past achieve- — we start overreaching — we’ll have early warn- Foundation’s award ments but also for its ongoing and future effort ing systems that go off, indicators that say, ‘it’s time from Air Transport to bring awareness to serious safety issues to pull back to make sure we maintain the level of World Senior Editor around the globe.” safety we’ve achieved over these decades.’” ● Aaron Karp. William R. Voss, FSF president and CEO, accepted the award, saying, “We all have a lot J.A. Donoghue to celebrate today. We have an industry that has achieved extraordinary levels of safety around the world. And I have to say that it is quite an honor to have the contributions of FSF recog- nized here today. But I have to share that honor with 1,200 members of the Foundation that make that work possible, including many of you in the room here today.” Voss discussed several FSF initiatives. “First of all, a new and sort of activist role for us. We have great victories in aviation safety, but the victories aren’t universal. There are places around the world that are still struggling to do well. I spend a lot of time working with those people. www.flightsafety.org | AeroSafetyWorld | April 2008 | 19 FlightTECH Novelty marked the 2008 air show in the heart of aviation’s high-growth region Singapore’s New Show By J.A. Donoghue uestions about whether the new Sin- show, and it flew. The rest of the flying during gapore Airshow site, organizers and the show’s one-hour daily flying window was business climate would measure up to done by military solo and team efforts. However, the standards set by the previous and corporate aviation was well represented in the Qnow-departed “Asian Aerospace” show generally static displays, as manufacturers didn’t miss an received positive responses from visitors to the opportunity to display in one of the fastest grow- 2008 event. ing corporate aviation markets in the world. The new exhibit The newly constructed show facility and Singapore also is where many international hall’s proximity to the roads, set on reclaimed land developed on the aerospace manufacturing and service compa- static display area eastern side of the island city-state, were vastly nies are establishing or expanding their Asia/ (bottom) was one of superior to the old site. Plenty of exhibit space, Pacific facilities, taking advantage of the national many improvements. adjacent aircraft display areas, air conditioning government’s drive to expand aerospace in Stratech’s iFerret that worked and well-planned roads made the Singapore. During the show there were nine runway foreign object physical act of attending and exhibiting much ceremonies marking facility groundbreakings, surveillance system less arduous than before. The new organizers’ ef- expansions or openings. (below) was ordered forts took care of most new-show kinks, as well. Lufthansa Technical Training joined the for Singapore’s However, coming on the heels of record or- trend, opening a new training center at Temasek Changi Airport. ders booked last year at the Paris and Dubai air Polytechnic, joining other facilities in Tianjin, shows, the Singapore show was unlikely to com- China, Haikou, China and Manila, Philip- pare well. While exhibitors announced US$13 pines. The demand for training in the region is billion in sales of new aircraft, engine and sup- skyrocketing due to aviation’s growth, but that port equipment, a number that would have been growth “is making it very difficult to hold onto” seen as fairly healthy in past years, that figure the trained people, said Ralph Kaeding, general paled in comparison with the $100 billion and manger of the training center. “When the more $75 billion logged at Paris and Dubai. However, prosperous regions have a [personnel] need they the fact that many production lines are sold out take out the wallet and say, ‘I need the people, so many years into the future made significant what is the cost?’” additional orders unlikely. Nonetheless, Lion Air Kaeding told ASW there are cultural differ- stood out with its $4.4 billion order for 56 more ences in the employee turnover problem: “Cer- Boeing 737-900ERs, elevating its order book for tain nationalities stay at a job for life.” In other that type to 178 airplanes. places, including the Philippines, Singapore and There was a decided lack of airliners at the Indonesia, turnover “is difficult.” show. Just the Airbus A380 appeared at the Despite new training facilities opening all the time in the Asia/Pacific region, “in some places with big growth they’re not prepared for this.” The Singapore maintenance, repair and overhaul cluster alone requires 1,000 newly trained people annually, Kaeding said.
20 | flight safety foundation | AeroSafetyWorld | April 2008 FlightTech
The flying was closed each day by the Royal Australian Air Force Roulettes demonstration team flying Pilatus PC‑9s.
Keith Tan, vice president and general Gulfstream announced its new Flight manager of Goodrich Aerostructures Service Operations Risk Management Service that will Center—Asia in Singapore, said that even with enable operators to conduct flight data moni- the nation’s system of polytechnic schools, “we toring programs, also known as flight opera- need to do our own specialized training” to feed tions quality assurance (FOQA), on all of its a Goodrich presence that has grown from 14 to in-production aircraft, plus several aircraft no 700 people in 10 years. The company, however, longer in production. While the Gulfstream does not have a major turnover problem, he program can supply full analysis services, using said, possibly because it sits at the top of the Austin Digital for that function, the system food chain. “Due to our people philosophy and can support any FOQA program, a company a good incentive plan, very few people leave us. official said. It’s all about how you treat your people, and we Honeywell’s Integrated Primary Flight Dis- have a good reputation.” play (IPFD) received its technical standard order The growth of Among the safety advances highlighted approval from FAA the day before the show corporate aviation in the at the show was the first order for Stratech’s opened. The IPFD utilizes “digitized data base Asia/Pacific area attracted iFerret runway surveillance system that uses of worldwide terrain and obstacles to provide business aircraft (above). a line of cameras to visually inspect the run- pilots a synthetic ‘3-dimensional, real-time, Airbus delivered its way, preventing foreign object damage. After a out the window’ representation of terrain and second A380 to Singapore 15-month trial at Singapore’s Changi Airport, obstacles on an aircraft’s primary displays,” the Airlines days before its the system was ordered by the Civil Aviation company said. The system integrates existing demonstration aircraft flew Authority of Singapore to monitor Changi’s two flight deck information with head up display at the show (bottom). main runways. The iFerret system uses artificial advanced symbology, generated from the intelligence to detect a new foreign object on enhanced ground proximity warning system ter- the runway, alert operators and zoom for close rain database and graphics generators. ● inspection. An evaluation by the U.S. Federal Aviation Administration (FAA) is to be con- ducted starting this spring at Chicago O’Hare Airport, Stratech officials said. All photos: J.A. Donoghue J.A. All photos:
www.flightsafety.org | AeroSafetyWorld | April 2008 | 21 FlightOPS
arly in 2007, our company was encouraging. At an elevation of 7,300 ft, approached about conducting the airport is tucked ino a deep val- an around-the-world flight that ley, flanked by 18,000-ft mountains. promised to be a real logistics The only instrument approach was a
© Alan Tobey/iStockphoto © Alan Echallenge. The itinerary and time frame very-high-minimums “cloud-break” were daunting, but one location in procedure that did not even serve our particular gave us pause. Our customer approach category. One portion of the needed to fly into Paro, in the Kingdom chart was filled with the type of terrain of Bhutan. contours that immediately give one To say we were unfamiliar with pause, but an equally large portion of the the place would be an understate- chart was blank and marked “Relief Data ment — most of us had never heard of Incomplete.” As far as we were con- it. We knew Tibet, had even worked cerned, it may as well have read “Here trips to Nepal, but never to the small, Be Dragons.” Internet searches yielded isolated country nestled between them. photos of the airport environment that Our initial look at the airport was not did not offer much encouragement. in the VFRBY PATRICK CHILES A challenging flight Himalayasrequired painstaking preparations.
22 | flight safety foundation | AeroSafetyWorld | April 2008 FlightOPS
At an elevation of 7,300 ft, the
© Md. Aminul Hassan/Wikimedia airport is tucked into a deep As our research progressed, we were fortu- nate to find an article in a 2003 issue of Boeing’s valley, flanked Aero magazine describing technical demonstra- tions at Paro of a BBJ, the same type aircraft that by 18,000-ft we operate. The demos actually were flown in mountains. an aircraft that had originally been destined for our company. So, with photographic evidence of a BBJ in NetJets livery taking off from that very airport, with a majestic Himalayan valley in the background, how could we say no?
Not Been There, Done That Of course, things are never that simple. A picture
is no guarantee of success. The demo flights were © iStockphoto conducted under the general operating and flight rules of U.S. Federal Aviation Regulations Part 91 — though their obstacle analysis went far beyond former Soviet Union and terrain data from the U.S. anything strictly required for Part 91. The pro- National Aeronautics and Space Administration cedures were validated by Boeing engineers and space shuttle radar topography mission (SRTM). flown by their test pilots. Our company, on the The SRTM data proved to be an excellent source, other hand, would have to run this operation as with resolution down to 90 m (295 ft). a Part 135 charter, requiring rigorous procedure Initial attempts to develop an engine-out development and pilot training. departure path focused on attempting a steady We first looked for the “low-hanging fruit” climb out of the valley with a minimum of turns. and investigated potential required navigation Our goal was to limit turns to a maximum of 15 performance (RNP) procedures, such as those degrees of bank. This led to a creative solution © Douglas J. McLaughlin/Wikimedia© Douglas J. recently developed by China for Linzhi, one of that clearly would not work, because it ultimate- Tibet’s most inaccessible airports. As a matter ly would have required a blind 180-degree turn of fact, the final approach to one of the runways around a 12,000-ft ridge, with no way to know in Paro looked remarkably similar to Linzhi. what type of weather was coming up the valley However, no such procedures existed — Paro is on the other side of the ridge.
a daytime-only, visual flight rules (VFR) airport. United Nations/Susan Reed There certainly would not be enough time to China create and certify a new RNP approach — the Linzhi trip was two months away. New Delhi Nepal Paro So, our planning had to be based on the Kathmandu Bhutan simple fact that the flight would have to arrive
and depart in visual conditions. Bangladesh India VFR operations meant that we would have Dhaka to carefully analyze our approach and depar- Myanmar ture paths, and set appropriate minimums. We Bay of Bengal obtained detailed topographic maps created by the www.flightsafety.org | AeroSafetyWorld | April 2008 | 23 FlightOPS
Previous experience in designing area navi- gation (RNAV) procedures at Eagle Regional Airport, high in the Colorado Rocky Mountains, prompted us to hire an outside vendor to assist in terrain evaluation and procedure design. ASRC Research and Technology Solutions’ assis- tance and insight proved invaluable in validating our procedures. They were able to acquire the old Red Army topographic charts and applied three-dimensional stereo-imaging of overhead photos to confirm the charted contours and evaluate both man-made obstacles and naturally occurring obstacles, such as trees. We made it a point early in our relationship U.S. National Aeronautics and Space Administration to avoid leading the vendor to any one preferred conclusion. ASRC’s analysis came to the same in- In a locale of This led us to have another look at the exist- dependent conclusion about the takeoff paths from Shangri-La ing procedures. These departure paths were Paro’s single 7,332-ft (2,235-m) runway. This was proportions, Paro based on turns inside the valley walls at 25- and also good for our comfort level; now we had three lies deep within 30-degree banks, which we had hoped to avoid. different analyses — Boeing’s, ASRC’s and our own the Himalayas. But given the terrain and our engine-out climb — that arrived at nearly identical solutions. capability, there was no alternative but to plan for turns inside the valley. We determined right away Eyes in the Sky that it would be wise to use a greater allowance While our chief pilot, Rick Weeks, and I worked for lateral terrain separation than the regulatory on procedure design with ASRC, our director of 300 ft/90 m (ASW, 7/07, p. 26). The procedures safety and standards, Mark Atterbury, established we had seen had used a 500-ft/150-m margin, contact with Bhutan’s state airline, Druk Air. Their and that seemed a fine place to start. chief pilot, Dhondup Gyaltshen, was invaluable to As it turned out, there wasn’t much room for our success. To obtain a landing permit at Paro, breaking new ground in procedure design. any private aircraft operator must train its pilots in a flight simulator that has a visual model of Paro or Terrain Dictates Flight Path have one of Druk Air’s pilots in the observer’s seat Planning for the flight out of Paro gave us our during actual operations at the airport.
©Jon Larson/iStockphoto expected takeoff weight, which we used to We elected to do both. Atterbury, who would make an early determination of V-speeds. This serve as pilot-in-command during the trip, defined our climb capability and turn perfor- received training in a BAe 146 flight simulator at mance, so procedure development became an the BAE Systems, now Oxford Aviation Academy, iterative process: fit the curves defined by weight facility in Manchester, England. The facility has and speed within the valley at the appropriate one of only two visual simulator models of Paro; heights, with a 500-ft margin. The valley walls the other model is at the Airbus facility in Beijing. would define the path our flight crew would Atterbury also flew to Paro as a cockpit ob- have to follow in the event of an engine failure server in a Druk Air A319. While on the ground
before V1 and a decision to continue the takeoff. in Bhutan, he drove up the valleys from each Although we endeavored to not copy those who end of the runway to identify landmarks he had had gone before us, in the end the procedures seen from the air. were almost identical. The terrain is what it is — Flying the simulator, observing from the there was little margin for individual preference. cockpit and arranging to have an experienced
24 | flight safety foundation | AeroSafetyWorld | April 2008 33764 FDS ASW Iron Maiden 0208 11/3/08 3:37 pm Page 1
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safety pilot in the jump seat gave every- within a reasonable value — this would reduce our choices of destinations and one a high level of confidence that we allow the crew to visually avoid the ter- alternates. There are few airports within could accomplish this trip safely and on rain. This speed limit included a 10-kt range that could be used for either. If our customer’s demanding schedule. margin for improved climb performance the weather went below minimums at The simulator training alone would and stall protection in the steeper bank, these airports, the flight would be stuck
have been adequate for practicing the recalling that the V2 values in the aircraft in Paro until the weather improved. In engine-out turns, but the safety pilot was flight manual provide stall protection for addition, very high minimums had to crucial for getting there in the first place, turns with 15 degrees of bank. Besides be set for the visual arrival and depar- because descending into the wrong val- needing a higher speed for stall margin, ture. Finally, this trip would be operated ley reportedly was easy to do and could the improved climb benefit was needed just prior to Bhutan’s monsoon season. have disastrous consequences. to ensure that the aircraft would clear a Temperatures would be getting warmer, The visit to Paro provided a surpris- ridge at the end of the turn. and winds in the valley are such that it ing revelation, which pointed out the Once the required true airspeed for is common practice to cease operations limits of our comparatively academic a given weight and flap setting is estab- after 1000 local time even though the exercise with the turn procedures. De- lished, turn radius becomes a function airport technically is open until sunset. spite the care we had taken to evaluate of bank angle, regardless of the aircraft Because of this, we found it useful to topography, our conclusions about the — a specific model’s aerodynamics are gather all the historic climatology data safest direction for takeoff were literally relevant only to the loss of climb gradi- that were available, and we contracted turned 180 degrees. Our analysis had led ent within the turn. special forecasting services through our us to believe that departing on Runway 15 This led to an interesting conclusion international handler, Jeppesen. We also would be preferable, but the opposite was that fell outside the well-known takeoff used this information to evaluate the true, according to Atterbury’s flight to performance limitations: field length, tire effects of unanticipated winds aloft on Paro and look-around from ground level. speed, brake energy, climb and obstacles. turn radius and climb distance. As he put it, “Runway 33 was the While obstacles and climb gradient were Armed with this information, the obvious choice since you could see the certainly driving forces, the takeoff ef- simulator training and the site visit, the entire maneuvering area from the air- fectively would be limited by turn radius flight crew was able to safely make this field, and it provided enough clearance and airspeed. Due to the turn clearance, it challenging trip happen on schedule. Sev-
to continue climbing while circling in was critical to keep V2 as close as possible eral other individuals and entities helped the valley, if need be. Runway 15 could to the established speed limit without ex- our success, particularly the authori- have you flying into weather not vis- ceeding it. That, in turn, drove the weight ties and airline employees at Paro. Only ible from the ground and then rely on down to a hard limit to ensure the 140-kt within the last few years has Bhutan been the terrain mapping to stay out of the “magic number.” opened to expanded tourism. It is by all ‘cumulogranite’ buildups.” This would allow us only about an accounts a beautiful locale of “Shangri- hour’s worth of trip fuel, not counting La” proportions. We have since had Back to the Drawing Board reserves. One factor that worked in our more requests for trips, as have other BBJ A departure from Runway 33 would re- favor was that the Boeing demo flights operators I have met, and our European quire immediate turns as soon as the air- had been performed at a thrust rating division has flown there twice this year. craft reached the regulatory minimum of 26,000 lb (11,794 kg) to emulate a Paro is certainly an excellent candi- of 50 ft above ground level (AGL). The standard-issue 737‑700. The BBJs are date for RNP procedure development. most challenging turn would require a rated to 27,300 lb (12,383 kg) thrust, Until that happens, our experiences are 30-degree bank to reverse course within which improved our weight off the run- presented here to the aviation safety the valley, back toward the airport, for a way over that of the demonstrator. community in the hopes of encouraging 228-degree heading change. We deter- thorough training and rigorous analysis. ● mined that keeping a maximum V of Limited Alternates 2 Patrick Chiles is technical operations manager 140 kt true would produce a turn radius Other mitigating factors worked to for the NetJets Large Aircraft (BBJ) program adequate to maintain 500 ft of lateral narrow our window of opportunity. The and a member of the FSF Corporate Advisory separation and keep the deck angles weight-limited range would, of course, Committee.
26 | flight safety foundation | AeroSafetyWorld | April 2008 FoundationFocus
Tell us who deserves an award for advancing aviation safety. Call for Nominations
The Flight Safety Foundation annual The following awards will be presented to aviation safety, through basic design, safety awards recognize outstanding at the 61st International Air Safety device or practice.” individual and group achievements. Seminar in Honolulu, Hawaii, October A retired U.S. Navy admiral and a Recipients of these prestigious awards, 27–30, 2008: Foundation president in the mid- nominated by aviation profession- The Flight Safety Foundation–Boeing 1950s, de Florez was influential in the als and organizations worldwide, are Aviation Safety Lifetime Achievement development of early flight simulators. selected by independent boards. Award recognizes an individual for his He received the 1943 Collier Trophy — TThe following awards are being pre- or her lifetime commitment and contri- one of the most prestigious awards for sented at Honeywell’s Press Dinner at bution to enhancing aviation safety. aeronautical achievement in the United the Farnborough International Airshow, States — for his work in training com- Nominees should have devoted ef- July 12, 2008: bat pilots and flight crews. forts spanning two decades or more The Honeywell Bendix Trophy for Avia- to enhance civil aviation safety and/ The nominating deadline is May 9, 2008. tion Safety was re-established in 1998 or military aviation safety beyond the The Cecil A. Brownlow Publications by AlliedSignal (which later merged normal expectations of their particular Award was first presented in 1968 and with Honeywell) to recognize contribu- job assignments. Nominations can be renamed in 1988 in memory of Cecil tions to aerospace safety by individuals posthumous. A. Brownlow, the FSF editor of publica- or institutions through innovation in The nominating deadline is May 9, 2008. tions from 1981 until shortly before his advanced safety equipment and equip- death in 1988. ment utilization. The Laura Taber Barbour Air Safety Award recognizes notable achievement The award recognizes significant The nominating deadline is April 21, 2008. in the field of aviation safety — civil or contributions by journalists to aviation The Aviation Week & Space Technology military — in method, design, inven- safety awareness. Candidates may be Distinguished Service Award — the old- tion, study or other improvement. individuals, publications or organiza- est of the Foundation’s awards — has The award’s recipient is selected for a tions. Nominations may be for long- been sponsored since 1949 by Aviation “significant individual or group effort term achievement or for outstanding Week & Space Technology and is admin- contributing to improving aviation articles, books or works in electronic istered by the Foundation. safety, with emphasis on original con- media published or broadcast between tributions,” and a “significant individual July 1, 2007 and June 30, 2008. The award is presented for “distin- or group effort performed above and guished service in achieving safer utili- The nominating deadline is July 31, 2008. beyond normal responsibilities.” zation of aircraft.” It was the brainchild For complete award criteria, informa- of Jerry Lederer, the founder of Flight The nominating deadline is May 9, 2008. tion about past recipients and online Safety Foundation and a pioneer in Presented since 1966, the Admiral Luis nomination forms, please visit the FSF aviation safety. de Florez Flight Safety Award recognizes Web site
flight safety foundation | AeroSafetyWorld | April 2008 27 | 28 Philadelphia Fire Department | causalfactors Fire in the
Hold warning oftheimpendingconflagration. warning The DC-8flightcrew received little flight safety foundation BY MARKLACAGNINA |
World AeroSafety |
A pril 2008 pril © Erich Ball © Erich causalfactors
wenty-five minutes after the flight crew six hours the morning of the accident flight. The detected a faint odor like burning wood, first officer said that he had slept about two hours their 40-year-old freighter was doomed by that morning and “napped for a few hours in the a raging cargo fire. On final approach to afternoon.” The flight engineer said that he had TPhiladelphia International Airport near midnight followed his normal layover routine, sleeping Feb. 7, 2006, the crew of the McDonnell Douglas about five hours in the morning and napping for DC‑8‑71F was running out of time. There was about two hours in the evening, and that he felt little, if any, prospect of a successful go-around. rested for the flight. The report said, however, “They didn’t have minutes. This flight was that there was no evidence that the flight crew’s seconds from disaster,” said Deborah Hersman, performance was degraded by fatigue. a member of the U.S. National Transportation Hold ‘Smells Like Wood Burning’ Safety Board (NTSB), during the board’s public meeting on the accident in December 2007. Nighttime visual meteorological conditions Billowing smoke blinded the three crewmem- prevailed when the DC‑8 departed from Atlanta bers soon after they brought the airplane to a stop at 2241 local time. The first officer was the on the runway. They escaped with minor injuries pilot flying. The crew said that the flight was from smoke inhalation. The DC‑8 was a total uneventful until they began the descent from loss, and most of the cargo aboard the airplane cruise altitude — Flight Level (FL) 330 (about was destroyed or damaged by the fire. In its final 33,000 ft) — about 157 nm (291 km) southwest report, NTSB blamed the fire for the accident of Philadelphia. The airplane was descending but said that the ignition source could not be through FL 310 at 2334 when the first officer determined “due to the destruction of potentially said, “Smells like wood burning. Smell that?” helpful evidence.” “I smelled it for a couple of seconds,” the “Contributing to the loss of the aircraft were flight engineer said. the inadequate certification test requirements “It’s pretty strong now,” the first officer said. for smoke- and fire-detection systems, and the The flight engineer vacated his seat and pulled lack of an on-board fire-suppression system,” open the left side of the smoke curtain, a ventila- the report said. tion barrier that covers the netting between the The DC‑8, operated as Flight 1307 by United galley and the main (upper) cargo compartment. Parcel Service (UPS), was inbound to Philadel- The compartment holds 18 cargo containers and is phia from Atlanta. The flight crew were working not accessible after the cargo containers are loaded. the second day of a five-day sequence. They had A smoldering fire had begun inside a container flown the DC‑8 from Atlanta to Philadelphia and near the back of the compartment. back to Atlanta the night before the accident. The flight engineer used a flashlight to The captain, 59, had about 25,000 flight inspect the left wall of the compartment. “He hours, including 16,000 flight hours as a DC‑8 stated that he could smell the odor but that he pilot-in-command. He was hired by UPS in did not see any smoke or fire,” the report said. 1988. The first officer, 40, had 7,500 flight hours, The captain considered diverting the flight to including 2,100 hours as a DC‑8 second-in- a nearby airport but decided to continue to Phila- command. He joined UPS in 1996. The flight delphia. The report said that this decision was engineer, 61, had 9,000 flight hours, including “not inappropriate,” considering the circumstanc- 430 flight hours as a DC‑8 flight engineer. He es: There was no visible smoke, and no annuncia- was employed by UPS in 1994. tor lights had illuminated to warn of smoke or The captain and the first officer told investiga- fire in a cargo compartment. “Further, the flight tors that they had difficulty transitioning from crew stated that unusual odors could be common their daytime off-duty schedules to their night- from nonthreatening factors, such as flying over time work schedules. The captain had slept about forest fires or unusual cargo,” the report said.
www.flightsafety.org | AeroSafetyWorld | April 2008 | 29 causalfactors
The AOM did not specify when the “Fumes McDonnell Douglas DC-8-71F Evacuation” checklist should be used, the report said, noting that the checklist is appropriate when fumes “cause irritation or otherwise prevent the flight crew’s ability to operate the airplane.” The report discussed an international project sponsored in 2004 by Flight Safety Founda- tion to improve guidance for air carrier pilots in responding to nonalerted smoke/fire/fumes events. Project participants developed the Smoke/Fire/Fumes Checklist Template, as well as directions for completing the checklist with © George W. Hamlin/Jetphotos.net information provided by the airplane manu- facturer and guidance on using the checklist in ouglas Aircraft Co. began production of the DC‑8, its first jet transport, in 1959. The first five versions of the DC‑8 have the conjunction with other checklists in the AOM Dsame overall dimensions. In 1965, a stretched version, the (Flight Safety Digest, 6/05, p. 31). DC‑8‑61, was introduced. Douglas merged with McDonnell Aircraft “The initial steps of the proposed checklist Corp. in 1968. consist of a series of simple, rapid actions to ad- In 1981, the DC‑8‑61’s four Pratt & Whitney JT3D engines were dress the most likely sources of fire,” the report replaced with CFM International CFM56s; the re-engined airplane said. “The guidelines state that these actions is called the DC‑8‑71. The -71F is the freighter version and has an upward-hinged cargo door on the left side of the forward fuselage. should require no decision making by the flight Cargo capacity is 8,810 cubic ft (247 cubic m). Maximum landing crew, be airplane-specific and be determined weight is 258,000 lb (117,029 kg). by the manufacturer based on event history for
Source: Jane’s All the World’s Aircraft each specific model airplane. “According to the proposed checklist guide- lines, unless clear visual evidence exists that all Inappropriate Checklists fire hazards are resolved after the initial steps, There were no specific procedures in the aircraft the flight crew should initiate a diversion and … operating manual (AOM) for responding to not delay landing to continue the checklist for an unusual odor in the absence of a warning additional source identification and/or source light. The AOM contained four checklists that isolation or elimination.” dealt with smoke, fire or fumes, but none was Boeing, which merged with McDonnell appropriate for the situation, the report said. Douglas in 1997, is using the checklist template The checklists were titled “Fire,” “Fumes Evacua- to develop new procedures related to nonalerted tion,” “Lower and/or Main Cargo Compartment smoke, fire and fumes, the report said. The Smoke” and “Pack Smoke.” checklists will be available for most current The DC‑8 was about 65 nm (120 km) from models but not for older models such as the 707, Philadelphia, descending through FL 180, at 2343, 727, DC‑8, DC‑9 and DC‑10. The report said when the flight engineer announced that he had that operators of these models will have to work set the air-conditioning packs to maximum flow with the manufacturer and the U.S. Federal and had turned off the recirculation fan. The Aviation Administration (FAA) to develop their report said that these actions, performed in ac- own checklists for the airplanes. cordance with the “Fumes Evacuation” checklist, In one of the many recommendations gener- exacerbated the situation by increasing airflow ated by its investigation of the DC‑8 accident, in the cargo compartment. The increased airflow NTSB called on the FAA to provide “clear guid- diluted the smoke, inhibiting its detection, and ance to operators of passenger and cargo aircraft provided additional oxygen to the fire. … on flight crew procedures for responding to
30 | flight safety foundation | AeroSafetyWorld | April 2008 “Yeah,” engineer replied. flight the “Smells like it At 2346,aPhiladelphia approach controller 15,000 ft at15,000 ft captain the 2347,when asked the 10 mivisibility, clear skiesand atemperature of The captain told then approach the controller (ARFF) alarm and(ARFF) alarm told captain the that emer was more to back there.” the were from 260degrees at 6kt and cleared the 2004 smoke, fire and initiative.” industry fumes 27R. Reported weather Reported conditions27R. at airport the Runway 27Rand to establish radiocommunica- www the captainthe replied. “And, listen, uh, we just tion tower with airport the controller. insight.that had airport the The controller they turning airplane the directly toward airport. the that “CARGO the SMOKE” light had illumi- there “does not appear any to be smoke or haze.” though, something like that?” ‑8 forto DC sequence the landing on Runway told crew the aheading to of fly 050degrees, ft atft engineer announced flight the 2354,when flight engineer ifhesmell odor.flight the could still recorder (CVR)indicated that first officer the it?” said first officer. the it?” “You didn’t smoke, see included winds surface from 270degrees at 7kt, have equipment the The controller us?” meet nated. announced The first officer that he was crew to land on Runway “Cleared 27R. to land,” cleared crew the to conduct approach avisual to compartment with and his flashlight said that the evidence ofevidence afire absence inthe of acockpit odor was “definitely stronger in the back” but that 0 degrees C(32degrees F). Runway Change got acargo smoke indicator come on. Canwe gency responsegency equipment would the meet activated aircraft the and rescue fire fighting and the flight engineer donned their oxygen oxygen their donned engineer flight the and alert based on guidance the based developed byalert the airplane on landing. “Smells like cardboard burning, doesn’t The tower controller said that winds the The airplane was descending through 3,600 The engineer again flight searched cargo the The airplane was descending through about Sounds recorded by the cockpit voice voice cockpit the by recorded Sounds .flightsafety.org |
World World AeroSafety |
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Philadelphia Fire Department ‘Have to DoanEvacuation’ The “Lower and/or Main Cargo Compartment the changethe inrunway assignment, however. to land on Runway 27L; he said nothing about zero six two is wind “The said. controller the Compartment Cargo Main and/or “Lower the captainthe said. “And through run that mask on he when acknowledged clearance the for use in emergencies. “UPS thirteen oh seven seven oh thirteen “UPS emergencies. in use for for called officer first the after Soon masks. required that landing the to specify runway as - ing indicated that the captain had his oxygen oxygen his had captain the that indicated ing is designated by the airport emergency plan plan emergency airport the by designated is four comprises which area, cargo lower the in Smoke or Fire” checklist required flight the heavy is cleared to land runway two seven left,” seven two runway land to cleared is heavy Smoke or Fire” checklist. neer verbalized his actions while conducting his actions verbalized neer while nounced that the “LOWER CARGO FIRE” FIRE” CARGO “LOWER the that nounced light had illuminated, warning of smoke/fire “Landing” the and extension gear landing checklist by yourself, The engi- flight OK?” crew to land on runway, parallel the 27L,which cargo compartments. checklist at engineer an flight 2355,the - signment changed. had been The CVRrecord- at six.” The controller didnot, and was not “Oxygen masks on if you don’t you them,”if have on masks “Oxygen At 2356, the tower controller cleared the the cleared controller tower the At2356, smoke indicator come equipment meetus?” causalfactors “We justgotacargo on. Can we have the |
31 causalfactors
engineer to vacate his seat so that he could open that he could not see his hand in front of him,” an access panel on the wall behind the cockpit the report said. bulkhead and close the cargo air valve. Black Both the captain and the first officer at- smoke billowed out when he opened the access tempted to retrieve the “Notice to Captain” panel. After closing the cargo air valve, he an- (NOTOC), a document that contains informa- nounced that he had seen smoke. “We’re going tion about the locations and types of hazardous to have to do an evacuation, OK?” he said. “Tell material being shipped aboard the airplane; them we are going to have to do an evacuation however, they were unable to find it. During the when we get down.” flight, the NOTOC had fallen from its storage The captain and first officer were finishing area behind the captain’s seat, and the flight en- the “Landing” checklist at 2358, when the tower gineer had placed it on a bulkhead at his station. controller asked the crew to confirm that they The flight engineer took a breath of oxygen were landing on Runway 27L. “It appears you from his mask before leaving his station to are lined up for the right,” the controller said. deploy the emergency slide for the left forward “I’m sorry,” the captain replied. “I thought we door. All three crewmembers used the slide to were cleared for the right. Are we cleared to land evacuate the airplane. on the right?” The captain told ARFF personnel that there “You are cleared to land on the right,” the were hazardous materials aboard the airplane controller said. “We will just tell fire [i.e., ARFF and that he had not been able to locate the NO- personnel].” TOC. The three flight crewmembers then were The smoke had “The change in landing runways — from transported to a local hospital and treated for 27L to 27R — resulted in a subsequent change smoke inhalation. become so dense in standby positions,” the report said. “ARFF A firefighter located the NOTOC about 35 that the pilots could personnel reported that the change in runways minutes after ARFF personnel began fighting resulted in a 60- to 90-second delay in respond- the fire with water and aqueous film-forming not see each other. ing to the accident scene. Seven [airport] ARFF foam. “The first fuselage burn-through occurred vehicles responded.” about 0200 and was located in the crown of the The DC‑8 touched down on Runway 27R at fuselage aft of the wings,” the report said. “The 2359. “Immediately after touchdown, the flight fire was characterized as being ‘fully involved’ engineer reported smoke in the cockpit,” the around 0220. ARFF personnel reported that the report said. “After the airplane came to a stop fire was under control about 0407.” [on the runway], the first officer called for an emergency evacuation, and the captain and first Twenty-Minute Delay officer conducted the The DC‑8 model originally was certified to ‘Emergency Evacua- the transport category airplane airworthiness tion’ checklist.” The standards of U.S. Civil Aviation Regulations 4b, smoke had become so which was recodified as Federal Aviation Regu- dense that the pilots lations Part 25 in 1965. The accident airplane could not see each was manufactured in 1967 and purchased by other. UPS in 1985. It had accumulated about 67,675 “The first officer flight hours when the accident occurred. stated that, after he Examination of the airplane’s smoke-detection transmitted to the system revealed no anomalies. There are seven [tower controller] that smoke detectors on the ceiling of the main cargo they were evacuat- compartment and 19 in the lower compartment. ing the airplane, the Investigators determined that the fire smoke was so heavy likely began inside cargo container 12, 13 or 14 U.S. National Transportation Safety Board
32 | flight safety foundation | AeroSafetyWorld | April 2008 causalfactors
(Figure 1). Among the items that had been shipped in these containers were DC-8 Cargo Configuration electronic devices, including laptop computers, with rechargeable lithium batteries. Several lithium batteries of the same type also were found loose in the accident debris. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Noting that “testing and incident data 31 32 33 34 indicate that lithium batteries can pose a fire hazard,” the report said there was no Note: The numbers 1 through 18 designate cargo container locations in the main cargo compartment. The evidence that lithium batteries were the numbers 31 through 34 designate lower cargo compartments. source of ignition aboard the DC‑8. Source: U.S. National Transportation Safety Board “A review of FAA and CPSC Figure 1 [Consumer Product Safety Commis- sion] records shows that the number of loaded cargo containers on smoke systems in air carrier cargo compart- of … lithium-battery-related incidents detection, the report said. ments. Following the May 11, 1996, — many of which involved laptop “With cargo containers loaded in cargo-fire-related crash of the ValuJet computer fires that resulted from either the cargo compartment, air exiting the Airlines DC‑9 in Florida (Accident internal or external short-circuiting air-conditioning vents in the ceiling is Prevention, 11/97), the FAA issued a of [rechargeable] lithium batteries — primarily directed outward and down- regulation requiring fire-suppression has increased consistently over the ward toward the floor [i.e., away from systems in the cargo holds of years,” the report said. The accident the smoke detectors],” the report said. passenger-carrying airplanes. investigation generated several recom- “The cargo containers also create a bar- As a freighter, the UPS DC‑8 mendations designed to prevent such rier that the smoke must traverse before was not equipped with, and was not incidents (ASW, 3/08, p. 42). it enters the open space of the cargo required to be equipped with, a cargo- Investigators determined that the compartment, where it can be detected fire-suppression system (ASW, 1/08, smoke-detection system aboard the DC‑8 by the smoke-detection system.” p. 36). “As a result, the fire, which did not perform according to applicable Current transport airplane certifi- began as a smoldering fire in one of the certification standards, which require cation standards require a crew alert cargo containers, was able to develop an “acceptable indication to the crew” no within one minute of smoke genera- into a substantial fire that burned more than five minutes after smoke is ini- tion. Nevertheless, certification tests of through the container,” the report said. tiated in a cargo compartment. The flight smoke- and fire-detecting systems still The report said that the FAA rejected crew received the first smoke warning 20 are typically conducted in empty cargo previous recommendations in part minutes after the first officer detected an compartments, the report said. because it believed that fire-suppression unusual odor related to the fire. Based on these findings, NTSB systems would unduly add weight and re- During the original certification recommended that the FAA “ensure that duce cargo area aboard freighters. Point- tests of the DC‑8’s smoke-detection the performance requirements for smoke- ing to the recent development and testing system, detection times varied from 12 and fire-detection systems on cargo by FedEx of a system that extinguishes seconds to three minutes, which were airplanes account for the effects of cargo fires inside cargo containers before they well within the existing standard. The containers on airflow around the detec- breach the containers, NTSB again told report noted, however, that the certifi- tion sensors and on the containment of the FAA that all cargo airplanes should cation tests were conducted in empty smoke from a fire inside a container.” have fire suppression systems. ● cargo compartments. This was done This article is based on NTSB Accident Report because the smoke would disperse in the Freighter Fire Hazards NTSB/AAR‑07/07: “Inflight Cargo Fire; open area, requiring greater sensitivity The report noted that NTSB over the United Parcel Service Company Flight 1307; by the detection system. However, this past 20 years has made several recom- McDonnell Douglas DC‑8‑71F, N748UP; method does not account for the effects mendations to require fire-suppression Philadelphia, Pennsylvania; February 7, 2006.” www.flightsafety.org | AeroSafetyWorld | April 2008 | 33 threatanalysis Departure
Deviations Problems arise when the assigned SID differs from the one in the FMS.
BY HANS HOUTMAN AND DICK VAN ECK
nintended deviations from The involved airlines use “operation- SIDs. They are identified as Spijkerboor standard instrument depar- al flight plans,” which provide pilots with 1S and Andik 1S. Although they pre- ture (SID) procedures are an route information, including the SIDs scribe different initial turns, both lead everyday threat to the aviation that likely will be followed. An opera- toward the same northern airway point. system.U Unexpected turns or incorrect tional flight plan typically is prepared by The need for the two different routes
routes flown soon after takeoff create a flight dispatcher three to six hours be- is created by tactical use of the runway Stroes/Jetphotos.net @ Jeroen hazardous situations near airports with fore the scheduled departure. The flight system. In one runway configuration, heavy traffic or with multiple runways dispatcher considers all he or she knows the right-turn departure from Runway in use. at the time to anticipate the departure 24 — Spijkerboor 1S— is preferable; At Amsterdam Schiphol Airport, runway that will be assigned and to de- in another configuration, the left-turn for example, there have been several termine which SID can be expected. departure — Andik 1S — is favored. incidents involving pilots who flew a Schiphol, like many major airports, Aircraft turning right on departure different SID than the one assigned to is subject to environmental rules and from Runway 24 can interfere with traf- them by air traffic control (ATC) and changing meteorological conditions, fic arriving from the south to establish acknowledged by the crew. which sometimes lead to a change of on a right downwind leg for landing on Schiphol has six runways, some of runway configuration after an opera- Runway 18R. Aircraft turning left on which converge. Pertinent to this discus- tional flight plan has been developed departure from Runway 24 can interfere sion are Runway 24, which is the primary and given to the pilots. The pilots might with traffic departing from Runway 18L. runway for departures, and Runway 18R, already be on their way to the airport Therefore, when traffic is landing the primary runway for landings, under with the operational flight plan for their on Runway 18R, aircraft departing southerly wind conditions. In addition, outbound flight in their pockets. from Runway 24 to the north will pro- there is Runway 18L, which also is used For aircraft departing from ceed via the Andik 1S departure (left occasionally for departures (Figure 1). Schiphol’s Runway 24, there are two turn). When Runway 18L also is being
34 | flight safety foundation | AeroSafetyWorld | April 2008 threatanalysis
used for departures, aircraft departing from loss of ATC traffic separation, and controllers Runway 24 to the north will use the Spijkerboor had to intervene by issuing heading changes 1S departure (right turn). and/or level-off instructions to other aircraft On several occasions, pilots departing in the vicinity to maintain separation. To date, Schiphol from Runway 24 have turned right after the problem has not resulted in any dangerous takeoff although they were cleared for the Andik situations at Schiphol, but it poses a very real 1S departure, with a left turn away from traffic and significant threat to aviation safety. arriving on right downwind for Runway 18R. On These incidents are not unique to Schiphol Problems arise when the assigned other occasions, it was the other way around: pi- and are not a reflection of one airport’s situa- SID differs from the one in the FMS. lots were cleared for the Spijkerboor 1S departure, tion. They occur regularly at airports around with the right turn to avoid traffic departing from the world. At Schiphol, the threat was reduced Runway 18L, but flew the Andik 1S departure after one of the involved airlines stopped toward the traffic coming off Runway 18L. including the expected SIDs in its opera- Pilot-controller communication procedures tional flight plans, instead cautioning pilots requiring clearance readback are designed to “check SID.” Following this change, none to prevent such errors. Mishearing, however, of the airline’s aircraft has deviated from an allows the errors to persist. In most of the assigned SID. ● departure deviations noted above, the pilots’ Hans Houtman is coordinator-investigator in the office of readbacks of their departure clearances — which Performance and Incident Analysis at Air Traffic Control included a different SID than the one shown on the Netherlands. D.J. “Dick” van Eck is advisor general to their operational flight plan — to the clearance- ATC the Netherlands on air traffic management training delivery controllers were correct. And on many and human factors. occasions, though not all, the tower controllers specifically mentioned the assigned SIDs in Departure/Arrival Sequences at Schiphol their takeoff clearances as a final check. Not to Scale Investigations showed part of the problem was that, in an effort to manage their workload, the pilots had programmed their flight manage- SID ment systems (FMSs) with the SIDs that had SPIJKERBOOR 1S been chosen by the flight dispatchers for their operational flight plans. However, no corrections Runway 18R
Runway 18L
to the programmed FMS routes later were made arriving 18R Tra c after different clearances were issued by ATC. Runway 24
Even inclusion of the assigned SIDs in the takeoff Traffic departing 18L clearances did not alert the pilots to the errors. Apparently, the mindset of the pilots was not in line with what actually was put in the FMS. Sometimes, the pilots’ readbacks of their clearances were incorrect — the pilots “read back” the SIDs shown on their operational flight
plans and not the ones assigned — and the ANDIK 1SSID controllers did not notice the errors. The result, however, was the same: the aircraft, on autopilot,
followed the SIDs programmed in their FMSs, SID = standard instrument departure
not the ones assigned by ATC. Source: Hans Houtman, Dick van Eck The resulting wrong turns sometimes were detected at a very late stage, almost causing a Figure 1
www.flightsafety.org | AeroSafetyWorld | April 2008 | 35 CEOs on Training A SERIES
“At Amway safety is our top priority. That’s why we’ve insisted on FlightSafety’s professional training for more than 30 years.”
RICH DEVOS Amway co-founder, NBA Orlando Magic owner and chairman
Rich DeVos co-founded Amway Corp. in 1959 and acquired with his family the Orlando Magic in 1991. He continues to serve on his company’s board and travel to deliver his inspirational messages to independent Amway distributors and other audiences. He is the author of Believe!, Compassionate Capitalism and Hope From My Heart: Ten Lessons for Life, which was inspired by his heart transplant at the age of 71 in 1997.
fter more than 80 years, Rich DeVos still looks The company’s belief in the many benefits and forward to each day with the same “can do” attitude advantages of business aviation and the passion DeVos A that propelled him to become one of the world’s most has for aviation continue today. He may have retired successful entrepreneurs. He was barely out of high school from the day-to-day responsibilities of running Amway, but when he returned from overseas after service in World War II his retirement hasn’t slowed him down. When he flies – to start an aviation business with his friend Jay Van Andel. which he does often as a business leader, philanthropist That business and other ventures together took off, and and speaker – his flight crews are FlightSafety trained. they eventually founded Amway from their homes in 1959. As far as he’s concerned, it’s the only way to go. Amway within a few years was a household name, known for pioneering the sales of products through independent distributors. Today the company records over $6 billion in annual sales in more than 80 countries. Serving a growing global operation required fast, efficient world travel. Amway established a flight department and turned to FlightSafety for aviation training. “We’ve been fortunate that Amway has enjoyed tremendous
success,” DeVos says. “Success requires confidence and For more information, please contact any of our Learning Centers or call persistence and demanding the best of ourselves and others. Scott Fera: 636.532.5933. Our headquarters are at the Marine Air Terminal, LaGuardia Airport, New York 11371-1061. Email: [email protected] That’s why our flight department insists on FlightSafety’s professional, safety-focused training for our jets and helicopters.” flightsafety.com
FLIGHTSAFETY DEVOS_AMWAY CEO AD Bleed: 8-3/4” x 11-1/4” Trim: 8-1/2” x 11” HIRES PDF VERIS COLOR PROOF FlightTECH
long-awaited fire safety enhancement has with regulations of the European Aviation Safety moved closer to reality for the global airline Agency (EASA).1 Specific considerations of type industry, the U.S. Federal Aviation Admin- certification may supersede this rule. For ex- istration (FAA) says. After Sept. 2, 2009, ample, the FAA determined in August 2007 that Amanufacturers of transport category airplanes with the composite fuselage structure of the Boeing passenger seating capacity of 20 or more — includ- 787 inherently will provide an equivalent level ing Airbus, ATR, Boeing Commercial Airplanes, of safety in fire-penetration resistance. Bombardier Aerospace and Embraer — will be Various factors delayed implementation of required to ensure that thermal acoustic insulation this rule, which was proposed in September 2000
materials installed in the lower half of the fuselage and became final in July 2003. The provisions Rosenkrans Wayne during manufacturing meet upgraded regulatory for fire-penetration resistance were to have been standards for fire-penetration resistance. effective in September 2007. Most delays were at- Above, Marker with a The standards, which also specify insula- tributed by the FAA to unforeseen circumstances next-generation burner. tion flammability criteria and tests of flame in obtaining equipment such as identical nozzles Below, the FAA’s “gold propagation in these and smaller transport and airflow vanes for burners in laboratory test standard” insulation- category airplanes, were issued in September rigs, and refining equipment configurations and burnthrough test with a 2003 by the FAA and are being harmonized procedures so that all materials laboratories can Park burner.
By Wayne Rosenkrans Blanket Protection Upgraded thermal acoustic insulation should afford extra minutes to escape a fuel fire before fuselage burnthrough. U.S. Federal Aviation Administration Aviation Federal U.S.
www.flightsafety.org | AeroSafetyWorld | April 2008 | 37 FlightTECH
All occupants evacuated safely during the China Airlines Boeing 737 pool fire in 2007 before the fire destroyed the cabin.
© AP photo/Kyodo News. Tomoyasu Yamauchi
obtain results that match the FAA’s own J. Hughes Technical Center. “The bulk or no impact forces, in which a large laboratory tests within accepted toler- of the work is behind us. We have spillage of jet fuel erupts into a pool ances. Other delays involved airframe interacted with industry to help set up fire beneath or adjacent to an intact manufacturers’ difficulty — as late as their tests, especially [reviewing] that aluminum-skin fuselage. Since the 1960s, 2006 — procuring compliant insulation they are accurate and their results are fatalities in burnthrough accidents have materials that would not be heavier or traceable back to the results we got at been rare, primarily because of success- more expensive than those envisioned the Technical Center. Their normal ful evacuations. Nevertheless, any pool by the FAA, and their reluctance to com- process of material screening, material fire is assumed to present a lethal threat mit to materials amid other uncertain- selection and implementation seems to because typical 2024-T3 aluminum skin ties about compliance details. be pretty much on track. A couple of on the lower half of a fuselage can melt As of March 2008, however, the FAA additional visits will be made to some and be breached by such a fire in less expressed confidence that these issues airframers for last-minute tweaks on than one minute. Two barriers beyond essentially have been resolved and laboratory equipment, but at this stage, the aluminum skin — thermal acoustic — barring a new major glitch — the they are ready to start certifying insula- insulation blankets and sidewall panels/ effective date stands. After a success- tion materials for use.” The Technical cabin floors — historically have not been ful review of its facilities by the FAA, a Center also assists the FAA Air Trans- designed for fire resistance. Insulation materials laboratory becomes eligible port Directorate, FAA aircraft certifi- simply has muffled slip stream noise and to conduct certification testing. “At this cation offices and other civil aviation helped to maintain cabin temperatures point, the airframers have candidate authorities in ongoing review of the comfortable for occupants. materials identified that they will use industry compliance activities. in their implementations,” said Tim The motivation for the standards Thermal Acoustic Materials Marker, an aerospace engineer and fire is burnthrough accidents — survivable Among many possible ways for research specialist at the FAA William events on the ground involving low fire-hardening a passenger airliner,
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© Thomas Mitchell/Jetphotos.net
upgrading insulation and its installa- placed inside the lofted fiberglass bat- More Time to Escape tion has seemed a simple solution. In ting of the blanket; or a fire-resistant “[With this rule] we were looking at how past practice, the fuselage belly gener- film cover that surrounds the batting. we could get people off the airplane ally has been lined with two layers of For example, one alternate batting before this type of fire — whether it 1-in (2.5-cm) lofted fiberglass batting material — polyacrylonitrile (PAN) — be from a broken or cracked wing or encapsulated in one of many types of in place of fiberglass can become the a [ruptured] belly tank or [other fuel protective film that prevents absorption only fire barrier, Marker said. Blanket leak] — burns through the belly and of condensation. “In the sidewall and fabricators also can laminate a very thin gets access into the cabin,” Marker up near the crown, there can be as many barrier, such as ceramic paper, onto said. “The whole [FAA fire research] as five layers of 1-in lofted fiberglass,” film so that the resulting cover itself program and all the new test methods Marker said. “We don’t see [manufactur- becomes the fire barrier, he said. that we have developed — not just the ers] abandoning anytime soon the use The FAA recognizes that the fire- burnthrough tests — are really aimed at of lofted materials such as fiberglass for penetration test — from the airframe delaying flashover,” a point in fire pro- acoustic and thermal insulation.” manufacturers’ viewpoint — is just gression when the cabin environment Construction of a blanket, assum- one of many criteria for selection of suddenly becomes non-survivable. ing proper installation, determines how insulation materials. “Each [candidate] “During flashover, off-gassing of the well it can function as a fire barrier. material probably has to [pass] some [cabin] materials that are being burned To comply with the new standards, 20-odd internal tests for the airfram- produces flammable gases, and at some fire-resistant insulation can replace ers before it can be used, such as water point these all begin to combust with a industry-standard fiberglass with a absorption and thermal conductivity,” large release of heat and oxygen [deple- more fire-resistant material, including Marker said. “Throw in weight, cost tion] at the same time,” he said. “If we mixed layers of the new material and and burnthrough, and a small group of can extend a flashover that normally fiberglass; a thin fire-resistant material materials will fulfill all those needs.” would have happened at three minutes
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to five minutes, we have basically given last maybe 50 seconds [before melting],” when thermal limits were exceeded. passengers two additional minutes of Marker said. “But every [pool fire] acci- “We used a higher fuel-flow rate so that escape time.” dent is very scenario-dependent in terms we could get the thermal insult [flame One “landmark” case in the study of of available exits, fire size and position, radiation] needed to simulate the full- burnthrough accidents is the British Air wind direction, passenger load, condition scale tests,” Marker said. “If [the tester] Tours Boeing 737 accident at Manchester, of passengers or [a passenger opening an sees the fire coming through before England, in August 1985 in which 55 exit to the fire] … all these are critical in four minutes, the material fails; [when passengers died, Marker said. Recent the ultimate survivability. Two [identical] the tester] looks at the heat-flux trace examples of burnthrough accidents in airplanes both may have 118 people on data, if it was above 2 BTUs per sq ft which all occupants survived were the Air board, but you may have very different per second, the material fails.” France Airbus A340 landing overrun ac- outcomes because of external [factors].” cident in Toronto in August 2005 and the Researchers then wanted to focus on Industry Feedback China Airlines Boeing 737 pool fire on where external fuel fires entered the cabin. Beginning in 1999, the Technical arrival at the gate in Okinawa, Japan, in In the mid-1990s, the FAA con- Center enlisted airframe manufactur- August 2007. The China Airlines accident, structed a full-scale test rig at the ers and their insulation suppliers to according to preliminary findings by Technical Center. It showed that after conduct tests with sets of laboratory Japanese accident investigators cited by penetrating the fuselage skin and any apparatus duplicating the Technical the FAA in two emergency airworthiness insulation present, a pool fire typically Center’s “gold standard” rig and with directives, is a reminder of the role that penetrates entry points from below to blankets of known characteristics. In mechanical failures/malfunctions, includ- the fuselage cheek area, then proceeds these round robin tests, they com- ing uncontained engine failures, may play through cabin floor–level air-return pared fire-penetration results. For in burnthrough accidents, Marker said.2 grills. Another way fuel fires penetrate years, results varied too widely to be One of the most recent fatal burnthrough is through a window, which eventually acceptable; then in 2006 and 2007, the accidents — with 89 fatalities — was the will shrink from exposure to the fuel standard deviation dropped to ac- One-Two-Go Airlines McDonnell Doug- fire and will fall out of place. ceptable levels. “Their people perhaps las MD-82 crash at Phuket, Thailand. “After a year or two of running were starting to become more serious An international search for solu- full-scale tests [on blankets], we started after the rule making, to really pay tions was prompted partly by safety- to develop an appropriate lab-scale test,” attention [to test details],” Marker said. benefit analyses sponsored by the FAA Marker said. “The [FAA and industry] refined the in 1999 and 2003, analyzing 17 burn- test until we were getting a very low through accidents that occurred from Laboratory-Scale Replication standard deviation — significantly 1966 to 1993. The authors argued that The U.K. Civil Aviation Authority and below 15 percent — and it became a the industry would be able to achieve the Direction Générale de l’Aviation repeatable test.” about 12 lives saved annually with fire- Civile of France worked with Techni- Physical characteristics of materi- resistant insulation. cal Center researchers on developing als were another challenge. “By nature, a method for measuring whether thermal acoustic insulation is very light Full-Scale Awareness insulation blankets could resist for at and its density is very low, so it can be The FAA in the early 1990s studied the least four minutes burnthrough caused influenced a lot by the nature of the effects of pool fires on full-scale surplus by a jet of flame from the nozzle of a flame — any deviations in the very commercial jet fuselages by lighting large modified Park burner, the type already intense fire are going to be magni- fuel fires underneath, exposing them to familiar to manufacturers for seat flam- fied,” Marker said. “We [issued] a very temperatures and heat flux approximat- mability tests and cabin panel heat-re- tight specification as to how to set up ing real postcrash fires. “Aluminum skin lease tests. Burnthrough is determined this equipment. We also had a very does vary slightly in thickness depending either by noting the first appearance of tight standard in terms of the output on where you are in the airplane … the a 0.25-in (0.64-cm) diameter hole or by of the burner. From the [round robin], thinnest material would probably last 30 reading data from thermal flux sensors we were able to improve the appara- seconds and the thickest material would on the “cold side” of a blanket showing tus, then we moved into even more
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refinement, providing calibration ma- Research and development also Protection. “We want to make sure they terials that we had tested.” Specifically, will continue on intumescent coat- install blankets in such a way that if the Technical Center later supplied to ings, which were discussed during they do have a fire, the blankets don’t other laboratories its “next generation” the rule making process for fire- fall out and the attachments don’t break burner, called a sonic burner because resistant insulation. When sprayed down,” Marker said. its air-choke regulator contains a onto a substrate such as aluminum Airlines should expect no sig- sonic orifice, also called a critical flow fuselage skin then exposed to fire, an nificant operational changes as a result venturi, that substitutes for the Park intumescent coating swells to form a of switching to airplanes that have burner’s large cast-aluminum pressure thick insulating barrier that can resist upgraded insulation in the lower half vessel. Either burner can be used for flame penetration. “We ran some tests of the fuselage. Extended evacuation certification of materials. where the external skin was coated time cannot be assumed. “There is no with an intumescent, and it showed guarantee that occupants are going to The Way Forward a lot of promise,” Marker said. More get five minutes,” Marker said. “There The Technical Center continues to work needs to be done to address the may be an accident where there is conduct research that may or may not Technical Center’s questions about in- such a large fire threat that it com- lead to standards that complement service wear of the coatings on aerody- pletely overwhelms [the fire-resistant the current standards. “In an exten- namic surfaces and other issues, and insulation barrier]. On the flip side of sion of the burnthrough test using the to establish a safety track record for the coin, there could be an accident identical sonic burner [attached to an them, he said. Comparatively, insula- where the fire is relatively minor, and enclosure containing chemical assay tion in general already has proven to the occupants may get eight minutes instruments],3 we are exposing the in- be robust and low-maintenance; blan- of protection with this new type of sulation from the standpoint of mak- kets are not known to degrade during insulation.” ● ing sure that no toxic materials come the service life of an airliner, he said. off of it,” Marker said. The toxicity test Although the regulation allows Notes was derived from Technical Center airframe manufacturers to propose to 1. U.S. Federal Aviation Regulations Part research in fall 2005 on the combus- the FAA alternate means of compliance 25.856(a). In the flame-propagation test, tion/non-combustion of composite with the standards, “everyone is stick- insulation material exposed to radiant fuselage materials. Several insulation ing to the thermal acoustic insulation heat and a propane-burner flame cannot materials underwent full-scale toxicity approach,” Marker said. “However, propagate the fire more than 2 in (5 cm) tests in late 2007 and early 2008. “If there have been some variations.” One from the flame, and any flame on the material cannot continue more than three we see [toxicity becoming] a problem airframe manufacturer is actively seconds after burner removal. at all, I don’t know [yet] how it would pursuing a design for protecting the be handled, whether there would be bottom side of the cabin floor with 2. FAA. Emergency Airworthiness Directive AD-2007-18-52 said in part, without a new regulation,” Marker said. “Any insulation blankets as the burnthrough specifying the accident, “In another case, regulation would be in addition to barrier. Another likely will continue an initial investigation revealed that the current standards — it would not its practice of attaching blankets to following retraction of the slats after land- impact the compliance date of current the floor of the cargo compartment ing on a Model 737-800 airplane, loose standards.” rather than line the lowest part of the parts of the main slat track downstop belly. Airframe manufacturers also are assembly punctured the slat can, which resulted in a fuel leak and a fire that ulti- Future Technology granted some flexibility in configuring mately destroyed the airplane. We issued Technological advances likely will be the installation of insulation per the [AD-2007-18-51] to detect and correct inevitable. “Lighter, better-performing new standards. loose or missing parts from the main slat materials can replace older ones, and All configurations have to follow, or track downstop assemblies, which could I don’t think insulation will be any provide an equivalent level of safety to, result in a fuel leak and consequent fire.” exception,” Marker said. “We are going the examples in FAA Advisory Circu- 3. The primary instrument for detecting tox- to see lighter insulation that still meets lar 25.852-2, Installation of Thermal/ ic gases in this test is a Fourier transform this very rigid standard.” Acoustic Insulation for Burnthrough infrared spectrometer analysis system. www.flightsafety.org | AeroSafetyWorld | April 2008 | 41 Insight
n December 2007, the Transpor- on this, saying, “A well-conducted ft AGL.” However, later on, the report tation Safety Board of Canada investigation should therefore identify states, “From then on (below the DH), (TSB) published its final report all immediate and underlying systemic the deviations were below the thresh- on the Air France A340 accident causes of an accident and recommend old at which the PNF [pilot not flying] atI Toronto in August 2005 (ASW, appropriate safety actions aimed at was required to make a call regarding 2/08, p. 40). The crew was faced with avoiding the hazards or eliminating the deviations.” These statements are rapidly deteriorating weather during the deficiencies. … Thus, a properly presented as facts but appear to be mu- the approach, deviated above the ILS conducted accident investigation is tually incompatible and contradictory, glideslope about 200 ft above ground an important method of accident and are questionable when compared level (AGL), crossed the threshold prevention.” with Air France’s standard operating of Runway 24L 40 ft high, entered an The understanding of this accident procedures, which unambiguously area of heavy rain during the flare hinges in a large part on understanding state: “After passing decision height, if and landed 3,800 ft (1,159 m) down what the crew actually thought and did, the visual references, the trajectory or the 9,000-ft (2,744-m) runway. This and a transcript of the cockpit voice the position of the aircraft evolve in a left the crew with 5,200 ft (1,585 m) recorder (CVR) is absolutely essential. fashion to compromise the successful of available stopping distance. With a This is especially true since the report completion of the approach or landing, 10-kt tailwind and a wet runway, this says that several standard calls were the captain must initiate a go-around or was not enough; the aircraft ran off missed and that nonstandard proce- missed approach or aborted landing.” I the end of the runway at about 80 kt. dures were applied. For example, the re- think it is safe to say that the trajectory International Civil Aviation Orga- port says Air France procedures require of this flight evolved in a fashion that nization (ICAO) Annex 13, Aircraft the captain to call either “we continue” compromised the successful comple- Accident and Incident Investigation, and or “we go around” at decision height tion of the approach and landing. Manual of Aircraft Accident Investi- (DH). Was this done? We do not know. Should the PNF not have called this gation, Doc 6920-AN/855/4, which Although Doc 6920 says that voice re- out? is currently being replaced by Doc corder readouts “are generally attached According to the report, the crew 9756-AN/965, are assumed to have as an appendix” to an accident report, became “overwhelmed” and “task- guided the development of this report. this report has no CVR transcript at all. saturated” after crossing the threshold Annex 13 says, “The sole objective Yet, the report says, “All relevant data but were also “committed to landing of the investigation shall be the preven- were transcribed in full.” and believed that their option to go tion of accidents and incidents.” Doc The readouts of the flight data around no longer existed.” There is no 6920 says the purpose of the inquiry recorder, in Appendix F of the report, discussion of why they believed they is “to determine the facts, conditions require a specialist to interpret and could not go around, when Air France and circumstances pertaining to the should have been expanded and ex- had taught them that a go-around is accident with a view to establishing the plained in more detail. safe until the thrust reversers have been probable cause thereof, so that appro- In noting Air France’s stabilized deployed. priate steps may be taken to prevent a approach criteria, the report says, The A340 has an automatic voice recurrence of the accident and the fac- “There is no requirement to monitor callout of altitude below 50 ft. It also tors which led to it.” Doc 9756 expands the localizer and glideslope below 200 has a voice command, “Retard,” if the Flawed ReportBY ERIK REED MOHN Questions about the overrun accident in Toronto went unanswered.
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thrust levers are not retarded to idle investigation, which is the prevention would, without doubt, have prevented below 20 ft in manual landing condi- of accidents and incidents.” Further- the accident. In not including the tions. These things are not mentioned more, it states, “Deviations from the documented contraventions as causes, and discussed in the report. accepted norms of compliance with the report fails miserably. The fact that The facts detailed above add up regulations and procedures should the relevant Air France procedures and to an approach that became badly be clearly identified when relevant to regulations requiring a go-around were unstabilized and was carried through the accident … in order to explain the ignored by the crew is not even men- to a very long landing, resulting in a safety implications of the deviation.” It tioned in the conclusions section of the touchdown at a point where stopping also states, “For a contravention to be report. Had a proper go-around been on the remaining runway was impos- included as a cause, it should be clear made, this accident would not have sible. Yet this is not even mentioned in that complying with the regulation or happened. Because of the fuel situation, the conclusions section of the report. procedure could have prevented the the crew would have had to divert to ICAO Doc 9756 says that “blame or accident or lessened the consequences their alternate, and what would have liability might sometimes be inferred of the accident.” happened there is impossible to know. from the [report’s] findings. When To me, at least, it is obvious that But the window they flew through to such is the case, it is essential that all the contraventions documented in this disaster at Toronto would have closed. the causes established be clearly pre- report are the primary causes of the ac- While I am sure that the TSB sented in the report. To do otherwise cident. Complying with the regulations intended to comply with Annex 13 and would jeopardize the objective of the and procedures applicable to this flight other relevant documents, the weak- nesses in this report render it almost useless as a tool for learning and pre- venting future accidents of this kind. The main problem with this report’s misleading and incomplete conclusions is that they prevent a serious discussion of what can be learned from this trag- edy and how this kind of accident can be prevented. If this report is allowed to stand as is, it will cheapen the impact of investigation reports everywhere. The best thing to do is to withdraw the report and reopen the investigation in accordance with paragraph 5.13 of Annex 13. ●
Erik Reed Mohn, a fellow of the Royal Aeronautical Society, is an A340/330 captain for SAS. He was co-chair of the FSF ALAR
© AP Photo/CP, Frank Gunn Frank © AP Photo/CP, Operations and Training Working Group.
InSight is a forum for expressing personal opinions about issues of importance to aviation safety and for stimulating constructive discussion, pro and con, about the expressed opinions. Send your comments to J.A. Donoghue, director of publications, Flight Safety Foundation, 601 Madison St., Suite 300, Alexandria VA 22314-1756 USA or [email protected].
www.flightsafety.org | AeroSafetyWorld | April 2008 | 43 CABINSafety Wayne Rosenkrans Wayne
hallenging questions demanded candid Among the most safety-oriented highlights of Winninganswers from presenters and workshop Formulathe symposium (see “Keeping Cool,” p. 48, and leaders in February 2008 when the South- “Full-Scale Insights,” p. 47) were the following ern California Safety Institute (SCSI) messages. Cbrought flight attendants and other airline Merlin Preuss, director general of civil safety, health and security specialists together aviation in Canada, said that the introduc- for the International Aircraft Cabin Safety Sym- tion of safety management systems urgently posium (CSS) in Montreal. requires research, open dialogue and global People who manage, train and/or compose harmonization of solutions for various cabin today’s cabin crews increasingly see themselves safety problems. “There will be a rapid in- as agents of change in the aviation safety com- crease in the number of seniors in the next munity, according to Sharon Morphew, SCSI’s five years. … The baby-boomer generation manager of the CSS, and other symposium will be traveling more than any other gen- organizers (see “Beyond Expectations,” p. 46). eration,” Preuss said. “Cabin crews then can
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expect to encounter 10 percent of seniors events — heart attacks, for example — is with health issues affecting their mobility or the extremely short time available to make Left, foreground, agility or causing pain; 4 percent with hear- a difference in the outcome. “The chance of Ragna Emilsdottir ing impairments; and 3 percent with vision surviving decreases 10 percent every min- and Heidi Faith impairments.” ute; after 10 minutes [without any first aid], of Air Atlanta Robert Matthews, Ph.D., senior safety ana- you can forget it. … Even if you are over Icelandic, and lyst in the U.S. Federal Aviation Administra- an airport, you will have to wait about 20 Lisa Crocket of tion (FAA) Office of Accident Investigation, minutes before landing — so the responsibil- United Airlines. discussed why the federal transportation poli- ity to respond is on flight attendants, nobody Below, Hilliary. cy says lap infants would be significantly safer else. … [Physician-passengers typically]
Wayne Rosenkrans are not trained to handle out-of-hospital emergencies.” Colette Hilliary, program manager of cabin safety training, FlightSafety Internation- al, said that the industry has been reassessing cabin crew training since the investigation of the Helios Airways Boeing 737 decompres- sion accident in Greece in August 2005. One improvement for some airlines has been to ensure that every portable oxygen bottle is preassembled for instant use. Others have in- troduced flight attendant mixed-gas hypoxia- awareness training, which does not involve a conventional hyperbaric chamber. The train- ing prepares crewmembers to recognize early- onset symptoms and their first/predominant occupying a secured child restraint system in individual symptom, such as tunnel vision or an airliner cabin, yet the government stops numbness; to observe/hear subtle indications short of requiring parents or guardians to buy in the cabin; and to take immediate corrective extra airline tickets for them. The FAA’s posi- action before losing mental acuity because of By Wayne Rosenkrans tion is that the average U.S. family — asked to hypoxic degradation. “The sensations are dif- spend 45 percent more to fly instead of driv- ferent from anything you have ever felt unless ing a typical highway trip of 480 mi (772 km) you have had hypoxia-awareness training,” Symposium’s — would choose highway travel rather than Hilliary said. “Rapid decompression occurs far-safer airline travel. The FAA argues that in one to three seconds, and slow/insidious Winning Formula unflinching focus a net increase in fatalities would occur — at decompression occurs over more than three on concerns raised least 60 more infants killed in motor vehicles seconds. … In a slow/insidious decompres- by flight attendants compared with one infant traveler’s life saved sion, [flight attendants] may or may not hear influences airlines by a child restraint system over 10 years. whistling near the doors or window seals, the Paulo Alves, M.D., medical director of cabin may become cool or appear hazy [but worldwide. MedAire, said that the aging population will these signs] may be slight. What is the first affect the quality and quantity of in-flight indication of a slow decompression that we medical events. “[The percentage of] people have typically? It is the masks dropping out of living beyond age 100 is increasing, and not the passenger service unit.” ● because we are more healthy but because we are surviving our diseases,” Alves said. The For an enhanced version of this story, go to
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Beyond Expectations
he International Aircraft Cabin Safety Symposium (CSS) this year celebrates a quarter century of
T Rosenkrans Wayne facilitating the exchange of increas- ingly specialized knowledge among flight attendants, pilots, airline manag- ers, regulators, aircraft/equipment manufacturers, accident investigators and academic researchers. The airline industry and regulators today count on the expertise, perspective and commit- ment of flight attendants far more than when the first CSS was held in February 1984, co-founder Barbara Dunn says. Around that time, the cabin crew’s role in survivability of major accidents Dunn, with her award, and Sharon Morphew of the Southern California Safety Institute. was coming into sharp focus. The in- flight lavatory fire and emergency land- the flight deck door. When I was hired years to dispel that label of being strictly ing of Air Canada Flight 797 at Cincinnati as a flight attendant in 1971, all I had to a union group,” she said. In later years, in June 1983 — in which 23 passengers do was be able to write down how to the symposium drew more diverse were killed by smoke, toxic gases and open a door. If I could memorize that audiences. Flight attendants demanded flash fire about 60 to 90 seconds after portion of my manual and reproduce it more sophisticated content and showed evacuation began — was one of many on a piece of paper I passed.” willingness to listen to subject specialists reasons to challenge the status quo, As a result, Dunn and a few col- holding viewpoints contrary to theirs; Dunn said. Changes such as floor- leagues in 1982 began pitching the and growing emphasis on crew resource level emergency lighting, fire-blocking idea of a new industry forum dedicated management (CRM) helped to bridge dif- standards for seat cushions, and higher primarily to cabin safety. After first ferences in professional cultures, she said. standards for cabin interior panel flam- approaching Flight Safety Foundation “I have seen a massive improve- mability and smoke toxicity gradually — which began its International Air ment in CRM and joint pilot-flight followed. “Flight attendant training also Safety Seminar in 1947 and Corporate attendant training in CRM,” Dunn said. was improved at that time, with specific Aviation Safety Seminar in 1955, and “Most of the people who come to this attention on firefighting issues,” she said. which began publishing Cabin Crew symposium are in-flight trainers, super- Dunn was then an Air Canada flight Safety in 1956 — she and Toni Ketchell, a visors and safety managers. Our unions attendant and, from 1974 to 1989, flight attendant who in November 1965 are more knowledgeable now as far as national health and safety chairperson of survived the American Airlines Flight safety is concerned. The industry as a the Canadian Airlines Flight Attendants 383 controlled flight into terrain ac- whole looks at us very differently than Association, now the Airline Division of cident near Cincinnati, turned to Richard 25 years ago — we are treated more as the Canadian Union of Public Employees. Brown, Ph.D., director of aviation safety safety professionals by the airlines. We In the late 1970s and early 1980s, she programs at the University of Southern are in a position to accept that respon- found herself increasingly frustrated with California Institute of Safety and sibility in a better fashion.” the lack of action on cabin safety issues Systems Management, who joined them Brown, Dunn and Ketchell were that most concerned flight attendants. in founding the CSS at the university. recognized in Montreal for their roles “In those days, even our safety Cabin safety specialists from flight as the CSS co-founders; Dunn also ac- role on the aircraft was still pretty ill- attendant unions comprised the majority cepted the Excellence in Cabin Safety defined,” she said. “We were not given of CSS attendees in the early years, and Award from the Southern California a lot of credit for any of the expertise their “agitating for improvements” in Safety Institute, which currently con- or knowledge we had. I basically talked existing practices gradually gave some ducts the symposium. to anybody I could about cabin issues. people in the industry an erroneous — WR There just wasn’t a lot of interest in impression of the purpose, Dunn said. what was happening on the aft side of “We have fought very hard over the
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Full-Scale Insights
irbus shared lessons from its hours, half theory/half practice, over said. “Assertive, short, loud and clear full-scale emergency evacuation three days, plus a half-day visit to the commands have no meaning without Ademonstration on the A380-800 demonstration aircraft. “During the the correct body language, gestures — many applicable to cabin crews of aircraft visit, trainees were all told to and facial expressions. There is no any airliner — during the International look around, try out every cabin crew point in shouting a command with a Aircraft Cabin Safety Symposium. station and stand in every assist space,” big smile on your face — no one will Videos of the evacuation, as recorded Jacobs said. “They had to check what take you seriously. Gestures are as by overhead interior cameras, revealed they could see and with whom they important as commands and should more clues to how the two pursers could communicate.” be used in tandem.” The videos show and 16 flight attendants in March Jacobs and her colleagues decided all the flight attendants shouting and 2006 evacuated 873 people in 78 at the outset that psychological prepa- gesturing at a high level of intensity, seconds via three upper-deck slides rations would be essential — specifical- as if expressing extreme anger to all and five lower-deck slides in Hamburg, ly for each flight attendant to be able the passengers. Germany (ASW, 1/07, p. 46). to continuously manage the situation, Instructors deliberately spent time “The behavior and assertiveness be assertive and be direct. Training building trust and friendship during of the cabin crew had a great impact would prepare them to mentally focus breaks/lunches, mixing humor and on the speed with which they man- on their crowd-control techniques, not frequent reminders that each flight aged and directed the passengers on the crowd. “We had to work with attendant is in control with personal and the exits,” said Carmen Jacobs, attitude — we had to give the crew challenges to perform at their best. “We cabin crew training policy manager, confidence in being able to handle a worked with their individuality … their Airbus Training and Flight Operations crowd,” she said. “We had to teach them personalities and skills,” Jacobs said. Support and Services. “The success- [not] that they can be in control — that “They all encouraged one another to ful evacuation in less than 90 seconds they are in control.” practice being able to do things simul- came about with the crowd-control Asserting control then called for taneously and to increase the speed of techniques, our attitude and our dif- specific attention on how to com- their actions.” ferent approach as instructors towards bine conventional commands with For an enhanced version of this story, go to the cabin crew we were training. The delivery techniques that likely would
© Fraport Wayne Rosenkrans Wayne
www.flightsafety.org | AeroSafetyWorld | April 2008 | 47 CABINSafety
Keeping Cool
ifferences between what airline Flight attendants from two airlines management rates as a comfort/ participated in the feasibility phase of Dconvenience issue and what flight a new cabin air quality study June– attendants consider unsafe/unhealthy December 2007 and returned 4,012 can be difficult — but not impossible completed surveys; a report will be — to resolve and objective data help, published later in 2008. In first-phase several presenters told the International feasibility testing, researchers had Aircraft Cabin Safety Symposium. activated air samplers on 47 of 67 paid Christopher Witkowski, director flight segments as of February 2008. of air safety, health and security for AFA-CWA also described a problem- the Association of Flight Attendants– solving partnership with an unspecified Communications Workers of America airline to look at how heat stress in a (AFA–CWA), recapped controversy tropical climate might affect occupants
surrounding cases of exposure to of some ATR 72 aircraft flying in south Rosenkrans Wayne particles of engine oil, hydraulic fluid Florida, U.S., and Caribbean airports (see Grace or byproducts contaminating the air figure). “These aircraft are not config- in passengers or crew, illness symp- provided by the environmental control ured to have an auxiliary power unit on toms reported by passengers or system of a passenger airliner. Past board, so they are extremely reliant on crew, and aircraft-related causal studies have yet to put these concerns ground cooling,” said John Grace, nation- factors. The research relied on the to rest, Witkowski said. al health committee representative. “We U.S. National Oceanic and Atmospheric By early 2008, several initiatives had to come up with a testing protocol Administration [NOAA] Heat Index were in place to help find answers. that would create accurate data that
(percent) 40 in their environmental control system configured for maximum heating effect 20 during winter operations, Grace said.
Predeparture heat index category index heat Predeparture The airline assigned a full-time ground 0 EIS EYW FLL FPO JAX MIA NAS PUJ SJU SLU STT STX monitor responsible solely for prevent- (17) (22) (10) (15) (24) (115) (49) (16) (162) (21) (16) (16) ing excessive heat conditions. Airport (number of measurements) —WR Below warning threshold Caution Extreme caution Danger
Source: Association of Flight Attendants — Communications Workers of America
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Maintenance Check Incorrect installation, inadequate control are highlighted in U.K. maintenance-error reports.
BY RICK DARBY
mong 21 “high-risk” maintenance- incidents into “maintenance control,” “incomplete error reports studied by the U.K. Civil maintenance” and “incorrect maintenance action” Aviation Authority (CAA) from 1996 categories.3 For this latest study’s data set, the CAA through 2005, 12, or 57.1 percent, in- added second-level descriptors and Air Transport Avolved “incorrect maintenance actions,” six, or Association of America (ATA) chapters categoriz- 28.6 percent, involved “incomplete maintenance” ing the affected components (Figure 1, p. 50).4 and three, or 14.3 percent, involved poor “main- Table 1 (p. 50) shows the distribution of tenance control.”1 MORs among the three maintenance-error Of a much larger number of maintenance- types and the second-level descriptors within error incidents of all risk levels in the same each type. The three most frequent ATA study period, about half were attributed to chapters in the data set were chapter 25, “equip- “incorrect maintenance actions,” and about ment and furnishings,” with 19.2 percent of a quarter each to “ineffective maintenance the total; chapter 32, “landing gear,” with 11.0 control” and “incomplete maintenance.” percent; and chapter 27, “flight controls,” with The data were derived from the CAA’s 9.0 percent. When all the chapters, 71–80, mandatory occurrence reporting (MOR) pro- related to engines were combined, however, the gram and included reports involving jet aircraft maintenance errors represented 15.0 percent of heavier than 5,700 kg — considered equivalent the data set, making engine maintenance error to 12,500 lb — maximum takeoff weight.2 The second only to “equipment and furnishings.” analysis began with a database of 3,535 MORs Figure 2 (p. 51) shows the breakdown of citing maintenance error, although 611 reports selected reports under the ATA chapter “equip- were eliminated from the study because they ment and furnishings.” The CAA report said, were judged nonpertinent, leaving 2,924. “By far the most common problem is with escape An earlier study limited to 312 MORs had slides, accounting for 42.0 percent of the oc- developed a taxonomy that sorts maintenance currences in ATA [chapter] 25. Cabin dividers www.flightsafety.org | AeroSafetyWorld | April 2008 | 49 DataLink
Maintenance Error Types and Second-Level Descriptors U.K Reported Maintenance Errors, 1996–2005 Maintenance Percent occurrence Within Type Number Type Maintenance control Scheduled task 223 30.4 Maintenance Incomplete Incorrect control maintenance maintenance action Inadequate tool control 84 11.5 Deferred defect 81 11.0 Airworthiness data Not tted Incorrect t Airworthiness directive Not set correctly Incorrect part Airworthiness data 78 10.7 Certi cation Not removed Incorrect procedure Component robbery* Incorrect repair Tech log 67 9.2 Con guration control Not tted Airworthiness directive 66 9.0 Deferred defect Not set correctly MEL interpretation Poor maintenance practice Modification control 55 7.5 Modi cation control Procedure not adhered to MEL interpretation 37 5.0 Scheduled task Not removed Technical log Configuration control 23 3.1 Inadequate tool control Certification 13 1.8 MEL = minimum equipment list Component robbery 6 0.8 * E.g., inadequate control of parts removed from one component or aircraft to be fitted to Total 733 another. Incomplete maintenance Source: U.K. Civil Aviation Authority Not fitted 268 44.5 Figure 1 Not set correctly 229 38.0 Not removed 105 17.5 Total 602 were a particular problem that one operator had Incorrect maintenance and generated 67 occurrences between 1996 Incorrect fit 619 39.0 and 2004. Issues relating to passenger seats were mainly associated with inadequate attachment Not set correctly 447 28.1 to the aircraft structure.” Incorrect part 160 10.1 Poor maintenance practice 94 5.9 Maintenance-error Maintenance-error reports classified as “landing gear” were fairly evenly divided among Procedure not adhered to 83 5.2 MORs as a percentage wheels, gear and brakes (Figure 3). “The most Not fitted 78 4.9 frequent problem with wheels was associated Incorrect repair 62 3.9 of total MORs with fitting the wheel itself (34.0 percent of the Incorrect procedure 24 1.5 Not removed 22 1.4 received during the wheel issues), while by far the most frequent issue with ‘landing gear’ was associated with Total 1,589 study period varied landing gear safety pins, accounting for 42.0 Grand total 2,924 percent of the ‘landing gear’ occurrences,” said MEL = minimum equipment list from a high of 5.9 the report. Note: Maintenance errors were reported in the U.K. Civil Aviation Authority mandatory occurrence reporting (MOR) For the ATA “flight controls” chapter, the percent in 1997 to program. most frequent reports involved the flaps/slats Source: U.K. Civil Aviation Authority a low of 3.0 percent system, the report said (Figure 4). Among MORs related to the combined ATA engine Table 1 in 2005. chapters, further analysis “showed little of significance,” the report said. Errors involving were categorized as involving “other” engine foreign object debris, borescopes, latches, bolts, components or events. seals, panels and compressor washes accounted Maintenance-error MORs as a percentage for 3 percent or less each. Fully 80.0 percent of total MORs received during the study period
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with three events, or 14.3 percent. Maintenance er- U.K. Reported ‘Equipment and Furnishings’ rors for the combined engine-related ATA chapters, Maintenance Errors, 1996–2005 including chapter 72, “engines,” totaled five. The report discussed the three maintenance error types:
Other Escape Incorrect maintenance action: The report said (31%) slide that this was “clearly the most common category,” (42%) IFE (1%) and “the issues are largely focused around the in- FOD (1%) Cabin correct installation of components, although it is Life vests (1%) divider not possible from the data available to determine Crew seats (2%) (13%) the underlying attributable causes.” Passenger seats Maintenance control: “The focus of hu- (10%) man factors initiatives has largely been on FOD = foreign object debris understanding and preventing maintenance IFE = in-flight entertainment system error based upon the premise that the system, Note: Categories are based on the Air Transport Association of America (ATA) Specification 100 Code, Chapter 25, designed to support the engineers [mainte- “Equipment and Furnishings.” nance technicians], is robust and effective,” the Source: U.K. Civil Aviation Authority report said. “As can be shown from the data, maintenance control issues contribute just as Figure 2 significantly to maintenance error in terms of U.K. Reported ‘Landing Gear’ their effect. Errors associated with configuration Maintenance Errors, 1996–2005 control, deferred defects and control of airwor- thiness directives can impact the integrity of the aircraft in the same way as the actions of the FOD (3%) Other (12%) maintenance [technician].” Control (6%) Wheels (25%) “Failure to perform scheduled tasks” was the Doors (6%) most common error among the second-level de-
Gear scriptors within the “maintenance control” type, Steering (7%) Brakes (22%) with 223 MORs, or 30.4 (19%) percent, falling into that U.K. Reported ‘Flight Controls’ category. “The second Maintenance Errors, 1996–2005 FOD = foreign object debris largest number of errors Note: Categories are based on the Air Transport Association within ‘maintenance Roll control (1%) Pitch control (1%) of America (ATA) Specification 100 code, Chapter 32, control’ was hazards Yaw (2%) Other (3%) “Landing Gear.” Speed brake (3%) Source: U.K. Civil Aviation Authority relating to inadequate Stabilizer (7%) tool control,” the report Figure 3 said. “There were 84 Spoiler (8%) Flap/slat occurrences where this (37%) Aileron varied from a high of 5.9 percent in 1997 to a was the primary cause (10%) low of 3.0 percent in 2005. of the hazard affecting Elevator Rudder The 21 MORs during the study period that the aircraft. Of these 84 (13%) (15%) the CAA classified as “high risk” were distributed events, 43 (51.0 percent) according to second-level descriptors as shown in were due to personnel Note: Categories are based on the Air Transport Association of America (ATA) Specification 100 code, Chapter 27, “Flight Table 2 (p. 52). The three individual ATA chapters inadequately controlling Controls.” associated with the reports were “landing gear,” their own personal tools Source: U.K. Civil Aviation Authority with five events, or 23.8 percent; “flight controls,” or belongings. … Just with four events, or 19.0 percent; and “engine,” three (4.0 percent) of the Figure 4 www.flightsafety.org | AeroSafetyWorld | April 2008 | 51 DataLink
events involved tools particularly between 2001 and 2002, the report U.K Reported ‘High Risk’ that would have been speculated that the drop “may be explained Maintenance Errors, 1996–2005 issued to personnel by the CAA campaigns, conferences and road Percent for which the system shows in 1999 and 2000 on maintenance er- Within Type Number Type would have demand- ror management, culminating in the issuing 5 High-risk incidents — maintenance control ed their return to of Airworthiness Notice 71 in March 2000. Scheduled task 3 100.0 stores after the work Airworthiness Notice 71 laid out CAA’s policy Airworthiness data 0 0.0 had been completed.” on error management and the expectation that Airworthiness directive 0 0.0 Aircraft main- maintenance organizations adopt good human Certification 0 0.0 tenance personnel factors principles and practices in the form of Component robbery 0 0.0 in the United King- instituting error management programs in their ● Configuration control 0 0.0 dom invariably own organizations.” their own standard Deferred defect 0 0.0 Notes equipment, the report Inadequate tool control 0 0.0 said. “These tools 1. CAA Safety Regulation Group. “Aircraft MEL interpretation 0 0.0 are not subject to a Maintenance Incident Analysis.” CAA Paper 2007/04, Modification control 0 0.0 December 2007. Available via the Internet at
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Culture Shock Defining acceptable behavior in a ‘just culture’ has its pitfalls.
BOOKS Trying to reconcile these two value systems has led to a keen interest in the idea of a “just Just Culture: Balancing Safety and Accountability culture” — one that is neither weighted toward Dekker, Sidney. Aldershot, England, and Burlington, Vermont, U.S.: finding fault nor infinitely tolerant. Fairness and Ashgate, 2007. 165 pp. Figure, table, index. justice are its keynotes. o longer do we see accidents as “A just culture is something very difficult meaningless, uncontrollable events,” to define, as ‘justice’ is one of those essentially “NDekker says. “On the contrary: ac- contested categories,” Dekker says. “‘Essentially cidents are evidence that a particular risk was contested’ means that the very essence, the very not managed well enough.” nature, of the concept is infinitely negotiable. But From there it is only a short step to perceiv- that does not mean we cannot agree, or make ing an accident as a “failure” of risk manage- some progress on, some very practical problems ment. Someone’s job wasn’t done right. Someone related to what we could call a just culture.” must be blamed. In the abstract, it is easy enough to come up That normal — if questionable — reaction with a verbal formula to describe a just culture. to an accident stands in the way of an opposite Most people would agree that there is a vast trend in risk management, which is to look at realm in which honest mistakes take place, and the accident as a systemic failure, not the error that those who make them ought not to suffer of a particular person or persons. According as a result, but a “line” separates that realm to this view, the important thing is to create an from negligent or even criminal behavior. atmosphere of organizational trust, in which Nevertheless, says Dekker, “We delude our- people readily acknowledge problems that could selves that there should be consequences for lead to an accident, or that were involved in an operators or practitioners who ‘cross the line.’ incident or accident, so that the causal factors … We don’t realize that lines don’t just exist can be systematically resolved. ‘out there,’ ready to be crossed or obeyed, but There is a tension between these two ways of that we — people — construct those lines, that looking at a situation. A “no blame” culture can we draw them differently every time, and that encourage transparency and allow the organiza- what matters is not where the line goes — but tion, not just individuals, to learn from mistakes. who gets to draw it.” Realistically, however, no organization can afford Dekker cites one typical, and long, definition an absolute hands-off policy toward people of negligence that uses terms such as “normal associated with bad events. Not only does it go standard,” “reasonably skillful,” “reasonable against human nature, it doesn’t acknowledge care” and “prudent,” with a failure to meet such that negligence and irresponsibility exist. benchmarks considered negligent. www.flightsafety.org | AEROSafetyWorld | April 2008 | 53 InfoScan
“Rather than clarifying which operational There is no evidence that a judicial system behavior is ‘negligent,’ such a characteriza- will improve safety, Dekker says: “The idea that a tion shows just how complex the issue is,” charged or convicted practitioner will serve as an Dekker says. “There is an amazing array of example to scare others into behaving more pru- judgment calls to be made. Just see if you, for dently is probably misguided: instead, practitioners your own work, can (objectively, unarguably) will become more careful only in not disclosing define things like ‘normal in the community,’ ‘a what they have done. The rehabilitative purpose reasonable level of skill,’ ‘a prudent person,’ ‘a of justice is not applicable either, as there is usually foresight that harm may likely result.’ … And little or nothing to rehabilitate in a pilot or a nurse don’t we all want to improve safety precisely or air traffic controller who was basically just doing because the activity we are engaged in can his or her job. Also, correctional systems are not result in harm?” equipped to rehabilitate the kind of professional In addition, Dekker says, judgments about behaviors (mixing medicines, clearing an aircraft whether an act was negligent, reckless or oth- for takeoff) for which people were convicted. erwise “over the line” are subject to hindsight “Not only is the criminalization of human bias. That is, knowing the outcome, it is almost error by justice systems a possible misuse of tax impossible to understand the situation as it money — money that could be spent in better appeared to someone who didn’t have fore ways to improve safety — it can actually end knowledge of what would happen. up hurting the interests of the society that the “Of course, it is not that making such judg- justice system is supposed to serve.” ments is impossible,” Dekker says. “In fact, Despite the problems inherent in defining we probably do this quite a lot every day. It is, what is allowed in a just culture, Dekker says however, important to remember that judgment that many organizations adopt pragmatic solu- is exactly what [it is]. … What matters is which tions that work reasonably well. Those solutions, processes and authorities we in society (or you he says, derive from answering three central in your organization) rely on to decide whether questions: Who in the organization gets to draw acts should be seen as negligent or not.” the line between acceptable and unacceptable He is very concerned about the trend toward behavior? What should be the role of domain mixing accident investigations with judicial expertise in judging whether behavior is accept- proceedings. (See “Deterring Criminalization,” able or unacceptable? And how protected are ASW, 3/08, p. 12.) “As long as there is fear that safety data against judicial interference? information provided in good faith can end up being used by a legal system, practitioners are REPORTS not likely to engage in open reporting,” he says. “Many admit that they will only file a report Safety Management Systems for Airports. when there is the chance that other parties Volume 1: Overview will disclose the incident (for example, an air Ludwig, Duane A.; Andrews, Cheryl R.; Jester-ten Veen, Nienke R.; Laqui, Charlotte. Washington, D.C.: Transportation Research traffic controller may think that a pilot will Board of the National Academies, Airport Cooperative Research report a close call if he or she does not), which Program (ACRP) Report 1. 2007. 39 pp. Figures, photographs, list of would make the event known in any case. This abbreviations. Available via the Internet at
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with instituting such a system and explains the the SMS implementation must be assigned at four components or pillars (safety policy, safety an early stage. … The first task is establishing risk management, safety assurance and safety a safety policy that reflects SMS principles. promotion) that are part of an SMS. The report • “Perform a gap analysis. Compare existing also provides the background information on safety components with SMS program the International Civil Aviation Organization’s requirements and identify all elements that (ICAO’s) requirements for SMS at airports and require development. A gap analysis fre- relates the experiences of airports located out- quently begins with a list of all the current side the United States in implementing SMS.” operations and procedures that occur at SMS represents a “next level” approach to the airport. One can then verify whether safety management, which goes beyond analyz- they are performed in accordance with ing past accidents and acting to remedy defects SMS philosophies. found to have been causal factors. It is based on prevention, not only cure. More than that, • “Develop a strategy for SMS implementa- when an SMS is in place, prevention efforts are tion. This is essentially a roadmap that lays not random or brought about just by individu- out the steps required to fully implement als; they are a fixed, standardized component of SMS. The experience of other airports us- every level of an organization. ing SMS may prove helpful in determining “A well-structured SMS provides a system- an efficient phased approach and transi- atic, explicit and comprehensive process for tion plan. managing risks,” the report says. “This process • “Develop individual SMS elements. Fol- includes goal setting, planning, documentation, lowing the roadmap, the processes that and regular evaluation of performance to ensure make up SMS must be developed, docu- that goals are being met.” mented, reviewed and verified.” Among the benefits of SMS for airports, the report says, are reduction of the direct and This overview will be followed by the develop- indirect costs of accidents; improved employee ment of a guidebook that will provide detailed morale and productivity; logical prioritization information about how to develop an SMS at an of safety needs; legal compliance; more efficient airport. The guidebook is expected to be com- maintenance scheduling and resource use; pleted in the last quarter of 2008 and published avoiding operational disruptions; and continu- as the second volume of this report in 2009. ous improvement of operational processes. After sections on ICAO guidance for airport WEB SITES SMS and the experience of airports outside the International Helicopter Safety Team, United States, the report considers a “Vision of
IHST provides a considerable amount of and identifies and implements high-leverage information on its public site. Examples are: interventions or safety enhancements to reduce the fatality rate in these areas.” • Safety analysis reports from Australia, CAST was formed in 1998 as a coopera- Canada, the United tive U.S. government–industry initiative to Kingdom and United identify and implement safety enhancements States, including titles to reduce the commercial aviation fatality such as The U.S. Joint rate in the United States. Its success has Helicopter Safety Anal- enabled it to expand internationally and form ysis Team: Year 2000 regional safety alliances to strategically target Report to the Interna- commercial air carrier accident prevention. tional Helicopter Safety Contact information for international part- Team, September 2007 ners and government and industry members (an analysis of 197 is listed. helicopter accidents in The Web site provides organizational back- one year considered ground and descriptions of the three types of representative of ac- CAST joint safety teams (safety analysis, data cidents in other recent analysis and implementation); the CAST Safety years); Plan; a list of safety enhancements completed • A list of member organizations with active or under way; its glossary and taxonomy; links to their Web sites; CAST reports (1998–2007); and PowerPoint presentations. All can be viewed in full text • The Safety Management Systems Toolkit, online, and printed or downloaded at no cost. edition 1, a compilation of best practices Some documents are large, in color and con- and solutions from small, medium and tain figures and tables. ● large helicopter operators; airlines; in- dustry groups; and governments. Using a performance-based approach, the 40-page document says it “helps the organization determine [its] level of compliance and develop an action plan to include the nec- essary components”; and,
• Fourteen categories of additional resource materials to support information present- ed in the tool kit, such as risk assessment tools, safety communications, safety train- ing, performance measurements, forms, checklists and sample cases.
Commercial Aviation Safety Team, Source
www.cast-safety.org/index.cfm * Transportation Research Board Business Office he Web site says that CAST “identifies the 500 Fifth St., NW top safety areas through the analysis of acci- Washington, DC 20001 USA Tdent and incident data; charters joint teams Internet:
56 | flight safety foundation | AEROSafetyWorld | April 2008 OnRecord Bogus Stall Warning Stick shaker activated four seconds after liftoff.
BY MARK LACAGNINA
The following information provides an aware- maintained the existing pitch attitude. The pilot- ness of problems in the hope that they can be in-command (PIC), concerned that the stick avoided in the future. The information is based pusher might activate, applied forward pres- on final reports by official investigative authori- sure on the control column to reduce the pitch ties on aircraft accidents and incidents. attitude. The 717 was about 168 ft above the runway when the stick shaker ceased. “The crew JETS maintained the aircraft in the existing configu- ration — landing gear retracted, and the wing False Alarm Traced to Slat Sensor Signal flaps and leading edge slats extended — until Boeing 717-200. No damage. No injuries. the aircraft climbed clear of the surrounding he 717 was departing from Alice Springs, terrain,” the report said. Northern Territory, Australia, for a sched- The weather was clear, and the PIC told Tuled flight with 63 passengers to Perth, investigators that visual contact with the ground Western Australia, the morning of Aug. 2, 2006, was maintained throughout the incident. After when the flight crew received warnings of an consulting with company engineers, the crew impending stall. The aircraft was about 31 ft decided to continue the flight to Perth. above the runway, and the pilots were retracting The report said that the false stall warn- the landing gear when the stick shaker activated ings likely were triggered by an incorrect signal and airspeed warnings appeared on the primary generated by one of the two left wing slat flight displays, said the report by the Australian proximity sensors; the other sensor generated Transport Safety Bureau (ATSB). a correct signal. “Consequently, the different The report said that the crew had used slat-position signals from the two sensors in appropriate takeoff settings and techniques. the left wing resulted in the PSEU [proximity- Pitch attitude was 4.5 degrees at liftoff and had sensing electronics unit] defaulting to the increased to 16 degrees, resulting in an angle- slats-not-extended indication for the left wing,” of-attack of 11 degrees, when the stall warnings the report said. “As a result of the different slat- began. Airspeed was 160 kt — 39 kt higher than position signals sent by the PSEU for the left the stall speed corresponding to the aircraft’s wing (slats not extended) and right wing (slats weight and flaps/slats setting. “The aircraft did extended), the aircraft’s flight control comput- not approach an aerodynamic stall condition at ers used the flaps-extended/slats-retracted any time during the [four-second] stick shaker stick shaker angle-of-attack schedule, lead- activation,” the report said. ing to stick shaker activation and other stall The crew responded appropriately to the indications.” stall warning, the report said. The copilot, According to Boeing, the 717 stick shaker the pilot flying, applied maximum thrust and activates at an angle-of-attack of 16.3 degrees www.flightsafety.org | AEROSafetyWorld | April 2008 | 57 OnRecord
with flaps and slats extended, and at 9.5 degrees and the commander selected the Emergency with flaps extended and slats retracted. Yellow brake system, which does not include False stall warnings previously had been anti-skid. reported by two other 717 flight crews. Both Skid marks from the four tires on the main incidents occurred during approaches; one was landing gear extended 473 m (1,552 ft) to where traced to a faulty right slat proximity sensor, the the 146 stopped on the paved undershoot area for other to a PSEU failure. Runway 28. “Toward the end of the skid, all four Boeing, which participated in the investiga- main landing gear tires burst,” the report said. tion, told ATSB that “there were no conclusive No system malfunctions were found, and the findings to establish a root cause of the three 146 was returned to service after the wheels and reported 717 events” and that “there does not tires were replaced. The report did not specifi- seem to be a systemic problem for this issue in cally state why the lift spoilers did not deploy the 717 fleet,” which comprises 156 aircraft. but noted that a friction test revealed that a force of 14 lb (6 kg) was required to move the lever Abnormal Deceleration Misdiagnosed through the airbrake position detent into the BAe 146-200. Substantial damage. No injuries. lift spoiler position and that the aircraft had not he aircraft was inbound with 55 passengers been modified in accordance with a nonmanda- to London City Airport from Paris Orly tory service bulletin requiring a maximum force TAirport the morning of Feb. 20, 2007. The of 12 lb (5 kg). U.K. Air Accidents Investigation Branch (AAIB) “Previous AAIB investigations have found that report said that weather conditions were “be- pilots commonly misdiagnose spoiler failure on nign,” with surface winds from 170 degrees at 5 landing as brake failure,” the report said. “The safe- kt. Runway 10, the landing runway, was damp. ty factors incorporated into landing performance The report said that airspeeds appropriate calculations mean that in the event of a spoiler “Toward the end for the 146’s landing weight, 32 tonnes (70,548 failure, an aircraft which touches down within the lb), included a reference landing speed (Vref) of correct margins of speed, at the touchdown posi- of the skid, all four 110 kt and a touchdown speed of 103 kt (Vref tion, will stop before the end of the LDA [landing minus 7 kt). The landing data card prepared by distance available], provided that appropriate brak- main landing gear the flight crew showed a Vref of 119 kt. Record- ing effort is made by the flight crew.” tires burst.” ed flight data indicated that the aircraft touched down at 119 kt with a level pitch attitude at the Communication Faulted in Turbulence Event end of the runway touchdown zone, about 330 Boeing 757-200. No damage. One serious injury, five minor injuries. m (1,083 ft) from the approach threshold. he airplane was near top of descent at Flight “The data also shows that the lift spoilers Level (FL) 400 (about 40,000 ft) during a flight did not deploy and suggests that the aircraft was Twith 104 passengers from New York to Los probably close to ‘wheelbarrowing’ during the Angeles on April 12, 2007, when the flight crew re- early part of the landing roll, mainly as a conse- ceived information about turbulence below 12,000 quence of the lack of spoilers,” the report said. “It ft. “The captain advised the flight attendants to is likely that the main landing gear was com- have the cabin secured and be in their seats within pressed only just enough to ‘make’ the weight- 15 minutes,” said the report by the U.S. National on-wheels switches, with the aircraft mainly Transportation Safety Board (NTSB). supported by aerodynamic lift from the wings.” The first officer gave the prepare-for-landing The commander said that he perceived “not announcement as the 757 descended through a hint of deceleration” and, believing that the FL 250. “In a written statement, the first officer Green hydraulic system wheel brakes had failed, said that turbulence departing New York had selected the Yellow hydraulic brake system. The been very bad; therefore, in order to miti- aircraft continued “coasting down the runway,” gate any passenger anxiety when he made the
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prepare-for-landing announcement, he added steadily applied more pressure on the brake that the turbulence would not be as bad as it was pedals but felt that the brakes were less effective on departure,” the report said. “The flight atten- than normal,” the report said. “He stated that as dants may have interpreted this added informa- the aircraft decelerated below about 70 kt … it tion concerning turbulence as a relaxation of the began to veer to the right.” “The aircraft captain’s earlier instructions.” The copilot released pressure on the right None of the flight attendants was seated brake pedal and applied full left brake and full landed with the when the airplane encountered turbulence while left rudder. The commander also applied full nosewheel steering descending through 15,500 ft, more than 15 left brake and rudder, and attempted to steer the minutes after the captain’s advisory. The 757, on aircraft with the tiller. “Despite this, the aircraft ‘ON,’ contrary to autopilot, was rolling out of a 12-degree banked continued to veer to the right … and departed turn. The turbulence lasted about 10 seconds; the runway onto the grass,” the report said. Air- instructions in longitudinal and vertical acceleration spiked at speed was about 50 kt when the CRJ ran off the the QRH.” about 2.0 g — that is, two times standard gravi- right edge of the runway; it came to a stop about tational acceleration — and lateral acceleration 16 m (52 ft) from the runway edge. None of the varied between 0.10 g left and 0.05 g right. 36 occupants was injured. All six flight attendants, but none of the Examination of the aircraft revealed a leak passengers, were injured. After the airplane was at the elbow joint of the outlet of one of the two landed, one flight attendant received medical pumps in the no. 3 hydraulic system. “An O-ring treatment for a fractured fibula; the other flight had ruptured, and the failure appeared consis- attendants were treated for minor injuries. tent with a rapid loss of fluid,” the report said. “A NTSB said that contributing factors in the locking wire was missing between the pump and accident were “the apparent conflicting informa- the elbow fitting, and either this or the incor- tion provided by the flight deck to the flight at- rect installation of the O-ring appeared to be the tendants and the flight attendants’ interpretation cause of the failure.” of that information.” Tests of the CRJ’s nosewheel steering system showed that when hydraulic pressure decreased Neglected Checklist Leads to Overrun below the normal value, 1,650 psi, but not below Bombardier CRJ100ER. No damage. No injuries. 650 psi, the system steered slowly right at a hile extending the landing gear during rate of about 1 degree per second without any approach to Southampton (England) command input. “The pressure could be in this WAirport the night of Jan. 17, 2007, the range after a hydraulic leak and with one, or flight crew received indications of a failure of both, of the no. 3 system pumps being ‘ON,’” the the no. 3 hydraulic system. “The commander report said. Below 650 psi, the nosewheel swiv- took what he believed to be the necessary ac- eled freely, as designed. tions prior to landing but without apparent ref- The report said that the hydraulic failure erence to the QRH [quick reference handbook],” occurred more than two minutes before the CRJ the AAIB report said. “As a result, the aircraft touched down and that the incident would not landed with one of the no. 3 hydraulic system have occurred if the crew had conducted the pumps still running and the nosewheel steering QRH procedures. However, if a hydraulic failure ‘ON,’ contrary to instructions in the QRH.” occurred just before touchdown, “it would be The copilot, the pilot flying, said that the unreasonable to expect a crew to take the ap- CRJ touched down normally in the runway propriate actions quickly enough to prevent a touchdown zone and aligned with the center- similar lack of controllability on the ground,” the line. The ground spoilers deployed, and the report said. copilot applied maximum reverse thrust and Based on this finding, AAIB recommended began to apply the wheel brakes. “The copilot that Bombardier “review the design of the www.flightsafety.org | AEROSafetyWorld | April 2008 | 59 OnRecord
nosewheel steering system in the CRJ100 and oth- all of the mechanics indicated that they never er company products, to prevent uncommanded use lanyards and expressed concerns with quick nosewheel steering following a hydraulic failure.” release and escape during an emergency.” Mechanic Pulled Into Engine During Test Ailerons ‘Freeze’ on Transatlantic Flight Boeing 737-500. Substantial damage. One fatality. Dassault Falcon 20. No damage. No injuries. he flight crew saw a puddle of fluid under he Falcon was en route with five passengers the right engine while preparing for a flight from Little Rock, Arkansas, U.S., to London Tfrom El Paso, Texas, U.S., to Houston the Ton May 9, 2007. During approach for a fuel morning of Jan. 16, 2006. A contract mainte- stop in Gander, Canada, the pilot flying noticed nance facility at the airport was asked to investi- that the ailerons were unusually stiff, said the gate the apparent oil leak, the NTSB report said. AAIB report. After aileron trim was centered, There were 114 passengers and five crew- roll control improved, and the commander The captain members aboard the 737 when three mechanics believed that the cause of the stiffness was increased power opened the engine fan cowl panels and began the mistrimming of the ailerons. inspection. “The mechanics made a request to the About two hours after departing from after verifying with captain, via a ground-to-cockpit intercom system, Gander, the commander noticed a flickering for an engine run to check for the leak source,” “TRIM” indication on the primary flight display. the mechanic that the report said. “One mechanic positioned him- “The commander applied corrective trim, in the the area around the self on the inboard side of the right engine, and required direction, but the caption reappeared the other mechanic on the outboard side of the from time to time,” the report said. The com- airplane was clear. engine. The third mechanic was positioned clear mander used aileron trim several times when of the engine because he was assigned to observe the aircraft, which was being flown on autopilot, the procedure as part of his on-the-job training.” began to drift off track. The flight crew started the engine and ran The roll control problem worsened as the it at idle for about three minutes. One of the commander attempted to comply with air traffic mechanics told the captain that a small oil leak control (ATC) radar vectors during the descent was detected, and he asked the captain to run the to London Stansted Airport. During a left turn, engine at 70 percent power for two minutes so bank angle continued to increase; the commander that further checks could be made. The captain disengaged the autopilot when bank reached 45 increased power after verifying with the mechan- degrees. “He found that the roll control was very ic that the area around the airplane was clear. stiff when rolling to the right, and he used the rud- “Witnesses on the ground and in the air- der to bring the aircraft to a wings-level attitude,” plane saw the mechanic on the outboard side of the report said. “Both pilots now applied force to the engine stand up, step into the inlet hazard the control wheel but were unable to move it.” zone and become ingested into the intake of the The crew declared an emergency, advising engine,” the report said. “The mechanic was not ATC that they were able to make only shal- wearing any type of safety equipment or lanyard low left turns. ATC then provided vectors that to prevent the ingestion.” resulted in a series of left, 270-degree turns to The mechanic, 64, had been a certified position the Falcon for the instrument landing maintenance technician for 40 years. He had system (ILS) approach to Runway 23. “The com- received training by the airline on on-call mander was able to intercept and maintain the maintenance procedures but had not received ILS course by using the rudder,” the report said. specific training on ground engine runs and the Surface winds were from 240 degrees at 16 associated hazards. kt, gusting to 25 kt, when the aircraft was landed The report said that during interviews with safely. “Some 20 minutes after the aircraft had the airline’s maintenance technicians, “nearly been shut down, the control wheel was still
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jammed,” the report said. “The [copilot] carried The crew had conducted a Part 91 posi- out an external inspection of the aircraft and tioning flight to Ciudad Juárez, Mexico, where found that he could not move the ailerons either.” cargo was loaded for the return flight to El When the aircraft was inspected 36 hours later, Paso. While taxiing for departure, however, the the ailerons moved freely, and no system malfunc- Metro’s wing tip struck the wing tip of another tions were found. However, a large quantity of airplane. “The [Metro’s] wing tip was repaired water was found below the cabin floor, in the area using duct tape, and the flight then continued to of the roll trim actuator assembly. “As a hand was ELP [El Paso],” the report said. The crew left the dipped into the water in the area of the manual damaged airplane in El Paso and flew another drain, the drain opened and water started to pour Metro on a Part 135 cargo flight to Frankfort, out onto the ground at a considerable rate,” the Kentucky; a positioning flight to Knoxville, report said. “It is estimated that at least 20 liters [21 Tennessee; and a cargo flight to Tuscaloosa, qt] of water was drained from the aircraft.” Alabama. The flight from Tuscaloosa to Grain The Falcon had rarely been operated on Valley was conducted under Part 91; the crew extended flights. The report said that the water was to pick up parts needed to repair the Metro likely had accumulated over a long period that had been damaged earlier in Ciudad Juárez through a leaking cabin door seal and/or over- and return to El Paso. flow from an icebox reservoir. “There appears little doubt that the [water] was responsible for Jammed Power Levers Lead to Overrun the initial ‘heavy’ feel and subsequent freezing of Dornier 328-100. Minor damage. No injuries. the [aileron] controls,” the report said. ompleting a flight from Stavanger, Norway, After the incident, Dassault issued an urgent with 16 passengers on June 22, 2006, the bulletin to Falcon operators, reminding them Ccopilot landed the aircraft at 105 kt and that fuselage drains must be checked before the about 530 m (1,739 ft) from the approach end first flight of the day. of Runway 34 at Aberdeen (Scotland) Airport. “The commander stated later that the touch- TURBOPROPS down was a little further along the runway than he would have preferred, but he considered it to Fatigue Cited in Landing Undershoot be entirely safe,” the AAIB report said. Fairchild Metro III. Substantial damage. One minor injury. With about 1,300 m (4,265 ft) of runway aytime visual meteorological conditions remaining, the copilot was unable to lift the (VMC) prevailed when the Metro struck latches on the power levers that allow the levers Da fence and terrain during approach to the to be moved aft from the flight idle setting to airport in Grain Valley, Missouri, U.S., at 1551 select ground idle and reverse thrust. local time on Aug. 17, 2006. The first officer The company operations manual specified received minor injuries. that the power levers must be moved to the flight The NTSB report said that fatigue was a idle position before attempting to lift the latches. contributing factor in the accident. The flight “There have been instances of premature lifting of crew had been on duty nearly 19 hours and had these latches causing the power levers to become conducted flights under the general operating jammed,” the manual said. The procedure for and flight rules of U.S. Federal Aviation Regula- clearing a jam is to release the latches and move tions Part 91 and the commuter and on-demand the power levers forward and then back to flight operating rules of Part 135. idle before attempting to lift the latches again. The captain told investigators that he was The copilot conducted this procedure but tired and that neither he nor the first officer had again was unable to lift the latches. The com- slept since reporting for duty at the company’s mander then took control, applied heavy wheel base in El Paso, Texas, at 2030 the previous night. braking and made four more attempts to clear www.flightsafety.org | AEROSafetyWorld | April 2008 | 61 OnRecord
the jam. The repeated power applications pre- PISTON AIRPLANES vented the ground spoilers from deploying. “As the aircraft approached the end of the Gear Was Up When Propellers Struck Runway runway, the commander steered the aircraft Cessna 421B. Substantial damage. Two serious injuries. to the left to avoid colliding with the approach he NTSB report said that the corporate pilot lights and localizer antenna on the extended did not extend the landing gear during ap- runway centerline,” the report said. The Dornier Tproach to Marathon, Florida, U.S., the morn- came to a stop about 350 m (1,148 ft) from the ing of May 8, 2006. The pilot radioed that he was end of the runway. conducting an “emergency go-around.” The report The report discussed several previous inci- did not specify whether the landing was rejected dents and a fatal accident — in Genoa, Italy, in before or after the propellers struck the runway. February 1999 — involving the inability of flight The 421 climbed about 100 ft, then descend- crews to move the power levers aft from the flight ed, struck utility poles and crashed in a saltwater idle position. After the Aberdeen accident, AAIB canal. The pilot and passenger-pilot were seri- recommended that the European Aviation Safety ously injured. Agency require the Dornier 328 type certificate Examination of the airplane revealed “ex- holder to redesign the power lever latch system. tensive torsional twisting and bending” of all six propeller blades, several of which had fractured Servo Tab Separation Causes Control Loss or missing tips, the report said. The circuit Viking Air DHC-3T. Substantial damage. No injuries. breaker for the landing gear warning horn was he aircraft, a turboprop conversion of the de found in the “pulled/tripped” position. Havilland Canada Otter, was descending dur- Elevated Cockpit Affects Sight Picture Ting a charter flight with five passengers from Broome, Western Australia, to Cone the morning Carvair ATL-98. Substantial damage. No injuries. of Feb. 15, 2006, when the pilot felt an unusual he flight crew was delivering a cargo of movement in the control system. The Turbo Otter fuel bladders to a remote mining site near then pitched down and entered a rapid and uncon- TMcGrath, Alaska, U.S., on May 30, 2007. trolled descent, said the ATSB report. During the landing flare, the right main landing “With the assistance of the front-seat pas- gear separated when it struck the edge of the senger, the pilot was able to arrest the descent 4,200-ft (1,280-m) gravel runway. The right and regain control of the aircraft before making wing then struck the runway and separated from a precautionary landing at Lombadina Station,” the fuselage, the NTSB report said. the report said. The ATL-98 is a modified Douglas DC‑4. Investigators found that the outboard end of The modification includes replacement of the the right elevator servo tab had separated and forward fuselage with a large nose section com- entered a gross oscillatory movement, or flutter. prising an elevated flight deck and a nose cargo “Aerodynamic flutter within the elevator trim door. The pilot told investigators that, because and servo tabs of the DHC‑3 aircraft type had the sight picture during landing is higher in the been known since the 1960s; however, the devel- Carvair than in the standard DC‑4, “I think I opment of turboprop engine conversions for the was lower than I perceived.” aircraft had resulted in an increased potential for tab failure,” the report said. Aerobatic Maneuver Overloads Airframe An airworthiness directive (AD) issued by Beech 58 Baron. Destroyed. Five fatalities. the U.S. Federal Aviation Administration in 2004 he NTSB report said that after attending a required modification of the DHC‑3 tab assem- recent air show, during which a Beech 18 bly. Similar ADs became effective in Canada in Twas rolled by a performer, the pilot told March 2006 and in Australia in May 2006. acquaintances that he believed he could roll
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his Baron, which is not certified for aerobatic The LongRanger was about 50 ft above the maneuvers. “He had previously attempted to roll road when the oil pressure and torque indi- the airplane, but a pilot-rated passenger stopped cations began to fluctuate. “Right after that, the accident pilot from completing the aerobatic there was an explosion, and the engine failed,” roll,” the report said. the report said. The rear portion of the skids On April 22, 2007, the pilot departed from contacted the ground during the autorotational Gulf Shores, Alabama, U.S., for a personal flight landing, the helicopter pitched forward, and the with four passengers. About an hour later, a wit- main rotor severed the tail boom. ness heard sounds similar to an airplane in aero- Examination of the engine revealed that the batic flight and then saw the Baron descending in a temperature of two of the nine bearings had 45- to 60-degree nose-down attitude at high speed. exceeded 900 degrees C (1,652 degrees F) before “The witness stated he observed a wing or part of the bearings were destroyed. “At this tempera- the tail separate from the airplane,” the report said. ture, it is normal for oil to dissipate rapidly, by The Baron struck terrain near Hamil- evaporation and burning,” the report said. “The ton, Georgia. “Postaccident inspection of the oil level became very low, causing the engine airplane by the NTSB investigator-in-charge oil pump to cavitate and the engine oil pres- and the NTSB Materials Laboratory disclosed sure to fluctuate. Furthermore, since the oil did evidence of pilot-induced overload failures of not return to the tank, the oil temperature did the tail and wings,” the report said. not change, or at least not significantly, and the pilot falsely deduced that the engine oil pressure HELICOPTERS gauge was displaying an incorrect indication.” Because of the extent of damage to the two bear- Normal Oil Temperature Was Deceptive ings, the cause of their overheating and failure Bell 206L-3. Substantial damage. No injuries. was not determined. he helicopter was en route from La Tuque, Quebec, Canada, to Val-d’Or for a sched- Exhaust Duct Separates, Strikes Tail Rotor Tuled maintenance inspection the morning Agusta A109A. Substantial damage. No injuries. of June 7, 2006. About 20 minutes after takeoff, he helicopter was on a positioning flight the pilot observed a fluctuating oil pressure in- from Redhill Aerodrome to pick up two dication and conducted a precautionary landing Tpassengers at Biggin Hill Airport in Kent, in a marsh, said the report by the Transportation England, on Oct. 9, 2006, when the outboard Safety Board of Canada. exhaust duct on the left engine separated and “After shutting down the engine, an unusual struck the tail rotor, causing the tail rotor gear- amount of bluish smoke was observed coming box to separate. out of the exhaust pipe,” the report said. The pilot “After an initial yaw to the right, the pilot telephoned a maintenance technician, who rec- regained limited control,” said the AAIB report. ommended that he check for oil leaks and suffi- “However, a further sudden yaw, possibly as- cient oil quantity, and perform an engine run-up sociated with a partial structural failure of the before contacting him again. While conducting upper vertical stabilizer, prompted an immedi- the run-up, the pilot noticed that oil pressure was ate autorotative descent, which culminated in a low but stable and that oil temperature was nor- successful forced landing.” mal. Believing that the oil pressure indicator was The clamp that had attached the exhaust defective, the pilot decided to fly the LongRanger duct to the engine was found loose in the engine to a road 1 km away. “It appears that the marsh’s bay. The report said that the clamp failure was inaccessibility and the infestation of mosquitoes caused by a stress corrosion crack that could not influenced the pilot’s decision to move the heli- have been detected visually or by nondestructive copter to the road,” the report said. testing unless the clamp was removed. ● www.flightsafety.org | AEROSafetyWorld | April 2008 | 63 OnRecord
Preliminary Reports
Date Location Aircraft Type Aircraft Damage Injuries
Feb. 1, 2008 Trinidad, Bolivia Boeing 727-200 destroyed 159 none En route from La Paz, the flight crew conducted a missed approach at Cobija because of adverse weather and diverted to Trinidad. An emergency landing, possibly due to fuel exhaustion, was conducted in a jungle clearing near the airport. Feb. 1, 2008 West Gardiner, Maine, U.S. Cessna 525 CJ1 destroyed 2 fatal Soon after departing from Augusta State Airport in freezing rain, the pilot declared an emergency and reported an attitude indicator failure. The CJ then crashed in a wooded area. Feb. 1, 2008 Mount Airy, North Carolina, U.S. Raytheon King Air C90A destroyed 6 fatal Visibility was 2 1/2 mi (4,000 m), and ceilings were broken at 300 ft and overcast at 600 ft when the King Air crashed in a residential area during a missed global positioning system (GPS) approach. Feb. 5, 2008 South Padre Island, Texas, U.S. Eurocopter AS 350B2 substantial 3 fatal A local airport was reporting 8 mi (13 km) visibility and a 1,400-ft overcast when the emergency medical services helicopter crashed into the bay while maneuvering to pick up a patient. Feb. 7, 2008 Darwin, New South Wales, Australia Boeing 717 substantial 84 none The 717 entered a high sink rate on final approach and landed hard. Feb. 7, 2008 El Seibo, Dominican Republic Britten-Norman Islander substantial 9 NA The crew conducted an emergency landing after an engine failed during a scheduled flight from Santiago de los Caballeros to La Romana. No fatalities were reported. Feb. 11, 2008 Atlantic Ocean Cessna 310N destroyed 1 fatal The pilot ditched the 310 about 50 nm (93 km) from Keflavik, Iceland, during a ferry flight from Narsarsuaq, Greenland, to Reykjavik, Iceland. Feb. 12, 2008 Caracas, Venezuela McDonnell Douglas DC-9 substantial none The unoccupied DC-9 apparently broke free while being towed from a hangar and crossed a runway before coming to a stop. Feb. 13, 2008 Sterling, Kansas, U.S. Piper Aztec destroyed 1 fatal Daytime VMC prevailed when the Aztec crashed in an open field during a cargo flight from Wichita to Hays. Feb. 13, 2008 Los Roques, Venezuela BAe Jetstream 31 substantial 16 NA The airplane overran the runway on landing and came to a stop on the edge of a lagoon. Feb. 14, 2008 Yerevan, Armenia Bombardier CRJ100ER destroyed 21 minor Calm winds were reported when the airplane flipped over and burned while departing for a scheduled flight to Minsk, Belarus. Feb. 16, 2008 Benton, Kansas, U.S. Cessna 414A destroyed 2 fatal A 300-ft overcast and 6 mi (10 km) visibility were reported when the 414 struck trees and crashed soon after departing under visual flight rules for a positioning flight to Wichita. Feb. 18, 2008 Caico Seco, Venezuela Cessna Citation III destroyed 3 fatal The Citation crashed in a field during a flight from Valencia to Puerto Ordaz. Feb. 21, 2008 Mérida, Venezuela ATR 42-300 destroyed 46 fatal The airplane struck a mountain soon after departing for a scheduled flight to Caracas. Feb. 22, 2008 Kayenta, Arizona, U.S. Raytheon 1900D substantial 2 serious, 3 minor, 15 none The airport had 1 1/2 mi (2,400 m) visibility, a 400-ft overcast and 3 in (8 cm) of snow on the runway when the crew missed the first GPS approach. During the second approach, the 1900 touched down at midfield and overran the runway.
NA = not available This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed.
64 | flight safety foundation | AEROSafetyWorld | April 2008 Let us give you the world. AeroSafety W ORLD
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