Aviation Safety World, November 2006
AviationSafety w o r l d BUILDING AFRICAN SAFETY Infrastructure development is key WORKING TIRED Preventing fatigue in aviation AIRPORT CONSTRUCTION RISK Planning preserves safety AUTOPILOT BACKLASH Metro III accident review
CARGO CONCERNS U.S. ACCIDENT RATE DRAWS ATTENTION
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ello to the readers of Aviation Safety of urgency and ownership in the boardroom World and supporters of Flight Safety as it is on the flight line. It must continue to Foundation! involve regulators, leasors, manufacturers, As the new president and CEO of the airlines, airports, insurance firms and more HFlight Safety Foundation, I get this space each in concerted action. I believe one of Flight month to speak my mind about safety and what the Safety Foundation’s key roles is to drive the Foundation is doing. But for my first effort I thought developing safety consciousness for all of these it made sense to tell you a little about me and my institutions, around the world, all of the time. initial plans at the helm of this organization. We already are working with many partners, I join the Foundation after spending many including manufacturers, airport and pilot groups, years at the U.S. Federal Aviation Administration airline associations and air traffic control provid- and International Civil Aviation Organization. ers, to develop a Safety Roadmap that will focus Over the years I have developed an appreciation and coordinate our efforts. for what can be achieved when industry partners Together we can achieve great things. and regulators combine efforts to improve aviation I deeply admire all the accomplishments of the safety. Our aviation system has achieved some Flight Safety Foundation. It’s an awe-inspiring task impressive safety goals – especially in the US, to take over the running of this organization. It has Western Europe, and parts of Asia. a proud history and a well-earned reputation for But we cannot celebrate gains in some regions technical competence and independence. I assure of the world while other regions continue to you that the pursuit of new global goals will not endure tragic losses. Aviation is fundamentally a dilute the technical excellence that has been the global industry. A crash in Western Africa might hallmark of this institution. involve a dry lease from a company in Florida, an I want to acknowledge Stuart Matthews, the airworthiness certificate from southern Africa, outgoing president and CEO. He worked tirelessly an airline based in the Middle East, pilots from to make the Flight Safety Foundation fiscally strong Eastern Europe, and a bank from in the Mediter- and internationally respected. Without his efforts ranean. The aircraft might carry passengers of a over the years, the Foundation would not be in a dozen different nationalities. Accidents today have position to spread the message of safety throughout global roots and have global impacts. We need to the world with the effectiveness it has today. I look find global solutions. forward to continuing that work while we expand The solutions we find must be systemic. Much our efforts in all facets of the aviation industry. of the burden for safety remains on the shoulders of the technical professionals, a burden that grows heavier as the demand for air travel outpaces the development of our workforce and infrastructure.
We must continue the effort to spread the burden, William R. Voss the sense of responsibility for safety. The subject President and CEO of safety must be approached with the same sense Flight Safety Foundation www.flightsafety.org | AviationSafetyWorld | November 2006 | AviationSafetyWorld
contents November2006 Vol 1 Issue 5 features
13 HumanFactors | If You Don’t Snooze, You Lose 13 18 InfraStructure | Basic Needs 25 CabinSafety | Listen Up! 18 28 CoverStory | Balancing Cargo Safety 34 AirportOps | Rebuilding Airports
38 AuditReview | Auditing Management
40 ThreatAnalysis | Tricks of Light
42 FlightTech | Shutting Out the Noise
46 CausalFactors | Cross-Control Upset 28 departments
1 President’sMessage | An Introduction
5 EditorialPage | Open Minds
6 AirMail | Letters From Our Readers
| flight safety foundation | AviationSafetyWorld | November 2006 40 46 contents 34 AviationSafetyWORLD William R. Voss, publisher, 7 SafetyCalendar | Industry Events FSF president and CEO [email protected], ext. 108 8 InBrief | Safety News J.A. Donoghue, editor-in-chief, FSF director of publications [email protected], ext. 116 11 LeadersLog | Basil J. Barimo Mark Lacagnina, senior editor [email protected], ext. 114 51 DataLink | Looking East Wayne Rosenkrans, senior editor [email protected], ext. 115 53 InfoScan | Airworthiness Now Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor 57 OnRecord | Recent Accidents and Incidents [email protected], ext. 113 Karen K. Ehrlich, web and print production coordinator [email protected], ext. 117 Ann L. Mullikin, production designer [email protected], ext. 120 Susan D. Reed, production specialist [email protected], ext. 123 Patricia Setze, librarian [email protected], ext. 103
About the Cover Editorial Advisory Board Cargo airline accident rates in the U.S. remain well above passenger airline rates. David North, EAB chairman, consultant © Steve Lake William R. Voss, president and CEO Flight Safety Foundation We Encourage Reprints (For permissions, go to
www.flightsafety.org | AviationSafetyWorld | November 2006 | Serving Aviation Safety Interests for More Than 50 Years Officers and Staff Chairman, light Safety Foundation is an international membership organization dedicated to Board of Governors Amb. Edward W. the continuous improvement of aviation safety. Nonprofit and independent, the Stimpson President and CEO William R. Voss FFoundation was launched officially in 1947 in response to the aviation industry’s need Executive Vice President Robert H. Vandel for a neutral clearinghouse to disseminate objective safety information, and for a credible General Counsel and knowledgeable body that would identify threats to safety, analyze the problems and and Secretary Kenneth P. Quinn, Esq. Treasurer David J. Barger recommend practical solutions to them. Since its beginning, the Foundation has acted in the public interest to produce positive influence on aviation safety. Today, the Foundation Administrative provides leadership to more than 900 member organizations in 142 countries. Manager, Support Services Linda Crowley Horger Financial Chief Financial Officer Penny Young MemberGuide Flight Safety Foundation Staff Accountant Maya Barbee 601 Madison Street, Suite 300, Alexandria, VA, 22314-1756 USA Membership tel: +1 703.739.6700 fax: +1 703.739.6708 Director, Membership www.flightsafety.org and Development Ann Hill Membership Manager David Chu Membership Services Coordinator Namratha Apparao Communications Director of Communications Emily McGee Technical Director of Technical Programs James M. Burin Deputy Director of Technical Programs Fred Wenger III Technical Programs Specialist Millicent Wheeler Member enrollment ext. 105 Managing Director of Air Ann Hill, director, membership and development [email protected] Transport Safety Services Louis A. Sorrentino III Seminar registration ext. 101 Technical Specialist/ Namratha Apparao, membership services coordinator [email protected] Safety Auditor Robert Feeler Manager, Seminar/Aviation Safety World sponsorships ext. 105 Data Systems and Analysis Robert Dodd, Ph.D. Ann Hill, director, membership and development [email protected] Manager of Exhibitor opportunities ext. 105 Aviation Safety Audits Darol V. Holsman Ann Hill, director, membership and development [email protected] Aviation Safety World orders ext. 102 Past President Stuart Matthews David Chu, membership manager [email protected] Founder Jerome Lederer 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]
| SINCE 1947 flight safety foundation | AviationSafetyWorld | November 2006 Editorialpage OPEN Minds
ore than a century into the degree of fatigue protection — usually There has been dramatic change in age of flight, we have learned pilots and air traffic controllers — to the use of the expression “pilot error,” a lot about aviation safety. Not include other system participants. seen as a sole causal factor much less fre- only have we learned about Pilots are certain to welcome this new quently than several decades ago, when Mthings to do and not to do, we’ve also look at fatigue, having argued for years it was applied to numerous accidents discovered a great deal about extracting that even when regulatory mandates for without the “but why?” sort of questions valuable lessons from the accidents that hours of work, duty and rest are strictly that are asked today, drilling deeper in still occasionally occur. And as the art followed, there are still times when they the causal search process. However, our of flying has developed and matured, feel brain-dead at inopportune moments. current understanding of pilot error lessons learned are compiled in that big Operators, however, diligently enforcing may not push the inquiry far enough, as book of “How Things Are Done,” or not work and duty-time limits set through a story being prepared for an upcoming done, if you will. decades of experience and negotiation issue of this publication will discuss, once Aviation professionals are by nature with workers on one side and national again challenging long-held beliefs with a conservative lot, prone to sticking to a regulators on the other, likely will need a new vision. successful course of action until over- more convincing. This is how it should We must allow ourselves, finally, to whelming proof is presented in favor of be; new ideas should not become part become persuaded by new ideas, if for no a different course. It is hard to argue with of the fabric of aviation without first the other reason than to adjust to changing success, and the vast majority of aviation exercise of rigorous diligence in seeking circumstances and new technology. But practices and assumptions are inarguably validation. our willingness to accept new views of successful. Therefore, with each passing The idea of extending the discussion the accident process and improve our day it becomes more difficult to set aside of fatigue-related limits to new groups ability to affect the elements in the chain what works in favor of what might work of aviation system participants so far has of events leading to an accident must not better. not been embraced. Although this topic get bogged down in satisfaction with our In this issue of Aviation Safety World is still early in the discussion process, I current state of success. we present new ways to look at fatigue expected more of a response than the that go beyond mere hours flown or simple “no” I received this summer when hours served, the new philosophy ad- I asked the top two officials from the Eu- dressing other elements that factor into ropean Aviation Safety Agency if, having mental fatigue. Breaking another barrier, just adopted work rules for those who fly the story also questions whether consid- the aircraft, EASA staff was considering erations of fatigue should be expanded such a package for those who maintain beyond the groups currently having some the aircraft. www.flightsafety.org | AviationSafetyWorld | November 2006 | AirMail
TAWS/EGPWS Misunderstandings was and still is the main safety action, more of these ongratulations to everyone in- the operational emphasis needs to be issues as a factor. volved with the recent approach refocused. Briefings are still important, None of the inci- C and landing accident reduction but they do not necessarily identify chart dents that I reviewed were reported, (ALAR) workshops. errors or procedural misunderstandings. and only a few have been subsequently The risk of controlled flight into ter- Use of an altitude versus range chart investigated — an issue of safety rain (CFIT) remains high; data indicate for all approaches will aid error detec- culture? a continuing threat from many CFIT tion — note the importance of checking Dan Gurney near misses. There appear to be many altitude before range. FSF CFIT/ALAR Action Group misunderstandings about terrain aware- In most TAWS events, the crews did ness and warning system/Enhanced not identify the errors: both crewmem- Editor’s note: See the continuing series in Aviation Safety World, beginning in the July Ground Proximity Warning System bers suffered the same error at the same 2006 issue, on approach-and-landing incidents (TAWS/EGPWS); pilots often retain time, so there was no cross-monitoring. that might have ended in CFIT if TAWS had not inappropriate biases about nuisance Monitoring can be improved with provided timely warnings. This month’s incident warnings which are totally unfounded. good standard operating procedures discussion is on page 40. Honeywell reports over 30 EGPWS (SOPs). Altimeter-setting error is one saves. However, from my research the critical issue (it also affects vertical number is probably over 100; many navigation, or VNAV), so there need flight operational quality assurance/ to be independent paths in obtaining flight data monitoring (FOQA/FDM) and setting the pressure datum before providers are “writing off” EGPWS cross-checking. warnings as faults without justification. The main SOP item is where a pull- encourages In my experience, every EGPWS warn- up procedure uses a conditional check Aviation Safety World comments from readers, and will ing is valid until proven otherwise. — “if visual, if ground clearance has been assume that letters and e-mails There are still vast gaps in crews’ established.” This may not preclude errors are meant for publication unless knowledge about EGPWS capability, — that is, errors of mis-set altimeter or otherwise stated. Correspondence the availability of software updates, visual illusion — that led to the warning is subject to editing for length and database currency and the activation of in the first instance, enabling the crew to clarity. the obstacle mode (already present in believe that they are safe. Thus, these con- all EGPWS). The latter mode has prov- ditional checks give the crew an incorrect Write to J.A. Donoghue, director en its worth in one “save,” a very-near and dangerous “opt out” of the pull-up of publications, Flight Safety miss involving a high-rise building. procedure, or a reason to conclude that Foundation, 601 Madison St., The underlying factors in the EGPWS a nuisance warning has occurred, and Suite 300, Alexandria, VA © 2006 iStock International© 2006 iStock Inc. events are essentially the same as those could strengthen their false perception of 22314-1756 USA, or e-mail identified in Flight Safety Foundation an erroneous altimeter/visual scene. Four
ALAR studies. Whereas fitting TAWS of 12 events that I studied had one or Copyright Photos:
| flight safety foundation | AviationSafetyWorld | November 2006 ➤ safetycalendar
Nov. 23–24 ➤ EU–India Aviation Summit. Feb. 15–17 ➤ 18th Annual Women in Ministry of Civil Aviation of India and European Aviation Conference. Women in Aviation Commission Directorate-General for Energy and International. Orlando, Florida, U.S. Connie Transport. New Delhi. Pallavi Agarwal,
Dec. 5–6 ➤ Airport, Port & Transport Security March 13–14 ➤ 13th Annual Middle May 8–10 ➤ 52nd annual Corporate Europe. London. Sarah Kershaw,
www.flightsafety.org | AviationSafetyWorld | November 2006 | inBrief Safety News ATC Language Change Sought
he U.S. National Transportation on Runway 27R at Philadelphia Inter- had not understood the change in land- Safety Board (NTSB) has recom- national Airport after reporting a cargo ing clearance.” Tmended that air traffic controllers smoke indication (see “FlightOps,” page The recommendation said that, use more precise language when advising 28). although the pilot read back the amended flight crews of a change in the landing The crew had received a clearance clearance for landing on Runway 27L, he runway. for a visual approach to Runway 27R was “in the midst of responding to emer- The recommendation says that, before the smoke indicator illuminated. gency checklist items, and it appears that when amending a runway assignment, After being told of the smoke indication, he did not recognize that the local con- a controller should “provide a specific air traffic control (ATC) — acting in troller had changed his landing runway.” instruction to the pilot advising of accordance with the airport’s emergency The recommendation said that, the runway change; for example, ‘UPS procedures — changed the clearance to to minimize misunderstanding, the 1307, change to Runway 25L, cleared Runway 27L. controller could have asked the pilot “can to land.’” “Although the pilot acknowledged you accept Runway 27L?” and then could NTSB’s Sept. 25, 2006, action fol- the change in landing clearance, he con- have told the crew to “change to Runway lows its investigation of a Feb. 7, 2006, tinued for Runway 27R,” the recommen- 27L.” accident in which the crew of a United dation said. “The controller ultimately The three crewmembers received Parcel Service (UPS) Douglas DC-8- cleared the flight to land on Runway 27R minor injuries in the accident, and the 71F conducted an emergency landing when it was apparent that the flight crew airplane was substantially damaged.
Canada to Increase Landing Visibility Requirements Changes in Australian Airspace Management anadian aviation regulations have approach, flight crew, aircraft and air- been modified to prohibit opera- port requirements. irspace classification and Ctors of commercial aircraft from “This new requirement, combined with designation functions are beginning an approach when visibility existing safety measures and regulations, Abeing transferred to the is so poor that a successful landing is will help to enhance the safety of passengers Civil Aviation Safety Author- unlikely. and crew and help to prevent accidents,” said ity (CASA) of Australia from The regulations, which will take ef- Lawrence Cannon, minister of transport, Airservices Australia in a move fect Dec. 1, 2006, will establish mini- infrastructure and communities. intended to “establish require- mum visibility requirements of at least The change will help Canadian ments for a single common risk- 1,600 ft/500 m, depending on factors regulations harmonize with international management framework and involving the type of instrument standards, he said. processes for assessing and im- plementing future changes, and make agencies more accountable for their regulatory decisions,” said Warren Truss, minister for transport and regional services. The change will place regula- tion of airspace in its “natural home” with the safety regulator, Truss said. He added that new technologies, including automatic dependent surveillance–broadcast for air traffic surveillance, will help provide for “better tracking of aircraft, less restrictive air traffic control separation standards and reduced fuel burn and travel time.”
© Copyright Shutterstock
| flight safety foundation | AviationSafetyWorld | November 2006 inBrief
FAA Asked to Evaluate Safety GPS Trial Extended Inspector Requirements he U.K. Civil Aviation Authority have flown the approaches and only 26 he U.S. Federal Aviation Admin- (CAA) has extended its trial of have provided feedback information, istration (FAA) is being asked to Tglobal positioning system (GPS) ap- Elder said. Tdevelop a new computer model proaches for general aviation aircraft at Those who have provided feed- to evaluate the number of aviation six airports. The trial will continue until back have indicated that they are not safety inspectors required to ade- Dec. 31, 2006. sufficiently familiar with the equip- quately staff the FAA Flight Standards The extension is intended to pro- ment and that there is confusion Service. vide more time for pilots to participate about “procedure representation and The recommendation from the in the trial, said Ron Elder, head of the distance to runway during the final U.S. National Research Council, a CAA Safety Regulation Group’s Licens- approach,” CAA said. “These com- nonprofit institution that advises the ing Standards Division. Of 1,700 pilots ments have significant implications U.S. government on research and who could fly the approaches, 100 for the development of human factors technology, says that the current pilots have registered for the trial, 47 issues and training guidance.” model does not provide adequate © Copyright Garmin, Ltd. staffing. FAA currently employs about 3,600 aviation safety inspectors — 95 percent of them in the Flight Stan- dards Service — and the number has remained stable in recent years, even as the aviation industry has adopted more advanced technologies and new manufacturing tools and techniques, the council said. At the same time, FAA has relied more on designated nongovernment inspectors to perform some tasks previously handled by safety inspectors. New Child Safety Restraint Gains FAA Approval
new type of child safety restraint younger than two years of age to sit has been approved by the U.S. on an adult’s lap during flight, but use AFederal Aviation Administration of an approved child safety device is (FAA) for use on commercial flights. recommended. The device — the AmSafe Aviation © Copyright AmSafe Aviation CARES — is a smaller, lighter-weight alternative to forward-facing child safety seats and is designed for children who weigh between 22 and 44 lb (10 and 20 kg). CARES uses an additional safety belt and a shoulder harness that en- circles the airplane seat back and attaches to the passenger seat lap belt. It is not approved for use in motor vehicles. FAA Administrator Marion C. Blakey said that the device will “provide parents with options so they can make the right decision for their children when they travel by air.” FAA regulations allow children © Copyright Dreamstime © Copyright
www.flightsafety.org | AviationSafetyWorld | November 2006 | inBrief
A380 Vortices Will Extend Takeoff Wait for Other Aircraft
ircraft taking off or landing behind an Airbus A380 would have a longer wait than is now required to avoid wake vortices, according to a study by a panel Copyright Airbus Copyright S.A.S. 2006 © Aof international aviation officials. Airbus said that the study found that, on takeoff, large aircraft following an A380 would be required to wait two additional minutes; medium-sized and small aircraft would wait an additional three minutes. On approach to landing, crews of other aircraft would be required to increase their separation from an A380 preceding them by an additional 2 nm (4 km) for large aircraft, an additional 3 nm (6 km) for medium-sized aircraft and an additional 4 nm (7 km) for light aircraft. TCAS May Be Required in The panel said that overall delays would be shorter than the wait times Canadian Aircraft because there would be no constraints on A380s following other aircraft. The panel’s conclusions may be revised, based on further reviews. ransport Canada (TC) has pro- posed requiring the installation Tof collision avoidance equipment in all large commercial aircraft. The In Other News … proposal, published in September, provides for a 30-day period for public Claire Tomlin, a Stanford (California, U.S.) University associate professor of comment, followed by TC’s review aeronautics and astronautics, is one of 25 recipients of the 2006 “genius awards” of comments and publication of final from the MacArthur Foundation. Tomlin, an aviation engineer whose specialty is regulations. the development of methods for analyzing hybrid control systems and applying the The proposal also calls for installa- results to practical problems, was notified in September that she will receive the tion of traffic alert and collision avoid- MacArthur fellowship and an accompanying US$500,000 grant. … George Ferito, ance systems (TCAS) in all recently a member of the Flight Safety Foundation Corporate Advisory Committee, has manufactured aircraft, TC said. been named director of business development for rotor wing aircraft at FlightSafety “Ensuring Canadian aircraft have International. … William O. McCabe has formed The McCabe Group, an aviation the additional tools to improve safety consulting firm, in Newark, Delaware, U.S.; he is a member of the Flight Safety will help us maintain our enviable Foundation Board of Governors and the Board’s Executive Committee, and a retired aviation safety record,” said Lawrence global managing director for aviation at DuPont Co. … Administrator Marion Cannon, minister of transport, infra- C. Blakey of the U.S. Federal Aviation Administration (FAA) has appointed a structure and communities. committee to develop recommendations on whether the United States should adopt a new international standard to allow pilots over age 60 to continue flying commercial airplanes. The International Civil Aviation Organization standard, effective in November, would increase the age limit from 60 to 65. The FAA Age 60 Aviation Rulemaking Committee is scheduled to complete its work before the end of November.
Ferito Copyright Stanford University Stanford Copyright
© Tomlin
Compiled and edited by Linda Werfelman. Copyright RockwellInc. Copyright Collins, ©
10 | flight safety foundation | AviationSafetyWorld | November 2006 LeadersLOG
Shaping the Future ATC System By Basil J. Barimo
was a watershed year voice communication, radar surveillance and in shaping the future of navigation over fixed points on the ground as its our air traffic control three core components. This effectively creates (ATC) system. The “one-lane roads” in the sky, where aircraft oper- 1956sad fact is that a tragedy — the midair collision ate with verbal guidance from an air traffic con- between two airliners over the Grand Canyon troller monitoring them by radar. The system — had to occur before we took seriously the is straightforward but increasingly inefficient, need for a more proactive approach to develop- as the limited nature of those one-lane roads ing a safer ATC infrastructure. combines with scarce radio frequencies and Moving aggressively in the late 1950s — with radar constraints to cause congestion. The ATC the dawn of commercial jet operations — the system that fueled dramatic economic growth in United States led the world in deploying a the U.S. now threatens to stifle it. state-of-the-art ATC system. Through innova- While the system remains incredibly safe, its tion, and an unfailing commitment to safety design lacks the growth potential to meet burgeon- on the part of both industry and government, ing demand. This demand will grow from 45,000 new technologies continued to improve system flight operations per day to 61,000 daily flight performance and capacity. This innovation operations by 2016. Increased congestion will be- now includes technologies such as the traffic come prevalent as new classes of aircraft — such as Basil J. Barimo is VP of alert and collision avoidance system, which has very light jets and unmanned aerial vehicles — are operations and safety proven to be highly effective. Similarly, the risk introduced into the system. for the Air Transport presented by controlled flight into terrain has In the past, growth has been ac- Association. been substantially reduced through the deploy- commodated by adding more air traffic ment of ground proximity warning system and controllers and equipment and subdivid- terrain awareness and warning system technol- ing airspace. Adding more staffing to the ogy. Wind shear detection and alerting systems, system, however, is providing diminish- another breakthrough for aviation safety, contin- ing returns. As we run out of Band-Aid ue to help pilots avoid dangerous weather. solutions, inefficiency increases. The Today, the result is, inarguably, the safest and situation is further complicated by an the most reliable system of transportation. antiquated funding mechanism that di- However, the concept of operations in vorces system use from system revenues today’s ATC system has not changed since the and, as a result, has not kept pace with 1950s, and that presents us with a real problem. the investment needed to keep the ATC Why? Simply put, the basic design elements system up to date, let alone to undertake of the ATC system cannot be “grown” to meet the modernization needed for next- increasing demand. Today’s system relies on generation technologies. www.flightsafety.org | AviationSafetyWorld | November 2006 | 11 LeadersLog
Without question, the inadequacies of the centers and 168 terminal radar approach current ATC system pose a significant chal- control facilities in the U.S. The fact is, lenge to maintaining the standards of safety and those facilities could be easily consolidated efficiency we expect from the aviation industry. into a handful of secure network-enabled But this crisis is not limited to the airlines; it is operations centers, which would safely and shared among all those who use the National smartly service the entire nation. Airspace System (NAS), including those in the • Increase the capacity and efficiency of the business aviation and general aviation com- current system by leveraging navigation munities. We cannot afford to let delays and equipment already aboard, transitioning to capacity limits become the safety margin of the performance-based NAS, achieving visual future. This human-centric, maintenance-inten- arrival and departure rates during instru- sive, ground-based system must be transformed ment conditions and rationally segregat- to avoid stifling economic growth, which is a ing different types of aircraft to optimize direct result of a safe and vibrant air transporta- traffic flow. The Global Positioning System tion system. does not do much good if we are still The time has come for us to set the course limited to flying along the rigid highways for the future of aviation growth. The wise in the skies. choice — supported by empirical data and We cannot afford decades of analysis — is to begin at once the • Build a system that enables growth through transition to an information-centric, satellite- the deployment of modular technologies for to let delays and driven, digital air traffic management system, a scalable, flexible architecture. Much of the taking full advantage of existing and developing technology envisioned for the future system capacity limits technologies. Efficient growth in system capac- has already been developed and tested. become the ity translates into even higher levels of safety, Although addressing the shortcomings of our an expanding economy, environmental benefits outdated ATC system seems an obvious choice safety margin and continuing world aviation leadership. It is in the face of mounting congestion, the process the smart solution. is fraught with challenges. The transition will of the future. By leveraging existing technologies and require a new approach to the way funding adopting improved procedures, we can facilitate and investment decisions are made, as well as growth and enable the economy to continue to systematic facility consolidation, innovative benefit from an extensive air transport network. financing to accelerate technological deploy- The transformation of the U.S. ATC system ment and a commitment by system users to pay involves more than simply replacing old equip- for the services they consume. All of us must ment and manual processes, however. A closer embrace change. look reveals two distinct but equally important Maintaining the highest level of aviation strategies: deploying technologies and replacing safety and security continues to govern every outdated and redundant infrastructure. There decision as we plan for the next-generation are three key principles to implementing these system. A safer and more secure air transport strategies: system is what the public expects and what U.S. • Reduce the cost of the current system airlines will continue to deliver. Safety and se- through automation and productivity curity are not only the foundation of the airline improvements. Consolidating redundant industry — they are indeed the foundation of facilities, decommissioning obsolete our future. Transforming our nation’s air traffic equipment and procedures, and ratio- control system is a formidable challenge. Bold nalizing the workforce will further free change is needed and tough decisions must be up funds for capacity investments. For made. When the dust settles, the flying public example, today we rely on 21 en route deserves a NAS that is safer, smarter and fairer. ●
12 | flight safety foundation | AviationSafetyWorld | November 2006 humanfactors
If You Don’t Snooze, You Lose There’s more to fighting on-the-job fatigue than simply limiting the number of hours worked.
BY LINDA WERFELMAN
© Copyright iStockphoto
raditional methods of managing fatigue be assumed for mental fatigue. … Regulatory in the aviation workplace by limiting models based only on shift duration are unlikely work hours are inadequate and should to produce congruence between what is safe and be replaced by comprehensive fatigue what is permitted and what is unsafe and not Trisk management systems (FRMSs) that help permitted.” detect fatigue-related behavior and thereby Dawson and McCulloch’s comments were prevent fatigue-related accidents, sleep re- included in one of four fatigue-related presenta- searchers say. tions that were part of a fatigue risk manage- “The traditional prescriptive HOS [hours ment session held during the joint meeting of of service] approach most likely derives from the Flight Safety Foundation 59th annual Inter- earlier regulatory models for managing physi- national Air Safety Seminar (IASS), the Interna- cal, rather than mental, fatigue,” Drew Dawson tional Federation of Airworthiness 36th annual and Kirsty McCulloch of the University of South International Conference and the International Australia Centre for Sleep Research said in Air Transport Association. remarks prepared for delivery at a worldwide Dawson and McCulloch said that recent aviation safety seminar in October in Paris.1 research and policy initiatives in Australia, “While the application of prescriptive duty Canada, New Zealand and the United States limitations may have been an appropriate have examined the “defenses-in-depth” method control for physical fatigue, the same cannot of fatigue management often used in the
www.flightsafety.org | AviationSafetyWorld | November 2006 | 13 humanfactors
© Copyright iStockphoto
military. This method, which includes fatigue “Each of the four steps in the general error management within the framework of a safety trajectory for [an] FRI provides the opportunity management system (SMS), provides a “more to identify potential incidents and, more impor- defensible conceptual and scientific basis for tantly, the presence (or absence) of appropri- managing fatigue-related risk as well as the ate defenses in the system,” they said. If such potential for greater operational flexibility,” defenses are not developed, the overall system they said. probably will not be protected against fatigue- They said that within an SMS framework, related incidents, they said. five levels should be considered in managing For example, limits on a crewmember’s fatigue risk: “sleep opportunity, or average sleep hours of service would be — according to obtained across the organization, actual sleep Figure 1 — a Level 1 defense designed as an obtained by individual employees, presence of attempt to ensure that the crewmember had fatigue-related behavior, occurrence of fatigue- an opportunity for sufficient sleep. If the related errors and occurrence of a fatigue- crewmember did not receive adequate sleep, related accident and/or incident [Figure 1].” the error trajectory would continue beyond In this context, a fatigue-related incident Level 1; “thus, a system with little or no haz- (FRI) is “merely the end point of a causal chain ard controls at Level 2 or beyond may be quite of events or error trajectory and is always pre- poorly defended against FREs,” the presenta- ceded by a common sequence of event classifica- tion said. tions that lead to the actual incident,” Dawson Dawson and McCulloch suggested that a A fatigue-related and McCulloch said. “Thus, [an] FRI is always determination could be made of the likely extent preceded by a fatigue-related error (FRE). Each of a crewmember’s fatigue by calculating the incident … “is merely FRE, in turn, will be associated with an individ- amount of sleep received during the 48-hour ual in a fatigued state exhibiting fatigue-related period immediately prior to beginning work the end point of a symptomology or behaviors. The fatigued state and the length of time from the last wake-up causal chain of events in the individual will, in turn, be preceded by until the end of the shift. If the time awake, as of insufficient recovery sleep or excessive wakeful- the end of the shift, exceeds the amount of sleep or error trajectory.” ness, [which] will be caused by either insuffi- obtained in the 48 hours before beginning work, cient recovery sleep during an adequate break ... there is “a significant increase in the likelihood or by an inadequate break.” of a fatigue-related error, and the organization An FRMS can be effective only if it addresses should implement appropriate hazard-control each of the five levels with organized defense procedures for the individual,” the presentation systems, they said. said.
14 | flight safety foundation | AviationSafetyWorld | November 2006 humanfactors
Defenses-in-Depth Approach to Managing Fatigue
Hazard Assessment Error Trajectory Control Mechanism
Prescriptive hours of service Sleep opportunity/ Level 1 Aggregate prior sleep-wake model Average sleep obtained Fatigue modeling
Actual sleep obtained Level 2 Prior sleep and wake data
Diminishing Fatigue’s Impact Symptom checklists Behavioral symptoms Level 3 Self-report behavioral scales In recent years, Transport Canada has exam- Physiological monitoring ined similar fatigue issues in the Canadian avi- ation industry, where — as in most countries Fatigue proo ng strategies Fatigue-related errors Level 4 — flight and duty time limits apply to flight SMS error analysis system crewmembers but not to aviation maintenance personnel, Transport Canada officials said in a presentation prepared for the IASS (see “Main- Fatigue-related incidents SMS incident analysis system tenance Concerns Yield Plan to Fight On-the- 2 Job Fatigue,” page 16). Level 5 “The main drive to address the fatigue issue Actual Incident in Canadian aviation came initially from the SMS = Safety management system aircraft maintenance side of civil aviation,” the Source: Dawson, Drew; McCulloch, Kirsty. “Managing Fatigue: Defenses in Depth.” In Enhancing Safety Worldwide: Transport Canada presentation said. After a Proceedings of the 59th Annual International Air Safety Seminar. Alexandria, Virginia, U.S.: Flight Safety Foundation, study found that “fatigue and excessive peri- 2006. ods of work may be present in the work force,” Figure 1 Transport Canada developed an FRMS toolbox, designed to aid in implementation of an FRMS — in both flight operations and maintenance therefore contribute to reducing the number of — as a mandatory component of an operator’s fatigue-related incidents and accidents, as well SMS. The next step will be a 12- to 18-month as improving productivity and work-related FRMS implementation trial involving flight satisfaction.” and maintenance personnel at a medium-size Canadian airline. Scheduling Changes “Transport Canada believes that the An FRMS already is in place at easyJet, which implementation of an FRMS as an integral in April 2005 received an “alleviation” from part of [an] SMS will provide the various U.K. Civil Aviation Authority (CAA) flight operators with a flexible and company-specific time limitations, representatives of the airline approach to managing workplace fatigue,” said in a presentation prepared for delivery at the presentation said. “In the long term, it is the IASS.3 expected that well-implemented FRMSs will The alleviation followed a six-month diminish the impact of fatigue problems and trial at two easyJet bases, which eliminated a www.flightsafety.org | AviationSafetyWorld | November 2006 | 15 humanfactors
Maintenance Concerns Yield Plan to Fight On-the-Job Fatigue
oncern about fatigue among aviation work, night work and long working periods,” maintenance personnel — whose duty said Jacqueline Booth-Bourdeau, chief of Ctime often has been unregulated — was technical and national programs of the Aircraft a primary impetus behind the search for Maintenance and Manufacturing Branch of measures to address fatigue in the Canadian the TC Civil Aviation Directorate.2 “The link aviation industry, Transport Canada (TC) of- between fatigue and performance impairment ficials say.1 is somehow perceived as less critical because In a presentation prepared for delivery the maintainer is not seen as being on the at the joint meeting of the Flight Safety ‘front line.’ Foundation 59th annual International Air “The fact remains, however, that many Safety Seminar (IASS), the International maintenance tasks are performed in the Federation of Airworthiness 36th annual middle of the night when the propensity for International Conference and the International human performance error is at its greatest.” Air Transport Association, the TC officials cited — LW past research that found that “maintenance Notes tasks involving planning, documenting, com- municating, supervising, troubleshooting and 1. Marcil, Isabelle; Booth-Bourdeau, Jacqueline; inspecting can be severely affected by fatigue.” Laurence, Mark; Dawson, Drew. “Fatigue One of the officials who produced the Risk Management in the Canadian Aviation Industry.” In Enhancing Safety Worldwide: presentation said, in earlier writings on fatigue, Proceedings of the 59th Annual International Air that the association of fatigue and mainte- Safety Seminar. Alexandria, Virginia, U.S.: Flight nance error has never been as clear as the Safety Foundation, 2006. association of fatigue and pilot error. “This is in spite of the fact that the 2. Booth-Bourdeau, Jacqueline. “Fatigue and physiological challenges are still the same: shift Performance Degradation.” Aircraft Maintenance Technology, March 2001.
“6/3” work roster (three days with early roster, compared with 2.6 per sector on the duties, three days with late duties and three 5/2/5/4 roster. days off) and replaced it with a “5/2/5/4” The presentation said that these and other work roster (five days with early duties, two data supported the April 2005 switch to a days off, five days with late duties and four 5/2/5/4 roster at all 14 easyJet bases. In the days off). months following adoption of the new ros- “The 5/2/5/4 roster was predicted to ter, flight data monitoring found that serious reduce fatigue by decreasing the number of events, such as 500-foot altitude deviations, days worked consecutively and increasing the decreased to about one-third the rate that had amount of time off provided for the change- been reported one year earlier; however, at the over from early to late duties,” the presenta- same time, crewmembers’ complaints of fatigue tion said. increased. Monitoring of crew performance found The airline responded with crew workshops that 1.8 percent of duties on the 6/3 roster designed to produce a better understanding of were associated with a fatigue risk described as the sources of fatigue and their effects on per- “high or very high,” compared with 0.7 percent formance, and the work schedule subsequently on the 5/2/5/4 roster. In addition, line opera- shifted to a 5/3/5/4 pattern, with an additional tions safety audit (LOSA) observers found a day off “as a risk-mitigation step between early mean error rate of 5.2 per sector on the 6/3 and late sequence duties,” the presentation said.
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“The experience of developing a safety case operations, with significant implications for the to work outside [flight time limitations] ... has operational performance of flight crew and the enabled the company to develop a sophisticated overall safety of flight operations.” ● FRMS,” the presentation said. The FRMS has been included within a Notes broader risk-management system, which is 1. Dawson, Drew; McCulloch, Kirsty. “Managing intended to evaluate overall system risk and Fatigue: Defenses in Depth.” In Enhancing Safety implement measures to mitigate those risks, the Worldwide: Proceedings of the 59th Annual presentation said. International Air Safety Seminar (IASS). Alexandria, Virginia, U.S.: Flight Safety Foundation, 2006.
Degraded Crew Performance 2. Marcil, Isabelle; Booth-Bourdeau, Jacqueline; A separate study of international long-haul Laurence, Mark; Dawson, Drew. “Fatigue Risk Management in the Canadian Aviation Industry.” In flight crews found that fatigue was associated Enhancing Safety Worldwide: Proceedings of the 59th with degraded crew performance, especially in Annual IASS. Alexandria, Virginia, U.S.: Flight Safety areas of increased mismanagement of opera- Foundation, 2006. tional threats, increased rates of error occur- 3. Stewart, Simon; Holmes, Alexandra; Jackson, Paul; rence and increased mismanagement of errors Abboud, Rafeef. “An Integrated System for Managing that were detected by the crew, researchers Fatigue Risk Within a Low-Cost Carrier.” In from the Centre for Sleep Research at the Uni- Enhancing Safety Worldwide: Proceedings of the 59th versity of South Australia said in a presentation Annual IASS. Alexandria, Virginia, U.S.: Flight Safety prepared for delivery to the IASS.4 A reduction Foundation, 2006. in sleep during the 24 hours preceding flight 4. Thomas, Matthew J.W.; Petrilli, Renée M.; Lamond, was the fatigue-related variable most consis- Nicole; Dawson, Drew; Roach, Gregory D. tently associated with changes in crew perfor- “Australian Long Haul Fatigue Study.” In Enhancing mance, they said. Safety Worldwide: Proceedings of the 59th Annual IASS. Alexandria, Virginia, U.S.: Flight Safety “Crews take longer to make decisions if Foundation, 2006. they have obtained a small opportunity to sleep, A reduction in sleep based on recent duty history; have obtained a Further Reading From FSF Publications small amount of sleep in the prior 24 hours; are during the 24 hours FSF Editorial Staff. “Fatigue Evaluation Indicates Most experiencing high levels of subjective fatigue; Aviation Maintenance Personnel Obtain Insufficient preceding flight and/or have slow response times,” the presenta- Sleep.” Aviation Mechanics Bulletin Volume 49 tion said. “Taking longer to make decisions may (November–December 2001). was the fatigue- have negative implications for operational safety, Hobbs, Alan; Williamson, Ann. “Survey Assesses as this could lead to greater time pressures, Safety Attitudes of Aviation Maintenance Personnel related variable which may enhance the risk of errors during the in Australia.” Aviation Mechanics Bulletin Volume 48 later stages of flight.” (November–December 2000). most consistently The study also found several areas, such as Caldwell, J. Lynn. “Managing Sleep for Night Shifts associated with improved cross-checking, in which fatigue was Requires Personal Strategies.” Human Factors & Aviation associated with improved performance, perhaps Medicine Volume 46 (March–April 1999). changes in crew because fatigued crews anticipated errors and FSF Editorial Staff. “Overcoming Effects of Stress Offers “devoted more cognitive resources and targeted Greatest Opportunity to Sleep Well.” Human Factors & performance. behavioral strategies towards the detection of Aviation Medicine Volume 45 (July–August 1998). fatigue-related error.” Flight Safety Foundation Fatigue Countermeasures Nevertheless, the researchers said that their Task Force. “Principles and Guidelines for Duty and study “reinforced the conventional wisdom that Rest Scheduling in Corporate and Business Aviation.” fatigue is a real issue within commercial flight Flight Safety Digest Volume 16 (February 1997).
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igh accident rates are the most visible pressure to comply with world air transport consequence of Sub-Saharan Africa’s safety standards, are building hope in the region. challenged aviation system, where The concept of aviation infrastructure used physical infrastructure shortcomings by the World Bank includes not only physical Hand failures of political will have some nations’ assets such as airports, but also elements such air transport systems locked into a downward as laws and safety oversight. Sound governance spiral. Without interventions, their airlines and the political will to competently, strictly risk more accidents and blacklisting by other and transparently conduct safety oversight are regions, and may even have difficulty leasing, essential elements, many specialists agree. financing and insuring newer and safer com- Disparity of safety levels around the world mercial jets. However, new programs to finance was driven home by six major airline accidents the physical and institutional assets needed for in fall 2005. The accidents provided “timely improved safety, backed by international reminders that systemic deficiencies identified
BasicSub-Saharan Africa cannot afford to delayNeeds air transport infrastructure upgrades. By Wayne Rosenkrans
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under the Universal Safety Oversight Audit Pro- standards; no preparation for a safety manage- gram [USOAP] since 1999 were still present,” said ment system (SMS); unstable primary electrical Dr. Assad Kotaite, then-president of the Council power and unreliable secondary power for na- of the International Civil Aviation Organization vaids and lighting; lack of bird hazard programs; (ICAO) in early 2006. Follow-up USOAP visits missing emergency plans and equipment; inad- during 2001–2004 revealed that a significant equate airport fencing and/or perimeter roads;
© 2005 Charles E. Schlumberger/The World Bank World © 2005 Charles E. Schlumberger/The number of the 162 countries had not prepared insufficient or unavailable aircraft rescue and or implemented corrective action plans after the fire fighting; and inadequate pavement mainte- 1999–2001 USOAP audits. nance. Additional problems found included the Left: “We collectively own the world safety re- lack of emergency drills, unserviceable airfield Sir Seewoosagur cord,” said Paul Lamy, chief of the ICAO Flight lighting and approach/runway lighting, faded Ramgoolam Safety Section, during the May 2006 ICAO–Air and/or nonstandard markings, and excessive International Airport, Transport Action Group (ATAG)–World Bank rubber deposits on runways. Mauritius, supports Development Forum. “It is in everyone’s best in- Uncorrected problems included a lack of air tourism. Above: The terest to support effective assistance programs.” traffic control (ATC) service, failure to imple- control tower is a Where help is needed most is obvious: The ment current nonradar procedures for aircraft freestanding structure Africa operator region had only 3 percent of the separation, inadequate coordination between air at Banjul, The Gambia. world’s flights yet 21 percent of the fatal accidents traffic control units, failure to publish current in the 1995–2004 period, according to a 2006 ICAO airport and airport obstacle charts, out- U.K. Civil Aviation Authority (CAA) aviation dated geographic coordinates of ground facilities, safety review of passenger and cargo operations and irregular issuance of notices to airmen. Nev- flown by large jets and turboprop aircraft. The ertheless, progress was reported: In 2005 about 50 rate of fatal accidents — 4.5 per million flight percent of deficiencies noted in air traffic services hours — was higher in this region than any other. in 2003 had been corrected, as had 75 percent of The Nigerian CAA reported that African aeronautical information services deficiencies. airlines had 14 fatal accidents in 2005, with 359 Air transport infrastructure often gets lower fatalities. Twelve of these aircraft were Eastern- priority than water, food, health, power, roads, built types. The International Air Transport education and social welfare, but the irony is Association (IATA) reckoned that 18 percent of that traveler confidence in aviation safety helps all 2005 accidents involved airlines domiciled in address all these by facilitating tourism, business its Africa region; 45 percent were fatal accidents travel, exports and investment. Serious safety and 70 percent were hull losses, said Martin concerns can mean that a manufacturing plant Maurino, IATA’s manager, safety analysis. The or product outlet will not be built, says Charles same data showed a hull-loss rate for Western- Schlumberger, principal air transport specialist built large commercial jets of 9.21 per million in the Transport Division of the World Bank. sectors flown for Africa versus 0.76 worldwide. Airline passengers do not want to be any IATA identified the most significant ac- more concerned about arriving safely than they cident factors as “intentional noncompliance, are about stepping into an elevator in a high-rise 25 percent; flight crew training deficiencies, 25 office building, he said. percent; standards and checking, 25 percent; Solutions underway include closely coordi- deficient flight crew communication, 20 percent; nating the efforts of ICAO, states, industry and inadequate safety management, 15 percent; and development institutions to assist developing poor regulatory oversight, 15 percent.” states; establishing regional safety oversight The main deficiencies reported by the ICAO organizations; and promoting SMS. In extreme Africa and Indian Ocean Planning and Imple- cases, ICAO said that the states should hand mentation Regional Group in 2005 included over safety oversight responsibility to a compe-
© 2006 Julian Whitelaw/Airliners.net © 2006 Julian failure to implement ICAO airport certification tent authority.1
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for some country-level corrective actions and regional safety oversight projects through its In- ternational Financial Facility for Aviation Safety funding mechanism; and arranges assistance from development institutions and industry through its Unified Strategy Program.
Roadmap Part 2 As Aviation Safety World went to press, release was imminent of Part 2 of the Global Aviation Safety Roadmap developed for ICAO by the Industry Safety Strategy Group (ISSG).2 Part 1, issued in March 2006, outlined why states, regions and industry should address 12 problem areas, including these linked to infrastructure: inconsistent implementation of international standards, inconsistent regulatory oversight, barriers to the reporting of errors and incidents, and ineffective accident and incident investiga- tion. Part 2 sets priorities based on an awareness of all world regions, said Robert Vandel, Flight Safety Foundation executive vice president and the FSF representative to ISSG. The roadmap first targets Sub-Saharan Africa. “In 2006, there has been a near-universal agreement among international safety organi-
© 2005 Charles E. Schlumberger/The World Bank World © 2005 Charles E. Schlumberger/The zations to support improvements in Africa,” Vandel said. Deficiencies in the Reform within some CAAs and airlines has oc- African safety specialists influenced safety control tower cab on curred only in response to international rewards or initiatives launched in the 1980s and 1990s. For the roof of the airport sanctions, Schlumberger said. “The ‘stick’ could be example, the FSF Approach-and-Landing Accident terminal at Pemba, the European Commission [EC] aviation blacklist Reduction (ALAR) Tool Kit encourages proven Tanzania, were and/or canceling loans by the World Bank because interventions with or without advanced tech- reported in October of the state of safety oversight in certain countries,” nologies. But some ALAR principles are made 2005. he said. “The ‘carrot’ could be our US$14.5 million irrelevant by infrastructure deficiencies in Africa, grant to Cameroon for security and safety im- said Capt. David Carbaugh, chief pilot, Flight provements at the airports and CAA. Experience Operations Safety, Boeing Commercial Airplanes. shows that political will is the first issue to address “For example, we advocate flying approaches — pleasant theoretical discussions and training as published to improve safety,” Carbaugh said. achieve very little.” “Crews of at least one airline I know in Africa ICAO promotes regional safety initiatives fly approaches using approach plates published such as cooperative development of operational in the 1970s because they got bootleg copies safety and continuing airworthiness programs from another airline. In some areas, there are no (COSCAPs); provides assistance and guidance navaids so crews use handheld global position- for 200 projects in 100 states through its techni- ing system (GPS) receivers and basically make cal cooperation program; operates the Flight up approach procedures. Obviously, it’s tough to Safety Information Exchange Web site; pays follow Tool Kit advice there.”
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The effects of infrastructure defi- reported by the end of 2006 by the Af- in South Africa and Namibia as well,” ciencies in Africa have not been as clear rica Partnership Forum, and reviewed at Radebe said. “An amazing 20 percent as, for example, the causes of approach the G8 summit in Germany in July 2007. of all tourism jobs [about 675,000] in and landing accidents worldwide. In 2005, G8 leaders pledged to cancel Africa are directly related to airborne South African Transport Minister Jeff the debt of the world’s most indebted tourists. … I assume the figures do not Radebe said, “One of the challenges … countries, mostly in Africa, providing count the increasing number of African is the lack of detailed data. … Decisions about $37 billion of debt relief over 40 tourists traveling within the continent.” on solutions and effective allocation of years, the World Bank said. African and non-African airlines resources will continue to be difficult.” Radebe described what is at stake often are hobbled by infrastructure The effects of inadequate mainte- using data developed for ATAG by deficiencies, preventing, for example, nance and the number of aging aircraft Oxford Economic Forecasting when he the substitution of large jets for turbo- in Africa have been assumed to a degree. told a national aviation safety seminar in prop aircraft on internal African routes, “As far as I know, a concentrated, in- February 2006, “Air transport … gener- Radebe said. Infrastructure improve- depth study of infrastructure effects on ates about 470,000 direct and indirect ments also can amplify the competitive the accidents in African countries has jobs across Africa, contributing over disparities among airlines. not been done,” Carbaugh said. “While $11.3 billion to African gross domestic Christian Folly-Kossi, secretary poor [aircraft] maintenance is part of product. If we add sectors such as tour- general of the African Airlines Associa- the problem, it is rarely directly a cause. ism that owe their existence to the air tion (AFRAA), in a May 2006 speech However, I believe that it is indirectly a transport sector, then the number of jobs said that African airlines are struggling cause of many of the accidents. Crews increases to about 3.1 million and the to compete. “African air transport is often have multiple inoperative equip- contribution to African gross domestic in deep crisis,” Folly-Kossi said. “The ment issues to deal with on every flight. product reaches some $55.5 billion.” African market currently represents 4.5 Unfortunately, many of the accident re- Tourism-fueled economic growth percent of the global traffic. Out of this, ports do not go into this kind of depth.” requires safe flights from both outside foreign airlines operate more than 70 of Africa and on intra-African routes. percent of the traffic and a small por- Competing Values “Tourism is a driving force in a number tion is left for Africans. … The global Shaping development assistance of African countries, including Kenya, liberalization that was precipitated worldwide are eight Millennium Mauritius, Morocco, Tunisia, Egypt, on the market, [without] control and Development Goals of the United Ghana, Senegal and Tanzania, and is as- safeguards, [had] a devastating impact Nations — which have a target date of suming an ever-increasing importance on many African countries.” 2015. A committee of 19 African states representing the African Union also The runway was in has laid out an agenda called the New “very poor condition” Partnership for Africa’s Development. at Arusha, Tanzania, The agenda partly seeks “to increase air but ability to compete passenger and freight linkages across with Kilimanjaro Africa’s subregions” and to “promote International private-public partnerships in the ra- Airport influences tionalization of the airline industry and redevelopment. build capacity for ATC.” The Group of Eight major industri- alized democracies and the European Union have agreed to increase develop- ment assistance in Africa by $25 billion a year by 2010 to support the objectives of the New Partnership for Africa’s De- velopment. Progress is scheduled to be
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© 2005 Charles E. Schlumberger/The World Bank Infrastructure
Travel between capitals of some Af- private capital. Africa’s domestic airline World Bank Angle rican states still requires a connection in industry has been at an impasse, how- Among several governments and large Europe thanks to slow implementation ever, given problems such as managing development institutions concentrat- of the continent’s open skies agreement, the change from traditional bilateral ing on Africa, the World Bank provides the Yamoussoukro Decision, ratified route agreements between states and $251 billion in worldwide loan com- in 2000. “The domestic continental inexperience regulating airline com- mitments, with about $32 billion (12.7 market should be built, liberalized and petition. Abdoulie Janneh, under-sec- percent) allocated to the transport sec- controlled by carriers of the continent,” retary-general and executive secretary tor, primarily for roads. Only around Folly-Kossi said. “As prescribed by the of the U.N. Economic Commission $1 billion of that $32 billion has been Yamoussoukro Decision, Africa as a for Africa, said, “Unfortunately, some allocated for air transport, including in- whole should … be a single airspace.” African countries are reluctant to fully frastructure. “With African institutions Ethiopian officials told a 2006 implement the Yamoussoukro Decision led by the African Union and ICAO, forum that the Yamoussoukro Decision because of their local aviation industry’s we are preparing a multi-donor facility “remains the single most important air fear of competition from foreign air- [loans and grants] for 2007,” Schlum- transport reform policy initiative by Af- lines.” Competitors include companies berger said. “This Africa project, our rican governments to date” to develop in other African states and non-African first on a large scale, will be operational intra-Africa air services and attract airlines that invest in them. in 2007–2010.”
State priorities include road construction in Nigeria and malaria treatment by Médecins Sans Frontières staff in Burundi. A community © 2002 Stuart Franklin/Magnum Photos © 2003 Ian Berry/Magnum Photos rally on the airport apron at Bukoba, Tanzania, coincided with a World Bank visit. Wayne Rosenkrans (FSF) Wayne Schlumberger © 2005 The World Bank World The © 2005
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The project includes elements to $14.5 million and Mali received $7.1 VSAT now provides many aeronauti- analyze and report on economic, legal million in IDA grants. Safety-related cal fixed telecommunication network and social benefits of liberalized air elements of the financing include tech- links, correcting a deficiency that lasted transport in Africa, the current state nical assistance for safety oversight and for decades. “This set of [telecommunica- of infrastructure and aircraft opera- autonomy; basic communications and tion] networks will provide a robust back- tors, policy and institutional capacity of aircraft inspection equipment; and re- bone for the improvement of both fixed countries, assessing regulatory over- placing navaids at the primary airports. and mobile communications,” he said. sight of safety (i.e., through USOAP) Another project is a $44 million FAA initiatives in African states and security and liberalization of IDA grant to Sierra Leone partly for have included technical advice on GPS air transport services; creation of an airport infrastructure and for improved navigation, law making and rule mak- implementation strategy tool kit based airport authority management. ing. “Our Safe Skies for Africa program on regional inputs; and coordinating all Whether revenues from aviation is engaged in ‘invisible infrastructure’ financial and technical assistance from alone can pay for infrastructure depends — not concrete and steel,” said Hank several donors and partners. on local factors. For example, the Tan- Price, an FAA spokesman. The program One model project is in Tanzania, zanian CAA raised $10.3 million for its and IATA jointly provide flight inspec- involving commitments of $20 million infrastructure in fiscal year 2005–2006 tion services for satellite-based systems for runways and $10 million for auto- by imposing an $8 airline ticket safety and related procedures in 14 states. matic dependent surveillance–broad- surcharge for international passengers. “ICAO’s Model Civil Aviation Safety cast (ADS-B).3 “In Tanzania, there is Mongolia, in North Asia, distributes Act and Model Civil Aviation Regula- one radar in Dar es Salaam and … the about 30 percent of $40 million received tions [MCARs] and associated guidance country is huge,” Schlumberger said. annually from overflight fees to air materials have been adapted to meet Another model project is in Cape transport infrastructure, regulation and [states’] own needs and requirements,” Verde, where TACV–Cabo Verde safety oversight, Schlumberger said. he said. “Cape Verde, The Gambia, Gha- Airlines now operates weekly service Sometimes infrastructure benefits na, Liberia, Nigeria and Senegal have between the national capital Praia and the whole continent. An example is used the MCARs. With FAA assistance Boston using Boeing 757-200ERs. “Cape IATA’s technical assistance for ATC and financial support, Kenya, Tanzania Verde received Category 1 [meets ICAO communications in Angola, Ghana and and Uganda have used the MCARs as standards] from the U.S. Federal Avia- Sudan, and for ATC surveillance in a basis to revise and harmonize their tion Administration [FAA] International Democratic Republic of Congo (DRC), regulations for use under a proposed Aviation Safety Assessment program Nigeria, Sudan and Tanzania. regional safety oversight organization.” after we had supported the country with “IATA assistance [in DRC] has a $1.2 million loan for capacity building resulted in the deployment of the VSAT Jumping Ahead and regulatory reform,” he said. “There [very small aperture terminal, fixed Advanced technologies could allow is a new law and a well-formed CAA satellite terminals that provide interac- some nations to jump ahead of inad- staff. This is the dream we want our cli- tive or receive-only voice/data com- equate legacy infrastructure, and often ents to achieve. Operating to the United munication] network,” Maurino said. will be “scalable for free,” according to States brings economic development.” “The Régie des Voies Aériennes (RVA), Boeing Commercial Airplanes.4 Major The World Bank also has a $150 the Congolese air navigation service safety-enhancing technologies include million project to help 23 West and provider, has established a special ADS‑B, satellite-based navigation, Central African CAAs comply with investment fund derived from RVA airborne collision avoidance system, ICAO safety and security standards, en route charges collected by IATA. terrain awareness and warning system and enhance security of their main Without the extended VHF coverage and flight data monitoring. international airports. In the first in western DRC, two new international Schlumberger advocates rapid phase, Burkina Faso received $6.46 RNAV/RNP10 [area navigation/re- adoption of satellite-based instrument million and Mali received $5.51 million quired navigation performance] routes approaches. “At the 2002 ICAO air in International Development Associa- could not have been opened to traffic in navigation conference, I said that devel- tion (IDA) credits; Cameroon received May 2006.” oped countries should start financing www.flightsafety.org | AviationSafetyWorld | novemBER 2006 | 23 Infrastructure
standalone GPS approaches in Africa,” or flight management system-based Ultimately, perpetuating the cur- but the proposal met opposition from Mode S extended squitter [ADS-B 1090 rent safety level can mean that the only those seeking an even bigger techno- MHz data link] for air carriers and a passenger airlines capable of profitably logical leap, he said, while “Africa has GPS-based Universal Access Transceiver serving Africa will be a few non-African air carriers … flying into mountains (UAT) ADS-B data link for general avia- carriers such as Air France and British every week or every month.” tion [in Tanzania],” he said. IATA’s posi- Airways and a few African operators such Years later, the EC, European Space tion favoring ADS-B as the surveillance as Ethiopian Airlines, Kenya Airways and Agency and Eurocontrol are preparing tool — but suggesting multilateration as South African Airways, Schlumberger to augment GPS and Galileo satellite an interim solution — has been accepted said. “I don’t think the world will give up navigation system signals in Europe by African states, Maurino said. Pending on safer aviation in Africa, but we can’t and Africa with the European Geo- implementation of ADS-B, multilatera- just wait another 20 or 30 years,” he said. ● stationary Navigation Overlay Service tion could enable ATC to track aircraft (EGNOS); EGNOS certifications for equipped with the Mode S extended Notes air navigation with GPS signals and squitter or ADS-B UAT or Mode S radio 1. International Civil Aviation Organization Galileo signals are scheduled for 2007 frequency data link (ACAS/ACAS II) or (ICAO). Report: Directors General of Civil and 2008, respectively. basic Mode A/C transponder replies.5 Aviation Conference on a Global Strategy “If I want to fix the problem today, African leaders have considered for Aviation Safety. March 20–22, 2006. I take what works,” Schlumberger said. ADS-B trials in light of ICAO’s en- 2. The Industry Safety Strategy Group “We are losing lives, so we should fi- dorsement of the Mode S extended comprises Airbus, Airports Council nance what is available today to reduce squitter; the avionics in new Airbus International, The Boeing Co., Civil Air accidents. The World Bank budgets and Boeing airplanes; and Australia’s Navigation Services Organization, Flight about $100,000 to $150,000 to conduct experience. Airservices Australia in Safety Foundation, International Air Transport Association and the International a WGS 84 airport site survey [for a 2007 is scheduled to be first to imple- Federation of Air Line Pilots’ Associations. GPS approach with vertical guidance] ment ADSB across a state’s entire that enables descent to 250 ft above the upper-level airspace, providing radar- 3. The U.S. Federal Aviation Administration has announced that initial implementa- highest obstacle, typically a minimum like surveillance throughout domestic tion of automatic dependent surveil- descent altitude of 400 to 500 ft.” airspace above 30,000 ft with 28 ground lance‑broadcast (ADS-B) for all U.S. Satellite-based navigation for Africa receivers and upgrades to its air traffic airspace will begin in fiscal year 2007; the comparable to the level established in management systems.6 full evolution is expected to take 20 years. the U.S. already is on the horizon. “The Worldwide auditing prompts ac- ADS-B equipment aboard an aircraft implementation of RNAV procedures at tion to fix infrastructure, and African downlinks data, including its three-di- mensional position, once per second. selected African international airports CAAs have taken strong interest in the will set examples for the use of RNAV IATA Operational Safety Audit (IOSA). 4. Lewis, Michael. “Challenges and procedures at secondary airports where “USOAP for states has led to COSCAP Opportunities of a Next Generation Air ground aids do not exist,” Maurino said. projects and to the joint safety oversight Transport System.” A presentation to the ICAO-ATAG-World Bank Development Ten reference and integrity monitoring project of the East African Commu- Forum, May 2006. systems soon will complete preopera- nity’s Africa and Indian Ocean office,” tional trials for EGNOS, which will Maurino said. “A total of 104 airlines 5. Wide-area multilateration uses “time dif- provide ICAO’s APV-1 performance and 32 states have participated in IOSA ference of arrival” techniques that enable an air traffic control central processor on level, 20 m [66 ft] vertical accuracy. seminars, and 19 gap audits [pre-audit the ground to triangulate three-dimen- Four additional reference and integrity assessments of where standards are not sional aircraft positions from basic aircraft monitoring systems will be required to met] have been conducted in develop- transponder replies or other data down- enable APV-1 approaches throughout ing countries worldwide, with another linked to a network of low-cost ground Africa. 29 scheduled in 2007. Seven of the 19 receivers that later can be used for ADS‑B.
The World Bank favors ADS-B for airlines have already progressed to a full 6. Airservices Australia. “Airservices African states for ATC surveillance. “We IOSA audit. Madagascar and Nigeria and SITA Undertake ADS‑B Trial in can implement a dual system GPS-based have mandated IOSA.” Indonesia.” Media release, Feb. 15, 2006.
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ListenA study seeks to model — and improve — passenger attention to safetyUp! briefings.
BY RICK DARBY
assengers do not pay as much negative assumptions — such as skepti- • Repetition. “Most respondents attention to cabin safety briefings cism about the likelihood of surviv- believed they had heard all the as they should, and airlines need ing — could stand in the way. As one content in the briefing before,” the to consider new strategies to mo- respondent said, “If there is going to be report says. “Ten percent pro- Ptivate them, according to a recently pub- a problem, I think all hell is going to vided unprompted feedback that lished report by the Australian Transport break loose, so [safety information] is they considered the briefing too Safety Bureau.1 The report offers 13 sug- not going to make any difference.” boring, and 29 percent agreed, gested actions for engaging passengers’ Other factors influencing passen- when prompted, that the briefing attention, as well as a model of factors gers’ attention to safety communica- was boring. Feedback from focus influencing passenger responses, or lack tions included: groups supported this notion to of them, to safety announcements. • Overconfidence. “Results showed an even greater extent.” The report, based on a study that that passenger ability to recognize • Confusion between recognition comprised a literature review, industry messages presented during safety and recall. Passengers tended to consultation, interviews of passengers communication is high,” the report believe that recognizing a stan- following flights and passenger focus says. “This is endorsed by high dard safety message meant they groups, concludes that the overall effec- levels of passenger agreement with understood or could remember it. tiveness of cabin safety communication ‘having seen all the content in the “However, the results also sug- is “generally weak.” Although the study briefing before’ and ‘knowing all gested that ability to recall safety results are based on data from Australia, the information I need.’” information and perform safety the level of attention to safety commu- actions when required may be nication is “similar … to that of other • Social norms in the aircraft lower than passengers expect,” says countries, a level that has been regarded cabin. The report says, “Passen- the report. almost universally by cabin safety experts gers associated those who pay at- as too low to maintain good passenger tention to safety communications Planned Behavior Model safety,” says the report. with undesirable stereotypes, such The study showed that “passengers “Perceived relevance” of safety as the nervous or inexperienced, recognize the importance of cabin information is one key to passenger and identified peer group behav- safety and are aware of behaviors attitudes, the study says. Although iors that tend not to favor paying expected of them; however, the per- it seems axiomatic that passengers attention. … The impact of such ceptions and actual behaviors do not would be interested in facts that might norms appears to be greatest on reflect this recognition.” The report help keep them alive in an accident, infrequent and younger travelers.” offers a framework for understanding
www.flightsafety.org | AviationSafetyWorld | November 2006 | 25 CabinSafety
the dissonance between perceived and Theory of Planned Behavior: Attention to Cabin Safety Communication actual behaviors. Icek Azjen, currently head of the Attitudes Towards the Behavior Division of Personality & Social Psy- Usefulness — Probability of Use Usefulness — E ectiveness chology, University of Massachusetts at Risk of Not Being Prepared Emotional Beliefs — Empowering vs. Amherst (U.S.), formulated the theory Disturbing of planned behavior (TPB).2 The theory Existing Knowledge — Relevance Politeness to Crew “has been a significant and influential Existing Knowledge Subjective Norms social-psychological model used in the Behavioral Safety Context (Country) Perceptions — Frequent Flyers Intention Behaviors determination of consumer decision Previous Exposure Perceptions — Safety Behaviors Favorable or Watching making and attitudes toward behaviors Airline Brand Safety Perceptions of Others Unfavorable Listening Survivability Responsibility for Others Reading for some time,” the report says. Past Experiences In uence of Crew According to the TPB model, Politeness human behavior is driven by inten- Perceived Behavioral Control tional and motivational factors that Time Distractions and Interruptions influence “how hard an individual is Flight Stage Procedures and Requirements willing to try or how much effort they are planning to exert in order to plan Source: Australian Transport Safety Bureau the behavior.” The individual’s existing Figure 1 knowledge, the starting point or con- text, is influenced by three indepen- dent variables, described by the report Attitudes Towards the Behavior other passengers should an emergency as follows: The report says that attitudes that arise.” • “Attitudes towards the behavior could contribute to inattention to Perceived Behavioral Control — the degree to which a person cabin safety communication include has a favorable or unfavorable the perception that needing to apply Perceived behavioral control measures, … appraisal of the behavior in the information is improbable; the in effect, how much pressure a person question, including behavioral discomfort that safety information experiences to perform a task. The outcomes; produces in some or, conversely, the more pressure, the lower the perceived reassurance it offers others; the per- behavioral (self-)control. A high level of • “Subjective norms — the per- ception that the passenger recognizes perceived behavioral control means the ceived social pressure to perform the message and considers his or her person feels in control. or not to perform the behavior, safety knowledge to be good; and the Generally, perceived behavioral con- including motivation to comply perception that safety information trol among passengers is high because with others’ expectations; and, may not be effective in an emergency. nothing particularly demanding is re- • “Perceived behavioral control quired to pay attention, the report says. Subjective Norms — the perceived ease or difficulty “To a limited extent, perceived of performing the behavior, The report says, “In establishing what behavioral control may influence reflecting past experience, as well subjective norms could contribute to passengers through the distractions as anticipated impediments and low levels of attention to cabin safety of other tasks,” the report says. “This obstacles.” communications, this study has identi- may arise by the perceived priority fied that some passengers consider of other tasks relative to the priority The TPB is shown schematically in paying attention socially undesirable; given to in-flight safety (communi- Figure 1. consider peer group compliance to cating with other passengers, sorting The report considers how each pay attention is low; observe a lack of personal possessions, etc.). Percep- component of the TPB plays out in flight attendant enthusiasm; [and] do tions of the availability of time to cabin safety communication. not perceive an inter-dependence on perform these tasks during this stage
26 | flight safety foundation | AviationSafetyWorld | November 2006 CabinSafety
of flight may also be a contributing tailored cabin safety communica- providing newspapers and magazines, factor.” tion strategies for frequent flyers that amenities and nonessential information The 13 suggested actions (Table 1) account for the unique challenges of — “regardless of class of travel” — until are in some cases designed to counter- effectively delivering safety messages to after the safety communication or even act factors described in terms of the such passengers.” Action no. 6, “Con- until after takeoff. ● TPB. Because the perceived behavioral tent variation,” might also be helpful in Notes control in connection with cabin safety reaching this audience. 1. Australian Transport Safety Bureau communication is typically high, it can The perception that flight atten- (ATSB). Public Attitudes, Perceptions be inferred that attitudes towards the dants are unconvincingly delivering the and Behaviours Towards Cabin Safety behavior and subjective norms offer the safety briefing by rote is addressed by Communications. ATSB Research and best opportunities to improve passen- Action no. 7, “Flight attendant brief- Analysis Report B2004/0238. Final Report. gers’ attitudes and behavior. ings,” designed to encourage better June 2006. For example, the “I’ve heard it all a flight attendant performance through 2. Azjen, Icek. “The Theory of Planned hundred times before” attitude of many training and observation. Distraction Behaviour.” Organisational Behaviour and frequent flyers might be countered by factors can be minimized, Action no. Human Decision Processes Volume 50 Action no. 1: “Airlines should develop 8 suggests, by airlines refraining from (1991), 179–211.
Suggested Actions for Improving Passenger Attention to Cabin Safety Briefings
Title Action No. Suggested Action Frequent flyers 1 Airlines should develop tailored cabin safety communication strategies for frequent flyers that account for the unique challenges of effectively delivering safety messages to such passengers. Passenger information 2 Additional factual safety information and resources about air travel and cabin safety should be made available to passengers at airports by airlines and safety authorities. Escape slides 3 Additional detailed information and/or emphasis regarding the operation and use of escape slides should be provided to passengers during safety briefings. Brace position explanation 4 Carriers should be encouraged to detail the brace position during safety briefings. Where a video- based briefing with visuals of the required brace positions is not provided, carriers should be required to provide a detailed verbal explanation of brace positions in the safety briefing/demonstration. Brace position understanding 5 Further investigation should be made into methods of improving passenger understanding of the brace position, particularly where the safety card is the primary means of information delivery. Content variation 6 Carriers should vary the content or creative format of safety briefings on a regular basis, notwithstanding regulatory requirements, to increase passenger attention. Such variation should not result in dilution of, or cause confusion in regard to, core safety messages. Flight attendant briefings 7 Carriers should monitor and enhance the ongoing performance of cabin crew in relation to delivery of the safety briefing. This may be achieved within existing crew management processes through training and observation. Passenger distraction 8 Carriers should refrain from providing passengers with reading materials (such as newspapers and magazines), amenities and nonessential information, regardless of class of travel, until the conclusion of the safety briefing and, where possible, after takeoff. Safety cards 9 The safety regulator, the civil aviation safety authority, should implement guidelines and approval processes for testing of the effectiveness and comprehension of airline passenger safety cards. Interaction effects 10 Beyond the extent of current requirements, passengers should be provided with an explicit direction that additional information exists in the safety card that is not contained in the briefing and that the card should be read. Safety disposition 11 Carriers should seek to understand the unique safety disposition of their passengers (versus that of other airlines) and tailor their safety communication strategies to suit. Safety media development 12 Airlines should utilize the resources of professionals experienced in consumer psychology and/or communication disciplines when designing future safety communications and associated media. Theory of planned behavior 13 Additional research should be initiated to investigate and validate the dimensions of the theory of planned behavior model presented in this study.
Source: Australian Transport Safety Bureau
Table 1 www.flightsafety.org | AviationSafetyWorld | November 2006 | 27 Coverstory
he accident rate in U.S. airline all-cargo involving U.S. cargo aircraft are decreasing and operations is two to five times higher that recently published guidelines for air carrier than the accident rate in passenger and operators will contribute to the trend. combined passenger/cargo, “combi,” National Transportation Safety Board Toperations, according to a recent study by the (NTSB) records show that in 1996 through Commercial Aviation Safety Team. The larger 2005, 63 (14 percent) of the 449 accidents that estimate results from eliminating relatively low- occurred in U.S. Federal Aviation Regulations risk events such as ramp accidents and turbu- Part 121 air carrier operations involved cargo lence encounters from the equation. aircraft (Figure 1, page 30). Cargo aircraft were Moreover, a study conducted by the National involved in five (21 percent) of the 24 fatal ac- Aerospace Laboratory–Netherlands (NLR) and cidents during the period. the U.K. Civil Aviation Authority (CAA) in 2000 Of the 742 accidents in Part 135 air taxi indicates that there are 2.5 accidents per million operations during the 10-year period, 282 (38 large cargo airplane flights in North America, percent) involved cargo aircraft (Figure 2, page which is nearly five times higher than the acci- 31). The total included 183 fatal accidents, dent rate for passenger flights in North America of which 85 (46 percent) occurred in cargo and more than twice as high as the accident rate operations. Part 135 applies, in part, to cargo for cargo flights in Europe.1 operations conducted in airplanes with payload Nevertheless, the U.S. Federal Aviation capacities of 7,500 lb (3,402 kg) or less, or in Administration (FAA) says that accidents helicopters. Balancing Cargo Safety © Steve Lake© Steve
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Inconsistencies © Chris Photography Sorensen Citing regulations that are less stringent for cargo operations than passenger/combi opera- tions, the Air Line Pilots Association, Interna- tional (ALPA) says that cargo operations never will match the safety of passenger operations until regulatory inconsistencies are eliminated to ensure “one level of safety.” Among examples discussed at an NTSB forum on air cargo safety in 2005 were exemptions from requirements for escape slides and active fire- suppression systems on the main decks of trans- port category cargo airplanes. Airport-certification information indicated that the fire-damaged cargo rules do not require aircraft rescue and fire fighting included laptop computers and cellular telephones (ARFF) facilities at airports served by cargo air- with lithium batteries. These items were not re- craft, which frequently carry hazardous materials. quired to be documented, marked and handled as An accident early this year that nearly de- hazardous materials because the lithium content of stroyed a Douglas DC-8 freighter highlights the the batteries was below the specified minimum. reason for concern about less-stringent regula- The Department of Transportation (DOT) tions applied to cargo operations. The airplane called lithium batteries “an immediate threat to
The United States grapples with a relatively high accident rate in freight operations.
Balancing Cargo Safety BY MARK LACAGNINA
was en route from Atlanta to Philadelphia on the flying public” when it outlawed their car- Feb. 7, 2006, when the flight crew detected an riage in the cargo holds of passenger aircraft in odor but could not determine the source. The 2004. The DOT action responded in part to an odor dissipated, and, because the airplane was incident at Los Angeles International Airport in near Philadelphia, the crew decided to continue April 1999, when two cargo pallets containing to the destination. The odor became detectable 120,000 lithium batteries caught fire after they again during approach, and a smoke-warning were damaged while being unloaded from a pas- © Chris Sorensen Photography light and then the lower-cargo-fire-warning senger aircraft. It took 30 minutes to extinguish light illuminated. Smoke began to enter the the fire, and NTSB found signs that the batter- flight deck, and the crew donned their oxygen ies had burst and melted. FAA subsequently masks. The flight engineer told investigators conducted flammability tests and concluded that the smoke became so dense by the time that “the presence of primary [nonrechargeable] the airplane was stopped on the runway that he lithium batteries can significantly increase the could not see his hand in front of him. The severity of an in-flight cargo-compartment fire.” DC-8 was substantially damaged by the fire, Nevertheless, DOT exempted cargo aircraft and the crew received minor injuries. from the prohibition against carrying lithium NTSB had not completed its investigation batteries because, it said, “the risk to public of the accident at press time, but preliminary safety is much lower.”
www.flightsafety.org | AviationSafetyWorld | November 2006 | 29 and rely on daytime sleep, which has been shown to be inferior to nighttime sleep. According to Mark Rosekind, Ph.D., Alert- ness Solutions’ president and chief scientist, complete circadian adaptation to night work rarely occurs. ALPA said that studies by the U.S. National Aeronautics and Space Administration have shown that night-cargo pilots lose an aver- © Chris Sorensen Photography age of two hours of sleep per day, resulting in an Back of the Clock accumulated sleep deficit of eight hours or more More than half of cargo operations are conducted by the end of the week. at night, while only about one-fifth of passenger Yet, cargo-airline pilots can be scheduled to and combi operations take place at night. Cargo fly more hours than other Part 121 pilots. Cargo pilots typically function on “the back of the clock” flights typically are conducted as “supplemental” operations under Part 121, and the regulations al- low cargo pilots to fly up to 48 hours per week. The U.S. Air Carrier Accidents1 weekly flight time limit set by Part 121 for pilots in
60 All Operations (449 total) domestic passenger/combi operations is 30 hours, Cargo-only Operations (63 total) 50 and the weekly limit for pilots in “flag,” or interna- tional, passenger/combi operations, is 32 hours. 40 ALPA says that the rules applied to supple- 30 mental operations were developed about 50 20 years ago for unscheduled freight operations
Number of Accidents 10 conducted in unpressurized piston airplanes and that an attempt begun by FAA in 1995 to 0 1996 1997 1998 1999 2000 20012 2002 2003 2004 2005 modernize flight time/duty time regulations has Year stalled for various reasons. The pilots’ union also has cited inconsisten- Fatal Accidents Fatalities cies in the establishment by airlines of modern Year All Operations Cargo-only All Operations Cargo-only safety programs. For example, of the 12 air- 1996 5 2 380 38 lines with flight operational quality assurance 1997 4 1 8 5 (FOQA) programs in 2005, one was a cargo air- 1998 1 0 1 0 line. Of the 32 aviation safety action programs 1999 2 0 12 0 in use, four were at cargo airlines. Line opera- 2000 3 1 92 3 tions safety audits were being conducted by 16 2 2001 2 0 266 0 airlines, none of which was a cargo airline. 2002 0 0 0 0 2003 2 0 22 0 Aging Aircraft 2004 2 1 14 1 Aging-aircraft problems are not unique to the 2005 3 0 22 0 cargo industry, but they are more pronounced as Total 24 5 817 47 economic factors drive cargo airlines to oper- 1. Aircraft operated under U.S. Federal Aviation Regulations Part 121, Operating Requirements: ate less expensive equipment. ALPA says that Domestic, Flag and Supplemental Operations. the average age of aircraft in the U.S. cargo fleet 2. Does not include the hijackings of four air carrier aircraft that were flown into buildings and the ground, with 265 fatalities, on Sept. 11, 2001. is 28 years, while the average for the passen-
Source: U.S. National Transportation Safety Board ger fleet is seven years. Outdated technology, higher maintenance requirements, lack of spare Figure 1 parts availability and the decline or absence of
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manufacturers’ support are among the issues U.S. Air Taxi Accidents1 associated with aging aircraft. Many passenger aircraft have been converted to cargo aircraft by 90 80 companies no longer in business. 70 Older aircraft typically do not incorporate 60 safety improvements developed after their 50 original certification. An example is the Emery 40 Worldwide Airlines DC-8-71F that crashed in an 30 Number of Accidents 20 automobile salvage yard while returning to land 10 All Operations(742 total) Cargo-only Operations(282 total) at Sacramento (California) Mather Airport on 0 Feb. 16, 2000. The airplane entered an uncom- 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year manded nose-high attitude before reaching take- off rotation speed. The pitch attitude continued to Fatal Accidents Fatalities increase despite forward movement of the control Year All Operations Cargo-only All Operations Cargo-only column and application of nose-down stabilizer 1996 29 13 63 16 trim by the pilot flying. “The airplane rolled and 1997 15 7 39 9 pitched and climbed and descended as the pilots 1998 17 9 45 10 tried different combinations of flight control 1999 12 5 38 6 inputs and engine power settings to counter the 2000 22 11 71 12 airplane’s uncommanded pitch-up while they 2001 18 10 60 14 attempted to maneuver back to the runway,” the 2002 18 7 35 7 NTSB report said. The airplane was being turned 2003 18 8 42 9 onto base leg when it struck terrain. 2004 23 10 64 12 DC-8 elevators are driven by control tabs on 2005 11 5 18 5 the trailing edges. NTSB determined that the Total 183 85 475 100 bolt attaching the pushrod to the control tab on the right elevator had been improperly secured 1. Aircraft operated under U.S. Federal Aviation Regulations Part 135, Operating Requirements: Commuter and On‑Demand Operations. and inspected during recent maintenance. The Source: U.S. National Transportation Safety Board bolt migrated from its fitting, and the discon- nected control tab moved to a trailing-edge-up Figure 2 position, creating aerodynamic forces that caused an extreme nose-up pitch attitude that the pilots were unable to correct. The accident airplane had been manufac- tured in 1968 and converted to a freighter in 1993. The DC-8 was certified in 1959 under the transport category airplane airworthiness stan- dards of Civil Aeronautics Manual 4b, which did not require two separate locking devices on critical fasteners in flight-control systems. The current standards in Part 25 require dual-locking devices at critical flight-control attachments.
Load Verification There are no license requirements for cargo- handling companies and personnel. “Cargo prepa- ration and loading personnel are frequently not © Chris Sorensen Photography www.flightsafety.org | AviationSafetyWorld | November 2006 | 31 Coverstory
extensively trained, and, in many cases, had trimmed the horizontal stabilizer to oversee and verify the procedures, use these jobs are minimum-wage, high- according to the center of gravity (CG) and calibration of scales for measuring turnover positions,” said ALPA’s Terry shown on the load sheet. However, the cargo weight, maintenance of cargo- McVenes and William McReynolds at cargo had not been loaded according restraint devices, and training cargo per- the NTSB forum. “Many cargo load- to the airline’s instructions; the CG sonnel and flight crews. The guidelines ers perform their jobs in adverse and was aft of the location indicated on the are specific to Part 121 cargo operations demanding physical conditions, under load sheet. The NTSB report said that and are not mandatory. schedule-driven pressure. These circum- the trim set by the crew likely caused a stances increase the likelihood of errors.” greater-than-expected pitching mo- Part 135 Accidents Ultimate responsibility for proper ment that was exacerbated by the lighter NTSB at press time had completed loading rests with the flight crew, but control-column forces resulting from the investigations of 74 of the 85 fatal cargo pilots often have no practical way the aft CG location. NTSB said that the Part 135 cargo accidents that occurred to verify the aircraft’s weight and balance accident might have been avoided if in 1996 through 2005. The aircraft before takeoff, the NLR/CAA study said. the crew had an independent method included nine twin-turboprop airplanes FAA data show that a disproportion- for verifying the aircraft’s weight and (12 percent); 10 single-engine turbo- ate percentage of Part 121 cargo aircraft balance. props (14 percent), all of which were hull loss and fatal accidents involve loss FAA said that Advisory Circular Cessna 208 Caravans; 32 piston twins of control on takeoff (Figure 3, page 33). (AC) 120-85, Air Cargo Operations, (43 percent); and 20 single-engine piston An example was the Aug. 7, 1997, crash was published in June 2005 in direct airplanes (27 percent). There also was of a Fine Air DC-8 at Miami Interna- response to safety recommendations by one jet — a Learjet 25 that struck terrain tional Airport. The airplane entered NTSB based on its investigation of the when the first officer, the pilot flying, an extreme nose-up pitch attitude on Fine Air accident. became disoriented during a takeoff in takeoff, stalled and struck the ground, The AC includes recommended pro- nighttime instrument meteorological killing the three flight crewmembers, a cedures for cargo loading and unloading, conditions (IMC) — and two helicopters security guard aboard the airplane and operational control of the procedures, that crashed in the Gulf of Mexico while one person on the ground. The crew designation of trained load supervisors transporting cargo to offshore platforms.
U.S. National Transportation Safety Board
Investigators are probing the role that lithium batteries played in a cargo fire that nearly destroyed a DC-8 freighter in February 2006.
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The final reports on 40 fatal accidents that U.S. Air Carrier Hull Loss and Fatal Accidents, 1987–2000 occurred in 2001 through 2005 classify 19 (48 percent) as loss-of-control accidents. Several re- 20 Cargo-only Operations ports cite the pilots’ failure to maintain adequate Passenger Operations airspeed. A Britten-Norman Islander entered 15 an uncontrolled descent after being flown into 10 thunderstorms. The pilot of a Piper Lance became spatially disoriented after the pneumatic 5 pump failed, rendering the attitude and direc- Percentage of Accidents Percentage tion indicators inoperative in nighttime IMC. 0
An elevator trim tab actuator was not properly CFIT secured during maintenance of a Cessna 402’s LOC Flight Turbulence Evacuation LOC Takeo LOC Ground Fire/Explosion elevator; the tab jammed, causing an excessive Midair Collision Runway Collision nose-down pitch moment when the airplane Crew Incapacitation was on final approach. LOC Approach/Landing Uncontained Engine Failure System/Component Failure Fatigue was cited as a cause of two fatal ac- cidents. The pilot of a Piper Aerostar had been CFIT = Controlled flight into terrain LOC = Loss of control on duty more than 14 hours when the airplane Source: U.S. Federal Aviation Administration struck terrain during a missed instrument land- ing system (ILS) approach. The report on a Piper Figure 3 Seneca that struck a mountain said that the pilot had made several requests for someone to accom- gauges voluntary acceptance and implementa- pany him on the flight because he was tired. tion of the recommendations in AC 120-85. Fifty-three (19 percent) of the 282 Part 135 Testifying at a congressional hearing on cargo aircraft accidents in 1996 through 2005 and FAA safety programs in September 2006, 11 (13 percent) of the 85 fatal accidents during Nicholas Sabatini, the agency’s associate the 10-year period occurred in Alaska. The risks administrator for aviation safety, said that the to flight operations in the vast state are amplified hull loss accident rate for cargo aircraft in Part by rough terrain, variable weather conditions 121 operations has consistently improved and and the lack of weather-reporting stations and currently is about one-third of what it was in navigational aids.2 Aircraft, primarily single- 1990. engine airplanes operated by single pilots under Similar data are not available for Part 135 visual flight rules, serve as the main link between cargo operations, but Sabatini said that the total regional hubs and widely scattered villages, many number of accidents in 2005 was about one-half of which have unlighted gravel or dirt airstrips. of the total in 1990. “In both types of operations, The state and the FAA have launched the accident rates are declining,” he said. “The several initiatives to improve safety in Alaska. trends are coming down.” ● The Capstone Program, for example, includes Notes development of global positioning system (GPS) approach procedures and dissemination of 1. Roelen, A.L.C.; Pikaar, A.J.; Ovaa, W. “An Analysis of the Safety Performance of Air Cargo Operators.” weather information and surveillance of traffic Flight Safety Digest Volume 20 (July 2001). via the automatic dependent surveillance– broadcast (ADS-B) system. 2. Bailey, Larry L.; Peterson, Linda M.; Williams, Kevin W.; Thompson, Richard C. “Controlled Wait and See Flight Into Terrain; A Study of Pilot Perspectives in FAA currently is deferring any rule-making Alaska.” Flight Safety Digest Volume 20 (November– action affecting air cargo operations while it December 2001). www.flightsafety.org | AviationSafetyWorld | November 2006 | 33 AirportOPS Rebuilding airport Safety Airport managers and pilots must take precautions so that changes in taxiway and runway configuration during construction and maintenance do not create a hazard.
BY GERHARD GRUBER
irports, like aircraft, periodi- and passenger movements. To meet life has expired or when new technol- cally undergo maintenance and these goals, airport managers must ogy is adopted. overhaul. Unlike aircraft, which arrange for construction of extensions The work required for keeping the can be temporarily taken out of the ground facilities. Maintenance airport up to the International Civil Aof service, airports typically must keep (scheduled and unscheduled) is an ad- Aviation Organization (ICAO) stan- operating even while they are being ditional ongoing process. dards may include resurfacing, repaint- repaired and expanded — and while Equipment and buildings ev- ing, extension or construction of any parts of movement areas are excluded erywhere have a service life. Those airside surface; the installation, testing from normal use. Consequently, safety within an airport are no exception. or calibration of electrical equipment; threats arise both for airports and air- Runways, taxiways, aprons and navi- and the demolition or construction of craft operators. gational aids (including mechanical buildings. Airports are obliged to provide and electrical parts) require regular Airside facilities are exposed to an infrastructure that will cope with servicing. They eventually will be re- extreme conditions. At many airports, increasing capacity demand for aircraft placed or renewed when their service the temperature can vary as much as 65
© Gerhard Gruber
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degrees C (117 degrees F) during the year, such as As traffic increases year by year, however, minus 25 degrees C to 40 degrees C or minus 13 many airports are running at maximum capac- degrees F to 104 degrees F. These environmental ity. Extending the infrastructure often is restrict- changes eventually take their toll on all exposed ed because of environmental considerations. materials and equipment. An asphalt or concrete Building an additional runway is hardly possible When maintenance surface expands and contracts with temperature for many airports, and even where feasible, variation, resulting in cracks or buckles. it usually takes far more time than expected work is arranged in Weather exposure and ultraviolet light cause because of the complex approval process. This, fading of surface markings and signs, requiring combined with traffic growth, can put consider- different phases, their repair or replacement. Tire material de- able pressure on airport infrastructure. ground personnel posits from landing aircraft obscure the surface Any maintenance of movement areas (espe- markings. Rain, snow and anti-icing chemi- cially taxiways or runways) affects capacity. A and pilots must pay cals accelerate the aging of paved surfaces and capacity restriction must be avoided as much as ground installations. possible. Therefore, construction often must be close attention. Water seeping into cracked surfaces can erode performed during nighttime, in different phases the underlying road base, creating depressions (stages), section by section and quite often close or “potholes,” which make an uneven or fragile to the minimum safe distances from aircraft surface. When water freezes between layers operations. The re-opening of movement of road base material or in cracks, it areas after nighttime maintenance is expands, producing damage. When also a big challenge for the airport pavement breaks down, the sur- operations staff. face material becomes loose Any required cross- and can break off. ings of movement areas Loose asphalt or bits of by ground vehicles require concrete create a serious threat special precautions and spe- of foreign object damage, or FOD, cific staff training. The coordi- to aircraft because these materials can nation of all tasks is complicated be sucked into the aircraft’s turbines, or and must be carefully scheduled. damage tires or the aircraft structure. Repair- When maintenance work is arranged ing such damage may mean an expensive out- in different phases, ground personnel and pilots of-service period for the aircraft. must pay close attention, since this will result in The airport operations staff, therefore, frequent closure and re-opening of parts of the performs frequent checks of the surface of the movement areas. Consequently, procedures such movement areas to ensure an environment free as taxi routing, wingspan restrictions and ap- of foreign objects. proach procedures are changed accordingly. All ground and flight personnel must be informed
© Copyright Shutterstock Closing Time about the situation by maps, taxi diagrams, Closure of some movement areas typically can- instructions, notices to airmen (NOTAMs), not be avoided when maintenance is necessary. automatic terminal information system (ATIS) In former times, this was an easy task for many and other means in time for them to adjust. airports. When capacity demand was low, single- runway operation of a dual-runway airport did Constant Change not create much restriction. The construction/ Heraclitus, the Greek philosopher, said that it maintenance site and aircraft operation could be is impossible to step into the same river twice. well separated. No crossing of an active move- Airports, thanks to their need for upkeep and ment area by ground vehicles was necessary. All growth, are also in a state of constant change. the work could be done during daytime. Pilots should never assume that the airport is
| 35 AirportOPS
applicable: either painting or pasting. surface markings are applied. Chang- For both methods the surface must be ing financial conditions may alter the dry before application. start date and duration of construction Pasting a temporary centerline by projects. using adhesive reflecting material has Considering all these factors, plans the advantage that it is highly visible, should assume that congestion and even during marginal light conditions. delays during peak airport operating It can be removed easily, causing no hours may occur from time to time damage to the surface. The disadvan- during construction or repair work. tage of this method is that the marking is susceptible to damage by the traction Displaced Thresholds © Gerhard Gruber of ground vehicles. One major threat is the temporary dis- in the same condition as it was the Painting a temporary surface mark- placement of a runway threshold, which previous day or even earlier the same ing is quite inexpensive. The disad- is required during runway extension day. It is extremely important that they vantage of this method is its removal, and other construction work near the check NOTAMs and ATIS prior to which can only be done by using high threshold. It has been shown in the past every arrival and departure for possible pressure water or mechanical methods, that accidents and incidents involving restrictions prompted by maintenance and this can damage the surface. displaced thresholds are a serious threat. or construction. To prevent such damage, usu- A pilot may be influenced by habit to Special precautions, such as tem- ally the painting method is used to use the original threshold, ignoring a porary surface markings, marshaller cover existing centerlines leading into temporarily installed precision approach service and physical barriers, must be construction areas. Caution is neces- path indicator, even though all its lights applied in complicated situations to sary, because under certain conditions are red and all other visual aids — sur- maintain the safety level and to help — glare from the sun or other light face markings, threshold lights, etc. prevent errors by pilots and ground sources — it might appear that the cov- — indicate the displaced threshold. Air- staff. Visual aids must be converted or ered line still exists, particularly when craft landing short may collide with the added to avoid false guidance of aircraft the surface is wet. elevated approach and threshold lights. into closed areas and to provide alter- Centerline lights and electrical cir- Experience with displaced thresh- native taxi routings. cuits must be reconfigured to prevent olds shows that even the publication When temporary centerlines need guidance of pilots or vehicle drivers of an instrument approach procedure to be introduced, two methods are into closed areas. Temporary vehicle involving a localizer and distance access roads or taxiways also may be measuring equipment is no guarantee necessary to re-route traffic around against landing short of a temporary construction areas. Every displacement displaced threshold. It is much safer needs careful planning to provide the when the electronic glideslope is dis- obstacle clearances required by ICAO. placed to compensate for the temporary Some construction and repair work threshold. This practice usually results can only be carried out within a speci- in a considerable amount of expen- fied range of meteorological conditions. sive work, such as building a concrete Certain phases of projects may have to basement for the ILS transmitter, the be completed in a specific sequence. relocation of all electric equipment and For example, all equipment must be recalibration of the localizer. removed from the sensitive areas when conducting calibration flights for an in- Signage strument landing system (ILS); paving The signage system also needs to be the surface must be done in favorable adapted to any new routing situation. © Gerhard Gruber weather and must be completed before Taxi signs and lighting that are, for
36 | flight safety foundation | AviationSafetyWorld | November 2006 airportOPS
A Grim Lesson in the Risks of Airport Construction
n Oct. 31, 2000, a Singapore Airlines crewmembers and 35 passengers received seri- Boeing 747-400 began a takeoff roll ous injuries. The 747 was destroyed by impact Oon Runway 05R at Chiang Kai-Shek forces and a post-accident fire. International Airport, Taiwan. Heavy rain and The accident report by the Aviation Safety strong winds from a typhoon were moving Council of Taiwan said that Runway 05R “was toward Taiwan and visibility was low. not available for landing, but pilots were able On Aug. 31, the Civil Aeronautics to request its use for takeoff.” According to the Administration of Taiwan (CAA) had issued CAA, the report said, there was no runway- a notice to airmen that part of Runway 05R closed indication near the Runway 05R thresh- was closed because of construction work, old because that portion of the runway was and would remain so until Nov. 22. The 747 still being used for taxi operations on the night flight crewmembers were aware of the partial of the accident. closure of Runway 05R, and believed they “In addition, given the inbound typhoon, were taxiing to the assigned runway, 05L. But it was not safe to erect mobile runway-closure instead of passing the threshold marking for signs, which may have been blown into taxiing Runway 05R and continuing to Runway 05L, aircraft,” the report said. “There were warning they turned the aircraft onto Runway 05R and signs demarcating the construction area on began the takeoff. Runway 05R but the distance from the 05R The airplane struck concrete barriers, threshold to the construction area precluded runway construction pits and construction the pilots from seeing those lights.” equipment. Four cabin crewmembers and 79 passengers were killed; four cabin — Rick Darby
the time, incorrect must be covered the closed area. Runway or taxiway • Situational awareness is extremely or clearly crossed out so that is obvi- closure lighting will be required during important to every operation in ous that the taxiway is no longer in nighttime. the dynamic airport environment, use. Crossing out the taxiway signs The safety assessment for every especially during airside construc- instead of fully painting over or erasing construction area and phase will need tion and maintenance operations, them has the advantage that pilots or to be performed in accordance with the to prevent disorientation and vehicle drivers can still use them for safety management system described in maintain critical obstacle clearance. orientation. ICAO Annex 14. This includes con- In case of a runway or taxiway sideration of jet blast into construction • Keep up to date with NOTAMs closure, physical barriers and signs areas. and ATIS, and always pay close must be erected to indicate the closure When tools or other loose equip- attention to changes in familiar and to prevent inadvertent entries into ment is not secured safely, jet blast can surroundings. easily blow them away. Therefore, the The ICAO safety management system specified safe distances must be kept and guidance from Airports Council between construction activity and air- International are both necessary when craft operations. Some situations even planning construction areas with the require temporary blast fences. required level of safety in the interest of the airlines, passengers and construc- Paying Attention tion or maintenance personnel. ●
Airport managers and pilots can take Gerhard Gruber is manager, rescue and airport away from this discussion two key operations, at Vienna (Austria) International © Gerhard Gruber concepts: Airport.
www.flightsafety.org | AviationSafetyWorld | November 2006 | 37 Auditing
ManagementBy Darol Holsman
afety management systems (SMS), which team found that aircraft “hands-on” emergency for many years were referred to as Safety evacuation and equipment training was not Programs by Flight Safety Foundation provided for executive management person- (FSF) and most other aviation safety orga- nel. In an ideal situation, a corporate operator Snizations, were found lacking at some opera- provides “hands-on” training for key passengers tions visited by the FSF Audit Team. in the use and operation of aircraft safety and As stated in the International Standard for emergency equipment and evacuation proce- Business Aircraft Operations Audit Procedures dures. The audit team strongly recommends this Manual, “A Safety Management System is a pro- practice, and a number of major corporations cess to explicitly identify, manage and measure have been able to adopt such programs. This is the safety risks that inevitably occur in all avia- particularly important for operators that do not tion operations.” U.S. Federal Aviation Admin- assign flight attendants to their flight crews. istration Advisory Circular 120-92 describes While hands-on training is very difficult to an SMS as, “essentially a quality management accomplish because of the busy schedules of the approach to controlling risk.” It also provides the company executives, the audit teams recom- organizational framework to support a sound mend that operators strive to secure a commit- safety culture. There is not much difference ment and direction from the CEO to support between the two organizations’ descriptions of a hands-on familiarization and demonstra- what an SMS should be and what it should do. tion program for key executives and manage- For more than 25 years, FSF Audit Teams have ment passengers who are frequent travelers on promoted the concept of a safety program in all company aircraft. A reasonable alternative for An effective types and sizes of flight operations. Safety pro- many corporations is to assign crewmembers safety management grams included the creation of an advocate posi- to conduct a thorough emergency briefing tion as an integral part of the leadership team, — hands‑on, or as hands-on as practicable — system should be usually with the title safety manager or safety for each of the key passengers once each year. coordinator. With the advent of the SMS, the in- Operators also should develop an intranet- an essential tegration of risk management has elevated safety based emergency procedures video that can be ingredient in all programs in flight operations to an even higher viewed on the company Web site by all passen- level of attention. An effective SMS should be an gers, particularly executive management. The flight departments. essential ingredient in all flight departments. management scheduling and passenger informa- The data for this study were compiled dur- tion data system can be utilized to track and mon- ing the 20 audits FSF Audit Teams conducted itor the completion of this emergency briefing in 2004. In 12 of those audits, or 60 percent, the annually, either face-to-face or via the intranet.
This article extends the discussion of the aviation department problems mostly frequently found by the FSF Audit Team, based on the final reports submitted to clients that contracted for operational safety audits during 2004, detailing the observations, findings and recommendations identified during the review (Aviation Safety World, Sept. 2006, page 46). Observations are documented policies, procedures and practices that exceed the industry best practices; findings identify areas in which the team advises the client to adopt better policies, procedures or practices to parallel industry best practices; and recommendations describe actions that could be taken by the client to meet industry best practices. The recommendations cited in this story are in response to the findings identified in the Administration and Organization topic area, and are the opinions of the FSF Audit Team.
38 | flight safety foundation | AviationSafetyWorld | November 2006 auditreview
Ten audits found no system for keeping records of accidents, incidents or near-midair anomalies. To provide a meaningful file of safety-related reports and enable a follow-up of identified safety concerns, a system of organized reports and resultant mitigation ac- tions must be identified. Without this documentation, factual data on previ- ous safety issues fades with individual memories and the details are lost. Every accident, incident or opera- tional anomaly, no matter how insig- nificant, should be documented and
© Chris Photography Sorensen investigated. Further, operators should establish an anomaly-reporting form In 10 of the audits — 50 percent of Also in 10 audits it was found with follow-up procedures, and include the total — no documented SMS was that the responsible party — the this information in the SMS documenta- found. A documented SMS is essential SMS manager, pilot or coordinator tion, and develop a permanent reference for the implementation of an effective — lacked formal training. The audit source for future safety managers and risk management program. A written team recommended that operators department personnel on accidents and program provides a “safety roadmap” consider sending the responsible party incidents experienced with their aircraft for the organization, which each year for formal training in safety program and facilities. identifies specific goals and tracks management at the University of South- Finally, operators should review progress in attaining those goals. ern California, George Washington industry data and publications to A written SMS should be developed University, Embry-Riddle Aeronautical identify accidents, incidents or opera- and incorporated in the flight operations University or other appropriate training tional anomalies experienced by other manual or as a separate document that institutions. operators that have similar equipment or will establish a working relationship with The best overall preparation course operational practices and include those the company safety, loss prevention and for a newly assigned safety manager is events in the internal documentation. risk management personnel, as appro- an aviation safety program manage- The operator does not have to experi- priate. An operator should integrate its ment course, which typically is avail- ence an accident or incident to benefit corporate safety goals and objectives into able at safety training institutions. from the lessons learned. ● the flight operations SMS. The operator also should permit the When the SMS documentation is safety manager, pilot or coordinator The data used in this article have been de‑identified. Questions about this article completed, all personnel should receive to attend the annual FSF Corporate should be sent to Darol Holsman, manager, a safety indoctrination training session; Aviation Safety Seminar and the annual Aviation Safety Audits, Flight Safety Foundation a similar orientation session should be- Bombardier/National Business Aviation at [email protected] or +1 618.345.7449 come mandatory for all new personnel. Association Safety Standdown. (office phone) or +1 202.258.2523 (cell phone). www.flightsafety.org | AviationSafetyWorld | November 2006 | 39 threatanalysis
Learning From Experience Tricks of Light Incident No. 5 Fifth in a series focusing on approach and landing incidents that might have resulted in controlled flight into terrain but for timely warnings by TAWS.
BY DAN GURNEY
© Carolina K. Smith, M.D.–Fotolia
imited visibility and a pattern The “obstacle” was several multi- There was no altitude/range table of street lights similar to the ap- story buildings 340 ft high and 1.8 nm on the approach chart, and there is no proach lights that the flight crew (3.3 km) from the runway threshold. indication that the crew used or even expected to see are possible fac- The buildings were at the edge of the had an independently prepared alti- Ltors in a close encounter with tall build- obstacle-free zone protecting the in- tude/range table. Without this monitor- ings that occurred during a nighttime strument approach glide path.2 ing guidance, any error in commencing nonprecision approach to an airport in The aircraft’s flight path on final the descent likely would not have been a major metropolitan area. approach was equivalent to a constant- identified during the final approach. The incident involved a modern, angle — 2.99-degree — descent that Beyond the FAF, the approach chart “heavy” air carrier aircraft that was began approximately 1.0 nm (1.8 km) provided only one check altitude, at a being flown on a localizer approach before reaching the final approach step-down fix 2.7 nm (5.0 km) from the in instrument meteorological condi- fix (FAF), defined by distance from localizer, about 2.0 nm (3.7 km) from tions. Visibility was limited by fog when the localizer. The localizer is offset the threshold. Beyond that, the crew was the crew descended below 600 ft, the 0.8 nm (1.5 km) beyond the runway’s dependent on the protection provided minimum descent altitude (MDA). approach threshold. It is possible that by conducting a missed approach at the The aircraft was 2.2 nm (4.1 km) from the crew began the premature descent MDA or by establishing visual contact the runway threshold and descending based on the EFIS (electronic flight in- with the runway environment. at 600 fpm through 480 ft when the formation system) display of distance The author’s analysis of the incident, terrain awareness and warning system from a VNAV (vertical navigation) which was reviewed by a select group of (TAWS) generated an “OBSTACLE, waypoint on the runway threshold that aviation professionals including airline OBSTACLE, PULL UP” warning.1 The had been entered in the flight man- pilots, did not establish a likely reason crew began the escape maneuver within agement system for a constant-angle for the aircraft’s low approach. Regard- two seconds (Figure 1). approach. less of the cause, the error apparently
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enabled the crew to gain visual contact with the together with track and airspeed information, are ground at an earlier point than the conditions vital elements of a monitoring scan. ● normally would have allowed. When the TAWS [This series, which began in the July issue ofAviation warning was generated, the aircraft was below Safety World, is adapted from the author’s presenta- the MDA; the crew likely believed that they had tion, “Celebrating TAWS Saves, But Lessons Still to Be the approach lights in sight and continued the Learned,” at the 2006 European Aviation Safety Seminar approach visually, in the foggy conditions. and the 2006 Corporate Aviation Safety Seminar.] It is possible that the crew mistook a pat- Dan Gurney served in the British Royal Air Force as a tern of street lights for the approach lights. Near fighter pilot, instructor and experimental test pilot. He the approach end of the runway are street lights is a co-author of several research papers on all-weather aligned both longitudinally and laterally, resem- landings. Gurney joined BAE Systems in 1980 and was involved in the development and production of the HS125 bling the centerline and crossbars of an approach and BAe 146, and was the project test pilot for the Avro light system. There are also light patterns resem- RJ. In 1998, he was appointed head of flight safety for BAE bling a PAPI (precision approach path indicator). Systems. Gurney is a member of the FSF CFIT/ALAR Action Group, the FSF European Advisory Committee and Lessons to Be Learned the FSF steering team developing the “Operators Guide to This incident is believed to be the first “save” by Human Factors in Aviation.” the TAWS obstacle mode. All operators should Notes retrofit this mode in their TAWS equipment or activate the obstacle mode in equipment in 1. Terrain awareness and warning system (TAWS) is which it already is available. The obstacle mode the term used by the International Civil Aviation Organization to describe ground-proximity warning is built into every Honeywell EGPWS; activation system (GPWS) equipment that provides predictive of the mode may require a minor modifica- terrain-hazard warnings; enhanced GPWS (EGPWS) tion — a wire-strapping change. The aircraft and ground collision avoidance system (GCAS) are involved in the incident was the first and, at the other terms used to describe TAWS equipment. time, the only aircraft in the operator’s fleet to 2. U.S. Federal Aviation Administration Terminal have been modified with the obstacle mode. Instrument Procedures, paragraph 954, “Obstacle The mode is active in the EGPWS equipment in Clearance,” states, “The transitional surfaces in most newly manufactured air carrier aircraft. localizer-only type approaches begin at a height When conducting a nonprecision instru- not less than 250 feet below the MDA [minimum descent altitude].” ment approach, it is essential for the flight crew to identify the correct descent point for the final approach and calculate the required approach Aircraft Flight Path timing and vertical speed. Accurate descent rate Localizer and airspeed control are required to avoid large deviations in the flight path. MDA 600 ft Beware of incorrectly identifying lighting features in low-visibility conditions. Take time to confirm what has been seen, and avoid the Constant-Angle Descent From FAF tendency to “see” what is expected. Cross-checking the visual scene by the pilot flying and the pilot monitoring is difficult when ground contact is first established. Both pilots could be susceptible to the Not to Scale same perceptual error. It is essential that the moni- FAF = Final approach fix MDA = Minimum descent altitude toring function be based on independent informa- Source: Dan Gurney tion that can confirm the aircraft’s continuing safe flight path below MDA. Altitude/range checks, Figure 1 www.flightsafety.org | AviationSafetyWorld | November 2006 | 41 Flighttech © Copyright Dreamstime © Copyright
SHUTTING Out the NOISE
ilots on the flight deck need to renders the other impossible to hear. Noise-induced hearing loss can be either hear what they want to hear as Low frequency noise — the sound pro- temporary or permanent. A temporary much as they need to be pro- duced by the slipstream, for example hearing loss is a brief shift in the audi- tected from what they don’t want — masks higher frequency sounds tory threshold that occurs after a rela- Pto hear. While visual information is such as an instruction from air traffic tively short exposure to excessive noise predominant on flight decks, com- control, a crewmember’s instructions or — more than 90 decibels (dB). Normal plete reception and comprehension of an audio warning. hearing recovers fairly quickly after the spoken words from air traffic control- Task performance may be affected noise stops. However, if the noise level is lers and other crewmembers and audio by the presence of noise, especially sufficient to damage the tiny hairs in the signals from electronic systems are vital loud noise. Studies suggest that noise cochlea — the part of the inner ear that to flight safety. Aviation headsets — es- reduces a person’s overall accuracy is responsible for transforming sound pecially with recent advances in noise and negatively affects the completion waves into the electrical signals that go reduction and sound attenuation — can of complex tasks1 — tasks that require to the brain — the threshold shift can enhance a pilot’s ability to hear those attention to a large number of cues pre- be irreversible, resulting in permanent words and signals throughout flight sented concurrently or in succession.2 partial or total hearing loss. while also protecting hearing. Noise can produce a host of reac- tions in humans. These can be physi- Three Components Consequences of Noise ological, such as headache, fatigue, On the flight deck, headsets — a Flight deck noise affects both the per- nausea and insomnia; psychological, considerable improvement over hand formance and safety of flight crewmem- such as irritability, anger and anxiety; microphones and speakers once widely bers, and can induce hearing loss. or cognitive, such as impaired concen- used by pilots — protect hearing and Noise on the flight deck affects tration and decreased ability to estimate reduce ambient noise while enhancing communication by masking important elapsed time. critical communications. audio signals. Masking is a process in Among the worst consequences Nathaniel Baldwin is credited with which one of two simultaneous sounds of high levels of noise is hearing loss. developing the first basic radio headset
42 | flight safety foundation | AviationSafetyWorld | November 2006 Flighttech
Technological advances have resulted in headsets that enhance communication and protect pilots’ hearing.
BY CLARENCE E. RASH SHUTTING Out the NOISE
while he was a student at Stanford Uni- Conventional passive noise reduc- enough energy to make the cup vibrate versity in California, U.S., and patenting tion consists of putting something and therefore are not heard. it in 1910. There was little interest in the — such as earplugs or earmuffs — in or ANR, first conceived in the 1930s device until the eve of World War I, when over the ears to block noise. Properly and refined in the 1950s, did not the U.S. Navy ordered 100 headsets.3 inserted, standard earplugs typically become prevalent in aviation until the Nearly all headsets have three basic provide about 30 to 35 dB of protection 1990s.4 In conventional ANR head- components: a microphone, ear cups across the entire noise spectrum. Most sets, the frequency and amplitude of or earplugs, and a harness or head- modern passive over-the-ears headsets the sound inside the headset cavity band. Most current aviation headsets use soft and flexible cushions to form are measured by a small microphone, are classified as either “heavyweights” a good seal, preventing ambient noise and a 180-degree out-of-phase copy is — which clamp over the user’s head, from directly entering the ear and pro- produced and fed back into the headset; covering both ears — or “lightweights,” viding 20 to 30 dB of protection, which the two signals superimpose and cancel which resemble personal music ear- is most effective at higher frequencies. each other. phones. Lightweights, while designed Anything that interferes with the seal, Regardless of the type of feedback to be more comfortable, typically do such as sunglass or eyeglass temples, loop used, in order for ANR headsets not perform as well as heavyweights in compromises the noise-protection to perform their task, they require blocking out aircraft noise. level. Sounds are conducted toward the electrical power from either a battery Another method of classification is ear when sound waves — such as the pack or the aircraft. The ANR technol- based on the hearing-protection tech- relatively high-frequency sound waves ogy is generally effective only at lower nology incorporated into the headset. produced by voices or audio signals frequencies. A protection level of 20 The two types of technology currently — hit the outer ear cup and cause the dB over this lower frequency range is used are passive noise reduction — or cup to vibrate; this, in turn, causes the typical. This makes this type of headset attenuation — and active noise reduc- air inside the cup to vibrate. Low- most effective in environments such tion (ANR) — also called electronic frequency sound waves such as those as aviation, where the noise spectrum noise cancellation. produced by the slipstream do not have consists of mostly lower frequency © Copyright 2006 iStock,© Copyright International Inc.
www.flightsafety.org | AviationSafetyWorld | November 2006 | 43 Flighttech
sounds.5 ANR headsets also provide headset communications. An approach about twice the cost, ANR headsets are signal-to-noise improvement — clear that provides the extra protection of considered superior to passive noise re- sounds — by reducing the masking ef- the earplug without compromising duction systems. Nevertheless, perfor- fects of low-frequency noise. communication is the communication mance depends greatly on the ability of However, ANR is not a one-size- earplug (CEP). the headset ear cups to seal over the ear. fits-all system. Every pilot has a differ- The CEP, which initially was devel- A label should disclose the headset’s ent hearing response. Therefore, the oped for use in U.S. Army helicopters, protection level — a noise reduction perceived performance of a selected provides the high-quality hearing pro- rating of at least 24 dB is recommended ANR headset varies from pilot to pilot. tection of an expanding foam earplug (see “Rating Systems”). Ultimately, the best method of evaluating while allowing clear passage of speech Although the FAA does not regulate the effectiveness of an ANR device is for communication to the ear. A miniature headsets, it does provide specification the pilot who plans to use it to try it out in speaker and foam earplug are coupled guidance in two technical standard the aircraft that he or she usually flies. to yield a lightweight communications orders (TSOs).8,9 Many of the specifica- ANR aviation headsets were de- device that can be used alone or in tions discuss construction and environ- veloped to cancel the lower frequency combination with over-the-ear hear- mental criteria for the manufacturer sounds produced by piston engines and ing protection. The CEP, when worn rather than operating and protection propellers. Because turbine engines in combination with other hearing performance criteria for the user. typically produce sounds in the mid- to protection, reduces noise exposure to Nevertheless, headsets that meet these high-frequency ranges, ANR headsets minimal levels. specifications bear the applicable TSO designed for use in piston aircraft will Tests conducted by the Army marking — and this should be a factor be less effective in turbine aircraft. showed reductions of “more than 30 in the selection process. Ideally, a detailed knowledge of the dB for the low frequency noise spectra Another performance factor is how noise spectrum of the specific aircraft, that are prevalent in helicopters,” said a headset receives its power. A headset compared with the performance of the Ben Mozo of Communications and Ear that can be operated with either battery ANR headset, will allow each pilot to Protection Inc., developer of the device. power or aircraft power is a plus. choose the ANR device that is best for In addition to active/passive him. Unfortunately, the noise spectrum Selection Criteria technology, overall comfort should be pattern produced by a specific aircraft A quick survey of the market reveals considered. Weight and “feel” — that is, is rarely available.6 more than 25 manufacturers offer- clamping pressure and headband/strap The U.S. Federal Aviation Adminis- ing more than 100 different aviation design — determine how comfortable a tration (FAA), as well as many hearing- headset models that range in price from headset will be, especially after several protection organizations, recommend about US$100 to more than $1,000. hours of flight. Headset weights typi- a dual protection approach, using both In addition to price, headset selec- cally are about 12 to 18 ounces (340 to earplugs and a headset.7 However, tion criteria can be separated into per- 510 grams); a difference of a few ounces the use of earplugs under a headset formance, comfort and added features. may not seem worth worrying about, is somewhat counter-productive; the For performance, the first decision but over a long period, the extra weight earplugs impede a pilot’s ability to hear is active or passive noise reduction. At can induce neck strain and headache.
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From left, Lightspeed Aviation’s LightFlight Mach 1 Headset, Lightspeed’s Twenty 3G, Communications and Ear Protection’s communications earplug, Lightspeed’s QFRXCc and David Clark Co.’s X11.
Clamping pressure and the monaural speakers, or individualized Clarence E. Rash is a research physicist at the headband/strap mechanism also are speaker controls on each headset ear U.S. Army Aeromedical Research Laboratory in Fort Rucker, Alabama, U.S. He has more important considerations. All headsets cup to allow for independent adjust- than 25 years of experience in Army aviation of reasonably good quality have some ment of the volume for each ear. research and development and is the editor of type of adjustment to permit expan- However, the stereo option is useless “Helmet-Mounted Display: Design Issues for sion or tightening of the ear cups. The if the aircraft’s audio system does not Rotary Wing Aircraft,” SPIE Press, 2000. amount of padding on the ear cups support stereo outputs. and headband/strap is a strong indica- As with most electronic equip- Notes tor of how comfortable the headset ment, keeping a headset in good work- 1. Miller, J.D. “Effects of Noise on People.” will be. ing order requires regular preventive Journal of the Acoustical Society of America Finally, if possible, the pilot should maintenance. Exterior parts should be Volume 56 (1974): 729–762. test the headset in the aircraft that he or cleaned regularly with mild soap and 2. Kahneman, D. Attention and Effort. she usually flies. water, and dried well before use. Peri- Englewood Cliffs, N.J., U.S.: Prentice Hall, Most headsets offer additional odic inspections should be conducted 1973. features. One option is a choice of ear to check for cracks on ear cup seals 3. SKC Communication Products. A Brief seals made of foam plastic or newer and missing parts, and to ensure that History of Headsets.
5. Gauger, D. “Should You Consider ANR for Hearing Protection?” The Newsletter Rating Systems for the Council for Accreditation in Occupational Hearing Conservation, Volume 15 (2000). ne method of rating the protection level provided by hearing protec- tion devices is the noise reduction rating (NRR) system specified by the 6. Kernstock, N.C. “Headsets, Helmets and OU.S. Environmental Protection Agency. It is the measure, in decibels (dB), Communications: A Buyer’s Market.” of how well a hearing protector reduces noise; the higher the number, the Rotor and Wing. May 2001. greater the noise reduction. When dual protectors are used, the combined NRR is usually accepted as 7. U.S. Federal Aviation Administration 5 dB more than the higher rating of the two devices. For example, if a pair of (FAA). Pilot Safety Brochure AM-400- earplugs with an NRR of 25 dB is worn under earmuffs with an NRR of 23 dB, 98/3, Hearing and Noise in Aviation. 1998. the NRR of the combination is 30 dB (25 dB + 5 dB = 30 dB). 8. FAA. Technical Standard Order (TSO) Additional protection rating numbers are in use throughout the world. TSO-C57a, Headsets and Speakers. 1983. These include the single number rating (SNR) system defined by International Organization for Standardization in ISO/DIS 4869-2.2. 9. FAA. TSO-C139, Aircraft Audio Systems — CER and Equipment. 2005.
www.flightsafety.org | AviationSafetyWorld | November 2006 | 45 causalfactors
Cross-Control Upset © James Eden
The Metro’s autopilot was engaged when the pilots The aircraft was scheduled to depart at 2100 induced a sideslip to balance fuel. When the autopilot local time, but the loading of the cargo was not completed until 2115. The flight crew then or- reached its control limits and disengaged, the aircraft dered about 1,000 lb (454 kg) of additional fuel rolled and entered a spiral dive. and told the fueler to put all of it into the left wing tank. “This was probably to expedite their BY MARK LACAGNINA departure after the delayed loading,” the report said. The crew took action to balance the fuel, ast year’s upset and in-flight breakup of and the wing tanks likely were within the 200-lb a Fairchild Metro III in New Zealand (91-kg) maximum differential specified by the has prompted investigators to call for the aircraft flight manual (AFM) for takeoff. development of a standard procedure The aircraft departed from Auckland at Lfor balancing fuel in the aircraft while in flight 2136. The captain, 43, had 6,500 flight hours, and for a warning that the autopilot must be including 2,750 flight hours in type, and was disengaged during the procedure. The Metro’s a Metro line-training captain for the operator, flight crew was using rudder trim to place the Airwork (NZ) Limited. The first officer, the aircraft in a sideslip while balancing fuel in the pilot flying (PF), 41, had 2,345 flight hours, in- wing tanks and lost control when the autopilot cluding 70 flight hours in type. Both pilots held disengaged and the aircraft abruptly rolled and Metro type ratings. They had flown together dived. once previously, five days before the accident The fatal accident occurred during a sched- flight. “The operator’s records showed that both uled cargo flight from Auckland to Blenheim pilots had been trained in autopilot use and in the night of May 3, 2005. In its final report, the fuel-transfer procedures,” the report said. New Zealand Transport Accident Investiga- The crew flew the aircraft to Flight Level tion Commission (TAIC) said that the upset (FL) 180 (approximately 18,000 ft), where they probably would not have occurred if the crew likely encountered instrument meteorological had hand-flown the aircraft while balancing conditions and moderate turbulence. The crew the fuel. requested, and received, clearance to climb to
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FL 220. After reaching that flight level, the crew this method was adequate and balanced the fuel maintained climb power for about 15 minutes quickly. Information obtained from pilots with to make up some of the delay in departure. The Metro experience with several operators con- report said that the aircraft likely was above the firmed that this method was used [and that] it clouds and in smooth air at FL 220. required minimal rudder-control input and was efficient. Some pilots reported that they would Unpublished Technique apply a small amount of rudder trim while the The Metro’s fuel system comprises two wing aircraft was flying on autopilot to achieve this.” tanks that supply fuel to their respective engines. After the crew completed the “Cruise” The tanks are connected by a crossflow tube con- checklist about 2212, the captain decided to taining a valve that can be opened to balance fuel transfer fuel from the left wing tank to the right between the tanks or, if one engine is inopera- wing tank. “There was no evidence of how much tive, to make the fuel in both tanks available to imbalance he was responding to,” the report said. the operative engine. “The gravity-crossflow fuel The imbalance likely resulted from the asym- system was unusual and probably confined to the metric fueling rather than a difference in the SA 226/227 [Merlin/Metro] family of aircraft,” engines’ fuel consumption. “The engine with the the report said. “Other types had either a pumped longer time since overhaul was still only halfway crossfeed system or a pumped crossflow system.” through the overhaul period, and the flight time Annunciator lights indicate when the since [the aircraft] left Auckland was probably crossflow-valve switch is selected to “OPEN” insufficient to develop much fuel imbalance,” and when the crossflow valve is not fully closed. the report said. “The imbalance may have been Several checklists, including the “Before Starting within AFM limits [200 lb] for the upcoming Engines” and the “Before Takeoff” checklists, landing but was sufficient for the captain to want require the crossflow valve to be closed. to tidy up while the aircraft was in cruise.” Airwork told investigators that it believed a The captain told the first officer, “We’ll just fuel imbalance was unlikely to develop during a open the crossflow [valve] again. … Sit on left typical flight duration with both engines operat- ball and trim it accordingly.” The report said that ing normally and with the crossflow valve closed. the captain then clarified the instruction: “Step However, other Metro operators said that they on the left pedal and just trim it to take the pres- had observed fuel imbalances as great as 120 lb sure off,” he said. “Get the ball out to the right as (54 kg) per hour “between engines that were at far as you can … and just trim it.” the opposite ends of the overhaul period.” The The first officer said, “I was being a bit cau- overhaul period for the Metro III’s Honeywell tious.” The report said that this comment likely TPE331 engines is 7,000 hours. The left engine indicated that the first officer was concerned on the accident aircraft had accumulated 710 that the rudder input commanded by the cap- hours since its last overhaul; the right engine had tain was excessive. accumulated 3,491 hours since overhaul. “Don’t be cautious, mate,” the captain said. Airwork did not have a written procedure “It’ll do it good.” for balancing fuel, and the AFM provided no The first officer asked, “How’s that?” The detailed procedure, the report said. captain replied, “That’s good. Should come right. “The operator’s usual but unpublished tech- Hopefully, it’s coming right.” nique to balance the fuel in flight, if necessary, was to open the crossflow valve and fly with the ‘You’d Better Grab It’ fuller wing held just higher than wings-level at- The report said that the autopilot likely was titude,” the report said. “Slight opposite rudder, maintaining the selected altitude and the se- or ‘cross-control,’ was necessary to maintain the lected heading or course. “When left rudder was desired heading. The operator considered that applied, the aircraft would have yawed left and www.flightsafety.org | AviationSafetyWorld | november 2006 | 47 48
| New Zealand Transport Accident Investigation Commission c a u sa l fa c tors seven moreseven angle” “bank warnings. next the 23seconds,During CVRrecorded the tion altitude, from selected the report the said. a chime, probably which indicated adevia cockpitthe voice recorder (CVR)recorded onds until bank angle decreases below 40 degrees. exceeds 40 degrees and is repeated every three sec said that this warning is provided when bank angle ated an aural “bank angle” warning. The report proximity warning system (GPWS) then gener mate. You’d better grab it.” The aircraft’s ground- increased, and the aircraft began to descend. began a gradual left turn. The turn rate then recorder (FDR) data indicated that the aircraft traffic control (ATC) radar data and flight data cruise setting, and airspeed began to decrease. Air sideslip to right.” the aircraft right-wing-downthe flew inastraight course) by applying more right aileron that so havealso to maintain tried heading the (or trol to counter rolling this and tendency would autopilot would have applied right aileron con namic yaw/roll coupling,” report the said. “The to roll astried aresult left of normal aerody Soon after angle” first “bank the Soon warning, The captain said, “Doesn’t like that one, The crew did not increase power from the
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- - aircraft —maximum operating airspeed, 227kt, to “grabofficer it” manual —take control of the Twelve seconds after captain the told first the as aircraft the through descended 19,900ft. ATC radar contact was lost afew seconds later, disengaged at CVRrecording 2213,the ended. that confirmed first officer the autopilot the was that autopilot the was disengaged. after Soon down into a steeply banked diving attitude.” input by rolling left and starting to yaw its nose craft abruptly responded to the trimmed rudder “With the autopilot constraint removed, the air servo reaching its torque limit,” the report said. lot had disengaged automatically as a result of a excursion and the altitude loss is that the autopi exceeded.” order, that so flight-envelope limitations are not promptly, positively and smoothly, and inthat taken to action needs The be report said, “This sequence for aspiral dive is: normal reportthe recovery action said. “The to return aircraft the to try to anormal attitude,” possible to what determine exactly crew the did FDR didnot record control positions, it so is not inability to regain control of aircraft. the “The likely fuel balance the contributed to crew’s the that applied trim had been The left-rudder to Trim Likely Thwarted Recovery data characterize a rapidly developing spiral dive.” about +1.5 g to +4.2 g,” the report said. “These 300 kt, the vertical acceleration increased from the airspeed increased from 175 [kt] to almost gravitational acceleration. limitthe of load or +3.02g, standard 3.02times was Wing exceeded. loading increased beyond flight safety foundation foundation safety flight Airspeed andAirspeed wing loading increased rapidly. The captain asked to confirm first officer the “The probable explanation for the bank angle “Over the last 20 seconds of recorded data, • • • “Pitch aircraft the up to horizon.” the “Roll aircraft the to wings-level; then, increase; “Reduce power to minimizeairspeed |
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The CVR recorded the sounds of power reduc- tion about seven seconds before the recording Fairchild SA-227AC Metro III ceased. “This was late in the development of the spiral dive, and the delay would have exacer- bated the situation,” the report said. Compression buckling in both wings indi- cated that the crew applied substantial right- wing-down aileron-control input. “This indicated that appropriate control input was being made to try to roll the aircraft to the right, towards wings- level, as the aircraft wing structure became loaded towards failure,” the report said. “The reason why the applied right aileron control was not effective in rolling the aircraft towards wings-level was not conclusively determined, but it was likely to have © Steve Lake been a direct result of the left rudder trim which esigner Edward J. Swearingen’s Merlin corporate/business aircraft had been applied, and which probably remained first flew in 1965 with Pratt & Whitney Canada PT6A-20 engines. applied throughout.” DAll subsequent versions of the Merlin and its longer-fuselage, re- gional airline derivative, the Metro, have had Garrett, now Honeywell, Increasing aerodynamic loads recorded by TPE331 engines. The Metro III, introduced in 1981, has longer wings, the FDR indicated that substantial up-elevator a greater useful load and more powerful engines than the preceding control input also was applied. “This elevator Metro models. input would have been ineffective in pitching The aircraft accommodates two pilots and 20 cabin occupants. the aircraft up towards the horizon, however, Maximum takeoff weight is 14,500 lb (6,577 kg). Maximum fuel weight because of the steeply banked attitude,” the is 4,342 lb (1,970 kg). Maximum rates of climb are 2,370 fpm with two engines and 690 fpm with an engine out. Maximum cruise speed at report said. “It could only have further tightened 25,000 ft and at 12,500 lb (5,670 kg) is 263 kt. Stall speeds are 98 kt the turn, escalating the spiral dive. The bank at- clean and 87 kt in landing configuration. titude needed to be reduced towards wings-level The Merlin/Metro series was produced by Swearingen Aircraft Co. before the elevator control could raise the nose and by Fairchild Aircraft Corp. Production was terminated in 1999. of the aircraft.” Source: Jane’s All the World’s Aircraft The report said that a fire erupted when both wings folded upward and separated from the aircraft. Several witnesses described an intense The incident involved a Fairchild Merlin III and unusual noise, and orange-yellow lights or that was on a charter flight in New South Wales fireballs falling through broken layers of cloud. on Aug. 30, 2004.1 The fuel systems in the Merlin The left wing was on fire as it fell. The flight and the Metro are essentially the same. The pilot deck, which had been struck by the left propeller said that after reaching cruise altitude, FL 160, he when the wing folded, also separated in flight. observed that the aircraft was in a slightly right- Most of the wreckage was found at about 700 wing-low attitude. He used left-rudder trim to ft on hilly farmland 7.0 km (3.8 nm) northeast level the wings and engaged the autopilot. About of Stratford, which is near the western coast of 2.5 minutes later, the autopilot disengaged, and New Zealand’s North Island. the aircraft rolled right and entered a spiral dive. The pilot regained control about 50 seconds later, Similar Events at 5,200 ft. Neither he nor his seven passengers The report cited an incident in Australia and a were injured. The pilot told investigators that, fatal accident in the United States in which fuel after regaining control, he noticed that the fuel imbalances and upsets likely occurred in similar gauges showed 772 lb (350 kg) more fuel in the aircraft. right tank than in the left tank. The final report www.flightsafety.org | AviationSafetyWorld | november 2006 | 49 causalfactors
on the incident by the Australian Transport autopilot would not have been readily apparent Safety Bureau said that the fuel imbalance likely on a dark flight deck at night.” occurred because the crossflow valve either was The report said that the absence of a writ- open when the flight began or was inadvertently ten standard operating procedure (SOP) for opened during the flight. balancing fuel with the Metro’s — and Merlin’s The U.S. National Transportation Safety — gravity-crossflow system creates the potential Board investigation of the Feb. 8, 2006, accident for individual pilots to use different methods, in Paris, Tennessee, was continuing at press time. including the “extreme sideslip” that the acci- “The amount of A preliminary report said that during a cargo dent captain instructed the first officer to use. flight from Ohio to Texas at 16,000 ft, the pilot “Written SOPs are the normal method for control-wheel of a Swearingen Metro II conducted 360-degree an operator to detail to crews how to perform turns to the left and right, and then requested common tasks,” the report said. “This ensures that displacement by the radar vectors to the nearest airport.2 After issuing tasks are carried out in a safe and efficient manner, autopilot would not a heading to the nearest airport, the air traffic and that each crewmember knows what is re- controller asked the pilot if he had an emergency. quired. While the fuel-balancing procedure might have been readily The pilot replied that he had an asymmetric fuel not be required on many flights, it clearly needed a condition. “About a minute later, the pilot trans- written SOP. Because the gravity-crossflow system apparent on a dark mitted ‘mayday’ six times, and shortly after this, was specific to the Metro family of aircraft, the flight deck at night.” radar and radio contact with the flight was lost,” appropriate procedure was unlikely to fall within the preliminary report said. “The airplane was pilots’ understanding of good aviation practice.” heard and then seen descending at a high rate of Based on these findings, the TAIC in February speed in a near-vertical attitude.” 2006 recommended that the New Zealand Civil Aviation Authority (CAA) work with the U.S. Fed- Tactile Feedback eral Aviation Administration (FAA) to amend the The TAIC report said that by flying the aircraft AFMs of the Metro/Merlin family of aircraft “to with the autopilot engaged, the first officer re- include a limitation and caution that the autopilot ceived no tactile feedback of the control forces that and yaw damper must be disconnected while in- were being applied during the sideslip maneuver. flight fuel balancing is done.” TAIC also recom- “If the autopilot had not been engaged, the PF mended that the CAA and FAA incorporate in the would have had to apply right aileron manually in AFMs a procedure for in-flight fuel balancing. coordination with the left rudder input to achieve In May 2006, the CAA replied that it accepted the same result,” the report said. “In manual the recommendations and had begun correspon- flight, the PF would have received continuous dence with FAA on amending the AFMs. ● tactile feedback from the controls to indicate the control forces and displacements he was produc- This article is based on New Zealand Transport ing, and would have had to monitor closely the Accident Investigation Commission Aviation aircraft attitude and heading on his instruments. Occurrence Report 05‑006: “Fairchild-Swearingen With the autopilot engaged, and especially with SA227-AC Metro III ZK-POA, Loss of Control the rudder trimmed out, he would not have had and In-flight Break-up Near Stratford, Taranaki such feedback because the autopilot would have Province, 3 May 2005.” The 44-page report con‑ been holding the control forces generated, and tains illustrations. the PF might not have perceived a need to moni- tor the aircraft’s attitude closely. Notes “In addition, both pilots may have been 1. Australian Transport Safety Bureau Aviation Safety monitoring the fuel gauges to observe the Investigation Report 200403209. success or otherwise of the fuel transfer. The 2. U.S. National Transportation Safety Board prelimi- amount of control-wheel displacement by the nary report ATL06FA045.
50 | flight safety foundation | AviationSafetyWorld | november 2006 DataLink Looking East For both Eastern-built and Western-built large transport aircraft, accident rates were higher for turboprops than for jets in 1995 through 2004.
BY RICK DARBY
astern-built large transport aircraft — manufactured in the Soviet Union Eastern-Built Aircraft Types or Russian Federation — were involved Jets in 5 percent of the world’s flights, 6 Antonov An-124 Ilyushin Il-62 Tupolev Tu-134 Yakovlev Yak-42 Epercent of flight hours and 34 percent of fatal Antonov An-225 Ilyushin Il-76 Tupolev Tu-154 accidents during passenger or cargo opera- Antonov An-72 Ilyushin Il-86 Tupolev Tu-204 tions between 1995 and 2004, according to the Antonov An-74 Ilyushin Il-96 Yakovlev Yak-40 U.K. Civil Aviation Authority (CAA) Safety Turboprops 1 Regulation Group. Antonov An-12 Antonov An-26 Antonov An-38 Let L-410 Turbolet Those aircraft, shown in Table 1, included Antonov An-140 Antonov An-28 Antonov An-8 Let L-610 turboprops and jets, but not business jets. Antonov An-22 Antonov An-30 Ilyushin Il-114 SAC Y-8 “Within the Eastern-built subset, 61 per- Antonov An-24 Antonov An-32 Ilyushin Il-18 XAC Y-7 cent of flights flown between 1995 and 2004 Source: U.K. Civil Aviation Authority were performed by Eastern-built jets and 39 percent by Eastern-built turboprops,” Table 1 the CAA report says. “The breakdown by hours flown between 1995 and 2004 shows Fatal Accident Rates for Eastern-Built Aircraft that 67 percent were [flown] by Eastern- Three-Year Moving Average, 1995–2004 built jets and 33 percent by Eastern-built 12 turboprops.” Eastern-Built Turboprops All Eastern-Built Aircraft The distribution of turboprops versus jets 10 Eastern-Built Jets in fatal accidents was approximately the reverse 8 of that for flights and flight hours during the same time period. Jets were involved in 61 per- 6 cent of flights but 36 percent of fatal accidents, 4 and turboprops flew 39 percent of flights but were involved in 64 percent of fatal accidents, (per MillionRate Hours) 2 2 says the report. 0 1997 1998 1999 2000 2001 2002 2003 2004 Figure 1 shows the three-year moving aver- Three-Year Period Ending age rates for fatal accidents involving Eastern- Note: Excludes business jets. built turboprops, jets and all aircraft.3 The Source: U.K. Civil Aviation Authority average peaked at 9.6 fatal accidents per mil- lion flight hours for turboprops. The report Figure 1 www.flightsafety.org | AviationSafetyWorld | November 2006 | 51 DataLink
gives a comparable picture for fatal accident flights flown (and 94 percent of hours flown) rates involving Western-built aircraft, also ex- by all jets and turboprops, and have been cluding business jets, during the same period, involved in 67 percent of the fatal accidents,” shown in Figure 2. the report says.4 “Western-built aircraft (jets and turbo- As with Eastern-built aircraft, the fatal ac- props combined) have generated 95 percent of cident rate was higher for turboprops than for jets. All the three-year moving average rates Fatal Accident Rates for Western-Built Aircraft for Western-built turboprops were lower than those for Eastern-built turboprops through- Three-Year Moving Average, 1995–2004 out the period, however. For Western-built aircraft, 70 percent of flights and 83 percent of 1.4 Western-Built Turboprops All Western-Built Aircraft flight hours involved jets. Fatal accidents were 1.2 Western-Built Jets divided equally between turboprops and jets, 1.0 says the report. 0.8 Fatal accident rates for all jets and turbo- 0.6 props in the same period are shown in Figure 0.4 3. The long-term trend for jets shows a de-
Rate (per MillionRate Hours) 0.2 crease, but no long-term trend for turboprops is evident. ● 0.0 1997 1998 1999 2000 2001 2002 2003 2004 Three-Year Period Ending Notes Note: Excludes business jets. 1. U.K. Civil Aviation Authority (CAA), Safety Source: U.K. Civil Aviation Authority Regulation Group. Aviation Safety Review 2005. Figure 2 CAP 763. Aug. 8, 2006. Available on the Internet at
Fatal Accident Rates for Eastern-Built and Western-Built Aircraft 2. Data originated from Airclaims, supplemented by accident briefs and reports from other sources, Three-Year Moving Average, 1995–2004 and were reviewed by the CAA. Utilization data for Eastern-built aircraft (i.e., flight hours) were Turboprops 2.0 Jets estimated to a greater extent than for Western- 1.8 built aircraft. 1.6 1.4 3. A moving average is an average that is recomputed 1.2 periodically in a time series by removing the oldest 1.0 data and including the most recent data. The effect 0.8 is to smooth out the data points and make trends 0.6 more visible. 0.4 Rate (per MillionRate Hours) 0.2 4. One of the fatal accidents was a midair collision 0.0 involving an Eastern-built aircraft and a Western- 1997 1998 1999 2000 2001 2002 2003 2004 built aircraft. “Midair collisions are normally con- Three-Year Period Ending sidered as one accident but, when the accidents Note: Excludes business jets. are broken down by class of aircraft [e.g., Western- Source: U.K. Civil Aviation Authority built turboprops], there will be double counting if the individual components are summed back Figure 3 together,” says the report.
52 | flight safety foundation | AviationSafetyWorld | November 2006 InfoScan
Airworthiness Now A current guide to certification sees progress in the integration of European standards under one safety organization.
BOOKS role is a step forward. He says, “In spite of a huge amount of work accomplished for unifica- Airworthiness: An Introduction to Aircraft tion of regulations and procedures in Europe, Certification the JAA did not have the authority to impose De Florio, Filippo. Oxford, England, and Burlington, Massachusetts, these rules. The EASA now has this power and U.S.: Butterworth-Heinemann, 2006. First edition. 261 pp. Figures, can perform as a single authority. For instance, bibliography, index. once an aircraft is type certificated by the EASA, o allow an aircraft to be operational in this type certificate is valid for all the Member normal air traffic, it is necessary to dem- States, without being just a ‘recommendation’ “Tonstrate that its design and construction for the issue of a national type certificate. Today, are in compliance with the applicable require- we have a single European agency instead of 25 ments; the verification of such compliance is national authorities, and a single certificate for entrusted to the competent authorities,” says aeronautical products.” De Florio. “Airworthiness introduces aerospace engineering students and engineers into this Fundamentals of Aviation Law world consisting, on the one hand, of designers, Speciale, Raymond C. New York: McGraw-Hill. 360 pp. Figures, appendixes, bibliography, index. manufacturers and operators, and, on the other, of airworthiness authorities, in two disciplines t is important for all aviation profes- that should work in unison, because they should sionals, including pilots, executives, aim at a common goal: flight safety.” “Iair traffic controllers and mechanics, The book discusses certification regulations, to have a fundamental understanding of the the agencies that write them and the agencies that legal environment in which they operate,” verify that they are followed from aircraft design Speciale says. He notes, however, that there is to construction. Chapters cover the International no universal recognition of “aviation law” as a Civil Aviation Organization and national and distinct branch of legal systems, and subjects regional civil aviation authorities such as the that apply to aviation can fall under tradition- Joint Aviation Authorities (JAA), the European al headings such as commercial law, tort law, Aviation Safety Agency (EASA) and the U.S. employment law and property law. Non-U.S. Federal Aviation Administration; airworthiness readers should note that the book is mainly requirements; type certification; products, parts based on U.S. law, although the final chapter and appliances; airworthiness certification; and takes up international aviation law with sec- continued airworthiness in flight operations. tions on international agreements such as the De Florio believes that the creation of EASA Chicago Convention, Warsaw Convention and and its gradual assumption of the regulatory bilateral treaties. www.flightsafety.org | AviationSafetyWorld | November 2006 | 53 InfoScan
Chapters are devoted to tort (injury) liability organization held runway safety seminars in and air commerce, administrative agencies such as its various regions, culminating in the runway the U.S. Federal Aviation Administration, com- incursion prevention guidelines on which this mercial law’s applicability to aviation transactions, manual is based. corporate and property law for aviation enterprises “An evolution in terms of safety thinking and employment law for the aviation industry. has led to a change of focus, from individuals Ways in which criminal law can affect to organizations,” the manual says. “It is now pilots and air carriers are discussed in chapter acknowledged that senior management decisions 3. Offenses can include document falsification, are influential in shaping the operational contexts transporting hazardous materials without au- within which operational personnel perform thorization, operating an unregistered aircraft, their duties and discharge their responsibilities. and unauthorized fuel tank modifications. It is also well known that, no matter the extent to “Whether a regulatory violation crosses the which operational personnel may excel in their line into the realm of criminal violations is a performance, they can never ultimately outper- difficult question to answer at times,” Speciale form, safety-wise, systemic deficiencies and flaws says. He cites the U.S. federal government in- in the system that [includes] them.” dictment of SabreTech, the operator of a repair Chapters discuss contributory factors in station that packed partially expended oxygen runway incursions; establishing a runway incur- generators as cargo aboard ValuJet Flight 592 in sion prevention program; recommendations for May 1996. The airliner crashed in the Florida prevention of runway incursions — for aircraft Everglades, killing all 110 people aboard, after operators, pilots, air traffic services providers the eruption of a fire that later was attributed to and controllers, and regulators; incident report- the oxygen generators on the airplane. ing and data collection; and severity classifica- An appeals court overturned a conviction tion of runway incursions. against SabreTech and several of its employees Systems can and should be improved, the on the grounds that “these aviation repair sta- manual says, but ultimately “properly selected, tion personnel committed mistakes, but they did trained and motivated personnel” are the last not commit crimes.” line of defense against breakdowns of the system that are rare but inevitable. “Operational per- REPORTS sonnel are the true goalkeepers of the aviation Manual for Preventing Runway Incursions safety system,” says the manual. International Civil Aviation Organization (ICAO). Document 9870. Main Report for the 2005/2012 Integrated Risk First edition. 2006. 86 pp. Figures, references, appendixes. Available via the Internet at
54 | flight safety foundation | AviationSafetyWorld | November 2006 InfoScan
• What is the safety assessment of the over- “The group had a total of four meetings,” the all system? report says. “In the first session, a description of the flight crew training process was discussed • How might new elements (e.g., conflict and agreed upon. A brainstorm was held in the detection and resolution systems) interact? second session to identify flows of information • Can negative interactions be avoided, and and to describe existing interface problems. as-yet unplanned positive interactions be In the third session, solutions to the identified introduced into the system design concept? interface problems were generated. These solu- tions were further specified in the final session.” • What are the strong and weak safety areas The report concludes that the Gate to Gate in the overall system? Safety methodology works: “Within a limited amount of time and resources, this working • Is the resultant system risk-sensitive to the group came up with useful results.” sequence and timing of implication?
Web Sites The report concludes that the IRP methodology, International Civil Aviation Organization (ICAO), although needing further development, “provides
• The publications section lists a number of free items. Examples are Systems Manage- ment Manual (290 pages); preliminary, un- edited chapters from the Manual of Civil Aviation Medicine; and MRTD Report, the new ICAO journal devoted to machine- readable travel documents.
• The signature publication, ICAO Journal, is available in full text and color for years 1991–2005. Viewing these issues requires DjVu Viewer, a Windows program that can be downloaded at no cost using the posted Web link. The opening page of the training program • The aviation safety section of ICAO’s describes system and Internet requirements, home page links to the Flight Safety estimated downloading times and estimated Information Exchange, which has its own time to complete the program. Participants can online library. Some full-text documents comment on the programs through e-mail links and manuals are ICAO Manual of Prevent- to AOPA or Air Line Pilots Association, Interna- ing Runway Incursions, May 2006, and tional (ALPA). Principles and Guidelines for Duty and ALPA and FAA Office of Runway Safety and Rest Scheduling in Commercial Aviation by Operational Services provide alternative access the U.S. National Aeronautics and Space to this runway safety program through their Administration, May 1996. respective Web sites. REGULATORY MATERIALS Hard-copy and electronic versions of docu- ments and manuals are available for purchase Approval of Flight Guidance Systems through eCommerce, ICAO’s online catalog of U.S. Federal Aviation Administration (FAA) Advisory Circular 25.1329- publications. 1B. July 17, 2006. 146 pp. Tables, appendixes. Available from FAA via the Internet at
56 | flight safety foundation | AviationSafetyWorld | November 2006 OnRecord Absence of Required Lights Cited in Nighttime Landing Accident Hawker touched down off the left side of the snow-covered runway.
BY MARK LACAGNINA
The following information provides an aware- The report said that the airport was not ness of problems in the hope that they can be required to be closed because the runway edge avoided in the future. The information is based lights were out of service. However, the flight on final reports on aircraft accidents and inci- crew was prohibited from conducting a night- dents by official investigative authorities. time landing at the airport because the absence of runway edge lights or reflective markers JETS meant that the airport’s lights did not meet Canadian, or U.S., requirements. Passengers Did Not Receive Safety Briefing Bromont Airport did not have weather- Hawker-Siddeley HS-125-600A. Substantial damage. Three serious observation or reporting services. The report injuries, three minor injuries. said that weather conditions at Bromont were he Hawker, operated by a U.S. aircraft- similar to those at an airport 30 nm (56 km) management company, was on a charter away, which had 1 mi (1,600 m) visibility in Tflight from Montreal to Bromont Airport light snow flurries and cloud cover at 2,000 in Quebec, Canada, on Feb. 21, 2005. The flight ft. “According to paragraph 135.213(b) of the crew had not flown to Bromont before. The FARs [U.S. Federal Aviation Regulations], when captain, the pilot flying, had 5,000 flight hours, a flight is conducted under instrument flight including 750 flight hours in type. The copilot rules, the weather observations produced and had 1,700 flight hours, including 100 flight given to the pilots must be taken at the airport hours in type. where the aircraft is heading, unless otherwise The report by the Transportation Safety authorized by an operating specification issued Board of Canada (TSB) said that while the cap- by the FAA [U.S. Federal Aviation Administra- tain was filing an instrument flight plan before tion] or by a designated person,” the report takeoff, he was asked by the flight information said. “However, there is no indication that the center specialist if he needed notices to airmen company had such a specification.” (NOTAMs). The captain said that he did not The flight crew conducted the localizer need them. At the time, a NOTAM advised that approach to Runway 05L, which is 5,000 ft the runway edge lights at Bromont were out of (1,525 m) long and 100 ft (31 m) wide. During service. the approach, the copilot activated the airport’s www.flightsafety.org | AviationSafetyWorld | November 2006 | 57 OnRecord
radio-controlled lights and established radio facing back the way it had come, after traveling communication with the Unicom operator, who a distance of 1,800 feet during which it made a told the crew that there was snow on the runway full turn followed by a 180-degree turn.” and that the runway edge lights were not in Both pilots and one passenger received service. “However, the approach lights and the serious injuries, and three passengers received visual approach slope indicator did turn on,” the minor injuries. The pilots were unable to shut Two seconds before report said. down the left engine because of damage that The aircraft was about 5 nm (9 km) from the restricted movement of a fuel valve. The report touchdown, the runway threshold and at 1,000 ft when the crew said that the passengers, who had not received copilot asked the gained visual contact with the approach lights a safety briefing before departure, had diffi- and precision approach path indicator (PAPI). culty hearing the copilot’s evacuation instruc- captain if he had Although the approach chart and airport tions because of the noise from the engine. The diagram in the crew’s possession indicated that emergency exit above the right wing could not the runway in sight; the PAPI was on the left side of the runway, the be opened because of structural damage. The the captain did not crew apparently was unsure of its position. “In main door at the front, left side of the cabin was response to a query from the crew, the Bromont opened with difficulty, but the airstairs could reply. dispatcher [Unicom operator] indicated that not be lowered fully because of the collapsed the PAPI was on the right side of the runway,” nose gear. Several occupants tripped or entan- the report said. “From his location facing the gled their feet while exiting the aircraft. aircraft, the PAPI was to the dispatcher’s right.” Based on the findings of its investigation, The crew continued the approach visually TSB said that the following were causes or fac- and aligned the aircraft to touch down left of the tors contributing to the accident: PAPI. “At approximately two miles [4 km] from the runway threshold, the copilot noticed that • “The flight crew attempted a night landing the approach lights were at his right,” the report in the absence of runway edge lights; said. “He reported his observation to the cap- • “The runway was not closed for night use tain, who paid little attention to it.” Both pilots despite the absence of runway edge lights. apparently were focusing their attention outside Nothing required it to be closed; [and,] the aircraft; neither pilot noticed instrument in- dications of deviation from the localizer course. • “Poor flight planning, noncompliance with Two seconds before touchdown, the copilot regulations and standard operating proce- asked the captain if he had the runway in sight; dures (SOPs), and the lack of communica- the captain did not reply. “Since the snow- tions between the two pilots reveal a lack covered runway provided little contrast with of airmanship on the part of the crew.” the adjacent terrain, and the flight took place Glideslope Excursion Unexplained at night without runway edge lights, it was Boeing 747-200. No damage. No injuries. impossible to distinguish the runway from the surrounding terrain,” the report said. acking recorded flight information, inves- The aircraft touched down 300 ft (92 m) left tigators were unable to determine whether of the runway and 1,800 ft (549 m) beyond the Lan instrument landing system (ILS) signal threshold. “When the captain realized that he error or a fault in the aircraft’s equipment caused was not on the runway, he applied full power to the aircraft, which had 15 crewmembers and execute a missed approach; however, the aircraft 450 passengers aboard, to descend to 1,200 ft hit a ditch approximately four feet [1.2 m] deep when it was 8 nm (15 nm) from the runway that was perpendicular to the flight path,” the threshold during a coupled approach to London report said. “The nosewheel and right land- Heathrow Airport about 1220 local time Jan. 10, ing gear collapsed. The aircraft came to a stop 2006.
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The report by the U.K. Air Accidents Inves- aircraft soon after the incident rendered further tigation Branch (AAIB) said that visibility was investigation impracticable.” good below a 1,500-ft ceiling when the flight The report said that risk was minimal in crew was cleared to conduct the ILS approach the incident. Had the flight crew continued the to Runway 27R. The airplane was 14 nm (26 descent, they likely would have gained visual km) from the runway and at 4,000 ft when the contact with terrain in time to avoid controlled autopilot captured the glideslope and the aircraft flight into terrain. “Had the cloud base been began to descend. “The flight crew reported lower, the aircraft’s GPWS [ground-proximity that after a short time, they identified that the warning system] should also have provided a glideslope indications were showing progressively timely warning of proximity to the ground,” the greater ‘fly-down’ commands and the autopilot report said. was attempting to pitch the aircraft’s nose down to follow these indications,” the report said. Rough Runway Blamed for Jammed Nosewheel The crew then received a glideslope failure Cessna Citation 560XL. Substantial damage. No injuries. indication and a “NO AUTOLAND” message on he Citation was scheduled for a charter the engine indicating and crew alerting system. flight with four passengers from Stockholm, The first officer, the pilot monitoring, asked the TSweden, to Plovdiv, Bulgaria, the morn- air traffic controller if there was a fault with the ing of Dec. 1, 2004, and to return to Stockholm glideslope. The controller, who had observed the that evening. Neither pilot had flown to Plovdiv aircraft’s unusually low altitude, told the crew to previously. climb and said that the glideslope was service- “On short final during approach to Plovdiv, able. The aircraft was descending at 1,800 fpm the crew noticed that the runway consisted of when the commander disengaged the autopilot concrete blocks and had a rough appearance,” and conducted a climb to 1,800 ft. “With the said the report by the Swedish Accident Investi- glideslope indications then looking reasonable gation Board (SHK). “The crew considered the again and no failure indications, the commander landing and the rollout to be very severe for the armed the autopilot to capture the glideslope, aircraft.” and it did so,” the report said. “A successful auto- The pilots inspected the aircraft after landing pilot approach was completed, and the landing and found no visible damage. While preparing was accomplished manually.” for departure from Plovdiv that evening, they None of the pilots who conducted the ILS observed no abnormalities. The commander, the approach before and after the 747 crew reported pilot flying, applied the wheel brakes while set- problems with the glideslope. No faults or fail- ting takeoff power to decrease the length of the ures were recorded by the ILS self-monitoring takeoff roll on the rough runway. The crew cycled system. The 747 crew recorded the glideslope “When the landing gear was retracted after the landing gear fluctuation in the aircraft’s technical log but did takeoff, a warning was displayed that the nose not file a report on the incident. Heathrow con- gear wasn’t retracted,” the report said. The crew and flaps, but the trollers reported the incident as a level bust. cycled the landing gear and flaps, but the fault AAIB said that it became aware of the inci- indication remained. The commander decided fault indication dent several weeks after it occurred; by then, the to continue the flight to Stockholm. “Due to the remained. aircraft’s flight data and cockpit voice recordings faults, the flight continued with limitations of had been overwritten. “Based on the available the performance according to the checklist for evidence, the problem was either external to the abnormal procedures,” the report said. “After aircraft but experienced only by [the aircraft] or consultation with a responsible technician in an unidentified internal fault within the aircraft,” Gothenburg via satellite telephone, the pilots the report said. “However, the lack of recorded suspected that a failure had occurred in the flight data and the inability to evaluate the aircraft hydraulic system.” www.flightsafety.org | AviationSafetyWorld | November 2006 | 59 OnRecord
Entering Swedish airspace, the crew told air “The mist was accompanied by a smell which traffic control (ATC) that they would land the was described as ‘oily’ by the cabin crew,” said aircraft at Stockholm-Arlanda Airport, rather the AAIB report. “The flight services manager, than Stockholm-Bromma Airport. “The reason head of the cabin crew, notified the commander that the crew preferred Arlanda was that they over the intercom that there was ‘smoke’ in the [would have] more choices regarding runways if cabin.” any problem should arise in connection with the The flight crew also had detected an “oily- landing,” the report said. “All runways at Arlanda type” odor, but there was no smoke or mist on are longer than the single runway at Bromma and the flight deck. The commander completed the available rescue service has higher capacity.” after-takeoff checks, leveled at a safe altitude When the landing gear was extended on ap- and asked the relief first officer, who was in the proach to Runway 26, the green light indicating jump seat, to assess the situation in the cabin. that the nose landing gear is down and locked The relief first officer reported that there was no did not illuminate. The crew conducted the smoke in the cabin but the odor of oil persisted. alternate gear-extension procedure according to The captain decided to return to Heathrow. the “Abnormal” checklist. “They followed the list The flight crew declared an urgency — pan, with actions, with exception of ‘nose yaw’ — an pan — conducted the “Smoke/Fumes Removal” action where side forces help extension and checklist and advised the cabin crew and pas- locking, to solve the problem,” the report said. sengers of the situation. The aircraft was above The nose gear light did not illuminate. its landing weight limit, and ATC provided vec- The commander held the nose gear off the tors to a suitable area to jettison fuel. “It took ap- runway as long as possible after touchdown. The proximately 60 minutes to jettison the 83 tonnes aircraft was rolling at about 50 kt when the nose [182,600 lb] of fuel required,” the report said. contacted the runway. The aircraft then traveled “The subsequent approach and landing back at about 200 m (656 ft) before being brought to a Heathrow were uneventful.” Fire-service person- stop. The six occupants were not injured. nel inspected the aircraft after it was taxied off Investigators determined that the nose gear the runway and noticed nothing unusual. The A maintenance strut had not extended and the nose gear had aircraft then was taxied to a remote stand, where become jammed between the door-hinge arms. the passengers were deboarded. technician found a The report said that violent vibrations and stress The operator’s SOP for the A340-600 was to on the aircraft during the landing at Plovdiv had operate the auxiliary power unit (APU) during small drain hole near contributed to the leakage of nitrogen through a takeoff and until reaching 1,500 ft above ground the APU inlet blocked defective O-ring in the strut and the consequent level (AGL). Maintenance personnel detected reduction of pressure within the strut. a slight oily odor after selecting APU bleed air by a buildup of dirt Based on these findings, SHK said, “The but found no sign of an oil leak. The aircraft accident likely occurred because the aircraft was was released to service with the APU inopera- and dried oil. operated on a very rough runway, which caused tive. During subsequent routine maintenance, the damage [to] the nosewheel.” The board said a maintenance technician found a small drain that inadequate design of the nose landing gear hole near the APU inlet blocked by a buildup of retraction mechanism was a contributing factor. dirt and dried oil. When he cleaned the drain hole, almost a liter of an oil-water mixture ‘Oily Smell’ Prompts Turn-Around drained out. Airbus A340-600. No damage. No injuries. AAIB said that the mist and odor encoun- he cabin filled with a light white mist as tered during the incident flight likely resulted the aircraft was rotated for takeoff from from the drain hole becoming unblocked by TLondon Heathrow Airport for a flight with vibration during the takeoff and the subsequent 308 passengers to Los Angeles on Dec. 30, 2005. ingestion of the untrapped fluid by the APU.
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“Once ingested, this contaminant could pass NTSB said that the probable cause of the into the bleed air duct and subsequently into the incident was “the failure of the elevator down cabin air-conditioning system,” the report said. cable due to an improperly routed cable by un- known maintenance personnel” and that a con- TURBOPROPS tributing factor was “the improper inspection of the elevator cable by the operator’s maintenance Elevator Cable Snaps on Takeoff personnel.” Swearingen SA226TC Metro II. Minor damage. No injuries. Propeller Would Not Feather he pilot told investigators that he checked De Havilland Canada Dash 8-300. Substantial damage. No injuries. the aircraft’s flight controls before attempt- Ting to depart from Denver International he flight crew was not able to feather the Airport in visual meteorological conditions at propeller after the right engine failed soon 0623 local time April 5, 2006, for an unsched- Tafter takeoff from Manchester, England, on uled cargo flight to Dodge City, Kansas, U.S. He Aug. 9, 2005, for a scheduled flight to Aberdeen, said that the elevator control feel seemed very Scotland, with 33 passengers. The crew declared light during the takeoff roll. When he pulled the an emergency, returned to the airport and yoke back at rotation speed, the yoke moved to landed the airplane. its full aft travel, and the aircraft rapidly pitched “It was fortunate that, despite the propel- nose-up. ler not being fully feathered, sufficient rudder “The pilot reported that moving the yoke authority was available to maintain directional forward had no effect, and it felt disconnected control,” said the AAIB report. from the elevators,” said the U.S. National Investigators found that a propeller blade Transportation Safety Board (NTSB) report. support bearing had failed catastrophically, “The pilot quickly began to trim nose-down resulting in a large imbalance of engine loads. and reduced power to stop excessive nose-up The power turbine shaft fractured, and the con- pitch.” sequent overspeed of the power turbine led to The pilot gained marginal control of the the separation and ejection of the turbine blades aircraft and told ATC that he had a flight control from the rear of the engine. problem and was returning to land. He said that “The failure of the propeller to feather was while flying the downwind leg, he “experiment- due to a ball from the failed bearing becoming ed with various configurations … to determine jammed between the propeller blade root and the method of approach and landing” and then the propeller hub,” the report said. “The ori- conducted a gradual descent and an uneventful gin of the bearing failure was not determined, landing on the runway. although metallic examination revealed that Company maintenance personnel found cracking had been occurring for a period of that the elevator “down” cable was improperly time.” The failed bearing had accumulated routed at the pulley in the vertical stabilizer 16,714 hours in service. Another bearing in and had worn to the point of failure from con- the propeller had accumulated 24,737 hours tact with a guide. Maintenance records showed in service and showed no sign of impending that the cable had been installed by a previous failure. operator of the aircraft in 1998. The aircraft Strong propeller vibration had been reported had been inspected at the current operator’s six days before the incident, and vibration- maintenance facility 10 days prior to the inci- monitoring equipment had been installed in dent. “According to the inspection checklist, the aircraft. The report said, however, that the the elevator cables and related components equipment had been installed incorrectly, and were inspected, with no anomalies noted,” the no meaningful readings were recorded before report said. the incident occurred. www.flightsafety.org | AviationSafetyWorld | November 2006 | 61 OnRecord
Cargo Shift Causes Tail Strike Landing Gear Lever Breaks Convair 440. Minor damage. No injuries. Piper PA-23-250. Substantial damage. No injuries. he flight crew landed the airplane at Keno- flight instructor with 18,800 flight hours, sha (Wisconsin, U.S.) Airport at 2350 local including 500 flight hours in Aztecs, and Ttime Sept. 22, 2005, and removed the straps A a student pilot receiving training for a restraining the cargo. After waiting 1.5 hours for multi-engine airplane type conversion were con- the ground crew to arrive to unload the cargo, ducting takeoffs and landings at Napier (New the captain called the company and was told to Zealand) Aerodrome on April 13, 2006. The fly the aircraft to Milwaukee and have the cargo Aztec was on the downwind leg for the second unloaded there. landing when the student attempted to extend “Since we unstrapped the freight for offload the landing gear. “However, the handle of the almost two hours ago, we didn’t think to check landing gear selector lever broke off in his hand, the freight,” the captain told investigators. He and the gear remained selected ‘UP,’” said the also noted that the “Before Start” checklist does report by the New Zealand Transport Accident not remind the flight crew to verify that the Investigation Commission. cargo is properly restrained. The instructor told the tower controller The captain began the takeoff at about about the problem and their intention to fly the 0120. The aircraft had rolled about 400 ft (122 airplane to a safe position east of the airport m) when the cargo shifted. The aircraft’s tail where they could attempt to resolve the prob- struck the runway, and the captain rejected the lem. The Aztec had two emergency landing gear takeoff. extension systems, but the pilots were not able to use them because they require the landing PISTON AIRPLANES gear handle to be in the “DOWN” position. With the student flying the airplane, the instruc- Chieftain Strikes Trees During Approach tor attempted unsuccessfully to use the crash ax Piper PA-31-350. Destroyed. One fatality. to gain access to the remaining section of the he pilot was conducting a cargo flight gear lever. from Knoxville, Tennessee, U.S., to Unable to resolve the problem, the instructor TDayton (Ohio) International Airport in told the controller that he would conduct a gear- nighttime instrument meteorological con- up landing on the grass portion of the runway ditions on Dec. 7, 2004. He reported that and asked the controller to alert the airport’s the aircraft was established on the localizer emergency services. “During the circuit before course for the ILS approach to Runway 06L landing, the instructor shut down the right en- at Dayton. The tower controller told the pilot gine and feathered its propeller, and the student that touchdown RVR (runway visual range) turned off the fuel and magnetos,” the report was 1,800 ft (550 m). said. “To prevent any propeller damage during Radar contact was lost when the aircraft the landing, the instructor had the student crank was at 1,200 ft. The aircraft struck trees and the engine until the stationary propeller was came to rest inverted about 0.5 nm (0.9 km) aligned approximately horizontal.” from the runway at 0104 local time. A weather To prevent flap damage, the instructor did observation at the time of the accident not extend the flaps. “To reduce the potential of included RVR variable between 1,800 ft and a fire and to help minimize any engine damage, 2,000 ft (600 m) in fog and vertical visibility the instructor shut down the left engine and 100 ft. The published minimum visibility for had the student turn off the fuel, magnetos and the ILS approach was 1,800 ft RVR, and deci- master switch just before the aeroplane touched sion height was 1,198 ft, or 200 ft height above down,” the report said. The airplane touched touchdown. down smoothly on the grass portion of the
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runway and turned 90 degrees right when it slid HELICOPTERS onto the paved portion of the runway, where it came to a stop. Damage included a bent left Broken Hoist Cable Strikes Rotor Blades, Canopy propeller blade, scrapes on the lower fuselage Sikorsky S-61N. Substantial damage. One minor injury, five uninjured. and broken antennas. he crew was conducting a search-and- False Fuel Indications Lead to Ditching rescue training flight over the ocean south Beech E55 Baron. Destroyed. Two fatalities, two serious injuries, one of Waterford, Ireland, on Jan. 17, 2006. The minor injury. T helicopter was brought to a hover over a ship he owner of the airplane told investigators at anchor, and the winchman was lowered by that the fuel quantity indicators mounted in cable to the deck on the bow of the ship. As the Tthe instrument panel did not work properly. winchman prepared to release himself from the Before departing from Redmond, Oregon, U.S., hoist hook, he was thrown off balance when the for a flight to Friday Harbor, Washington, on ship rose on a 2-m (7-ft) swell; he grasped a lad- July 1, 2005, the pilot used the fuel tank sight der to steady himself. “During the process, a coil gauges to check fuel quantity. The left gauge of cable looped around a small steel protrusion showed 45 gal (170 liters), and the right gauge welded to the side of the ladder,” said the report showed 55 gal (208 liters), which the pilot by the Irish Air Accident Investigation Unit. believed was sufficient for the 1 hour, 50 minute The winch operator aboard the helicopter flight. saw that the winchman had released the hoist The airplane was descending to land when hook and began to winch the cable back aboard power was lost from both engines. The pilot the helicopter. “At the same time, the bow of the ditched the airplane in the ocean about 8 mi ship pitched down, load was put on the unseen (13 km) from the destination. Two passengers snagged cable, and the cable sheared just above were killed, the pilot and one passenger were the hook-attachment point,” the report said. seriously injured, and one passenger received The cable, which recoiled after shearing, minor injuries. The surviving passengers said lacerated the winch operator’s hand, broke the that the airplane hit the water hard in a slightly canopy above the pilots’ heads and struck two nose-down attitude and immediately began to of the five main rotor blades. The pilots flew the sink. helicopter back to their base. The NTSB report said that maintenance had been performed on the airplane four Ground Resonance Encounter months before the accident to replace leaking Agusta A109E. Destroyed. No injuries. fuel cells and that the fuel sight gauges were he 6,500-hour pilot was ground-taxiing installed incorrectly, resulting in float travel the helicopter at Fort Worth (Texas, U.S.) being restricted by wing structure. “If the sight TMeacham International Airport in prepara- gauges had been properly installed, they would tion for a repositioning flight on Jan. 19, 2005. have read in the cross-hatched (unusable) He said that when he applied the wheel brakes area,” the report said. to give way to an airplane that was being taxied NTSB said that the probable cause of the to the ramp, the helicopter began to shake and accident was “the pilot’s failure to refuel the turn 90 degrees left. airplane, which resulted in a dual loss of engine After the helicopter turned left, the main power during normal descent due to fuel ex- rotor and transmission assembly separated from haustion” and that a contributing factor was “the the aircraft. The pilot was not injured. incorrect installation of the left and right wing NTSB said that the probable cause of the fuel sight gauge/float assemblies by unknown accident was “the pilot’s inadvertent encounter persons.” with ground resonance.” ● www.flightsafety.org | AviationSafetyWorld | November 2006 | 63 OnRecord
Preliminary Reports Date Location Aircraft Type Aircraft Damage Injuries Aug. 28, 2006 Smith, Nevada, U.S. Raytheon Hawker/Schleicher ASW-27 substantial/destroyed 3 minor, 3 none The Hawker 800XP was descending through 16,000 ft when the captain saw the glider close ahead. She attempted evasive action, but the airplane’s nose struck the glider’s right wing. The Hawker pilots received minor injuries. The airplane’s right engine flamed out, and the landing gear would not extend. The pilots conducted a gear-up landing at Carson City, Nevada. The glider entered a flat spin after the collision, and the pilot bailed out. He received minor injuries after landing when the parachute dragged him across the ground. Aug. 29, 2006 Ravensthorpe, Australia British Aerospace 146-100 NA none Soon after takeoff, the flight crew reported a fire in the cockpit and returned to the Ravensthorpe airport. The pilots flew the airplane in a holding pattern over the airport while conducting the emergency checklist. They extinguished the fire and landed without further incident. Sept. 1, 2006 Mashad, Iran Tupolev Tu-154M destroyed 28 fatalities, 120 NA The nosewheel tires reportedly burst on landing, and the airplane swerved off the runway and caught fire. Sept. 1, 2006 Argyle, Florida, U.S. Mitsubishi MU-2B destroyed 1 fatal Intense to extreme weather radar echoes were recorded in the area when the aircraft broke up while descending to land at Panama City, Florida, during a business flight from Tulsa, Oklahoma. Sept. 3, 2006 Karachi, Pakistan Boeing 737-300 NA NA Soon after departing from Karachi, the flight crew heard a thud and felt a vibration. The crew saw an unsafe landing gear indication on approach to Doha, Qatar, and conducted a go-around and fly-by of the control tower, which reported that portions of the right elevator and trim tab were missing. Sept. 5, 2006 San Juan, Puerto Rico Boeing 757-200 substantial 116 none The aircraft began to drift right of the runway centerline, and the first officer, the pilot flying, disconnected the autopilot. “During the landing flare, the nose raised to a high angle, and the tail struck the runway,” the preliminary report said. Sept. 6, 2006 Porterville, California, U.S. North American OV-10A destroyed 2 fatal The airplane was being maneuvered during a forest-firefighting operation when it struck trees and mountainous terrain. Sept. 6, 2006 Somis, California, U.S. Hughes 369D destroyed 2 fatal The helicopter was engaged in a powerline-inspection flight when it struck powerlines about 75 ft AGL and descended to the ground. Sept. 14, 2006 Subic Bay, Philippines McDonnell Douglas MD-11 NA NA The aft portion of the aircraft was damaged by a tail strike while landing. Sept. 14, 2006 Fort Meade, Florida, U.S. Piper Aztec destroyed 2 fatal The aircraft was engaged in a mosquito-control flight when it struck a tower and descended to the ground. Sept. 17, 2006 NA Boeing 767-300 NA NA The aircraft was cruising at Flight Level 320 when the flight crew detected an electrical odor and saw smoke emerging from the autoflight mode control panel. The flight crew declared an emergency after losing the autopilot, autothrottles and flight directors, and diverted the flight to Pointe a Pitre, Guadeloupe. Sept. 18, 2006 Brisbane, Australia Boeing 777-200 none none Soon after departing from Brisbane for a scheduled flight to Malaysia, the flight crew reported that the right engine had flamed out. The crew was able to restart the engine and, after dumping fuel, landed at Brisbane. Sept. 21, 2006 Kodiak, Alaska, U.S. de Havilland DHC-2 Beaver substantial 1 fatal, 2 serious, 4 none The pilot had transported fishermen to a narrow stream 75 mi (121 km) northwest of Kodiak. Weather conditions deteriorated, and the pilot told the passengers that they would have to return to the operator’s lodge. Surviving passengers said there was heavy rain and strong winds when the float-equipped airplane crashed soon after taking off from the stream. One passenger was killed, one passenger was seriously injured, and the pilot and three passengers escaped injury. Sept. 22, 2006 NA Boeing 777-200 NA NA The aircraft was en route from Israel to the United States when smoke and fire emerged from the lower corner of the first officer’s windshield. The flight crew donned oxygen masks, declared an emergency and diverted to Brindisi, Italy. Sept. 29, 2006 Peixoto Azevedo, Brazil Boeing 737/Embraer Legacy destroyed/minor 155 fatal/7 none The 737 was at Flight Level 360 during a scheduled flight from Manaus to Brasilia when it apparently collided with the Legacy and descended into the Amazon jungle. The Legacy, which was on a delivery flight from Sao Jose dos Campos to the United States, was landed safely at Cachimbo Air Base. 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 | AviationSafetyWorld | November 2006 Now you have the safety tools to make a difference.
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Order the FSF : Member price: US$40 Recommended System Requirements: Nonmember price: $160 Windows® Mac® OS Quantity discounts available! • A Pentium®-based PC or compatible computer • A 400 MHz PowerPC G3 or faster Macintosh computer • At least 128MB of RAM • At least 128MB of RAM Contact: Namratha Apparao, • Windows 95/98/NT/ME/2000/XP system software • Mac OS 8.6/9, Mac OS X v10.2.6 or later Mac OS and Macintosh are trademarks of Apple Computer Inc. registered in the United States and other countries. Microsoft, Windows and are either registered trademarks or membership services coordinator trademarks of Microsoft Corp. in the United States and/or other countries. +1 703.739.6700, ext. 101. The FSF ALAR Tool Kit is not endorsed or sponsored by Apple Computer Inc. or Microsoft Corp. Flight Safety Foundation
19th annual European Aviation Safety Seminar EASS Staying Safe in Times of Change
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To receive agenda and registration information, contact Namratha Apparao, tel: +1 703.739.6700, ext. 101; e-mail: [email protected]. To sponsor an event, or to exhibit at the seminar, contact Ann Hill, ext. 105; e-mail: [email protected]. © Copyright 2006 Getty© Copyright Images Inc.