27984/Flight Safety Iss 60 5/12/08 15:39 Page 1 ON COMMERCIAL AVIATION SAFETY AUTUMN 2005 ISSUE 60 THE OFFICIAL PUBLICATION OF THE ISSN 1355-1523 UNITED KINGDOM FLIGHT1 SAFETY COMMITTEE 27984/Flight Safety Iss 60 5/12/08 15:40 Page 2 As Easy As Jeppesen’s EFB provides a flexible, scalable platform to deploy EFB applications and data that will grow 1,2,3 with you as your needs evolve. Class 1 Class 2 Class 3 Less paper; increased safety and efficiency; rapid ROI. Jeppesen's EFB makes it as easy as 1, 2, 3. Get more information at: 303.328.4208 (Western Hemisphere) +49 6102 5070 (Eastern Hemisphere) www.jeppesen.com/efb 27984/Flight Safety Iss 60 5/12/08 15:40 Page 3 The Official Publication of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE ISSN: 1355-1523 AUTUMN 2005 ON COMMERCIAL AVIATION SAFETY FOCUS is a quarterly subscription journal devoted to the promotion of best practises in contents 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. Electromagnetic Interference from 4 Editorial Office: Wireless Internet Equipped Laptops Ed Paintin The Graham Suite Fairoaks Airport, Chobham, Woking, Surrey. GU24 8HX ‘Send Three & Fourpence’ 5 Tel: 01276-855193 Fax: 01276-855195 by Paul Jones e-mail: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900 - 1630 Monday - Friday ‘STOP IMMEDIATELY’ 8 Advertisement Sales Office: UKFSC ATC Cancellation of Take-Off Clearance The Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey GU24 8HX Tel: 01276-855193 Fax: 01276-855195 Book Review 11 email: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900 - 1630 Monday - Friday UKFSC Members List 12 Printed by: Woking Print & Publicity Ltd The Print Works, St.Johns Lye, St.Johns, Woking, Surrey GU21 1RS Hazards to Aircraft from Foreign Objects 14 Tel: 01483-884884 Fax: 01483-884880 ISDN: 01483-598501 by SRG Research & Strategic Analysis Section e-mail: [email protected] Web: www.wokingprint.com FOCUS is produced solely for the purpose of Plane Crazy 16 improving flight safety and, unless copyright is by Mel Lewis indicated, articles may be reproduced providing that the source of material is acknowledged. Opinions expressed by individual authors or in Corporate Manslaughter: Reform at Last 17 advertisements appearing in FOCUS are those of the author or advertiser and do not by Sue Barham, BLG necessarily reflect the views and endorsements of this journal, the editor or the UK Flight Safety Committee. NetJets – A Unique Safety Challenge 19 While every effort is made to ensure the by Capt. Mike Jenvey & Capt. Catherine Thompson accuracy of the information contained herein, FOCUS accepts no responsibility for any errors or omissions in the information, or its consequences. Specialist advice should always be sought in relation to any particular circumstances. Front Cover Picture: A NetJets Citation XLS 1 27984/Flight Safety Iss 60 5/12/08 15:40 Page 4 Editorial Could the root cause of many incidents be the result of poor discipline? Many of the more common accidents during planning also contributes to these (CRM) training was introduced to improve and incidents have a “Human Factors” errors and highlights the need for better this aspect of multi crew operations. pre-flight planning. element to them. This is not surprising as The Captain of the aircraft is responsible the interaction between man and machine The use of the radio and the knowledge for the proper operation of the aircraft. He is subject to error as man is not infallible of the correct phraseology seems to have is therefore responsible for ensuring that and will make mistakes. deteriorated with time. The inability to the radio procedure is correctly executed, hear and read back instructions is the clearances are recorded and followed, Six areas of current concern in the cause of many unnecessary radio that pre-flight planning is adequately industry are: transmissions. This can at times overload done, that the checklists and company ■ Level busts the system and cause frustration to both procedures are followed, that assigned ■ Runway incursions pilots and ATC, leading to incidents and altitudes are not bust. He has a great deal ■ Deviations from Standard Instrument losses of separation. of responsibility and therefore needs to Departures (SID) be up to the task. ■ Deviations from Standard Arrivals Recent studies show us that one in four (STARS) first calls by pilots after departure are Good captaincy requires good self ■ Poor use of the radio incomplete. Remember Callsign, SID, discipline, the fostering of good cockpit Passing level and cleared level (or first discipline and thorough monitoring of all ■ Failure to follow Standard Operating stop altitude on a stepped SID). that takes place on and off the flight deck, Procedures (SOPs) and check lists ensuring that when things go wrong Why do pilots fail to follow everyone knows the reason and how not Level busts have as their main cause procedures and checklists? Is it to let it happen again. It is a position that one or more of the following human because they believe they know better? all first officers should aspire to. errors: failure to hear ATC instructions, Time and again we see incidents and failure to read back instructions correctly accidents caused by the crew failing to So why is it that there are so many or failure to set the correct values on follow the correct procedures. In a recent incidents and accidents? Is it because the instruments and autopilots. 30% of level incident where a crew experienced smoke standard of self discipline had been busts occur after a pilot has correctly fumes on the flight deck they failed to put allowed to decay? Is it because flight read back the cleared level to ATC. on their oxygen masks believing there to be deck discipline has deteriorated in spite insufficient smoke. Did they use the of the introduction of CRM training? Is it Is this because we have discouraged appropriate checklist? Did they not realise because captaincy skills are not being pilots from making a note of these critical that carbon dioxide can not be seen and passed on to the first officers? values on the pilot log? Has the can cause incapacitation. Failing to follow introduction of the paperless cockpit procedures and check lists is a known killer. If we intend to reduce the number of brought this about? It seems logical that accidents and incidents we need to find during the R/T transmission if you write So what do all of the above errors have in ways of improving the standards of down the critical information then you will common? They are all symptomatic of communication, management and have an aid to memory when reading one or more of the following: poor self discipline on the flight deck. back the information. This will also discipline, poor cockpit discipline and provide a reference for later. Not having a poor captaincy. The whole reason for note will mean that you have to rely on multi crew operations is to ensure that the your memory and we know how crew monitor what each other do. That unreliable that can be. includes listening to the radio, understanding the layout of airfields, Runway incursion and deviations correcting any errors made and ensuring from SIDs and STARs are caused in the the company procedures are followed to main by pilots failing to comply with the the letter and that all checks are followed instructions given to them or becoming and the actions correctly taken. Good confused and having no written notes of communication on the flight deck is their clearance. Lack of familiarity with the essential for the safe operation of the airfield and failing to read the airfield chart aircraft. Crew Resource Management 2 27984/Flight Safety Iss 60 5/12/08 15:40 Page 5 Chairman’s Column Emergency Evacuations by Stuart McKie-Smith It was very encouraging to see that all The case for listening carefully to the the end it is going to be the aircrew, and the passengers and crew of the recent cabin emergency briefing takes on even in particular the cabin crew, who A340 event were able to evacuate the greater importance with these larger contribute most to their survival. aircraft with only minor injuries. aircraft. The chances of sitting in the same seat The introduction of increasingly larger The regulations state that a safety briefing for every flight are remote, so noting the passenger aircraft into service over the must be given explaining the emergency nearest exit is well worth the few seconds last 20 years raises some interesting equipment. Unfortunately there is nothing that it takes to look. It is also worth discussions on passenger and crew to say that passengers actually have to checking your route to that exit to see evacuation. The internationally accepted listen to the briefing. It is understandably whom you are likely to be standing on to (and certainly for JAR operators) frustrating for the cabin crew (who are get there! evacuation time is 90 seconds from professional aircrew on board the aircraft aeroplane to ground. Compliance has to for the safety of the passengers) to find be shown by demonstration and, themselves on many occasions during amongst a variety of criteria that have to their demonstrations, talking to be fulfilled (JAR 25 – 803), the test must themselves.