AeroSafety WORLD LATE GO-AROUNDS What simulations show FIGHTING FATIGUE FRMS in maintenance TU-154 AT SMOLENSK FATAL FUEL IMBALANCE New report from Poland JUST POLICY TIPPING POINT Fair play in investigations THE JOURNAL OF FLIGHT SAFETY FOUNDATION SEPTEMBER 2011 The Foundation would like to give special recognition to our Benefactor, Patron and Contributor members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible. benefactors Snecma patrons contributors EXECUTIVE’SMESSAGE FRMS and You just left a big meeting at the International work rules. Or, a poorly protected system could Civil Aviation Organization (ICAO) about the allow a lot of very personal information to be realities of implementing fatigue risk manage- disclosed in court in a way that could damage ment systems (FRMS). First, I have to say that both the airline and its employees. I continue to be amazed at ICAO’s new sense of So here are some not-so-simple pre-conditions openness. I found myself surrounded by a mixture for a successful FRMS: First, there must be a of industry leaders, regulators and scientists that real commitment to the program on the part never would have been allowed through those hal- of the company and the employees. They have lowed doors a few years ago. In addition, we had in to agree that they are going to do this thing in our hands excellent guidance material that walked a way that makes life better, the company more both the operator and the regulator through the efficient and operations safer; second, there has process of FRMS implementation. It was especially to be a regulator involved that is smart enough exciting to see that the material carried the logos to know the difference between an FRMS and a of ICAO, the International Air Transport Associa- fancy PowerPointtm presentation and confident tion and the International Federation of Air Line enough to act on that knowledge; third, the effort Pilots’ Associations. must involve all the parties — if a union doesn’t But this was not a party to celebrate a roll-out; exist, there still must be a way to fully involve this meeting addressed real implementation issues. the crews, and every layer of management has to It included a frank discussion about what could understand the program, including scheduling, go wrong and where FRMS should not even be human resources and any other concerned de- attempted. It is important to remember that FRMS partment; finally, there must be a plan to protect is optional. It can be used as an airline’s primary all this amazing data so it doesn’t end up in the scheduling tool or as a tool to tweak existing newspaper after the first operational incident or flight-time and duty-time rules, or it can be left worker’s disability claim. on the shelf. FRMS rests on a foundation of flight Missing a few of those conditions? That isn’t time and duty time rules. It does not replace them. a shock. Conduct a frank and honest assessment There are plenty of good reasons to implement and see what can be salvaged. Keep in mind this an FRMS. It is a once-in-a-generation gift from sci- is not an “all or nothing” exercise. And remember ence. When done right, FRMS relieves the company to read the directions first. from arbitrary restrictions and gives crews the right Here’s a link to the program description: rest at the right time. Pilots who have flown for <www2.icao.int/en/FatigueManagement/Pages/ companies that have adopted this approach say they FatigueManagementTools.aspx>. wake up every day feeling better than they did when they were working for other airlines. FRMS can be one of those rare “win-win” programs. What can go wrong? Unfortunately, quite a bit. A short-sighted labor leader could use it to justify unreasonable bargaining positions. A misguided William R. Voss operator, with a weak regulator, could use it to President and CEO generate a data smoke screen to justify Draconian Flight Safety Foundation WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2011 | 1 AeroSafetyWORLD contentsSeptember 2011 Vol 6 Issue 7 features 14 CoverStory | Tipping Point for a Pilatus PC-12 20 Human Factors | FAA Fatigue Rule Delay 20 23 MaintenanceMatters | Slow Pace of FRMS 28 SafetyCulture | Just Policy at American Airlines 34 CausalFactors | Another Look at Smolensk 36 FlightOps | Go-Arounds After Touchdown 42 FlightOps | Dusty and Gusty 23 48 SafetyCulture | The Need to Notice Hazards departments 1 Executive’sMessage | FRMS and You 5 EditorialPage | How’s It Going? 8 AirMail | Letters From Our Readers 28 9 SafetyCalendar | Industry Events 10 InBrief | Safety News 2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2011 36 48 42 AeroSafetyWORLD telephone: +1 703.739.6700 54 DataLink | Runway Excursions a Continuing Threat William R. Voss, publisher, FSF president and CEO [email protected] 58 Info Scan | Before and After J.A. Donoghue, editor-in-chief, FSF director of publications 64 OnRecord | Ice Blocks A330 Pitot Probes [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 72 SmokeFireFumes | U.S. and Canadian Events 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 About the Cover [email protected], ext. 120 Ice blocked fuel flow from Pilatus PC-12’s left wing tanks. Susan D. Reed, production specialist © Chris Sorensen Photography [email protected], ext. 123 Editorial Advisory Board David North, EAB chairman, consultant We Encourage Reprints (For permissions, go to <flightsafety.org/aerosafety-world-magazine>) William R. Voss, president and CEO Share Your Knowledge Flight Safety Foundation 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, 801 N. Fairfax St., Suite 400, Alexandria, VA 22314-1774 USA or [email protected]. J.A. Donoghue, EAB executive secretary 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. Steven J. Brown, senior vice president–operations Sales Contact National Business Aviation Association Emerald Media Cheryl Goldsby, [email protected] +1 703.737.6753 Barry Eccleston, president and CEO Airbus North America Subscriptions: All members of Flight Safety Foundation automatically get a subscription to AeroSafety World magazine. The magazine also is available through an annual subscription for 11 issues at the cost of US$60 for subscribers in the U.S. and US$80 for all others. Go to our Web site, <flightsafety.org>, and click on the “ASW Don Phillips, freelance transportation subscription” button on the home page to start the process. reporter AeroSafety World © Copyright 2011 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, retired WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2011 | 3 Select the Integrated Air Safety Management Software Solution... 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