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Making Every Mission Possible The Official Publication of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE ISSN: 1355-1523 AUTUMN 2003 ON COMMERCIAL AVIATION SAFETY FOCUS is a quarterly subscription journal contents devoted to the promotion of best practises in 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. New ETOPS Regulations 4 Editorial Office: The Boeing Company Ed Paintin The Graham Suite Fairoaks Airport, Chobham, Woking, Surrey. GU24 8HX Tel: 01276-855193 Fax: 01276-855195 UKFSC Members List 12 e-mail: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900-1630 Monday-Friday Advertisement Sales Office: DVT - What is all the fuss about? 14 UKFSC The Graham Suite, Part II or, are airliners flying surgeries? Fairoaks Airport, Chobham, Woking, Simon Phippard Surrey GU24 8HX Tel: 01276-855193 Printed by: Woking Print & Publicity Ltd 737-600/-700/-800/-900 Approach Navigation Options 16 The Print Works, St.Johns Lye, St.Johns The Boeing Company Woking, Surrey GU21 1RS Tel: 01483-884884 Fax: 01483-884880 ISDN: 01483-598501 e-mail: [email protected] Web: www.wokingprint.com Air Safety Report Administration made Easier 20 Simon Earthrowl 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. Human Factors and Occurrence Reporting Systems 22 Opinions expressed by individual authors or in From a Maintenance Organisation’s Perspective advertisements appearing in FOCUS are those of the author or advertiser and do not C. R. Clark necessarily reflect the views and endorsements of this journal, the editor or the UK Flight Safety Committee. UKFSC Seminar 2003 24 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 consequences. Specialist advice should Front Cover: C17 in RAF livery always be sought in relation to any particular circumstances. Photo kindly supplied by Flight Images 1 Editorial Changing the Law prosecute anti social behaviour that sometimes occurs onboard aircraft. This behaviour can be frightening to both passengers and crew. Hopefully this change to the law will increase the success rate of the police in dealing with disruptive passengers and help to deter would be offenders. Credit for these changes must go to Frank Roy MP but also those crew members who have diligently submitted the disruptive passenger reports that have enabled the number and type of incidents to be monitored. Without their coopertion there would have been no For a number of years the Department of As a result of discussions at these information for analysis. Transport (DfT previously the DTLR) has meetings it was decided that the powers been holding twice yearly discussions of the police were inadequate to deal It is hoped that following the small with aviation industry representative effectively with such disruptive success aircrew will continue to submit bodies on disruptive passenger passengers. A proposal was made to the reports so that we can continue to behaviour. change the law to increase the powers of monitor the situation. It will be interesting the police attending to calls from aircrew to see what effect the changes to the law These meetings resulted in the who have experienced disruptive has. introduction of a disruptive passenger passenger incidents on their aircraft. report that is submitted to the Civil Aviation Authority (CAA) by aircrew The proposed changes to the law were following any disruptive passenger presented to Parliament in a Private incident. The response from airlines and Members Bill by Frank Roy MP for their aircrew to this initiative has been Motherwell and Wishaw. This Bill passed very good. These reports are categorised, its second reading on the 7th February collated and used to produce meaningful 2003 and became Law on the 9th July statistics to monitor and illustrate the 2003. scale of the problem. They are also used to indicate the trend of the incidents of The provision of the new Aviation disruptive passenger behaviour and to Offences Act gives the police greater brief various government officials. powers of arrest of suspected air rage offenders and will help the police 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 Close Encounters by John Dunne, Airclaims Runway incursions have been with us for some time now. They are a very real threat to Flight Safety and are increasing in risk exposure as traffic continues to increase. The CAA has recently requested the aviation industries participation in their “Runway Incursions – Research into Causes” initiative. This research is being conducted in parallel with similar initiatives from other regulators and flight safety bodies. The UKFSC welcomes this and is fully endorsing and supporting it through our Operational Safety Committee. Most of our members will have received a copy of the CAA’s questionnaire via e-mail and they are urged to ensure that their company responds. communications error, more significant humans do fail every now and then Those involved in safety management perhaps is that in each event no one (usually at the most inconvenient time) and systems continue to examine the individual involved appears to have had one that does not require judgemental or difficulties of communication and company the total picture of the event that unfolded interpretation skills. Additionally such a procedures with a view to preventing before them. Digging down a further layer system would need to meet the strict similar events. Perhaps it is appropriate on this element we can observe the certification requirements on both sides of for us to reflect where our organisations classic HF issues of confusion and lack of the Atlantic at a cost that is not prohibitive stand in relation to previous ground complete communications – a situation to smaller airports and is demonstrably collisions: Chicago F27 and DC6, poor where everyone has a clear picture of their reliable. weather compounded by communication version of the plan but not that of the other errors. Tenerife, 2 x B747s in poor visibility person and no one in that loop had the compounded by communication errors. overall picture. Paris, MD80 and Shorts S360, at night with visual distractions compounded by This maybe the time to stand back a little communication errors and the Linate (Italy) further from the coal face, reflect a little accident, ground collision involving and and consider the uncomfortable. We are MD80 and an executive jet have been all fallible; we all get it wrong sometimes. made available and highlight poor To paraphrase Lincoln: We can’t all be communication as being a significant right all of the time, but all of us can be contributory factor in the final link of the right some of the time. The problem is accident chain. when we get it wrong at the same instant as someone else who is operating A recent FAA report states that in the somewhere in the same loop as ourselves. period between 1999 and 2002 there were How do we realistically protect against in excess of 1,400 reported runway human fallibility? Perhaps we need to incursions in the USA. The majority of consider developing a simple mechanical these incidents contained an element of system on the established premise that 3 New ETOPS Regulations Extended-range operations with two- On December 16, 2002, the Aviation The ARAC ETOPS Working Group engine airplanes (ETOPS) rank among Rulemaking Advisory Committee (ARAC) - comprised expert representatives from the safest and most reliable of all flight an advisory committee of the U.S. Federal many of the world’s airlines, airframe and operations. Pending rulemaking by the Aviation Administration (FAA) - presented engine manufacturers, pilots’ U.S. Federal Avaition Administration may to the FAA its findings and associations, regulatory authorities, and expand these reliability enhancements recommendations on extended non-governmental organizations. In and operational protections to all operations (i.e., operations on routes with keeping with its proposal that the extended-diversion-time operations (i.e., the potential for an extended-duration extended-operations protection be flying on routes with the potential for an diversion).