AeroSafety WORLD HIGH CULTURE Nurturing core safety values VENTING FUEL 777 maintenance error PREMIUM FOCUS Insurers stress risk management CAUSAL FACTORS Recipe for CFIT disaster SUN DANGER CONSIDERING WEATHER FROM SPACE THEFlight JOURNAL Safety OF FFoundationLIGHT SAFETY FOUNDATION JUNE 2007 What can you do to improve aviation safety? Join Flight Safety Foundation. Your organization on the FSF membership list and Internet site presents your commitment to safety to the world. • Receive AeroSafety World, a new magazine developed from decades of award-winning publications. • Receive discounts to attend well-established safety seminars for airline and corporate aviation managers. • Receive member-only mailings of special reports on important safety issues such as controlled flight into terrain (CFIT), approach-and-landing accidents, human factors, and fatigue countermeasures. • Receive discounts on Safety Services including operational safety audits. An independent, industry-supported, nonprofit organization for the exchange of safety information for more than 50 years Wright Flyer photo/source: U.S. National Aeronautics and Space Administration If your organization is interested in joining Flight Safety Foundation, we will be pleased to send you a free membership kit. Send your request to: Flight Safety Foundation 601 Madison Street, Suite 300, Alexandria, VA 22314 USA Telephone: +1 703.739.6700; Fax: +1 703.739.6708 E-mail: [email protected] Visit our Internet site at www.flightsafety.org PRESIDENT’sMEssaGE Trust n the past few weeks, I have been reminded of The other storm involves air traffic control- just how badly politics mix with safety. There lers’ growing distrust of the Federal Aviation are two separate storms brewing in the United Administration (FAA). In a recent survey of States that could undermine the key ingredient controllers, less than 10 percent said that they Iof our safety programs — trust. trust FAA management. That is pretty serious if The first storm is the user fee debate, which we think about the challenges that the FAA faces. has been building for years. Airlines and business First, it has to deal with ever-increasing demand aviation are battling over the question of who pays on a system that is being pressed to its limits. for how much of the air traffic control system. I Second, it must start dealing with a large turnover worry that this debate could impact our future as controllers hired after the 1981 PATCO strike safety efforts. start to retire. Finally, the organization is going to One of the core functions of Flight Safety have to create and then transition to a Next Gen- Foundation has been to spread safety innovations eration Air Transportation System, which must be from one segment of the industry to another. revolutionary to be successful. But the debate is so intense and the feelings are The only way to deal with challenges like these so bitter that now I am not sure I can get safety is to lean heavily on tools such as safety manage- people from the airlines and business aviation in ment, threat and error management, normal the same room. operation safety studies and so on. These tools We can get a sense of what is at risk by looking rely on open and honest reporting and exchange at some of the safety programs these communi- of safety information. In other words, all of these ties have shared in the past. Our Approach and tools rely on trust. Landing Accident Reduction (ALAR) program I don’t deny anybody the right to lobby for has always reached out to airline and business their interests or fight for a fair deal. But I know aviation audiences. Our Ground Accident Pre- that we cannot let the festering aviation issues vention (GAP) program has been driven by the breed the crippling mistrust that could stop safety airlines, but some of the first products you will improvements in their tracks. At the end of the find on our Web site address business operations. day, regardless of who wins or loses, thousands of The Foundation’s work in the area of fatigue is people are going to have to reach down deep and supporting long-range operations in Boeing 777s find a way to trust again. There is no choice. We as well as Gulfstream 550s. live in a system that is built on trust. While there have always been competing interests, we have been able to put them aside. I hope that the trust and sense of mission that have held us together through the aftermath of the 9/11 attacks and spiraling fuel prices are not lost in this debate. Who knows what the next challenges will be — carbon-emission limits, avian flu, person- William R. Voss nel shortages? One thing is certain: We are always President and CEO going to need each other. Flight Safety Foundation WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2007 | 1 AeroSafetyWORLD 12contents June2007 Vol 2 Issue 6 features 12 SafetyCulture | Creating a Safety Culture 22 CoverStory | Space Weather Training 28 CausalFactors | CFIT in Queensland 35 HelicopterSafety | Loss of Control 37 StrategicIssues | Insurers and Risk 42 MaintenanceMatters | Faulty Procedures 22 departments 1 President’sMessage | Trust 5 EditorialPage | Attitude 6 SafetyCalendar | Industry Events 8 InBrief | Safety News 49 FoundationFocus | Membership Update 28 2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2007 35 42 contents 37 AeroSafetyWORLD telephone: +1 703.739.6700 50 DataLink | Unsafe Acts William R. Voss, publisher, FSF president and CEO [email protected], ext. 108 53 InfoScan | Aeromedical Primer J.A. Donoghue, editor-in-chief, FSF director of publications 57 OnRecord | Miscalculation [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, web and print production coordinator [email protected], ext. 117 Ann L. Mullikin, production designer [email protected], ext. 120 About the Cover Susan D. Reed, production specialist Safety threats from the sun prompt [email protected], ext. 123 greater interdependence of aviation professionals and solar scientists. Patricia Setze, librarian © Fotoeye75/Dreamstime.com [email protected], ext. 103 Editorial Advisory Board We Encourage Reprints (For permissions, go to <www.flightsafety.org/asw_home.html>) David North, EAB chairman, consultant Share Your Knowledge William R. Voss, president and CEO 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 Flight Safety Foundation 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]. 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 J.A. Donoghue, EAB executive secretary payment is made to the author upon publication. Flight Safety Foundation Sales Contacts J. Randolph Babbitt, president and CEO Europe, Central USA, Latin America Asia Pacific, Western USA Eclat Consulting 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 Subscriptions: Subscribe to AeroSafety World and become an individual member of Flight Safety Foundation. One year subscription for 12 issues Barry Eccleston, president and CEO includes postage and handling — US$350. Special Introductory Rate — $280. Single issues are available for $30 for members, $45 for nonmembers. Airbus North America For more information, please contact the membership department, Flight Safety Foundation, 601 Madison Street, Suite 300, Alexandria, VA 22314-1756 USA, Don Phillips, freelance transportation +1 703.739.6700 or [email protected]. reporter AeroSafety World © Copyright 2007 by Flight Safety Foundation Inc. All rights reserved. ISSN 1934-4015 (print)/ ISSN 1937-0830 (digital). Published 12 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 2007 | 3 Serving Aviation Safety Interests for More Than 50 Years OFFICERS AND STAFF Chairman, light Safety Foundation is an international membership organization dedicated to Board of Governors Amb. Edward W. the continuous improvement of aviation safety. Nonprofit and independent, the Stimpson President and CEO William R. Voss FFoundation was launched officially in 1947 in response to the aviation industry’s need Executive Vice President Robert H. Vandel for a neutral clearinghouse to disseminate objective safety information, and for a credible General Counsel and knowledgeable body that would identify threats to safety, analyze the problems and and Secretary Kenneth P. Quinn, Esq. Treasurer David J. Barger recommend