AeroSafety WORLD PILOTS TALK AUTOMATION Coping strategies AUTOMATION DISTURBED Causes AMS crash CONTROLLING FATIGUE Which approach is best PROFESSIONAL BEHAVIOR An NTSB examination LATIN SAFETY RENEWAL São Paulo gathering LIGHTNING STRIKES PROTECTION BY DESIGN THE JOURNAL OF FLIGHT SAFETY FOUNDATION JUNE 2010 BASS-Asia Business Aviation Safety Seminar-Asia november 10–11, 2010 changi Village, singapore Today’s besT safeTy pracTices for The asia pacific region. The rapid growth of business aviation in the Asia Pacific region represents opportunity for organizations and national economies. As other regions have discovered, however, expansion is also a safety challenge. Fortunately, business aviation has already developed best practices that BASS-Asia can be applied in Asia Pacific. is a new safety seminar, sponsored by four leading organizations to transmit practicable knowledge and techniques supporting safe flight. To register or to see a preliminary agenda, go to <flightsafety.org/aviation- safety-seminars/business-aviation-safety- seminar-asia-2010>. SINGAPORE AVIATION AsBAA ACADEMY Asian Business Aviation Association PRESIDENT’sMESSAGE GENTLEMEN’s Agreement think it is time for us to be honest with ourselves. This isn’t a new idea. Many industries, includ- With all that is going on in the world today, is ing medicine, civil engineering, shipping and aviation safety really that much of a priority? mining, set their own standards and measure I find the answer to that depends on who you themselves by those criteria. It isn’t even a new Iask. If you put a television camera in the face of a idea in aviation. The bolts that hold the wing on politician or an airline CEO, then, of course, safety are built to an SAE standard. Airlines qualify for is the number one priority. But once we get past International Air Transport Association (IATA) that public reflex, to be honest with ourselves, we membership with an IATA Operational Safety Au- must admit that safety improvements are publicly dit, and corporate flight departments prove their mandated, but privately discouraged. The system is safety management system competencies with entering a new age, and it is time to adapt. an International Standard for Business Aircraft Take a look at how fatigue regulation is pro- Operations (IS-BAO) registration. gressing in the United States and Europe. Improved All of these are standards established by in- fatigue regulations have been a public priority dustry for industry. This type of standard setting since the Colgan Air accident near Buffalo, New will be central to our future. Why do such a thing? York, U.S., in early 2009 (ASW, 3/10, p. 20). But Because the industry has no real choice. the poorly concealed truth is that vital regulatory Today, many leading airlines go far beyond initiatives are hitting an economic wall. Regula- the minimum regulatory requirement. That is tions have costs that, in many countries, must be great, until another company does the regulatory offset by verifiable benefits. Aviation is now so minimum and threatens to run the others out of safe that there is little chance a new rule might business by undercutting them on costs. immediately prevent an accident and save a life. If an industry wants to raise safety standards, it This cost-benefit hurdle is not a U.S. anomaly. It is must do so jointly, and publicly, and it has to call out common in many countries around the world. those who refuse to go along. There has always been Of course, the same type of analysis doesn’t ap- a gentlemen’s agreement among airlines that they will ply to security regulations, and that leads to an odd not speak ill of another’s safety efforts, but those days situation. It is OK from a regulatory perspective to may soon be over. Clearly, some airlines maintain a spend a nearly infinite amount of money to keep a higher level of safety and it may be time to admit it. human life from being lost due to hostile action; it We are left with two choices: Set our own standards is not OK to spend money as freely to protect that and celebrate them, or risk having market pressures same life from the consequences of human error. erode standards to the regulatory minimum. This is a distinction not appreciated by those who have lost loved ones in accidents. We have to find new tools. The idea of using regulations to ensure safety is wearing thin. It is time for the industry to think hard about how safe William R. Voss it wants to be, and to establish the standards by President and CEO which it can be measured. Flight Safety Foundation WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2010 | 1 AeroSafetyWORLD contents June2010 Vol 5 Issue 5 features 13 HumanFactors | Automation Complacency 18 CoverStory | When Lightning Strikes 13 24 SafetyCulture | Professional Behavior 28 FlightOps | Obscured by Fog 32 CausalFactors | Automation at Odds 37 SeminarsCASS | Back to Basics 40 HumanFactors | The Best Rest 18 46 StrategicIssues | Pan American Summit 24 departments 1 President’sMessage | Gentlemen’s Agreement 5 EditorialPage | Worst-Case Scenarios 7 SafetyCalendar | Industry Events 9 InBrief | Safety News 12 FoundationFocus | Mission Underwriters 2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2010 32 40 28 AeroSafetyWORLD telephone: +1 703.739.6700 51 DataLink | Australian Commercial Aviation Trends William R. Voss, publisher, FSF president and CEO [email protected] 54 InfoScan | Aircraft Hygiene J.A. Donoghue, editor-in-chief, FSF director of publications 57 OnRecord | Tail Strike Follows Bounced Landing [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Karen K. Ehrlich, webmaster and production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer [email protected], ext. 120 About the Cover Lightning poses challenges Susan D. Reed, production specialist to composite aircraft design. [email protected], ext. 123 © Adrian Jan Haeringer/iStockphoto Patricia Setze, librarian [email protected], ext. 103 We Encourage Reprints (For permissions, go to <flightsafety.org/aerosafety-world-magazine>) Editorial Advisory Board Share Your Knowledge David North, EAB chairman, consultant If you have an article proposal, manuscript or technical paper that you believe would make a useful contribution to the ongoing dialogue about aviation safety, we will be glad to consider it. Send it to Director of Publications J.A. Donoghue, 601 Madison St., Suite 300, Alexandria, VA 22314-1756 USA or [email protected]. William R. Voss, president and CEO The publications staff reserves the right to edit all submissions for publication. Copyright must be transferred to the Foundation for a contribution to be published, and Flight Safety Foundation payment is made to the author upon publication. J.A. Donoghue, EAB executive secretary Sales Contacts Flight Safety Foundation Europe, Central USA, Latin America Asia Pacific, Western USA Joan Daly, [email protected], tel. +1.703.983.5907 Pat Walker, [email protected], tel. +1.415.387.7593 Steven J. Brown, senior vice president–operations Northeast USA and Canada Regional Advertising Manager National Business Aviation Association Tony Calamaro, [email protected], tel. +1.610.449.3490 Arlene Braithwaite, [email protected], tel. +1.410.772.0820 Barry Eccleston, president and CEO Subscriptions: Subscribe to AeroSafety World and become an individual member of Flight Safety Foundation. One year subscription for 12 issues Airbus North America includes postage and handling — US$350. Special Introductory Rate — $310. Single issues are available for $30 for members, $50 for nonmembers. For more information, please contact the membership department, Flight Safety Foundation, 601 Madison St., Suite 300, Alexandria, VA 22314-1756 USA, Don Phillips, freelance transportation +1 703.739.6700 or [email protected]. reporter AeroSafety World © Copyright 2010 by Flight Safety Foundation Inc. All rights reserved. ISSN 1934-4015 (print)/ ISSN 1937-0830 (digital). Published 11 times a year. Suggestions and opinions expressed in AeroSafety World are not necessarily endorsed by Flight Safety Foundation. Russell B. Rayman, M.D., executive director Nothing in these pages is intended to supersede operators’ or manufacturers’ policies, practices or requirements, or to supersede government regulations. Aerospace Medical Association WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2010 | 3 SmartLanding_Ad:Layout 1 4/14/10 12:23 PM Page 1 SmartLandingTM Safe’til you stop. Here are more statistics that are hard to ignore: runway excursions cost the aviation industry $900 million per year and account for 83% of runway fatalities. Honeywell’s new SmartLanding helps reduce the risk of runway excursions by alerting pilots during unstable approaches and long landings. Safe from start to stop. Together, SmartRunway™ and SmartLanding provide a powerful continuum of awareness from takeoff to landing. SmartLanding is an easy software upgrade to Honeywell’s. Enhanced Ground Proximity Warning System (EGPWS). For details, visit Honeywell.com/runwaysafety. ©2010 Honeywell International Inc. EDITORIALPAGE WORSt-CASE Scenarios ast year I bought a parachute, not and guiding the ’chute to a good land- uncontrolled manner, and that never because I wanted to jump out of a ing — but I also should physically work turns out well. In an emergency ver- perfectly good airplane, but just in my way through that process as much as sion of get-home-itis, pilots want to case my airplane suddenly was no possible while sitting in the cockpit. land normally, even when that seems Llonger perfectly good. For someone who has never wanted nearly impossible. I fly gliders most weekends, and my to jump out of any aircraft into thin In probably the most popular ac- Pilatus is a nice aircraft with decent air, it was a sobering process, but the cident of all time — if there can be such performance.