FACING THE ISSUES BARS Audits Pinpoint Weaknesses ADVANCING AWARENESS Updating AOA Displays GOING ROGUE The Intentional Crash Phenomenon UNHEEDED WARNINGS ICE-INDUCED STALL DOWNS PHENOM THE JOURNAL OF FLIGHT SAFETY FOUNDATION SEPTEMBER 2016 IS THERE SAFETY IN NUMBERS? ABSOLUTELY G 7 decades G 150 countries G 1,100 members G 1st — International Air Safety Summit — Civil aviation accident workshop — Pilot safety global reporting system — Worldwide distribution of malfunction reports — BARS O shore Helicopter Standard G 30 ALAR regional workshops G 100+ issues of AeroSafety World since 2006 G 350 BARS audits completed G 40 awards of excellence G 30+ industry collaborations G 4 annual Air Safety Summits JOIN TODAY ightsafety.org MembershipAd2016.indd 1 4/19/16 9:12 PM PRESIDENT’SMESSAGE Coming Soon ater this fall, we will be launching a We understand that time is critical in The website also will be linked to new Flight Safety Foundation web- today’s fast-paced operating environment, our new membership database. A single site <flightsafety.org> that incorpo- and that safety professionals don’t want to sign-on will get FSF members immedi- rates the best of AeroSafety World be scouring the internet for useable news ate access to all of our latest content and Lin a redesigned format for internet-only and information. With that in mind, our member-focused communication, plus distribution to each reader’s preferred new website also will feature a federated tools to renew their membership and digital device. This will better serve our search engine that will enable users to to more easily register for our industry- members and more effectively dissemi- simultaneously find and retrieve their leading safety summits and seminars. nate aviation safety news and knowledge query results from the latest content, digi- There is not enough space in this around the world. tal archives of the Foundation, our Basic brief message to go into detail on all of Months of work involving just about Aviation Risk Standard program and our the new website features or to explain the everyone here at the Foundation, as well Global Safety Information Project website thinking behind all the decisions made as several outside partners, have gone <fsfgsip.org> — as well from Eurocontrol’s during development. Our purpose, how- into the planning and development of SKYbrary website <skybrary.aero> and ever, is simple and unchanged: to provide this new initiative. The work was not from the Aviation Safety Network website impartial, independent, expert safety entered into lightly; to keep pace with <aviation-safety.net>. Our editors and guidance and resources for the aviation an ever-changing industry, we carefully technical staff also will be curating relevant and aerospace industry. planned how best to create a more flex- safety content from around the world on a Stay tuned. ible, user-friendly and responsive digital daily basis and delivering it to you in the communication platform with which to new site’s Industry Updates section. support our members and the aviation AeroSafety World will have its own industry. dedicated pages, as noted, for content in Research has shown that media con- the new design, and will offer easy access tent like ours increasingly is being con- to all past ASW issues and legacy publi- sumed on mobile devices, such as tablets cations in Adobe PDF format, as always. and smartphones. In fact, because of this In addition, we are planning late in the preference, mobile-device traffic in 2016 year to roll out an ASW app that runs on accounts for at least half of all internet today’s most popular devices, which will traffic. Our new website will enable web- make it easier for aircraft crewmembers pages, including ASW articles, to display and other readers who are not always correctly and optimally regardless of the connected to the internet to download Jon L. Beatty type and size of the device used to access issues of the magazine and to read them President and CEO our website. whenever it’s safe and convenient. Flight Safety Foundation FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 1 AeroSafetyWORLD contents September 2016 Vol 11 Issue 7 features 12 Cover Story | Ice-Induced Stall Ends in Crash 18 RegionalSafety | Lessons From European Collaboration 24 AuditReview | BARS Pinpoints Operator Weaknesses 29 FlightTech | High Hopes for AOA Awareness 12 35 Human Factors | No Pattern for Pilot Suicides 18 41 Human Factors | Rogue Pilot–Intentional Crash departments 1 President’s Message | Coming Soon 5 Editorial Page | Clamp Down 7 Air Mail | Letters from Our Readers 8 Safety Calendar | Industry Events 2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 H C A O R P P A 24 29 35 9 In Brief | Safety News 47 Data Link | Accidents, Fatalities Down in 2015 51 On Record | ‘In the Same Boat’ 41 AeroSafetyWORLD telephone: +1 703.739.6700 About the Cover The wreckage of an Embraer Phenom Frank Jackman, editor-in-chief, lies near a house that it struck in FSF vice president, communications Gaithersburg, Maryland, U.S. [email protected], ext. 116 © Jose Luis Magana | Associated Press Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor We Encourage Reprints (For permissions, go to <flightsafety.org/aerosafety-world-magazine>) [email protected], ext. 122 Share Your Knowledge 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 Mark Lacagnina, contributing editor glad to consider it. Send it to Editor-In-Chief Frank Jackman, 701 N. Fairfax St., Suite 250, Alexandria, VA 22314-2058 USA or [email protected]. [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 payment is made to the author upon publication. Jennifer Moore, art director Sales Contact [email protected] Emerald Media Cheryl Goldsby, [email protected] +1 703.737.6753 Susan D. Reed, graphic designer Kelly Murphy, [email protected] +1 703.716.0503 [email protected], ext. 123 Subscriptions: All members of Flight Safety Foundation automatically get a subscription to AeroSafety World magazine. For more information, please contact the membership department, Flight Safety Foundation, 701 N. Fairfax St., Suite 250, Alexandria, VA 22314-2058 USA, +1 703.739.6700 or [email protected]. AeroSafety World © Copyright 2016 by Flight Safety Foundation Inc. All rights reserved. ISSN 1934-4015 (print)/ ISSN 1937-0830 (digital). Published 10 times a year. Suggestions and opinions expressed in AeroSafety World are not necessarily endorsed by Flight Safety Foundation. Nothing in these pages is intended to supersede operators’ or manufacturers’ policies, practices or requirements, or to supersede government regulations. | | FLIGHTSAFETY.ORG AEROSAFETYWORLD SEPTEMBER 2016 | 3 ASW_mar16_Ads.indd 1 2/23/16 11:00 AM EDITORIALPAGE Clamp Down isk mitigation is necessarily a cooperative rogue producers and exporters. And flagrant activity. It takes stakeholders from across abuses of dangerous goods shipping regulations, the aviation industry doing their parts indi- which place aircraft and passenger safety at risk, vidually and in coordination with others to must be criminalized,” Tyler said. Rcreate the effective layers of mitigations that keep Other interested parties should take a cue from crews and passengers safe flight after flight, year IATA and the battery supply chain and pressure after year. Organizations outside of aviation have governments to take action against rogue battery an important role to play, too, and sometimes that manufacturers and shippers. According to IATA, role is to enforce standards and regulations that lack of enforcement is increasing pressure on air- already are on the books. lines and regulators to unilaterally ban all forms of Recently, the International Air Transport Asso- lithium battery shipments from aircraft, which, in ciation (IATA) and trade associations representing turn, could drive rogue manufacturers and ship- leaders of the lithium battery supply chain released pers to increasingly mislabel battery shipments. a joint statement demanding stricter enforcement The safe shipment of lithium batteries and of international regulations regarding the transport other dangerous goods requires transparency and of lithium batteries (see “Safety News,”4 p. 9). The adherence to the rules by manufacturers, shippers call for stricter enforcement of regulations was and all other involved stakeholders. Anything less aimed at ministers of trade, industry and trans- could jeopardize safety. port and directors of civil aviation in the world’s largest lithium battery manufacturing and export countries. According to IATA Director General and CEO Tony Tyler, the rules that airlines, shippers and manufacturers have worked to establish to ensure that lithium batteries can be carried safely are only effective if they are enforced and backed up Frank Jackman by significant penalties. “Government authorities Editor-in-Chief, ASW must step up and take responsibility for regulating Flight Safety Foundation FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 5 Serving Aviation Safety Interests for Nearly 70 Years OFFICERS AND STAFF Chairman ince 1947, Flight Safety Foundation has helped save lives around the world. The Board of Governors