ON COMMERCIAL AVIATION SAFETY SPRING 2005

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ISSN: 1355-1523 SPRING 2005 ON COMMERCIAL AVIATION SAFETY

FOCUS is a quarterly subscription journal devoted to the promotion of best practises in contents aviation safety. It includes articles, either original or reprinted from other sources, related Editorial 2 to safety issues throughout all areas of air transport operations. Besides providing information on safety related matters, FOCUS aims to promote debate and improve Chairman’s Column 3 networking within the industry. It must be emphasised that FOCUS is not intended as a substitute for regulatory information or company publications and procedures. A Report on the UKFSC Annual Seminar 2004 4 Editorial Office: Ed Paintin The Graham Suite Fairoaks Airport, Chobham, Woking, Engine Thrust Hazards in the Airport Environment 10 Surrey. GU24 8HX Tel: 01276-855193 Fax: 01276-855195 The Boeing Company e-mail: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900 - 1630 Monday - Friday Book Review: 16 Advertisement Sales Office: UKFSC International Journal of Mass Emergencies and Disasters The Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey GU24 8HX Tel: 01276-855193 Fax: 01276-855195 Letter to the Editor 19 email: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900 - 1630 Monday - Friday

Printed by: Avoiding Tailstrikes 20 Woking Print & Publicity Ltd Peter Simpson The Print Works, St.Johns Lye, St.Johns, Woking, Surrey GU21 1RS Tel: 01483-884884 Fax: 01483-884880 ISDN: 01483-598501 e-mail: [email protected] Mandatory Occurrence Reporting 22 Web: www.wokingprint.com Simon Phippard FOCUS is produced solely for the purpose of improving flight safety and, unless copyright is indicated, articles may be reproduced providing that the source of material is acknowledged. Air Accident Investigation: The Role of the Police 23 Simon Phippard Opinions expressed by individual authors or in advertisements appearing in FOCUS are those of the author or advertiser and do not necessarily reflect the views and endorsements of this journal, the editor or the UK Flight Safety UKFSC List of Members 24 Committee.

While every effort is made to ensure the accuracy of the information contained herein, FOCUS accepts no responsibility for any errors or omissions in the information, or its Front Cover Picture: A Britten-Norman Defender consequences. Specialist advice should always off the South Coast of England be sought in relation to any particular circumstances. Picture courtesy of Flight Images

1 Editorial

Complacency – Stamp it out

For every MOR submitted to the CAA by and result in a better understanding of the an operator, about 30 Air Safety Reports event and improve the recommendations (ASRs) are filed within that operator. All of that stem from such events. these are scrutinised and action taken where necessary to fine tune the operation. Flight Data Monitoring is another tool for the operator to use in monitoring the safety Presently about 1,000 MORs are filed with of the operation. It is not a “Cure all”. the UK CAA each year. Many of these are discussed in detail during the Safety Each member of staff needs to be on their Information Exchange session at the UK guard for creeping complacency and must Flight Safety Committee meetings held stamp it out at the earliest opportunity. every two months. Man who is subject to repetitive tasks will In an environment like that which currently with time become complacent. It is exists in the UK, it may be easy to therefore necessary for each and every For many years operators in the United become complacent. Perhaps some manager to see that there is sufficient Kingdom have been operating what incidents are not reported because they variation in the task to ensure that their is believed to be the most open are thought trivial and perhaps some of us staff do not become complacent. Mandatory Occurrence Reporting (MOR) could put more effort into the quality of the system in the world. reports submitted. Often one hears that Nowhere is this more important than in fight safety officers are thinly stretched the aviation industry. The Civil Aviation Authority (UK CAA) to with too much to do and too little time in their credit, created a positive culture by which to do it. Does this mean that their encouraging the submission of these investigations are not as thorough as they reports and not using them as a means of should be? Probably not, but at times one penalising pilots. They have also promoted can not help feeling a little uneasy about the use of the MOR database and many the effect of cost cutting and increasing operators have used information from the commercial pressures. database in order to improve flight safety within their organisations. The introduction of routine Flight Data Monitoring may be seen by some as a As a result of the positive way that pilots “spy in the sky” exercise. If used wisely it in the United Kingdom have reported will assist operators to become aware of incident information and as a result of the those safety events that are not being sharing of this information between reported by some aircrew. It will also be operators to prevent similar incidents an aid in the investigation of the reported from occurring, the UK MOR system is events. More accurate data relating to admired around the world. safety events will become readily available to the investigating safety officer

UK FLIGHT SAFETY COMMITTEE OBJECTIVES To pursue the highest standards of aviation safety. ■ To constitute a body of experienced aviation flight safety personnel available for consultation. ■ To facilitate the free exchange of aviation safety data. ■ To maintain an appropriate liaison with other bodies concerned with aviation safety. ■ To provide assistance to operators establishing and maintaining a flight safety organisation.

2 Chairman’s Column

Safety and Security in Aviation

But how far does Flight Safety need to be involved in security? Well, there are no definitive lines to be drawn.

The locked cockpit door policy has the biggest effect on Flight Safety but it is only a very small part of the overall aviation security plan. Flight Safety managers (and us at UKFSC) must be careful not to be drawn into areas that are already well served by security experts. This does not mean that we should not be inquisitive, rather that we ensure that what we decide to do fits in with the overall security culture and that suitable advice is sought from those who are the 'experts' - but Flight Safety must always be the priority.

Passengers, those people who pay our way, have always taken it for granted that they will be transported in a safe manner. The events of 11th September 2001 and the need to secure aircraft for the They never used to distinguish between a changed the face of aviation permanently. groundcrew. safe flight and a secure flight - the two Aircraft were no longer being hijacked to were always integrated in their minds. It make a political point; they were now The days of allowing anyone on the flight is interesting that more passengers are being used as missiles. The rush to deck, easy entry by cabin crew, and even now taking note of the industry's security produce counter-measures resulted in flying with the door propped open have procedures and are not afraid to question tighter security checks both on and off all gone. The armoured wall has meant them. The media have done a lot to raise the aircraft, and the introduction of locked that crews have to ensure that their CRM the public awareness of aviation security and armoured cockpit doors. Like all and communication skills must leave no and thus their expectations when they instant solutions - some were good and room for doubt where the safety of flight travel. some were bad. Just over 3 years later is concerned. and the aviation industry have settled into We must ensure that none of them the routine of security measures at So what affect does all this security are disappointed! airports and aircraft. have on the role of the company Flight Safety team? One benefit that may be said to have come from all this is the relationship Well certainly more contact with their between safety and security departments. security counterparts. The CAA, in From government down through industry, conjunction with the Transport Security they have been talking more to each Section (TRANSEC) of the DfT has other than perhaps they did in the past. achieved some good agreements over Within airlines, both aircrew and ground the procedures for the use of hardened crew have been made more aware of cockpit doors. These procedures have their security responsibilities and how passed into Operation Manuals and have they fit into the Flight Safety culture. now become standard in UK aviation. Locked cockpit doors probably causing the greatest need for change for aircrew,

3 UK Flight Safety Committee Annual Seminar “Breaking the Barriers in Communication” 20th-21st September 2004 Radisson Edwardian Hotel, Heathrow Airport Report by Ian Sheppard

An impressive array of speakers lined up been needed at DHFS to nurture mutual learned in working together to avoid at Heathrow to throw light on the critical understanding in respect of “needs, compartmentalisation at the front line. issue of “enhancing aviation safety desires and key functions” while through better communication” – from a “fostering the core values of all three.” Meanwhile looming on the horizon is the military man to a lawyer, an airline ceo, a UK Flying Training System (MFTS) which leading academic, an industrialist, an air Collectively, meanwhile, the essential is being developed for 2012 and will be traffic controller and last, but by no military ‘can-do’ attitude is “very difficult outsourced under a £30 billion contract. means least, a regulator. to manage… at times the military has to “This will not have the compartmentalised push the envelope to get the job done management systems we still see today” Colonel Arthur Gibson, who in July [but] when do you allow crews to says Gibson, who concludes that through became Commandant of the UK’s deviate?,” he asks. “Are we different to all of these initiatives flight safety will “be Defence Helicopter Flying School, said civil or just being gung ho?” the winner”. that while the military thinks itself good at Leadership and communication have communicating, the three branches of the been central themes in the joint helicopter Barrister Charles Haddon-Cave QC, of armed services are perhaps “too command’s approach, with the aim of Quadrant Chambers in London, said that compartmentalised”. Much effort has improving command and control. Gibson in his experience management should be believes that pooling assets has worked “not too rigid and not too flexible – both in “enhancing can lead to problems”. Communications Airstaff Associates communications” and was an essential factor with the simplest he reflected that “it is words being easily misconstrued. “Trivial in association with remarkable that we errors or omissions can be catastrophic”, Nigel Bauer & Associates were able to make it he said, while increasingly complex work at all before.” systems, crowded skies and greater QUALITY MANAGEMENT FOR OPERATORS * JAR-OPS Quality Systems, documentation & auditing awareness of ’rights’, the risks were all 5 days - LGW - 16 May, 05 Sep, 05 Dec The Defence Aviation too real. NEW SAFETY MANAGEMENT SYSTEMS Safety Centre has New enlarged SMS course for air & ground operators been “leading the Good communication is clear, concise 3 days - LGW - 12 Sep way” in defining new and controlled – concise as busy people AUDITING IN AN OPERATIONAL ENVIRONMENT * regulations since its need to see the point “instantly” – Air & ground operations auditing formation in 2002. although the discipline of brevity and 3 days - on request or ‘in-company’ Gibson says that it is good structure is very hard to achieve; AUDIT IMPROVEMENT WORKSHOP “unbelievable” that controlled in three ways: between the Experience sharing & improvement of audit process 2 days - running shortly JSP318 (the military relevant parties; timely; and with the right ANO equivalent used priority. “Poor communications usually QUALITY FOR SENIOR MANAGEMENT JAR Quality Management Accountability until mid-2003) lacks one of these factors, with causation 2 days - ‘in-company’ only worked at all and can then lead to catastrophe”. * Incorporating Nigel Bauer & Associates even more so that IRCA certificated Internal Auditor Training course “CAA let us use it” – There are also “inhibitors” (as opposed to For further details including In-Company courses and consultancy or and says that the new barriers) to communication, he said, such auditing services please contact: joint regulations as a poor safety procedure. With the Airstaff Associates: JSP550 is far better, Herald of Free Enterprise disaster in Tel +44 (0) 1780 721223 e-mail: [email protected] Fax +44 (0) 1780 720032 url: www.shape.aero also covering areas 1987, closing the bow doors was the job Nigel Bauer & Associates: such as Joint Force of the assistant boson who had fallen Tel +44 (0) 1243 778121 e-mail: [email protected] Harrier and asleep on his bunk reading a Jeffrey Fax +44 (0) 1243 789121 url: www.nigelbauer.co.uk translating lessons Archer novel. There was no system for

4 checking that the doors were closed and no light on the bridge to indicate that they were still open. Meanwhile, six months beforehand a senior director had vetoed a suggestion for a warning light – as there was a seaman watching the doors!

At the public inquiry in front of admiralty judge Sir Barry Sheen, counsel described the management as “sloppy, from top to bottom” – with the switch from a lifting door design to a clamshell design, so the bridge couldn’t see if it was open or shut, not being acted upon. “There was a lack of appreciation of this change with some in the fleet – some masters of vessels put in place training while others did nothing,” and there was no company forum to The third inhibitor of good disseminates it around – cut, paste and discuss safety issues, said Haddon-Cave. communications is lawyers and the threat splurge”. He added that e-mails have Thus the case is still a reminder that of litigation. “There has been a sea made us “sloppy” and that wading through organisations need dedicated safety change in popular attitudes – give people them is “daunting”. “It’s a real problem in officers – but “not just superannuated rights and they exercise them, particularly my view”, Haddon-Cave concluded. pilots close to retirement with little clout.” where there are ‘men in suits’ as targets,” This mantra was reinforced following the he said. The European Convention on The second observation on new Marchioness disaster on the River Human Rights has given people rights technology is the “toy” aspect, even in Thames. Lord Justice Clark reported that and they use them, with the assumption the cockpit, with the opportunity for old- modern management needed trained being that it must be someone’s fault – fashioned communication often being risk managers. the result being that the threat of lost. “Glass cockpits can be mesmerising lawyers obtaining e-mails etc “stultifying and don’t necessarily communicate A second inhibitor to good open debate”. [information] as well as dials,” as was communication is “authority gradients”, illustrated in the Kegworth crash where said Haddon-Cave, citing a midair The fourth inhibitor which Haddon-Cave the first officer had been preoccupied collision where a pilot instructor had a highlighted was the tendency to make with reprogramming the flight computer, bag on his head but the junior pilot didn’t assumptions without asking or double- while by conducting a proper express his concerns. Similarly in the checking. People “often don’t voice conversation with the captain “he might crash on the M1 motorway at Kegworth, lingering doubts”, which is why the SAS have highlighted the mistake”. As it UK, where a Boeing 737-400 failed to mantra is “assumptions are the mother of happened the commander spooled up on make the runway having shut down the all cock-ups”. approach causing the single operating wrong engine, the passengers and cabin engine to fail. crew had been “surprised” at the The fifth inhibitor he cited as language announcement by the pilot that he’d shut difficulties, where there is broad scope for Finally Haddon-Cave said that post- down the right hand engine when they misunderstanding non-native speakers, accident communications were also could see that it was the left one that was and the sixth is “technology itself” as it essential. Both for damage limitation and on fire. ‘Passive’ passengers and ‘mere’ “completely changes” the way society to maintain confidence in the industry as cabin crew failed to get up and bang on thinks, operates and communicates. The a whole. Clarity and openness and finding the cockpit door to highlight the possible first aspect of this is information overload, out what happened to learn for the future mistake. “We fly the plane and you pour contrasting with the problem previously of should be the goal. It would also help the the drinks” was the prevalent attitude, too little information. “The temptation is to families of the victims and also the says Haddon-Cave. pour information and everyone company, which also suffers trauma of

5 James Reason, the former Professor of Psychology at Manchester University who is famous for his Swiss cheese analogy and who has written several books on managing maintenance error, said that safety relied on “timely and accurate communications”. “I have never read an accident report where communications was not a factor somewhere, although it is more a ‘condition’ which gives rise to an accident rather than being the cause.”

He cited the “horrors” of Tenerife as “where lots of this started”, going on to discuss the SAS MD-87 accident at Linate Airport, Italy, which hit a Citation which had inadvertently strayed onto the runway sorts. People in the companies involved miss things - too often the technology in the fog. While the air traffic controller often “clam up and become brittle” under does and people monitor”. With had a “mental model” that they were on the searchlight at a time when the communications between people, that it the right path, the Citation’s pilots, when company should be being more flexible. has become less hierarchical and more confronted with two signs at a fork in the The legal ramifications of not handling the open is good for a strong safety culture, taxiway went for ‘R6’ as it had clearer aftermath properly are also bad, leading where junior staff can talk openly to lights and was nearer. to a more bitter battle; Haddon Cave senior managers. A safety committee said he would encourage discussions with “people from the business” is Thus the pilots and ATC shared a under Chatham House Rules (a essential, said Eddington, as common misconception – a not confidentiality agreement.) departments may work well within their uncommon theme, whether in the flight own ‘silo’ but not together. crew-cabin crew relationship, or that British Airways Chief Executive Rod between shifts in ATC or maintenance, or Eddington said that safety is the heart Eddington also highlighted the between designer and user or airport and and soul of “the industry we all love and importance of a good relationship with ATC. Uberlingen was a prime example, serve” and most customers are happy to regulators, in his case the UK CAA, and also bringing trust and procedures swap between airlines they think are with key suppliers such as manufacturers involving technology into the picture. completely safe. “We can’t take safety, and airports. We need to “bring together There the supervisor failed to tell the and security, for granted though”, so nothing falls between the gaps”, as ATCO of ongoing maintenance work to the although the fact that they do is a tribute well as managing change, such as new short-term conflict alert system and the to the people involved and the way they cockpit doors, which have their own pilot of the Russian Bashkirian Tu-154 work together. It is now not uncommon for implications for communications between followed ATC instructions and ignored his a pilot to retire having never had an in- the cockpit and cabin crew. Traffic Collision Avoidance System (TCAS), flight shutdown (other than in the leading to the collision with the DHL 757. simulator) and now people on the ground Meanwhile, with an increasing number of can monitor the aircraft and see a the accidents that do occur being due to The TCAS manual did say to follow ATC if problem before the pilots. people being in the loop, a no-blame there is a conflict, although ICAO Annex culture is essential, including open 10 says TCAS advisories have to be The relationship between people and sharing of safety information with followed (although elsewhere ICAO says technology can pose both opportunities competitors. “Take good ideas wherever to look out if you do disobey!) “It’s a and threats, he said. As technology takes you can find them [including] learning crazy world”, said Reason, who went on over there is a danger that people from other industries”, he concluded. to say that the lengthy Dutch report on become “bored spectators [who] could the accident focussed somewhat unfairly

6 on castigating the poor culture of the Reason. There had been snow on the system is too fragmented, he said, which Swiss ATC provider. “We’re in danger of wings which people noticed but nobody has resulted in no action over the past missing the fact that it was an unlikely brought it to the attention of the pilots, 30-40 years and now a serious problem (but foreseeable) failure, and of missing leading the report to discuss the “culture with delays. the big picture, which is where of separation”. communications is crucial.” Communications is an issue in that many, Ian Linton, LATCC general manager, said Another example was the Embraer 120 such as airlines, are not clear on what is that TCAS had become a “fundamental accident at Eagle Lake Texas where happening with the proposals, there are independent safety net” and that it was screws had been removed from the so many concepts and initiatives extant. essential that everyone operating in stabiliser but nobody relayed the The EU has adopted SESAME, originally controlled airspace should use it – even information to the next shift. This led to proposed by Airbus as “Deploy”, but “few on military corridors. He added that “the the in-flight loss of the stabiliser ice-boot. people knew about it”. With three times jury is out on whether ATC should know as many aircraft expected in the same about it” but he thought they should, The Singapore Airlines 747 accident in airspace by 2025 “quite frankly current because as soon as ATC knew that the Taipei during a typhoon was a classic ATC methods can’t do that”, says pilots were responding to resolution example also, the pilots turning onto Levesley. The EU Single Sky programme advisories they would give only advisories runway 05R rather than 05L and now has a voice “much louder than any and not instructions.” ploughing into a construction site. of the others – because they have the Reason described it as “an extraordinary power to legislate.” There are efforts to equip military aircraft sequence of miscommunication.” The in the UK with TCAS but there have been taxiway lighting was sparse but that onto Industry consultation has not been lots of problems trying to fit it into older 05R was bright. “It was bound to straightforward. The EU was bound by aircraft. Alan Hudson, director of DASC, happen”, says Prof Reason, who advised the Maastricht treaty to consult and the said that they had gained useful going back to basics to understand Amsterdam Treaty said who was entitled experience with the C130J Hercules but common failures. to be consulted, but this excluded pilots that it was harder for fast jets. It was as the European Transport Federation, trialled in the Tucano trainer last year, he GATCO deputy president John Levesley which was selected as the industry’s said, and the Ministry of Defence has said that European communication is “a representative, represented no pilots. now cleared the whole Tucano fleet to strange beast”, with lots of voices on the BALPA and IFALPA were thus excluded be fitted. future of ATM – centrally ECAC, and has had to go through the European Eurocontrol and the EU itself. There are Cockpit Federation (which “has caused a Nearly half of pilot-controller errors are too many languages and the European few problems”). “readback-hearback” ones, says Reason, which is partly a workload issue. Also while en route controllers are typically relaying three bits of information, ground controllers give six. Academic studies have shown that as you get to over four bits of information, less than a third of the instructions get read back in full.

Reason cited various accidents, including that of an Air Ontario F28 in Dryden in 1989 which lead to a seven- volume investigation report drawing on 200 expert witnesses. After all that the report blamed the Canadian ATC system as a whole. “You get to a point where the statement becomes vacuous,” said

7 The rub is that only these “social or sector enhanced safety and reliability, in David King, Deputy Chief Inspector of partners” have to be listened to. This is particular the fact that there were now Accidents at the AAIB, highlighted the bureaucracy at its worst, said Levesley, around 5,000 ETOPS flights across the need for good communications with which “may work for Brussels, but does Atlantic a week compared with the 1970s. industry “so we can conduct investigations exclude an awful lot of people.” SES is Then an engine going 1,000 hours efficiently”. He compared aviation with driving convergence and Eurocontrol is incident free was a big achievement but other transport modes such as rail, which trying to bring itself into line, he said, and now 15,000 is getting to be routine. is under “tremendous pressure” to cope with the EU legislation having been with “recommendation overload” after passed “it will happen”, but there are John believes, however, that manufacturers high-profile accidents, and maritime, which “issues of considerable difficulty” to should communicate problems to get “struggles with a complex cultural mix to a manage future airspace demand. customer respect – “give us the bad news far greater extent than aviation”. Levesley concluded by saying: “Be as well as the good (before we read it in warned, there are many plans afoot to Flight International) – and that the ‘Working Aviation has a clearer appreciation of risk change the way that we work and live.” Together’ mantra should be extended to and probably a simpler regulatory continuing airworthiness. He added that structure, says King, although the Leading industry figure Stewart John communications were more important than European factor with EASA now presents OBE, of Thrust Logistics Company, ever in an industry which had been hit by “a serious challenge and quite a loss of focussed on engineering management so much, from the first Gulf War to Asian clarity.” ICAO has better communications and communication. He listed the many devaluation, SARS, 11 September and and a better way of controlling advances in aviation which have Asian Flu. international initiatives, he said. Meanwhile confidential reporting was good (the ‘CHIRP’ programme for example) but “could do better” – it has just been Aviation Safety and subject to a five-year review which Airworthiness Consultancy and Training concluded there was still a need for it.

EASA Regulation The push with the UK Department for Training Courses Transport is to encourage the Manchester investigation agencies under its auspices to work together and take a ‘multimodal’

THE CROWNE PLAZA MANCHESTER AIRPORT is a new venue for our highly approach, like the US NTSB although the effective training courses which will run alongside those at the Holiday Inn three groups are “very discrete”. Gatwick*. The training equips attendees with the knowledge and skills needed to rapidly achieve competence whilst ensuring the maximum safety Currently the three Chief Inspectors meet and economic benefits. Dates are as follows: to share best practice and compare notes • The Practical Application of EASA Part M/Part 145 on various issues – from sharing of (1 to 3 days optional) 7th/8th/9th June technical resources such as metallurgy • Maintenance Error Investigator (2.5 days) 28th to 30th June • EASA/JAR Quality Systems & Audit Skills (2 days) 4th & 5th July to international co-operation and new Client feedback: EU Directives. "This is clearly not a tick in the box response to a JAR 145 requirement and the standard of presentation transcended any such notion" (DHL Air Limited) Another more recent development is "An excellent course that highlighted some powerful techniques" (Marshall of Cambridge Aerospace Limited) improving family liaison, “giving out "I feel that I have learned an appreciation of the skills etc, that I can take into my job leaflets and briefing families throughout to make a positive difference" (westland Helicopters Limited) an investigation”. Families used to be *Please visit our website for more information on Gatwick or Manchester courses or call us if you would like to find out more about our kept at arm’s length but now they get complementary consultancy services. advance copies of reports and with the Tel: +44 (0)1276 855412 Website: www.bainessimmons.com recent Gerona investigation (Britannia 757), the families were taken down to Cardiff for a briefing ahead of the Spanish authorities publishing their report. This

8 was “quite effective” said King, “and aviation in terms of blame culture, and CVRs out of the para of Annex 13 of the Britannia were happy with it”. keeping the health & safety inspectors Chicago Convention where it currently and police off the scene of an accident – resides and give it a discrete level of Threats to efficient investigation include they are “quick to launch prosecutions”, protection. Although IFALPA wants to see the “public thirst for blame and said Robinson. From 2005 a new rail absolute protection for pilots, ICAO will be retribution” as well as new legislation – investigatory agency will be up and unable to achieve this as it has to leave new proposed legislation on corporate running and will “help enormously”. scope for national legal processes. killing, a new ‘public inquiry’ Act – and a lack of finding good people for the key jobs (partly because the “RAF sources Conclusion Ian Sheppard, BEng MRAeS, is a are drying up”). freelance aviation journalist and edits The Conference was quite wide-ranging his own monthly newsletter, Air Law EASA also represents a major challenge, and various issues were explored in more News. A former Editor of Aerospace as in late 2003 it became responsible for detail than there is space for here, in International and reporter with Flight all airworthiness issues and the CAA particular the Single European Sky, which International, he is currently studying handed over all type certificated. King seems to be subject to much confusion, law at Kingston University and said the challenge was knowing to whom and TCAS. One vital issue which arose specialises in writing on and it should send recommendations. during the Q&A session was that of researching air law issues. confidentiality of CVR material and the Bill Robinson, of the Rail Safety and industry’s need for a ‘no-blame’ Tel +44 (0)20 8337 0274 Standards Board, said that for safety approach. It was stated that prosecutors www.airlawnews.com communications you have to be clear can go to court to try to obtain the what everyone else is doing, and ensure material and the judge will balance that cultural issues are not swept aside. confidentiality against the public interest. Rail has had the same difficulties as There is now an ICAO initiative to take

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9 Engine Thrust Hazards in the Airport Environment

Boeing commercial airplanes are Exhaust velocity components are km/h) with temperatures of 100˚F (38˚C). equipped with engines rated from 18,000 attenuated with increasing distance from This wake velocity can increase two or to nearly 100,000 lb of thrust. Such thrust the engine exhaust nozzle. However, an three times as the throttles are advanced levels provide for safe takeoff, flight, and airflow of 300 mi/h (260 kn or 483 km/h) and the airplane begins to taxi. landing over a wide range of can still be present at the empennage, and temperatures, altitudes, gross weights, significant people and equipment hazards At the extreme end of the intensity scale and payload conditions. However, the will persist hundreds of feet beyond this is a Category 5 hurricane, with winds exhaust wake from these engines can area. At full power, the exhaust wake greater than 155 mi/h (135 kn or 249 pose hazards in commercial airport speed can typically be 150 mi/h (130 kn or km/h). Residential and industrial environments. Operators and airport 240 km/h) at 200 ft (61 m) beyond the structures would experience roof failure, authorities must carefully consider these airplane and 50 to 100 mi/h (43 to 88 kn or with lower strength structures hazards and the resulting potential for 80 to 161 km/h) well beyond this point. experiencing complete collapse. Mobile injury to people and damage to or caused homes, utility buildings, and utilities would by baggage carts, service vehicles, airport One approach to relating these values to be extensively damaged or destroyed, as infrastructure, and other airplanes. airport operations is to consider the would trees, shrubs, and landscaping. At hurricane intensity scale used by the U.S. rated thrust levels, a jet engine wake can National Oceanic and Atmospheric easily exceed the sustained winds 1. Power Hazard Areas Administration. A Category 1 hurricane associated with a Category 5 hurricane. has sustained winds of 74 to 95 mi/h (64 When modern jet engines are operated at to 82 kn or 119 to 153 km/h). At these rated thrust levels, the exhaust wake can velocities, minimal damage to stationary 2. Maintenance Activity exceed 375 mi/h (325 kn or 603 km/h) building structures would be anticipated, immediately aft of the engine exhaust but more damage to unanchored mobile High engine thrust during maintenance nozzle. This exhaust flow field extends aft homes and utility structures would be activity can cause considerable damage in a rapidly expanding cone, with portions expected. An idling airplane can produce to airplanes and other elements in the of the flow field contacting and extending a compact version of a Category 3 airport environment. An example of this aft along the pavement surface (fig. 1). hurricane, introducing an engine wake problem occurred after an airplane arrived approaching 120 mi/h (104 kn or 192 at its final destination with a log entry indicating the flight crew had experienced anomalous engine operation. Subsequent evaluation resulted in replacement of an engine control component, followed by an engine test and trim run to verify proper engine operation. The airplane was positioned on an asphalt pad adjacent to a taxiway, with the paved surface extending from the wingtips aft to the empennage. During the high-power portion of the test run, a 20- by 20ft (6.1- by 6.1-m) piece of the asphalt immediately aft of the engine detached and was lifted from the pad surface. This 4-in (10.2-cm)-thick piece of asphalt drifted up and into the core area of the left engine exhaust wake, where it shattered into numerous smaller pieces. The pieces were driven aft at substantial velocity, striking the aft fuselage and left outboard portion of the horizontal tail. The

10 maintenance crew was alerted to the ramp Flight controls disintegration and terminated the engine FOD can also affect flight control run. Subsequent inspection found that the system component interaction outboard 4 ft (1.2 m) of the left horizontal and system displacement force, stabilizer was missing, as was the entire which are intimately related to left elevator. Corrective action included properly functioning primary replacing the stabilizer and left elevator control surfaces. In most and repairing holes in the fuselage. airplanes, the elevator is powered by independent hydraulic systems through power control 3. Foreign Object Damage units. Some airplanes offer other modes that allow manual elevator Foreign object damage (FOD) caused by operation. In an unpowered high engine thrust can affect airport mode, aerodynamic balance operations as it relates to panels, linkages, and hinges interact to operations subject people, baggage assist in elevator deflection against air carts, service vehicles, and airport ■ Airplane structure. loads (fig. 2). These elements must work infrastructure to injury and damage. ■ Flight controls. together to ensure that actual elevator For example, unsecured baggage carts can ■ Equipment and personnel. displacement is proportional (and be displaced by the exhaust of passing repeatable) with respect to the control airplanes, causing airplane damage or injury column displacement, thereby providing a to personnel (see “Foreign Object Debris Airplane structure consistent pitch response. This and Damage Prevention” in Aero no. 1, Jan. In an incident related to FOD caused by interrelationship of proportional response 1998). Engine inlets represent a potential high engine thrust, Boeing was informed is sufficiently important that aviation personnel ingestion hazard (see “Engine that a 737 had landed at a European regulatory agencies impose certification Ingestion Hazards — Update” in the Jan.- airport and the flight crew had discovered requirements prohibiting airplane Mar. 1991 Airliner magazine). Airplane significant damage during their walkaround response reversal and requiring airplane reverse-thrust operations and the use of inspection. Damaged areas included the pitch response to be proportional to reverse thrust to move an airplane will right horizontal stabilizer leading edge and control column displacement. increase the power hazard area and require lower surface and elevator lower surface. particular care to ensure that people and Upon inspection, a piece of bricklike Even subtle FOD to the external portions of equipment are adequately protected (fig. 3). paving material was found embedded the elevator can change the surface within the stabilizer structure. Shortly before balance and alter the airflow characteristics “Taxi Operations By Maintenance the FOD was identified, the Boeing Field in a way which may induce surface flutter. Personnel” (Apr.-June 1988 Airliner Service representative at the originating This dynamic and uncommanded magazine) discusses the increased risk of airport was notified of runway threshold movement of the surface can grow in both injury and damage from inadequate damage. Subsequent correlation of these amplitude and frequency, causing additional clearance between the airplane and events matched the brick paving material damage. Portions of the surface may be surrounding objects. extracted from the airplane with identical destroyed by the violence of the induced material formerly located along the runway motion. If this motion is great enough, it can threshold. The paving material was lifted be coupled into nearby airplane structure 4. Precautionary Steps and blown aft by the engine exhaust as the and cause collateral damage. In exceptional airplane turned onto the runway for takeoff. cases, control surface flutter could lead to Understanding an airplane’s Repair included replacement of the loss of airplane control. characteristics and capabilities is crucial stabilizer, elevator, elevator tab, and to protecting the airplane, the personnel stabilizer-to-body closure panels. working around it, and the airport Equipment and personnel environment from the dangers of high- FOD also has the potential to affect the velocity exhaust. Operators should take many aspects of ramp operations. These precautions to prevent damage or injury

11 Maintenance activity how the exhaust wake affects the The AMM for each model is a well- surrounding environment. Techniques and documented source of precautions designed to help operators precautionary information on such deal with high thrust exhaust wakes are topics as engine mainte-nance run- available in Boeing publications and other ups, taxi operations by document sources. Operators should use maintenance personnel, and this information to develop the necessary related engine activities. Operators operational procedures and should address should refer to the procedures, the engine wake hazard issue in their safety practices, and precautions in the awareness and training programs. applicable AMM when developing their operating specifications, operations, maintenance, and engineering practices.

Airport environment Operators should consult in the following hazardous areas or during with the responsible airport hazardous activities: authority to ensure that ramp areas, runway aprons, and ■ Power hazard areas. engine run-up areas are ■ Maintenance activity. compatible with the intended ■ Airport environment. airplane operations. Further information about the design and maintenance of the airport Power hazard areas infrastructure is available in the These areas (fig. 4) are described ICAO Aerodrome Design Manual extensively in the applicable Aircraft and Airport Characteristics Data Maintenance Manual (AMM). Additional Bank. Other sources include the references can be found in the U.S. Federal Aviation “Maintenance Facility and Equipment Administration 150 Series Planning” and “Airplane Characteristics Advisory Circulars (several of for Airport Planning” documents provided which are described in the to each operator. The documents include accompanying chart). resources that describe engine exhaust velocity platform areas. These areas illustrate the horizontal extent of the Summary Jet Blast Damage and Injuries engine wake hazard and representative exhaust velocity contours, providing Thousands of safe takeoffs and landings The following examples reflect a sample invaluable information for service and occur throughout the world every day. of events from the past 30 years that support equipment location planning. The Each operation takes advantage of the reportedly involved jet blast and documents also contain auxiliary power benefits supplied by the high thrust levels illustrate the range of potential damage unit (APU) exhaust wake data, engine of modern jet engines. However, during and injuries. and APU noise data, and engine inlet taxi and maintenance activity, this same hazard areas. thrust capability and its related exhaust wake can become a hazard, which can Flying Object Damage be intensified by lack of awareness about ■ An airplane was stopped 900 ft (274

12 m) from a parking area on the flight required replacing. The initial section engine run-up bay within the operator’s ramp for an engine performance run- of asphalt that lifted was a sheet technical area. Engines no. 1 and no. 2 up. During run-up of engine no. 3, about 20 ft2 (1.9 m2) and 4 to 5 in were at 1.3 engine pressure ratio, with large sections of asphalt overlay were (10.2 to 12.7 cm) thick before engines no. 3 and no. 4 at idle. The jet broken loose and blown aft, with breaking into pieces. There were blast overturned and pushed a pickup pieces striking both upper and lower no injuries. truck for 165 ft (50 m). The truck was surfaces of the stabilizer leading edge thrown over a steel guard rail and up a vertical fin and body in the area of the 33-ft (10-m) embankment. The auxiliary power unit inlet. Jet Blast Damage operator of the truck was thrown clear ■ After arrival and while taxiing into the but sustained a fractured femur and gate, an airplane blew a nearby facial and chest injuries. Horizontal Stabilizer Damage helicopter into a parked airplane. ■ According to preliminary investigation ■ The tower reported that an airplane ■ While taxiing for takeoff, an airplane reports, an airplane departed from the took off using the restricted area of a reportedly made a sharp right turn gate and proceeded along the inner runway. The engine thrust tore up onto a taxiway. Blast from engines no. taxiway to a crossover, where it waited approximately 197 to 328 ft (60 to 100 3 and no. 4 blew a maintenance stand for clearance onto the runway. The m) of asphalt, and several large into engine no. 2 of another airplane. airplane was stationary for some time chunks struck the upper surface of The stand impacted the engine fan before continuing on the taxiway. An the right horizontal stabilizer and cowl, resulting in a 6- by 1-in (15.2- by airline operator’s vehicle was the lower surface of the right 2.5-cm) puncture. In addition, the reportedly traveling west on the outer vertical stabilizer. engine no. 1 cowl was laying under service road between crossovers. ■ During run-up, the left horizontal the engine and was blown across the After stopping to verify that the stabilizer on an airplane was ramp, causing damage to the latching airplane was stationary, the vehicle damaged when a large piece of mechanism. allegedly passed behind the airplane. asphalt lifted and impacted the lower ■ After aborting the takeoff, a flight At the same time, the airplane was surface of the stabilizer. Approximately returned to the gate because of asked to expedite to the runway and 20 in2 (129 cm2) of the lower skin was overheated brakes. The two inboard began applying power. Whether the destroyed, and four stringers were engines were shut down for the taxi. airplane began to move was not broken. The forward and aft spars However, the maximum allowable N1, established. According to eyewitness were not damaged, nor were ribs 13 40 percent, was required for the accounts, the truck, occupied by two and 14. The skin was cut back from airplane to maneuver into the gate. airline employees, was rolled over the front spar to the rear spar and The engine thrust resulted in jet blast three times by the jet blast. The driver approximately 7 in (17.8 cm) inboard that threw two DC-8 containers into of the vehicle died two days later. The of rib 13 and 7 in (17.8 cm) outboard the windshield of a vehicle being vehicle was a pickup truck with a low of rib 14. driven by an airline employee. cap over the back end, which was ■ An airplane experienced damage to even with the top of the cab. The truck the horizontal stabilizer during a had cleared the tail and was maintenance engine run. The airplane Injuries and Fatalities approximately 200 ft (61 m) behind was positioned for the run with ■ After pushback from the gate at the the airplane. It started to roll when it asphalt extending from close to the start of taxi, jet blast from an airplane was behind engine no. 3. wing trailing edges to beyond the overturned several loaded baggage empennage. During the high-power carts, and one cart fell on a baggage part of the run, asphalt lifted from handler. Several coworkers lifted the Structural Damage behind the left engine and broke into cart to free the trapped worker. The ■ An airplane sustained heavy structural pieces, sending large fragments into individual was hospitalized with damage to the 46 section and the aft fuselage and outboard injuries that included a dislocation and empennage sections during a high- horizontal stabilizer. The outboard 4 ft multiple fractures. power engine run. The right engine (1.2 m), including the elevator, was ■ Maintenance personnel were propelled large pieces of the taxiway sheared off, and the entire stabilizer performing high power run-ups at the into these sections.

13 Turbulence Damage Board. It summarizes a fatal commercial A Trans International Airlines DC-8-63F, ■ During an instrument landing system airplane accident near New York City that N4863T, Ferry Flight 863, crashed during approach, turbulence damaged the was later determined to be caused by takeoff at John F. Kennedy International roofs of three houses. Roof tiles fell, exhaust hazard. The report concluded Airport at 1606 e.s.t., September 8, 1970. damaging a car and slightly injuring that the introduction of new large jet two people. aircraft “...caused considerable erosion Approximately 1,500 ft after starting takeoff, along most taxiways and runways. the aircraft rotated to a nose-high attitude. According to New York Port Authority After 2,800 ft of takeoff roll, the aircraft Exhaust Hazard Accident personnel, the products of this erosion, became airborne and continued to rotate pieces of asphaltic material, rocks, etc., slowly to an attitude of approximately 60˚ The following is the abstract of Aircraft were being blown onto taxiways, ramps, to 90˚ above the horizontal at an altitude Accident Report NTSB-AAR-71-12 written and runways, making it difficult to keep estimated to have been between 300 and by the U.S. National Transportation Safety these areas clean.” 500 ft above the ground. The aircraft rolled about 20˚ to the right, rolled back to the left to an approximate vertical angle of bank, and fell to the ground in that attitude. The aircraft was destroyed by impact and postimpact fire. Eleven crew members, the only occupants of the aircraft, died in the accident.

The (National Transportation Safety) Board determines that the probable cause of this accident was a loss of pitch control caused by the entrapment of a pointed, asphalt-covered object between the leading edge of the right elevator and the right horizontal spar web access door in the aft part of the stabilizer. The restriction to elevator movement, caused by a highly unusual and unknown condition, was not detected by the crew in time to reject the takeoff successfully. However, an apparent lack of crew responsiveness to a highly unusual emergency situation, coupled with the captain’s failure to monitor adequately the takeoff, contributed to the failure to reject the takeoff.

Airport Planning, Design, and Operation References

Airplane operations in the airport environment are documented in multiple references from many sources, including industry organizations and airplane manufacturers. These references contain a broad range of relevant resources. Among

14 the topics SQUARE used are airport design, construction, maintenance, airport Aero magazine: development planning, airport marking, safety equipment, and operational safety. ■ “Aerodynamic Principles of Large ground operations, service equipment, and Airplane Upsets,” July-September terminal, ramp, taxiway, and runway design. ■ AC 150/5300-13, Airport Design: FAA 1998. recommendations for airport design. ■ “Foreign Object Debris and Damage ■ AC 150/5320-6D, Airport Pavement Prevention,” January-March 1998. International Civil Aviation Design and Evaluation: Design and Organization (ICAO) evaluation of pavement at civil airports. Annex 14, Aerodromes, volume I: ■ AC 150/5335-5, Standardized Method Douglas Service magazine: Specifications on the physical of Reporting Airport Pavement Strength: ■ “Airport Foreign Object Debris characteristics of the airport movement Use of the standardized ICAO method Prevention,” second issue, 1994. area including runway, taxiway, and apron to report pavement strength. areas; firefighting equipment and safety measures associated with Other installed equipment. The Boeing Company ■ “Design of Concrete Airport Pavement” Airplane Characteristics for Airport by Robert G. Packard, published by Annex 15, Aeronautical Information Planning: Issued as individual documents the Portland Concrete Association. Services: Notice to airmen (NOTAM) applicable to a specific model or model bulletins, which contain information on family, such as the 757. Information to With kind acknowledgement to The Boeing physical changes to the airport, airport assist engineers in airport design, Company Aero Magazine. service, or hazards. including airplane dimensional data, Accident Prevention Manual: pavement loading information, Development and maintenance of condensed airplane performance, jet accident prevention programs. engine wake velocity, and temperature and noise data. Maintenance Facility and Aerodrome Design Manual (five parts): Equipment Planning: Issued as individual Airport runways, taxiway, aprons, and documents applicable to a specific model holding areas designed to contribute to or model family, such as the 767. safe airplane operations. Information on such topics as noise hazard areas, power hazard areas, and Airport Services Manual (nine parts): engine exhaust wake velocity data. Airport services, including maintenance of the airport physical condition to ensure Aircraft Maintenance Manual: Applicable safe operations. to a specific airplane model; configured to reflect individual operator features. The aircraft general sections detail safe International Air Transport Association practices covering airplane ground (IATA) operations, taxiing, engine power hazard Airport Handling Manual: Safety areas, and precautionary practices to be precautions in aircraft handling operations observed during maintenance activities and aircraft pushback procedures and that require engine operation. recommendations for ramp marking.

Airliner magazine: U.S. Federal Aviation Administration ■ “Engine Ingestion Hazards,” January- (FAA) March 1991. Advisory Circulars: The 150 series of FAA ■ “Ramp Rash,” April-June 1994. Advisory Circulars (AC) on multiple ■ “Runways,” July-September 1985. aspects of airport planning, airport ■ “Taxiing,” April-June 1988.

15 Book Review International Journal of Mass Emergencies and Disasters August 2004, Vol. 22, No. 2, pp. 137–141

Airspaces. Pascoe, David. London: Reaktion. 2001. 303 pp. £17.95 (paperback). 1 86189 090 7 (Softcover).

nine percent of respondents said they Airspaces is an extraordinary book— had to deal with aggressive passengers concurrently a book about the technics of “regularly.” A TGWU official stated: “The commercial aviation, its social, economic survey clearly reflects the concerns of our and political context and the flying members in respect of what is fast experience. Commercial aviation is the becoming an epidemic” (Ananova 2004). world’s biggest industry and a stunning There have been several headline- technical achievement: As Pascoe puts it, grabbing incidents. In November 1998 a in the “vertical cities” of Positive 33-year-old female cabin crew member Controlled Airspace “at any given was hit over the head with a vodka bottle moment hundreds of thousands of beings by an inebriated passenger. live” (page 12). Pascoe’s discursive style Having broken the bottle the passenger mirrors that of Arthur Hailey, author of pushed it into the crewmember’s face. numerous aviation-centred novelettes. As There is violence elsewhere in the with Hailey, Pascoe weaves prosaic (yet commercial aviation system, too. Aircraft useful) factual description with have been hijacked and flown into illuminating discourse. But where Hailey symbolic targets (like the Pentagon and explores human emotion (affairs of the World Trade Center). Passengers waiting heart, broken-down marriages, intimations for flights have been bombed and strafed of mortality and the like) Pascoe Despite its technical, organizational and (as at Athens airport). Aircraft have been investigates air terminal design and operational complexity commercial hijacked and flown to desert airstrips decoration and its impact on passenger aviation is a remarkably safe mode of where they have been blown up in front of mood; the social, economic and political transport. the world’s media (as at Dawson’s Field resonances of commercial aviation; the in Jordan). human dimensions of disaster; and Innovations like primary and secondary aviation terrorism. Pascoe makes his radar, the turbojet engine and ground Aircraft have been blown up in mid-air (as points both directly and vicariously proximity warning systems have had an with Pan Am Flight 103 over Lockerbie in through aviation-inspired cultural products enormous impact on accident rates. Scotland). Aircraft and airports have been (that include novels, poems, paintings, Progress in the technical field has not burglarized. Massive sums have been photographs, sketches and blueprints). been mirrored elsewhere, however. stolen (as with the Brinks Mat bullion The effect is visceral. Consider, for Perhaps because air travellers’ robbery at London’s Heathrow Airport). example, Pascoe’s discourse on the demography has changed or perhaps Risk, then, has migrated from aviation’s outcomes of the 1974 DC-10 crash at because the amount of space allocated technical to its operational and social Ermenonville in France. After describing to most passengers has been reduced domain. (This migration brings to mind the facts of the crash and its aftermath (to reduce unit costs) cabin crews’ risk- Adams’s theories of risk compensation (including the way in which victims’ exposure has increased. The level of and risk homeostasis which suggest that relatives and friends were received at abuse and violence (commonly known as the overall level of risk in any Heathrow (a television set was wheeled in “air rage”) against cabin crew has sociotechnical activity tends to remain to the VIP lounge where it broadcast live increased. constant (Adams in Faith, 1997: 140-3)). images from the crash scene to the To understand why this has happened it assembled throng)), Pascoe invokes According to a survey conducted by the is necessary to consider commercial Martin Amis’s novel London Fields for UK’s Transport and General Workers’ aviation’s social, economic and political illumination (page 250). In Amis’s novel Union (TGWU), 75% of cabin crew context. Airspaces by David Pascoe talks the daughter of one of the Ermenonville claimed to be suffering from an illness about these tableaux in an engaging, dead “drove reflexively to the airport [...] triggered by abusive passengers. Forty- innovatory and insightful way. An airline official showed her into the VIP

16 lounge [...] She drank the brandy pressed 2003). This fact would seem to suggest somewhere else” (page 203). The airport on her by the steward. ‘Free’, he that airports should be designed to be as alienates and disorientates to the point, confirmed. And then, incredibly … they welcoming and comforting as possible. says Pascoe, where “the only version showed live film of the scattered [passengers] have of themselves is a wreckage, and the bodybags lined up on In Pascoe’s opinion, however, they seat number in an aluminum tube” (page the fields of France. In the VIP Lounge alienate and intimidate more than they 223). Vicariously Pascoe seeks to explain there were scenes of protest and violent comfort. In Chapter V, “Cultures of the how passengers’ physical and mental rejection”. While literary accounts should Terminal”, Pascoe reflects on the politics state might be affected by air travel. He of course be read with a degree of of the contemporary air terminal: “Despite quotes from Don DeLillo’s play Valparaiso scepticism, Amis’s narrative does have the material diversions, the cultures of (page 225): “I was intimidated by the the effect of bringing the episode to life. It consumption [airports can make more systems [said the air traveller]. The adds something. money from on-site sales than from air enormous sense of power all around me operators], any freedom within such [...] How could I impose myself against Pascoe is careful to situate commercial areas of containment is illusory [...] [T]he this force? [...] I felt submissive. I had to aviation. Commercial aviation is more individual is assailed by the devices of submit to the systems. They were all- than just a one-dimensional technical circulation, process and containment” powerful and all-knowing”. Airport pursuit. Commercial aviation is an (page 202). Pascoe quotes photographer designers’ and operators would do well to expression of the public will to promote Martha Rosler: “Air terminals, more like absorb this chapter. the nation-state and its constituent each other than like anything else, tell us Pascoe also explores the prevalence of ideologies (through the establishment only of themselves. The airport is where violence within the air transport system. In and subsidized operation of national “flag you would rather not be, on the way to Chapter IV he reviews several terrorist carrier” airlines), to experience different cultures, to make money and to relax and “have fun.” Commercial aviation, alleges UK FLIGHT SAFETY COMMITTEE Pascoe, is “undertaken, above all, in the name of economy and commerce” (page 27). In Chapter IV, “Theatres of War” Pascoe deconstructs Berlin’s Tempelhof Airport. Tempelhof was much more than a AVIATION SAFETY - mere air terminal. Tempelhof, according to Pascoe, was an expression of the LOOKING AHEAD 20 YEARS Fuhrer’s desire to make Berlin the Capital Annual Seminar 2005 of the World. As Pascoe explains: “On its completion, Hitler concluded, Tempelhof would undertake a crucial political role; through its size and appearance, it would 3rd & 4th Oct 2005 ‘silence every dissenting critic of The Radisson Edwardian Germany’” (page 158). Hotel, Heathrow

Pascoe’s most interesting commentary concerns how departure-lounged passengers come to terms with the prospect of being suspended miles above the earth in a tube whose pressurized aluminium skin never exceeds 3 millimeters in thickness. It has been estimated that about one third of airline passengers are nervous flyers (Bor,

1917 attacks and dissects West Germany’s atmosphere is the airport atmosphere [...] consciousness and promote Rote Armee Fraktion (RAF) terrorist I love the way you don’t have to think comprehension. The book is not an easy group. As he explains “If Bomber about where you’re going, someone else read. But for anyone wishing to develop a Command had flattened Hitler’s cities is doing that [...] The atmosphere is great, more profound understanding of from the sky, the RAF [the name-irony is it’s the idea of flying that I question. I commercial aviation and its impact on not highlighted] would destroy West guess I’m not an air person, but I’m on an humanity it is a valuable resource. Germany’s post-War machinery from air schedule, so I have to live an air life”. Aviation has transformed our lives. It has within” (page 183). In the 1970s and transformed our sense of self and place. 1980s, claims Pascoe, the airport Pascoe summarizes: “[Air terminals] are Airspaces helps one to understand how component of airspace provided the often experienced as [...] edgy zones, and why. world’s terrorists with the kind of platform places in which to experience oneiric they needed: “In order for the fate of the moods, loss of agency and imprisonment victims [...] to have the desired impact on within the confines of a technological References such targets, there had to exist [...] a system” (page 15). Later in the book he stage that would guarantee awe, outrage, observes: “Without proper accreditation Ananova. 2004. “Cabin crew illnesses anguish, or horror; that stage, inexorably, [a passport considered valid by the caused by stress of air rage.” became the airport itself, whose locums], the subject cannot move, but anonymous public spaces seemed to be must remain inert [...] and await the Reproduced at oddly complicit in random acts of terror” decision of authority [...] It is in these http://www.ananova.com/news/story/ 3 (page 191). Airports, then, constitute acrid, fluorescently lit holding pens, alive August. seductive targets for terrorists. with static electricity, sweat and polish that the traveller comes to understand Bor, R. (ed.) 2003. Passenger Behaviour. They are also useful for those attempting what it means to have been furnished Aldershot: Ashgate. to maintain the peace and with the identity of a nation state; and it is Faith, N. 1997. Crash. London: Boxtree. reassure the public. Witness, for example, here that the implications of statelessness the UK government’s occasional (yet on mental health are fully comprehended” Book reviewed by: widely reported) deployment of tanks and (page 211). I suggest that whenever the Simon Bennett troops at Heathrow. Airports’ symbolism issue of passenger anxiety, alcohol and Scarman Centre, attracts both well- and evil-wishers. drug abuse and misbehaviour is University of Leicester, England addressed analysts would do well to Perhaps the most interesting aspect of reprise Pascoe’s observations. the book, however, is its analysis of the design, dynamics and management of air Whatever one might think about the terminals and the behaviour of ensconced philosophical approach of Airspaces it passengers (in airline parlance, “PAX”). cannot be denied that in presenting a Given that one third of PAX are afraid of compendium of insights, observations flying, Pascoe’s analysis provides and constructs the book generates a valuable insights into fears and phobias. textured and multi-dimensional The question of how passengers perceive understanding of passengers, terminals and interact with air terminals and and the act of being propelled through construct the act of flight is addressed at the air in a fragile aluminium tube at close numerous points in the book, both to the speed of sound some six miles directly, via Pascoe’s own commentary, above terra firma. Pascoe uses and vicariously through the artistic output illustrations and literary representations as of others. Warhol’s thoughts on air travel heuristics. The beautifully reproduced are reproduced on page fifteen. The blueprints, photographs and sketches artist comments on the air terminal’s and carefully selected commentaries authoritarian tendencies and bemoans his (from Warhol, Rosler, Amis, DeLillo, Woolf, fear of flying: “Today my favourite kind of Fleming and others) expand

18 Letter

Naval Ramp Operations Issue 57 Winter 2004

Yes there is much that the commercial world can learn from the Armed Forces and this by no means is a one way street but the lessons are limited as both have a different raison détre. The main overriding thing that all have in common and all should strive for is Flight Safety along with the will to implement it. If this message is constantly pushed and never forgotten then surely it is this single unifying concept that makes it possible in the complex and hazardous world of the flight line for all the diversity of disciplines to achieve their roles.

Dear Sir, greased mechanism the Editorial If this could be achieved then I am I read with interest the Editorial on Naval mentions. There is also the fact that the confident a reduction in the 4 to 6 billion Ramp Operations in issue 57 WINTER Armed Forces can cherry pick its US Dollar cost can in time be reduced 2004. As a former RAF Technician and personnel and by the process of training, with a little more pride being felt by those having spent all my service career other education and doctrine the individual that involved. than training on operational flying emerges is ready to take their place Squadrons I am totally familiar with the within the mechanism with the old sweats observations and conclusions that were keeping an eye on them until they Best Regards, made. Different service same culture. become fully integrated. Compare this Jim Mowat The main thing that strikes ex service with the diversity of people required to Maintenance Control Engineer Engineers is the apparent lack of control turn around a large passenger transport and professionalism within the ramp aircraft, their different training environment by all organisations involved environments, organisational structure with a/c operations be it ground handling and commercial interests. or Engineering staff. This I must admit demoralised myself in the early days of my civil career as it often appeared as though we were not all “singing from the same Hymn sheet” and I was not alone in this. There was a lack of team spirit understandable if you are the only Engineer on duty. Everyone has a deadline to meet with little time to take pride in your work. This in time faded away as you became more familiar with your new world and realised that everyone was in fact trying their best in an often busy and difficult workday.

Of course the main differences are the commercial interest which even today the Armed Forces are not yet fully tied to. It is this one thing that I am convinced makes it very difficult to have the well

2119 Avoiding Tailstrikes Peter Simpson Manager Air Safety

Virgin Atlantic A340-600 rotation during takeoff. At VR, the pilot Malaysian B777-200 Washington-Dulles, July 2004 pulled on the sidestick to set the cross at a Zurich, July 2004 position corresponding to about 9 degrees The crew had a last minute change of The aircraft suffered tailstrike on on the moving pitch attitude scale. During runway, with crosswinds resulting in a 2kt touchdown at Dulles causing damage to the rotation, the pilot attempted to keep the headwind on the new runway. There was the tailskid section. cross on the same position of the moving a sudden 12kt increase in groundspeed reference. However, in this phase the with slow to nil increase in airspeed; aircraft pitch attitude increases and indicating a burst of tailwind effect. The therefore the pitch attitude scale of the Captain (PF) stopped rotation at 9 display moves down. Consequently degrees pitch as he felt the aircraft was maintaining the cross on the same mark of not lifting off, but reassessed his the moving scale led the pilot to judgment when he saw the positive progressively reduce the pitch-up sidestick speed trend indicated on the speed tape. command. The aircraft finally lifted off at the He then continued his rotation and struck runway end, after hitting some lights. Three the tail. The EICAS “Tailstrike” was tires burst and the flap mechanism was triggered. After circling and dumping fuel, damaged by tire debris. The crew landed a safe landing was completed. with flaps jammed in config 1+F.

Singapore B747-400 Tailstrike Avoidance Auckland March 2003 When the Captain rotated for lift off the Boeing have conducted an evaluation of tail struck the runway and scraped for the circumstances surrounding tail strikes some 490 metres until the aircraft (Boeing. 2004). They found several risk became airborne. The rotation speed had factors, one or more of which will precede been mistakenly calculated for an aircraft a tailstrike event (these are listed below). Virgin A346 tailstrike weighing 100 tonnes less (247t instead of The Boeing study also concluded that 347t). The rotation speed of 130kts was crew experience on type is a significant Air Canada A330-300 33kts less than that required for the factor. Most tailstrikes occur to pilots who Frankfurt, June 2002 weight. A take-off weight transcription are transitioning from one type to another The ACARS provided the Flight Crew with error of 100 tonnes led to the and have fewer than 100 hours of flight the final load figures, indicating a take-off miscalculation of the take-off data, which time on the new aircraft. Incidents are weight of 221 tonnes. The FO (PNF) in turn resulted in a low thrust setting and greatest among pilots during their first reinserted the final load figures and take- excessively slow take-off reference heavy-weight operation in the new model, off speeds in the MCDU. By mistake, the speeds. During the take-off the pilots did especially when weather is marginal. PNF typed a V1 speed of 126 knots not respond correctly to a stall warning. instead of 156 knots. Neither pilot noted the incorrect VI speed. The Captain (PF) Take-off Risk Factors rotated at 133 knots, with a pitch rate of 1. Mistrimmed stabiliser: This is the 2.8 deg/second. The tail strike occurred case when the aircraft has been when the pitch attitude was about 10.4 mistrimmed nose-up. Mistrimming can degrees and lasted for about 2 seconds. result from erroneous data, wrong The aircraft lifted off at a speed of 152 weights or incorrect C of G. knots and a pitch attitude of 13.7 2. Rotation at improper speed: Rotation degrees. The strike was not detected by is begun early because of some the pilots, but they were notified of the misinterpretation or at a Vr that has strike by ATC and Cabin Crew. been incorrectly calculated as too slow. 3. Excessive rotation rate: Crew Emirates A340-300 moving from unpowered flight controls Johannesburg, April 2004 to hydraulic controls are most The pilot used the sidestick position symbol susceptible to using excessive displayed on the PFD when the aircraft was rotation rates, as are crew moving to on the ground (the cross) to perform the side-stick configurations. Singapore B744 tailstrike

20 Malaysian B777 tailstrike

4. Excessive initial pitch attitude: manoeuvres further increase drag and Over-rotation often occurs due to reduce lift. Any increase in tailwind misjudgment. component now increases the risk of 5. Improper use of flight director: The tailstrike. High crosswinds can often Boeing 747 tailstrike FD is designed to give pitch guidance result in target fixation. only when airborne. 4. Over-rotation during go-round: Go- How to avoid tailstrike at TAKE-OFF 6. Crosswinds: Mishandling crosswinds rounds initiated during flare or after a Use normal takeoff rotation technique and improper crosswind technique. bounce can result in a tailstrike if the Do not rotate early pilot has not allowed the engines to Do not rotate at an excessive rate Landing Risk Factors spool up before rotating to a go-round Do not rotate to an excessive attitude A tail strike on landing tends to cause more attitude. Also, pilots can over rotate if serious damage than that during take-off. not using the instruments and flight Ensure t/o V speeds are correct and In the worst case, the tail can strike the director. Crew may try to avoid the adjusted for actual thrust used runway before the gear touches down, wheels contacting the runway due to Manage gusty winds and use proper damaging the aft pressure bulkhead. possible damage, however Boeing technique during crosswind state the risk of damage is minimal. 1. Unstabilised approach: An (Boeing 2004) unstabilised approach is the largest United Airlines, who have had around 60 How to avoid tailstrike at LANDING cause of landing tailstrikes. An tailstrikes in the last ten years, analysed Maintain an airspeed of at least unstable approach can result in the their data and came out with some Vref+5 until start of flare aircraft flaring with either excessive or specific information for their Airbus fleet insufficient airspeed (insufficient (United Airlines 2004). United found that Fly the approach at the ‘specified airspeed is worse). These situations pitch attitudes above 10 degrees were target airspeed’ can result in large power and pitch present in all their landing tailstrikes. Many Aircraft should be in trim at the start changes in the flare, often culminating of these pitch commands were in of the flare - do not trim in the flare in a vigorous nose-up pull at anticipation of the nose coming down Do not ‘hold the aircraft off’ in an touchdown. Boeing suggest that a rapidly when autobrakes were set at MED. attempt to make an excessively firm landing on the main gear is often smooth landing preferable to a soft touchdown with Some aircraft are more vulnerable to Immediately after the main landing the nose rising rapidly. tailstrikes, such as the B747 classic, which gear touchdown, release back 2. Holding off in the flare: A long flare has around 12 tailstrikes per million flights, pressure on the control column and to a ‘drop-in’ touchdown can cause compared to the B777-200 which only has fly the nose wheel onto the runway tailstrikes. Trimming the stabiliser in the around 2 per million flights (the B777-300 flare may also contribute to a long flare. has 0/million flights). Boeing state that it is (Boeing 2004) 3. Mishandling of crosswinds: Gusty a misconception that longer aircraft have (1) Boeing (20N). Tailstrike avoidance. Boeing Aero Magazine. conditions and wind changes with higher risk of tailstrike, as longer aircraft (2) United Airlines (2004) Tailstrike on landing. United SafetyLiner. (3) Boeing (2004). A Human Factor Approach to Prevention of Tailstrikes. height can result in windshear. usually have higher take-off speeds, and Crosswinds often result in minimal the same relative tail clearance as shorter Reprinted with acknowledgement to Kai headwind component, so high ground aircraft (Boeing, 2004) Talk magazine speeds and descent rates can occur, often with idle thrust settings. Slipping

21 Mandatory Occurence Reporting By Simon Phippard - Barlow Lyde & Gilbert

etc. at (broadly) licensed aerodromes, will have to make reports. The second change is that the obligation to report is not always restricted to public transport and turbine aircraft. Pilots, manufacturers and engineers still only need report occurrences on public transport and turbine aircraft. However managers of and ground handlers at licensed reported occurrences and, subject to The DfT is undertaking a consultation on aerodromes, and ATCOs, are subject to certain disidentification provisions, to make the UK’s proposed manner of the mandatory provisions, whatever the that information available to other implementation of European Parliament class of aircraft. and Council Directive 2003/42/EC on European Community aviation safety bodies. In general terms ordinary MORs Occurrence Reporting in Civil Aviation. This obviously has the potential to bring a are not disidentified; names and addresses That Directive was passed in June 2003 wider class of occurrences within the are removed in relation to accidents and and required Member States to implement scope of mandatory reporting. If the effect serious accidents; and voluntary mandatory occurrence reporting schemes, is a deluge of additional reports on an occurrence reports are disidentified. or to amend their existing schemes to already busy data reporting system will this comply with Directive 2003/42, by 4 July really operate in the interest of flight safety? 2005. The UK is to achieve this by Under the old law, it may have been arguable that the obligation to report an amending Art 117 of the Air Navigation If the DfT cannot be persuaded to revise occurrence would be subject to the right Order with effect from 3 July 2005. the amendment to the ANO on the basis not to incriminate yourself if you felt that it that the effect was unintended, the may expose you to criminal charges. The It is encouraging to see that in many solution may be for the CAA to take a new Directive makes it plain that where respects the European Directive closely pragmatic approach to reports relating to the authorities’ only knowledge of an reflects the existing UK scheme. The non-public transport operations and to infringement is because of a mandatory Directive does however, adopt “Euro- enforcement. For practical purposes the report, that report may not be used as the speak” in a number of ways and as a CAA has a degree of discretion in basis for disciplinary proceedings or result the revised Article 117 lacks some prosecuting instances of failure to report similar. There is however an exception in of the precision of its predecessor. As an but it would be unsatisfactory if one were cases of gross negligence and the example, the basic test for reportable entirely dependent on their good sense in interaction with criminal enforcement occurrences is those “which endanger or not enforcing what appears to be an generally is left vague. The moral, clearly, which, if not corrected, would endanger unintended requirement. an aircraft, its occupants or any other is not to be guilty of gross negligence when involved in a reportable occurrence! person”. What perhaps gives scope for The consultation process suggests that more confusion is a compendious annex there is no substantive change to the I am grateful to John Thorpe for of events, omissions etc. which are reporting requirements. To the extent that identifying one particular change to the “examples” of reportable occurrences. It this is a material change the failure to scope of mandatory reports. The current appears however that the intent is not that conduct a regulatory impact assessment regime is directed to public transport and each and every such occurrence is may give grounds for challenging the turbine-powered aircraft. Hence pilots, reportable, but only those where flight manner of implementation in the UK. manufacturers, engineers, ATCOs and so safety is endangered. On the other hand, However, because the Directive is now a on are obliged to report occurrences it is equally clear that the absence of an requirement of European law, the UK’s which relate to such aircraft – but not, for event from the list does not necessarily room for manoeuvre, on both context and instance, to many private aircraft. mean it need not be reported. The timing, is limited. general test of endangerment applies. The new scheme differs in two respects. The ANO will contain a specific obligation First, an additional category of personnel, upon the CAA to maintain databases of namely those involved in ground handling functions such as fuelling, loading, towing

22 Air Accident Investigation: The Role of the Police By Simon Phippard - Barlow Lyde & Gilbert

2 At the January meeting of the UKFSC we The AAIB guidance is on their website 1. The Lord Chancellor’s Department has had a very helpful briefing from Chief and contains a large amount of useful issued a document entitled “Disasters Inspector (Retired) Brian McConnell on material both on the legal background and the Law – Deciding the form of the responsibilities of the Police following and the practical issues which arise. As I Inquiry” but we have not been able to find aircraft accidents. He explained how in understand it, it is not formally agreed a copy. a fatal accident at least three with any other party nor is it a definitive organisations are likely to be involved. In statement of the law. However, since it is 2. http://www.aaib.gov.uk/cms_resources/ very brief summary: the basis on which AAIB educate others, guidance%20for20police%20and%20the% it is undoubtedly a very useful point of emergency%20services.pdf H M Coroner has to determine the cause reference if any misunderstandings arise of a sudden, violent or unnatural death; between the Police, the accident investigator and any party which may be The Police have to determine whether involved in the aftermath of an accident. there is suspicion of a criminal offence and if so ensure that evidence is preserved so that the criminal standard of proof, namely that the offence be proved beyond reasonable doubt, is met; The Air Accidents Investigation Branch of the Department for Transport discharges the UK’s obligations under Annex 13 to the Chicago Convention 1944 and EU Council Directive 94/56/EC on investigation of civil aviation accidents and incidents. In each case the purpose is to determine the cause of an accident and to make recommendations to prevent a recurrence, not to apportion blame or liability.

Others, such as the Health & Safety Executive or the Environment Agency may have additional functions.

Each body operates within its own statutory regime. The interrelationship of those regimes is not always clearly prescribed1 and in many instances depends on the good sense of those involved for each not to impede the others. One of the ways the AAIB goes about ensuring that problems are minimised is by publishing guidance on its own role and training Police representatives and others on its own role and procedures.

23 Members of

Full members Air Contractors British Airways Capt. Tony Barrett-Jolley Steve Hull Chairman flybe. Air Mauritius British Airways CitiExpress Stuart McKie-Smith Capt. Francois Marion Capt. Ed Pooley

Vice-Chairman Air Scandic British International Channel Express Capt. Terry Green Rob Trayhurn Air Seychelles CAA Treasurer Ben L’ Esperance Dave Lewis - MRPS Britannia Airways Chrys Hadjiantonis - Safety Data Dept. Jez Last Air Wales Ed Bewley - Flight Operations Capt. David Warren Alison Thomas - Intl. Services External Affairs Officer RAeS ALAE CargoLux Airlines Peter Richards Dave Morrison Capt. David Martin

Aegean Airlines Allianz Marine Aviation Cathay Pacific Airways Capt. Dimitris Giannoulatos Jerry Flaxman Rick Howell

Aer Arann Astraeus Ltd CityJet Capt. Julie Garland Capt. Simon Robinson Capt. Mick O’Connor

Aer Lingus BAA plc CTC Service Aviation (LAD) Tom Curran Francis Richards John Dunne

Aerostructures Hamble BAE SYSTEMS Reg. A/C DARA Dr. Marvin Curtiss Alistair Scott Brian Plenderleith

AIG Aviation BALPA DHL Air Jonathan Woodrow Carolyn Evans Peter Naz

Airclaims BMED Eastern Airways UK Ltd Paul Clark Robin Berry Capt. Jacqueline Mills

Air Atlanta Europe bmi regional easyJet Capt. Karl Gunnarsson Capt. Steve Saint Capt. Lance Jordan

Emerald Airways ADVERTISING IN THIS MAGAZINE Capt. Roley Bevan EUJet Focus is a Quarterly Publication which has a Peter Delany highly targeted readership of 32,000 Aviation European Air Transport NV/SA Vincent Lambotte Safety Professionals worldwide. EVA Airways Richard Lovegrove IfIf youyou oror youryour companycompany wouldwould likelike toto advertise in Focus please contact: Excel Airways advertise in Focus please contact: Graeme Stagg

Advertisment Sales Office: First Choice Airways Capt. Peter Harper UKFSC, The Graham Suite, Fairoaks Airport, FlightLine Chobham, Woking, Surrey. GU24 8HX. Capt. Derek Murphy Tel: 01276 855193 [email protected] Flyglobespan Capt. Adam Smith

24 Flyjet Ltd Ryanair Cardiff Intl. Airport Tom Conlon Capt. Gerry Conway Graeme Gamble

Ford Flight Europe SBAC Belfast Intl. Airport Richard Newton Martyn Graham - Secretariat Alan Whiteside Vic Lockwood - FR Aviation GATCO CHC Scotia Richard Dawson ScotAirways Mike Whitcombe Paul Calder GB Airways CHC Scotia Eng. Capt. Phil Lintott-Clarke Servisair/Globeground Eric Nobbs Goodrich Actuation Systems Ltd Eurocypria Keith Joyner Shell Aircraft Capt. Constantinos Pitsillides Brian Teeder Gulf Air Co Cyprus Airways Capt. Manin al Said SR Technics Ireland Ltd Capt. Spyros Papouis Frank Buggie Hong Kong Dragon Airlines Ltd flybe. Alex Dawson TAG Aviation (UK) Ltd Stuart McKie-Smith André Barker Independent Pilots Association flybe. Aviation Services Capt. Mike Nash The Boeing Co. Chris Clark Thor Johansen Irish Aviation Authority MOD Capt. Bob Tweedy Thomas Cook Airlines DASC Capt. Michael Evans Capt. Graham Clarke DASC Eng. Cdr. Ian Peck Kent Intl Airport - Manston HQ STC MOD Sqn. Ldr. Paul Cox Wally Walker Virgin Atlantic Airways MOD (DASC RN) Cdr Steve Pearson Alan Bradbury Loganair RAeS Capt. Stephen Gates Willis Aerospace Peter Richards Ian Crowe London City Airport RAeS Eng. Simon Butterworth Jim Rainbow Group members Lufthansa Consulting GmbH Capt. Simon Searle bmi Co-opted Advisers David Barry Malaysia Airlines AAIB Capt. Ahmed Zuraidi bmi Eng. Capt. Margaret Dean Tom Webster Manchester Airport plc CHIRP Peter Hampson Bond Offshore Helicopters Peter Tait Tony Duff Monarch Airlines GASCo Capt. Tony Wride Bond Offshore Helicopters (Maint) John Thorpe

MyTravel Legal Advisor Capt. Phil Oakes Bristow Helicopters Simon Phippard Capt. Derek Whatling Barlow Lyde & Gilbert NATS Paul Jones Bristow Helicopters Eng. Royal Met. Society Robert Taylor Dr John Stewart NetJets Capt. Mike Jenvey Britannia Airways Jez Last PrivatAir Patrick Danalet Britannia Airways Eng. Adrian Vaughan Rolls-Royce Plc Phillip O’Dell

25 Saving lives in general aviation

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