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On Propulsion System Malfunction Plus Inappropriate Crew Response

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On Propulsion System Malfunction Plus Inappropriate Crew Response AIA / AECMA Project Report on Propulsion System Malfunction Plus Inappropriate Crew Response (PSM + ICR) Volume 1 1 November 1998 G. P. Sallee D. M. Gibbons AIA Co-Chair AECMA Co-Chair i Foreword This document reports the results of a study to assess the causes and contributing factors in accidents and incidents where a single benign propulsion system malfunction occurred and the pilot(s) did not appropriately handle the situation. This study was undertaken in response to a Federal Aviation Administration (FAA) letter of 6 March 1996 requesting the Aerospace Industries Association (AIA) to use data from a previous AIA activity and a recent accident as a basis for initiating development of guidelines for an engine failure indications system. The AIA responded to the FAA on 19 June 1996 with a letter proposing to undertake the requested activity. The AIA proposed that the initial focus of activity would be on assembling all of the relevant facts and data associated with historical accidents and incidents, experience with various mitigation approaches, fixed-base and motion based simulator capabilities and programs, and other relevant information appropriate to a thorough study of engine failures coupled with inappropriate crew response(s). Once the data collection process had been accomplished, a follow-on phase would analyze and synthesize these data in order to prepare recommended corrective actions. AIA wrote that AIA believed that all parties would be best served by not prematurely focusing on “a solution”. Upon completion of this work a decision gate would be taken before deciding how to proceed into additional phases that could suggest multiple paths and increased use of resources. AIA requested The European Association of Aerospace Industries (AECMA) jointly sponsor and Co-chair the project on “Propulsion System Malfunction Plus Inappropriate Crew Response (PSM+ICR)”. Representatives from all affected organizations were invited to participate mindful that the project would ultimately progress into the Aviation Rulemaking Advisory Committee and Harmonization Processes. The organizations represented included regulatory authorities, accident investigation authorities, pilot associations, airline associations, training companies, and simulator, airplane and engine manufacturers. This report summarizes the facts and data collected, analytical results, conclusions and recommendations for potential corrective action. The report is being transmitted by AIA and AECMA to the Regulatory Authorities for consideration and appropriate action. It has been acknowledged that a similar situation exists in the rotorcraft industry; however, it was agreed in the beginning of this workshop that only Turboprop and Turbofan airplanes would be considered (14 CFR Part 23 & 25). It is recommended that a similar exercise take place for the rotorcraft industry outside of this workshop with the aid of appropriate industry experience. This report is separated into two volumes. Volume 1 contains the report results and appendices 1 through 3. Volume 2 contains the remaining appendices 4 through 15. ii Contributing Organizations and Individuals Aero International (Regional) Claude Bechet J. Andrew Bedson Aerospace Industries Association (AIA) Howard Aylesworth Aerospatiale Johann Hervault Patrick Zaccaria Air Accidents Investigations Branch (AAIB) Peter Coombs K. Smart AIR BC Hans Lammers Garrett Smith Kurt Ruhwald Air Canada John Hart Air Canada Pilots Association (ACPA) Capt. David Edward Capt. Thomas Jerrard Air Transport Association (ATA-STIG – Northwest Airlines) Duane Sebens Gary Vechik Airbus Industrie Yves Benoist Capt. Jim Duncan Jean-Michel Govaere Anne Jany Georges Rebender Capt. William Reichert Airline Pilots Association (ALPA) Kevin Comstock William Edmunds Capt. Daniel Ford Roland Liddell Michael Shelton Tim Hester Howard Long Capt. John Sciera Capt. Roy Tucker Allied Signal Engines David Looper William Moring Allison Engine Company Donald Risser Barry Rohm Association of European Airlines Peter Malanik Atlantic Coast Airlines Ken Latour Atlantic Southeast Airlines (Regional Airline Association) Dean Karnatz Bombardier Aerospace Jim Donnelly David Lamb British Aerospace (BAe) Tim Allen Mike Bayley Paul Emmerson Dave Gibbons Daniel Gurney Len Houston Colin Irvine Martin Maltby Rene Nibbelke CAE Electronics Capt. Kip Caudrey Canadian Airline Pilots Association Al Murray iii Contributing Organizations and Individuals Canadian Airlines International Peter Howe Capt. Jack Tucker Cessna Aircraft Company Doug Hazelwood Donald Mallonee CHIRP Peter Tait Cranfield University Helen Muir Embry-Riddle Aeronautical University Marco Pizer European Regional Airlines Association (ERA) Roy Humphreyson Ian Wigmore Federal Aviation Administration (FAA) Kathy Abbott Donald Armstrong Anne Azevedo Tom Boudreau Martin Buckman Tom Clinton Ed Cook Michael Dostert William Emmerling Steven Kolb Hals Larsen Dy Le George Lyddane Lee Nguyen Lanny Pinkstaff Robert Pursel Thomas Toula James Treacy Federal Express Corporation Capt. Ryan Swah Fokker Services B.V. Wim Overmars General Aviation Manufacturer’s Association William Schultz General Electric Aircraft Engines Roland Crandall Tony Freck Sarah Knife Joseph Marksteiner Gulfstream Aerospace Corporation Ted Mendenhall William Shira Hartzell Propeller Inc. Roger Stallkamp Independent Consultant Tony Wassell International Air Transport Association (IATA) Tore Granaas International Federation of Air Line Pilots Assoc. (IFALPA) Capt. Steve Last Joint Aviation Authorities (JAA/CAA) Robin Boning Hazel Courtney David Lambourne Rex Riddington Laurent Gruz KLM Desiree Van Leeuwen KLM - IFALPA Wynand Moonan Lockheed Martin Aero and Naval Systems Richard Trusis NASA Langley Research Center Paul Schutte Anna Trujillo iv Contributing Organizations and Individuals NASA Lewis Research Center Sanjay Garg Carol Russo Donald Simon National Transportation Safety Board (NTSB) Kenneth Egge Jerome Frechette Douglas Weigmann Pratt & Whitney Canada Mark Feeney Pratt and Whitney Dick Parker Al Weaver Raytheon Aircraft/Beech/Hawker Eric Griffin Conrad Jackson Reflectone Inc. Capt. Bruce Anderson Regional Airline Association David Lotterer Rolls Royce plc John Chambers Michael Cooper David Gibbons Securite’ de Vols – Aviation Safety Pierre Mouton Smiths Industries Aerospace Alison Starr SNECMA-Villaroche Gerard Clergeot Yves Halin The Boeing Company David Carbaugh James Johnson Pam Rosnik G. Philip Sallee William Shontz Jerry Swain Dennis Tilzey Van Winters The Boeing Company – Douglas Products Division Steven Lund Alan Macias Paul Oldale Tompson Training and Simulation Michael Brookes Mark Dransfield Transport Canada Andrew Chan Len Cormier Transport Canada Michel Gaudreau Larry Green Merlin Preuss Transportation Safety Board of Canada Nick Stoss UK Flight Safety Committee Peter Richards U.S. Air Force Ken Burke Major Jeff Thomas U.S. Army Lawrence Katz Robert Wildzunas United Airlines Steve Ferro Chuck Ferrari Capt. Bill Yantiss v VOLUME 1 – TABLE OF CONTENTS Page No. Foreword ii Contributing Organizations and Individuals iii Volume 1 – Table of Contents vi 1.0 Executive Summary 1 2.0 Introduction 4 3.0 Definitions and Acronyms 8 4.0 Data Collection, Analysis Process and Results 12 5.0 Propulsion System Instrumentation and Failure Warning Systems 36 6.0 Simulator Capabilities and Realism with respect to Propulsion System Malfunction 41 7.0 Flight Crew Training 44 8.0 Human Factors 50 9.0 Regulatory Requirements 63 10.0 Conclusions 66 11.0 Recommendations 69 Appendices List 72 Appendix 1 NTSB Final Recommendations for Jetstream 31 Accident, 13 Dec 94 73 Appendix 2 Letter from FAA to AIA 77 Appendix 3 Letter from AIA to FAA 80 vi 1.0 EXECUTIVE SUMMARY The task report presented herewith was undertaken by AIA/AECMA at the request of the FAA in response to an NTSB recommendation arising from the 13 December 1994 turboprop accident at Raleigh-Durham, which resulted in fatal injuries to 15 passengers and 2 crew. The NTSB findings in this event strongly suggested that a warning light intended to indicate the activation of a recovery function was falsely interpreted as engine failure and led to inappropriate crew action. The FAA recognized that there were additional data suggesting that this accident was one of a number of similar accidents, and that a study would be appropriate to look into all commercial transport accident histories where an inappropriate crew action may have been taken in response to what should have been a benign propulsion system malfunction. The rate of occurrence per airplane departure for PSM+ICR accidents has remained essentially constant for many years. These accidents are still occurring despite the significant improvement in propulsion system reliability over the past 20 years, suggesting an increase in rate of inappropriate crew response to propulsion system malfunction. At this point in time, the number of worldwide accidents for this propulsion system malfunction with inappropriate crew response “cause” is about 3 per year in revenue service, with an additional 2 per year associated with flight crew training of simulated engine-out conditions. A Project Group was formed, encompassing experts from authorities, accident investigation agencies, airframe, engine, and simulator manufacturers, and airline, pilot, and training organizations. The group also included human factors experts from various organizations. The Project Group gathered extensive data from all available sources where propulsion system malfunction coupled
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