Asw July13 LR

AeroSafety
WO R L D
AIRPLANE UPSET PREVENTION ETA for ICAO standards and manuals HEMS AS350 FUEL STARVATION Smartphone distraction controversy U.S. AIRLINE PILOT SHORTAGE Forecasts begin to converge
A330 CFIT IN TRIPOLI

THE JOURNAL OF FLIGHT SAFETY FOUNDATION JULY 2013
CAUSAL FACTORS FROM LIBYAN CAA
IASS 2013
october
2931, 2013
Omni Shoreham Hotel
66th annual International Air Safety Summit
Washington, DC, USA
IASS 2013 The 66th Annual International Air Safety Summit (IASS) will be held October 29-31, 2013 at the Omni Shoreham Hotel in Washington, DC, USA. Please visit website below for hotel details and further details about the event as they become available.
flightsafety.org/IASS2013 @Flightsafety #IASS2013
PRESIDENTSMESSAGE
Needs Your Help

O
n May 15, during one of the semi-annual meetings of our Board of Governors, I reported on the financial condition of Flight Safety Foundation. The Foundations financial report draws a lot of attention because it speaks directly to the organizations ability to meet its financial obligations and to carry on with its vital work of reducing risk in aviation. Beginning in late 2011, as the 2012 budget was being constructed, we saw signs that our primary funding source membership revenue was beginning to decrease because of a fall-off in existing member renewals and a slowdown of new member sign-ups. Other factors included a decrease in attendance at our safety summits and an increase in operating costs tied to the development of a major new safety program and to some internal operating inefficiencies. While the state of the world economy, which has at least an indirect impact on membership and conference attendance, is beyond our control, we have taken a number of steps to address our financial and operational situation. We studied where we could reduce overhead without negatively impacting our level of service, which essentially meant taking a look at how efficiently we meet the needs of our members and the aviation community as a whole. What resulted from that exercise was a reduction in full-time staff members from a total of 26 to 20 in our offices in Alexandria, Virginia, U.S., and Melbourne, Australia. Technical project facilitation, executive leadership and AeroSafety World production have been modified in order to reduce the overhead. Our ratio of operating costs to total intake is 14 percent, which is very good when compared with other non-profit organizations. We also are working to freshen up our safety seminars. We want our summits and seminars to be the most valuable and engaging safety events you attend each year. We recognize there are many other conferences to choose from, so we are working hard to make our summits and seminars the industrys best. I am working with our International Air Safety Summit (IASS) and Business Aviation Safety Summit (BASS) agenda committees to make the Foundations two premier events more real time, featuring carefully vetted presentations on more current safety and operational topics. We will be adding interactive technology so viewpoints and opinions can be shared instantaneously. We also are targeting venues that are interesting and easy to travel to, all the while keeping the cost as low as possible. But what we really need is your support. Whether you are currently a member, or a person who is aware of us and not a member, or someone who has just picked up this magazine for the first time, you need to support the Foundation. Our value to you and the industry is multi-dimensional. We continually facilitate reducing the risk in aviation through research committees, public and industry meeting appearances, our magazine and website, summits, and news media interviews. In addition, everyone associated with aviation has a responsibility to give back to the industry that we personally gain from. We must keep aviation as risk free as we can, in order to continue to thrive and grow. Without the Foundation to be that international, independent and impartial source to help facilitate the cause, the aviation industry may not progress as well as we have in the past. Please renew your membership, sign up as a new member, attend a summit or just donate. All these can be done on our website, and we need you now to help us continue to provide the service we all need!
THE FOUNDATION
Capt. Kevin L. Hiatt President and CEO Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JULY 2013
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contents
AeroSafetyWORLD
features
12
July 2013 Vol 8 Issue 6
CoverStory | Libyan CAA Accident Analysis MaintenanceMatters |

Mitigating Technician Fatigue
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18 23 27 33 38
FlightDeck | Short Supply of U.S. Airline Pilots FlightOps | ICAO Finalizes Upset Prevention Changes FlightOps | Crackdown on Distraction StrategicIssues | Constant-Angle, Nonprecision Approaches
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FLIGHTDECK
departments
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PresidentsMessage | The Foundation Needs Your Help FoundationFocus | Lederer Legacy SafetyCalendar | Industry Events InBrief | Safety News
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JULY 2013
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T
he often-forecast shortage of U.S. airline pilots may finally come to pass, fed by a perfect storm of increasing demand for new pilots, mounting retirements by babyboomer pilots and declining interest among young
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number of hours pilots may work that may lead to an increase in the number of required new pilots.1 The Boeing study had forecast a need for 460,000 new pilots worldwide by 2032, includ-
g usin ilots on p ir n a a an eb hile d th xten es w to e rpos s u t p n a nal Bw erso NTS for p The nes o h p n.| cell ratio ope is in
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Gary Arbach|Dreamstime.com
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FLIGHTSAFETY.ORG | AEROSAFETY WORLD | JULY 2013
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AeroSafetyWORLD
telephone: +1 703.739.6700
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DataLink | Business Aircraft Runway Excursions InfoScan | NextGen Midterm Challenges OnRecord | Automation Surprise
Capt. Kevin L. Hiatt, publisher, FSF president and CEO

hiatt@flightsafety.org
Frank Jackman, editor-in-chief, FSF director of publications

jackman@flightsafety.org, ext. 116
Wayne Rosenkrans, senior editor

rosenkrans@flightsafety.org, ext. 115
Linda Werfelman, senior editor

werfelman@flightsafety.org, ext. 122
Rick Darby, associate editor

darby@flightsafety.org, ext. 113
Jennifer Moore, art director

jennifer@emeraldmediaus.com
About the Cover The Libyan Civil Aviation Authority has disseminated safety findings based on the crash of this Airbus A330-202. Franois-Xavier Simon
Susan D. Reed, production specialist

reed@flightsafety.org, ext. 123
Editorial Advisory Board

David North, EAB chairman, consultant
We Encourage Reprints (For permissions, go to <flightsafety.org/aerosafety-world-magazine>) 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 glad to consider it. Send it to Director of Publications Frank Jackman, 801 N. Fairfax St., Suite 400, Alexandria, VA 22314-1774 USA or jackman@flightsafety.org. 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.
Frank Jackman, EAB executive secretary Flight Safety Foundation Steven J. Brown, senior vice presidentoperations National Business Aviation Association Barry Eccleston, president and CEO Airbus North America Don Phillips, freelance transportation reporter Russell B. Rayman, M.D., executive director Aerospace Medical Association, retired
Sales Contact
Emerald Media Cheryl Goldsby, cheryl@emeraldmediaus.com +1 703.737.6753 Kelly Murphy, kelly@emeraldmediaus.com +1 703.716.0503
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, 801 N. Fairfax St., Suite 400, Alexandria, VA 22314-1774 USA, +1 703.739.6700 or membership@flightsafety.org. AeroSafety World Copyright 2013 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. Nothing in these pages is intended to supersede operators or manufacturers policies, practices or requirements, or to supersede government regulations.
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PRISM
Safety Management Solutions IS-BAO Support Services Affiliate Certification Consultant
Committed to helping fixed-wing and helicopter professionals around the world create and maintain safe, high-quality, and compliant operations.
PRISM Partner Programs PRISM Services Include: SMS Briefings for Executives Training Classes tailored for Business Aviation, Air Carrier, and Helicopter Operations (Delivered in English or Spanish) SMS Facilitation Services (Develop, Plan, and Implement) IBAC Designated IS-BAO Support Services Affiliate On-site SMS Evaluation and Guidance Manual Review and Development FAA Recognized Certification Consultant Comprehensive Web-based and iPad Compatible Safety and Quality Management Software
prism.sales@prism.aero
+1 513.852.1010
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FOUNDATIONFOCUS
any of you are familiar with the fact that the Flight Safety Foundation has been around for more than 65 years. You also are aware of the work that the Foundation does on a daily basis to pursue its ever-important mission of being the leading voice of aviation safety around the world. You read AeroSafety World, you see us in the media, you do research on our website, use our tool kits, etc. All of these items do not come without a cost to the Foundation. Like so many non-profit organizations, we depend heavily on our membership dues to fund our safety efforts. We value and appreciate each member and the support that each member gives to us. In spite of that, membership dues are not always enough to keep our projects and efforts going, especially during the challenging economic times we are facing today. At a time of constrained resources, increased regulation and unprecedented scrutiny, the aviation industrys survival depends on safe operations. Practices for safe operations are researched, initiated and actively publicized and distributed by the Flight Safety Foundation. However, there is always more to be done. This job is never complete. The Foundation will always
Legacy
LEDERER
be needed in good economic times, but even more so during the downturns. In turn, we will always need support in order to do our work. The Foundation is a 501(c)3 organization, which in the United States simply means that we are recognized as a charitable organization and we are able to receive tax-deductible donations from companies and individuals around the globe. It is not uncommon for charities large and small to hold fund-raising drives and events to help sustain the organization, thereby keeping the core activities going. For this reason, we are kicking off the FSF summer fund-raising drive, highlighting the words and works of the late Jerry Lederer, the founder of the Foundation. Over the next few weeks, you will be seeing interesting facts and quotes from Jerry Lederer, as well as projects and products that the Foundation has had a hand in developing, both past and present. Check out our blog for our new feature Jerry Lederer Says... as our founder talks about safety and the Flight Safety Foundation. You will also see his comments on Facebook, LinkedIn and Twitter. We will be reaching out to members and non-members alike. We will always include a link to the donation page of the FSF website, so that anyone who wants to is able to donate to our cause. The drive will culminate in the FSF Inaugural Benefit dinner at the National Press Club in August in Washington. This dinner will be held to recognize the accomplishments of the Foundations past and honor Jerry Lederer, as well as showcase the current and future endeavors. We also hope to raise momentum to move into the future. The Flight Safety Foundation has recently had to adjust some of its current practices from the way things have been done in the past to the way it does business now. It is essential that we change with the times, so that we can continue to be the impartial, independent voice of aviation safety, as we are known around the world. A fund-raising drive is a new change, and a necessary addition to our business practice at this time. We want to create a new path to keep the Foundations legacy moving forward into the next 65 years and beyond. We hope that we can count on your support. Susan Lausch Senior Director, Membership and Business Development
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Serving Aviation Safety Interests for More Than 65 Years

OFFICERS AND STAFF
Chairman Board of Governors President and CEO General Counsel and Secretary Treasurer
David McMillan Capt. Kevin L. Hiatt Kenneth P. Quinn, Esq. David J. Barger
ADMINISTRATIVE
Manager of Support Services and Executive Assistant
Stephanie Mack
ince 1947, Flight Safety Foundation has helped save lives around the world. The Foundation is an international non-profit organization whose sole purpose is to provide impartial, independent, expert safety guidance and resources for the aviation and aerospace industry. The Foundation is in a unique position to identify global safety issues, set priorities and serve as a catalyst to address the issues through data collection and information sharing, education, advocacy and communications. The Foundations effectiveness in bridging cultural and political differences in the common cause of safety has earned worldwide respect. Today, membership includes more than 1,000 organizations and individuals in 150 countries.
FINANCIAL
Financial Operations Manager
MemberGuide
Flight Safety Foundation 801 N. Fairfax St., Suite 400, Alexandria VA 22314-1774 USA tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org
Jaime Northington
MEMBERSHIP AND BUSINESS DEVELOPMENT
Member enrollment
Senior Director of Membership and Business Development Director of Events and Seminars Seminar and Exhibit Coordinator
Ahlam Wahdan, membership services coordinator Namratha Apparao, seminar and exhibit coordinator Kelcey Mitchell, director of events and seminars
ext. 102 wahdan@flightsafety.org ext. 101 apparao@flightsafety.org ext. 105 mitchell@flightsafety.org ext. 112 lausch@flightsafety.org ext. 105 mitchell@flightsafety.org ext. 101 apparao@flightsafety.org ext. 101 apparao@flightsafety.org ext. 126 mcgee@flightsafety.org marshall@flightsafety.org
Susan M. Lausch Kelcey Mitchell Namratha Apparao Ahlam Wahdan Caren Waddell
Seminar registration
Seminar sponsorships/Exhibitor opportunities Donations/Endowments FSF awards programs
Susan M. Lausch, senior director of membership and development Kelcey Mitchell, director of events and seminars Namratha Apparao, seminar and exhibit coordinator Namratha Apparao, seminar and exhibit coordinator Emily McGee, director of communications
Membership Services Coordinator Consultant, Student Chapters and Projects
Technical product orders Seminar proceedings Website
COMMUNICATIONS
Director of Communications
Emily McGee
Basic Aviation Risk Standard

GLOBAL PROGRAMS
Greg Marshall, BARS managing director BARS Program Office: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia tel +61 1300.557.162 fax +61 1300.557.182
Director of Global Programs Foundation Fellow
Rudy Quevedo James M. Burin
BASIC AVIATION RISK STANDARD
BARS Managing Director
Greg Marshall William R. Voss

facebook.com/flightsafetyfoundation @flightsafety www.linkedin.com/groups?gid=1804478
Past President
Founder Jerome Lederer 19022004
SAFETYCALENDAR
JULY 819 Aircraft Accident Investigation. outhern California Safety Institute. San Pedro, S California, U.S. Denise Davalloo, <denise. davalloo@scsi-inc.com>, <www.scsi-inc.com/AAI. php >, +1 310.940.0027, ext.104. JULY 10 Hazardous Materials Air Shipper Certification Public Workshop. L ion Technology. Dedham, Massachusetts, U.S. (Boston area). Chris Trum, <info@lion.com>, <bit.ly/XNDWUv>, +1 973.383.0800. JULY 1011 Airline Engineering and Maintenance Safety. F lightglobal and Flight Safety Foundation. London. Jill Raine, <events. registration@rbi.co.uk>, <www.flightglobalevents. com/mro2013>, +44 (0) 20 8652 3887. JULY 1519 AAB International Annual Meeting. A ircraft Accreditation Board International. Kansas City, Missouri, U.S. <bayenva@auburn.edu>, <www.aabi.aero>. JULY 1524 SMS Theory and Application. ITRE Aviation Institute. McLean, Virginia, U.S. M Mary Beth Wigger, <maimail@mitre.org>, <mai.mitrecaasd.org/sms_course/>. JULY 1718 59th ALPA Air Safety Forum. ir Line Pilots Association, International. A Washington. Tina Long, <tina.long@alpa.org>, <safetyforum.alpa.org>. JULY 2324 Aviation Human Factors and SMS Wings Seminar. S ignal Charlie. Dallas. Kent Lewis, <lewis.kent@gmail.com>, <www. signalcharlie.net/Seminar+2013>, +1 850.449.4841. JULY 2426 16th Swinburne Aviation Industry Conference. H awthorn, Victoria, Australia. Peter Bruce, <pbruce@swin.edu.au> <swinburne.edu.au/engineering/aviation/events/ conference>, +61 3 9214 8507. JULY 29AUG. 2 Fire and Explosion Investigation. S outhern California Safety Institute. San Pedro, California, U. S. Denise Davalloo, <denise.davalloo@scsi-inc.com>, <www.scsi-inc.com/FEI.php>, +1 310.940.0027, ext.104. JULY 31AUG. 2 Airport Wildlife Hazard Management Workshop. E mbry-Riddle Worldwide. Dallas. <training@erau.edu>. AUG. 1216 Aircraft Performance Investigation. S outhern California Safety Institute. San Pedro, California, U. S. Denise Davalloo, <denise.davalloo@scsi-inc.com>, <www.scsi-inc.com/API.php>, +1 310.940.0027, ext.104. AUG. 1922 ISASI 2013: Preparing the Next Generation of Investigators. I nternational Society of Air Safety Investigators. Vancouver, British Columbia, Canada. Ann Schull, <isasi@ erols.com>, <www.isasi.org>, +1 703.430.9668. AUG. 2930 International Aviation Safety Management Infoshare. Flight Safety Foundation. Singapore. Namratha Apparao, <apparao@flightsafety.org>, <flightsafety.org/ meeting/infoshare2013> +1 703.739.6700, ext. 101. SEPT. 911 NextGen Ahead Air Transportation Modernization Conference. Aviation Week. Washington. <aviationweek.com>. SEPT. 2327 Unmanned Aircraft Systems. Southern California Safety Institute. San Pedro, California, U.S. Denise Davalloo, <denise. davalloo@scsi-inc.com>, <www.scsi-inc.com/ unmanned-aircraft-systems.php>, +1 310.940.0027, ext.104. SEPT. 2426 MRO Europe 2013. A viation Week. London. <aviationweek.com>. SEPT. 2527 ALTA Aviation Law Americas. Latin American and Caribbean Air Transport Association. Miami. <www.alta.aero/ aviationlaw/2013/home.php>, +1 786.388.0222. SEPT. 29OCT. 1 SMS/QA Symposium. D TI Training Consortium. Disney World, Florida, U.S. <symposium@dtiatlanta.com>, <www.dtiatlanta. com/Symposium2013.html>, +1 866.870.5490. OCT. 10 ACAS Monitoring Dissemination Workshop ( SESAR Project 15.04.03). Eurocontrol. Langen (Hessen), Germany. Stanislaw Drozdowski <stanislaw.drozdowski@eurocontrol.int> <bit.ly/10ok2HE>. OCT. 1416 SAFE Association Annual Symposium. S AFE Association. Reno, Nevada, U.S. Jeani Benton, <safe@peak.org>, <www. safeassociation.com>, +1 541.895.3012. OCT. 1516 Icing Conditions: On-Ground and In-Flight. European Aviation Safety Agency. Cologne, Germany. Carmen Andres <asc@easa. europe.eu> <webshop.easa.europa.eu/icing>, +49 221.89990.2205. OCT. 1517 Safeskies Australia 2013. anberra, Australian Capital Territory. Doug C Nancarrow, <office@safeskiesaustralia.org> <www.safeskiesaustralia.org>, +61 (0) 2 9213 8267. OCT. 2224 SMS II. MITRE Aviation Institute. M cLean, Virginia, U.S. Mary Beth Wigger, <maimail@mitre.org>, <bit.ly/YJofEA>, +1 703.983.5617. OCT. 2224 2013 NBAA Business Aviation Convention & Exhibition. N ational Business Aviation Association. Las Vegas. <www.nbaa.org/events>. OCT. 2931 66th International Air Safety Summit. F light Safety Foundation. Washington, D.C. Namratha Apparao, <apparao@flightsafety. org>, <flightsafety.org/aviation-safety-seminars/ international-air-safety-seminar>, +1 703.739.6700, ext. 101. NOV. 38 CANSO Global ATM Safety Conference. C ivil Air Navigation Services Organisation. Amman, Jordan. Anouk Achterhuis, <events@canso.org> <www.canso. orgsafetyconference2013>, +31 (0) 23 568 5390. NOV. 1315 10th ALTA Airline Leaders Forum. L atin American and Caribbean Air Transport Association. Cancn, Mexico. <conferencesandmeetings@alta.aero>, <www.alta.aero>. DEC. 2122 European Business Aviation Safety Conference. Aviation Screening. Munich, Germany. Christian Beckert, <info@ebascon.eu>, <www.ebascon.eu>, +49 7158 913 44 20. APRIL 13, 2014 World Aviation Training Conference and Tradeshow (WATS 2014). Halldale Group. Orlando, Florida, U.S. Zenia Bharucha, <zenia@halldale.com> <halldale.com/ wats#.Ub4RyhYTZCY>, +1 407.322.5605. APRIL 1617, 2014 59th annual Business Aviation Safety Summit (BASS 2014). F light Safety Foundation and National Business Aviation Association. San Diego. Namratha Apparao, <apparao@flightsafety.org>, <flightsafety.org/ bass>, +1 703.739.6700, ext. 101.
Aviation safety event coming up? Tell industry leaders about it.
If you have a safety-related conference, seminar or meeting, well list it. Get the information to us early. Send listings to Frank Jackman at Flight Safety Foundation, 801 N. Fairfax St., Suite 400, Alexandria, VA 223141774 USA, or <jackman@flightsafety.org>. Be sure to include a phone number and/ or an email address for readers to contact you about the event.
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INBRIEF
Safety News
METs defined by the NTSB as temporary structures that measure wind speed and direction during development of wind energy conversion facilities often are erected quickly and without notice to the aviation community. They typically are just under 200 ft above ground level (AGL), which is the threshold at which FAA notification is required, and they are unmarked and unlighted. Pilots have reported difficulty seeing METs from the air which has led to accidents, the NTSB said. Without measures to enhance their conspicuity, such as marking and lighting these structures and maintaining a record of their locations, METs pose a continuing threat to low-altitude aviation operations such as those involving helicopter emergency medical services, law enforcement, animal damage control, fish and wildlife surveys, agricultural applications and aerial fire suppression. The FAA approved recommended guidelines in June 2011 for a uniform and consistent scheme for voluntarily marking METs of less than 200 ft AGL; the guidelines did not discuss voluntary lighting, and the FAA said recommending lighting for the METs would not be practical because many are in remote locations without power sources. Ten states have acted to require at least some METs to be marked and/or registered, and the NTSB issued recommendations for states, territories and the District of Columbia to pass similar legislation. Other recommendations called on the American Wind Energy Association to revise the Wind Energy Siting Handbook to indicate the hazards that METs present to aviation operations and encourage voluntarily marking them [in accordance with FAA Advisory Circular 70/7460-1, Obstruction Marking and Lighting] to increase their visibility.
Weather-Tower Markings
he U.S. National Transportation Safety Board (NTSB), citing three fatal accidents involving small airplanes that collided with meteorological evaluation towers (METs), is recommending that all such towers be registered, marked and, if possible, lighted. The NTSB issued two safety recommendations to the U.S. Federal Aviation Administration (FAA), calling on the agency to require tower registration and marking and to establish a database for the required registrations.
U.S. National Transportation Safety Board
New Round for IOSA
n International Air Transport Association (IATA) conference has endorsed development of an enhanced version of the IATA Operational Safety Audit (IOSA). Enhanced IOSA is expected to be implemented by September 2015. IATA said that the current IOSA program has laid a solid foundation for improved operational safety and security, eliminating redundant industry audits. However, audit protocols have changed very little since IOSAs establishment in 2003, and modifications are needed to enhance operational safety and security practices, IATA said. The association said Enhanced IOSA will include measures to ensure continuous conformity with IOSA standards and recommended practices through quality control processes and self-auditing in between IOSAs two-year audit cycle. IATAs Ops Conference endorsed Enhanced IOSA at a May meeting in Montreal. During the same meeting, IATA said it was joining with other organizations, including the Association of European Airlines, Eurocontrol, the Civil Air Navigation Services Organisation and the International Federation of Air Traffic Controllers Associations, to develop an action plan for the Single European Sky (SES). The action plan includes plans to reduce infrastructure duplication within the SES area by centralizing services and streamlining computer technology.
Oleg_ivano.../Dreamstime
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INBRIEF
Pushing for SES
he European Commission (EC) has moved to update regulations that it says will accelerate changes in the regions air traffic control system as it implements the Single European Sky (SES) and avert the capacity crunch that is expected to accompany a 50 percent increase in air traffic over the next 10 to 20 years. The European Transport Workers Federation (EFT) is protesting the move, which it says is placing unacceptable pressure on air traffic management (ATM) employees. The ECs plan calls for organisational and budgetary separation of national supervisory authorities from the air traffic control organisations [that] they oversee while at the same time ensuring sufficient resources are given to the national supervisory authorities to do their tasks. Some supervisory authorities have not had adequate funding to perform their jobs, the EC said, adding that plans call for airlines to have a new role in signing off air traffic control organisations investment plans to ensure they are better focused on meeting customer needs. Another proposal would allow for more flexible operation of the functional airspace blocks (FABs) the regional units designed to replace the current patchwork of 27 national air traffic control units so that the FABs could create industrial partnerships and increase performance. At the same time, Eurocontrols role would be strengthened to allow it to operate centralized services more efficiently, the EC said. Other EC proposals call for strengthening the role of the EC in setting performance targets for European ATM in safety, cost efficiency, capacity and environment. The performance review body will operate with increased independence and have the authority to issue sanctions when targets are not met.
Tomgriger/Dreamstime.com
In addition, the EC proposed that support services including meteorology, aeronautical information, communications, navigation and surveillance be provided by private companies. European Union Transport Commissioner Siim Kallas said the proposals would strengthen the nuts and bolts of the system so it can withstand more pressure and deliver ambitious reforms. The EFT, however, objected that the plans are part of a never-ending process of liberalisation, deregulation and cost cutting in the ATM industry. The organization said that, although it originally supported the SES concept, it opposes mounting pressure on workers and will oppose new plans that do not address the social aspects of SES.
Runway Incursion Audit
U.S. government watchdog agency has begun an audit of the Federal Aviation Administrations (FAAs) efforts to prevent runway incursions. The Department of Transportations Office of Inspector General (OIG) said the audit is needed because of an increase in the number of serious runway incursions from six in fiscal year 2010 to 18 in fiscal 2012 and a 21 percent increase in total runway incursions from 954 in fiscal 2011 to 1,150 in fiscal 2012. The FAA has reorganized its Runway Safety Office and changed its methods of reporting runway incursions since the last program review in 2010. The OIG said the objectives of the audit, which was begun in late May, are to evaluate FAAs progress in implementing initiatives to prevent runway incursions and effectiveness in reporting and evaluating runway incursions.
InSapphoWeTrust/Wikimedia Commons CC-SA-BY-2.0
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INBRIEF
Complications for NextGen

ncertain funding and the possibility of future furloughs of U.S. Federal Aviation Administration (FAA) employees are complicating the agencys efforts to develop the Next Generation Air Transportation System (NextGen), FAA Administrator Michael Huerta says. In remarks to a meeting of RTCA (formerly known as the Radio Technical Commission for Aeronautics), Huerta said employee furloughs and cuts in the FAAs budget may be necessary in the fiscal year beginning Oct. 1, unless the U.S. Congress approves a long-term plan for federal spending. In May, the Department of Transportation determined that funds were sufficient to allow the FAA to transfer money into accounts to end furloughs of air traffic controllers and other FAA employees and to prevent the planned closures of 149 FAA air traffic control towers for the rest of the current fiscal year, which ends Aug. 31. The law that requires across-the-board spending cuts at all government agencies makes continuity of NextGen programs more challenging, Huerta said. The NextGen budget has increased from $130 million in 2007 to $1 billion for the current fiscal year, an expansion that represents the increasing urgency to modernize our system, Huerta said.
Trevor MacInnis/Wikimedia Commons
TSB Urges Lightweight Recorders
he Transportation Safety Board of Canada (TSB), citing the 2011 crash of a de Havilland Canada DHC-3 Otter in the Yukon, says the countrys small aircraft operators should install lightweight recorders in their aircraft to monitor flight data. For decades, recorded flight data has been instrumental in advancing safety for our larger operators, said TSB Chair Wendy Tadros. We think flight data monitoring should be an important tool for Canadas smaller carriers, too a tool to help them manage safety in their operations. She noted that 91 percent of commercial aircraft accidents in Canada and 93 percent of commercial aviation fatalities in the past 10 years have involved operators of small aircraft, and said, We need to look at new ways of bringing these numbers down. Recorded information will help accident investigators determine the causes of accidents and develop ways of preventing similar accidents in the future, Tadros said. The TSB was unable to determine the cause of the March 31, 2011, crash of the DHC-3, which broke up in flight and crashed, killing the pilot, the sole occupant.
U.S. Federal Aviation Administration
In Other News
Regular public transport operators in Australia and the organizations that maintain their aircraft face a June 27 deadline for completing the transition to key elements of new maintenance regulations. Work is continuing to update maintenance regulations for charter operations, aerial work and private operations. European leaders have reached agreement on plans to unite the continents airports and other transportation infrastructure into a unified network. The plans call for establishment of a core transport network by 2030.
Compiled and edited by Linda Werfelman.
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COVERSTORY
urprise and hesitation prevailed during the final seconds of an Afriqiyah Airways Airbus A330-202s approach to Tripoli, Libya, the morning of May 12, 2010. The Libyan Civil Aviation Authority (CAA) has determined that the aircraft was well below the minimum descent altitude for the nonprecision approach when the copilot, the pilot flying (PF), asked the captain if he should initiate a go-around.
Although neither pilot had the required visual references to proceed with the approach, seconds passed as the aircraft continued to descend. Finally, an aural warning generated by the terrain awareness and warning system (TAWS) prompted the captain to command a go-around. The copilot applied full power and initiated a climb. According to the CAAs final report, the sensory effects of the A330s acceleration likely
Inadequate crew coordination, an unstabilized approach and spatial disorientation during a delayed go-around led to an A330 crash off Tripoli.
H ES I TAT I O N
BY MARK LACAGNINA
Fatal
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COVERSTORY
Airways as an A320 captain in 2007. He earned an A330 type rating in May 2009. The copilot, 42, had 4,216 flight hours. He held type ratings in the de Havilland Twin Otter, A320 and A330. The report provided no details about his previous flight experience. The relief pilot, 37, had 1,866 flight hours and held type ratings in the A320, A330 and 727. The crew departed from Johannesburg at 2145 local time, with the copilot at the controls. In general, it is common practice within Afriqiyah Airways to designate the copilot as PF when weather conditions do not result in difficulty in handling the aircraft, the report said.
Louafi Larb|Reuters
Locator Approach
caused the copilot to falsely perceive that the aircraft had entered an excessive nose-up pitch attitude. He moved his sidestick forward, and the climb reversed into a steep descent. The captain assumed control, but he, too, likely had become spatially disoriented. Instead of pulling out of the dive, he moved his sidestick full forward. Too late, the pilots caught sight of the ground. The A330 struck terrain close to the runway threshold. The impact and post-impact fire caused complete destruction to the aircraft, the report said. Only one of the 104 people aboard the aircraft survived. The cruise portion of the flight was conducted at Flight Level (FL) 400 (approximately 40,000 ft). The flight took place without any notable events until the approach, the report said. At about 0530, air traffic control cleared the crew to descend to FL 90. The controller said that the weather conditions at Tripoli included calm winds, 6 km (4 mi) visibility, a clear sky and a temperature/dew point of 19/17 degrees C (66/63 degrees F). The airport had one precision approach, an instrument landing system (ILS) for Runway 27, but it was out of service. The VOR/DME (VHF omnidirectional range/distance-measuring equipment) facility at the airport also was out of service, and only locator approaches were available. The locator approach to Runway 09 was in use. The report said that the crew conducted a short approach briefing that included some details about the locator approach and how it would be flown. However, essential points, such as the intended use of the autoflight systems during the nonprecision approach, were not discussed. The fact that the approach briefing was incomplete indicates that the crew did not anticipate any special difficulty in the conduct and management of the approach, the report said. The locator approach was based on three compass locators (nondirectional radio beacons) lined up on the extended centerline of Runway 09. The first, identified as TW, was
Familiar Trip
The accident occurred during a scheduled 8.5hour flight from Johannesburg, South Africa, with 93 passengers, eight cabin crewmembers and an augmented flight crew of three pilots. Tripoli is the home base for Afriqiyah Airways, which at the time operated three A330s and six A320 series aircraft. The accident aircraft was manufactured in 2009. The report said that all three pilots had 516 flight hours in type. They had flown together often and were familiar with the Tripoli airport. The captain, 57, had a total of 17,016 flight hours. He had flown A320, Boeing 727 and Fokker 28 series aircraft for Libyan Arab Airlines and Nouvel Air before being hired by Afriqiyah
Aurlien Tranchet|Airliners.net
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COVERSTORY
3.9 nm (7.2 km) from the runway threshold and served as an initial approach fix as well as the final approach fix. The other two beacons, located near the approach and departure thresholds, respectively, marked the missed approach point and the turning point for the missed approach procedure. Generally, in the Tripoli Terminal Control Area, arrivals are carried out under radar vectoring until intercepting the extended centreline of the final approach segment, the report said. Investigators were unable to determine whether the crew conducted the approach checklist. The approach checklist seemed to be performed, but without any formal callouts, the report said. The only item called out by the crew was the altimeter setting.
HL(R)53
Plan and profile views of the Runway 09 Locator instrument approach procedure show the alignment of three compass locators and the altitude to cross the final approach fix inbound.
A330 began an early descent about 1.1 nm (2.0 km) before reaching the final approach fix. Investigators determined that the copilot might have inadvertently entered the distance from the TW locator to the VOR/DME (5.2 nm), rather than the distance from the locator to the runway (3.9 nm), when he programmed the point at which the flight management system would begin a descent on a three-degree glide path for the final approach. The aircraft was descending through 1,200 ft when the captain established radio communication with the Tripoli airport traffic controller. The controller asked if the runway was in sight, and the captain replied, Established inbound, sir. The controller then told the captain to report the field in sight.
Unexpected Fog
MSA 2,000 25 NM
from TW
MSA 2,000 25 NM
from TW
GHARARAH 301 TW T
E013 03.1 N 32 W 39.7
TRIPOLI VOR/DME 114.5 T TPI P I

N 32 39.7 E013 09.3
TRIPOLI 365 G G
N 32 38.8 E013 10.7
090
090
MHA 2,000
090
270 MSA 4,000 25 NM
from TW
270
270
MSA 4,000 25 NM
from TW
TRIPOLI 435 D d
N 32 39.8 E013 07.1
1 MIN
2,000 ft
090
270
L TW 2,000 ft
L D
1,350 ft
MISSED APPROACH: Climb straight ahead after passing L G turn RIGHT and proceed to TW L climbing to 2,000 and hold.
090
M
Elevation 262 ft Runway 09 0 NM
3.9 10 9 8 7 6 5 4 3
3.3 2 1
0.6
Early Descent
The crew established the A330 at 1,400 ft on the final approach course, 090 degrees, about 10 nm (19 km) from the runway. The approach chart the crew was using indicates that the aircraft should have crossed the final approach fix, the TW locator, at 1,350 ft before descending to the minimum descent altitude (MDA) of 620 ft. However, recorded flight data showed that the
14 |
Shortly thereafter, the pilots heard a radio transmission by the crew of a preceding aircraft advising that they had encountered patches of fog on short final before landing. This likely surprised the A330 crew and led the captain to focus his attention on the outside to acquire visual reference points, rather than on coordinating with the copilot and monitoring the flight parameters, the report said. Overall, the management of tasks during the approach deteriorated very quickly. Although the relief pilot was in the jump seat during the approach, there was no evidence that he said anything or interacted with the other pilots in any way. The aircraft was configured for landing when the copilot called for the landing checklist. However, this could not be applied at this moment in time due to exchanges between the PNF [pilot not flying] and the tower controller, the report said. The aircraft crossed the TW locator at 1,020 ft 330 ft below the published crossing altitude at 0600:01. Neither pilot apparently recognized the discrepancy. The captain was engaged in obtaining a landing clearance. He asked the controller, Confirm clear to land if we have the runway in sight? The
Susan Reed, adapted from International Civil Aviation Organization
COVERSTORY
controller replied, Affirmative. Clear to land. Wind calm.
Somatogravic Illusion
Continue
A few seconds later, the cockpit voice recorder captured an automated callout of hundred above, indicating that the aircraft was 100 ft above the MDA. The copilot asked in Arabic, Acceleration You see? The captain replied, Balance sensors As the airplane accelerates, Without visual cues or in inner ear (otoliths) inertia causes sensors in the feedback from instruments, Continue. inner ear to move as if the pilots may overcompensate Perceived position of airplane Company standard operatbody were tilted. This gives for these perceived Actual position of airplane a false sensation of climb. changes in attitude. ing procedures (SOPs) define the continue callout as indicatGo around, the captain said. Go around. ing that the PNF has acquired Go around. The copilot disengaged the autopithe visual references required to complete the lot, applied takeoff/go-around power, pulled his approach and landing. However, it is almost sidestick back and asked the captain to retract the certain that the weather conditions (as indicated flaps and landing gear. by the previous crew), the lighting conditions The captain, as PNF, did not make the apand the actual position of the aircraft in relation propriate callouts, the report said. It is likely to the runway threshold did not enable acquithat the captain did not expect to have to abort sition of the external visual references required the final approach and the TOO LOW TERto continue the approach below the MDA, the RAIN warning [had] destabilized him, the report said. The captain probably hoped to report said. obtain visual references in the next few seconds. Moreover, because the crew of the precedSomatogravic Illusion ing aircraft had been able to land despite the developing fog, the A330 crew might have been Four seconds after disengaging the autopilot confident that they also would be able to land, and initiating a climb, the copilot began to apply It is likely that the report said. nose-down pitch inputs on his sidestick. The the captain did Shortly after the copilot acknowledged the aircraft, which had climbed to 670 ft, entered a captains instruction to continue the approach, steep descent. not expect to have an automated callout advised that the aircraft The report said that the copilot likely had had reached the minimum, the MDA at 620 suffered spatial disorientation typical of a to abort the final ft, or 358 ft above ground level (AGL). somatogravic [perceptual] illusion occurring Neither pilot said anything for several in the absence of outside visual references. approach and the seconds. The copilot likely looked up from the This would have resulted from the aircrafts TOO LOW TERRAIN instruments and, not seeing the runway, asked, sudden acceleration affecting the balance Ill go around, captain? There was no immediorgans of his inner ear, creating a sensation warning [had] ate reply. The report noted that the copilot did of being tilted backward and the false percepnot initiate a go-around on his own volition, as tion that the pitch attitude was excessive destabilized him. required by SOPs. (although it wasnt). The aircraft was descending through 490 His reactions likely responded to the ilft 228 ft AGL when the TAWS generated lusion, rather than to the flight instruments. the TOO LOW TERRAIN warning. At no time was the go-around pitch attitude
Susan Reed, adapted from U.S. Navy, Chief of Naval Air Training, and <humanneurophysiology.com>
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COVERSTORY
to the cockpit at 0410, almost two hours before the accident occurred. The report said that the copilot and the relief pilot likely took their rest periods before the captain. However, the pilots had flown two consecutive night flights. This would impose a certain amount of fatigue which might [have] degraded the performance of the flight crew and increased the effect of somatogravic illusions, the report said. The pilots performance was likely impaired [by] fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.
Airbus A330-200
he two-engine A330 and the four-engine A340 were developed simultaneously by Airbus and share many systems and structural features. The base-model A330-300 entered service in January 1994, a few months after the A340. The A330-200 is an extended-range version of the -300 that was introduced in 1998 with a shorter fuselage and higher fuel capacity. Both models have General Electric CF6-80, Pratt & Whitney PW 4000 or Rolls-Royce Trent 700 series turbofan engines rated at about 70,000 lb (31,752 kg) thrust. The A330-200 accommodates 253 passengers in a twin-aisle cabin and has maximum weights of 230,000 kg (507,063 lb) for takeoff and 180,000 kg (396,832 lb) for landing. Typical operating speed is 0.82 Mach, and maximum range with reserves is 6,650 nm (12,316 km). In 2012, maximum takeoff weight was increased to 240,000 kg (529,109 lb) to accommodate extra fuel capacity and increase range to 7,050 nm (13,057 km). Currently, 484 A330-200s are in operation worldwide.
Sources: Airbus, Janes All the Worlds Aircraft
controlled, nor did the copilot follow the instructions from the flight director, the report said. Neither crewmember seemed to be aware of the flight path of the aircraft. As the A330 descended, the TAWS generated successive warnings of DONT SINK, TOO LOW TERRAIN and PULL UP. Nevertheless, seconds before impact, the captain pressed the priority pushbutton on his sidestick and applied a sharp nosedown input, the report said. The pitch attitude was 3.5 degrees nose-down as the aircraft descended through 500 ft. By this time, the copilot apparently had become aware of the aircrafts flight path and had pulled his sidestick all the way back, intending to recover from the dive but not recognizing that the captain had sidestick priority. The captain had not announced that he was assuming flight control. Shortly before impact, the captain apparently became aware of the aircrafts proximity to the ground
16 |
and reversed his sidestick input. The descent rate was 4,400 fpm when the A330 clipped trees and a high-tension power line, and struck the ground in a nearly level attitude at 0601:14. The impact occurred 1,200 m (3,937 ft) from the runway and slightly to the right of the extended centerline. Postmortem examination of the victims indicated that all fatalities resulted from severe trauma, the report said. Media accounts said that the survivor was a 9-year-old Dutch boy. He suffered serious injuries and was hospitalized in Tripoli for 48 hours before being transferred to a hospital in the Netherlands.
Lessons Not Learned

The report noted that a similar event had occurred 14 days before the accident: The captain and the copilot had conducted the same locator approach in the same aircraft on April 28. The approach was similar in having been unstabilized and marked by a premature descent. However, it terminated with a missed approach initiated slightly above the MDA and was followed by an uneventful go-around and landing on Runway 27. The crew did not report the go-around, as required, to Afriqiyah Airways. The investigation committee confirmed that analysis of the April 28 flight was not performed and the crew had not reviewed and fully understood what had happened during the April 28 flight, the report said.
This article is based on the Libyan Civil Aviation Authoritys Final Report of Afriqiyah Airways Aircraft Airbus A330-202, 5A-ONG, Crash Occurred at Tripoli (Libya) on 12/05/2010, February 2013. The report is available at <caa.ly>.
Fatigue Factor
Investigators determined that fatigue might have been a factor in the accident, though the evidence was not conclusive. All three pilots had received more than 15 hours of rest before reporting for duty at Johannesburg. Moreover, the captain had taken a rest period during cruise flight, returning
MAINTENANCEMATTERS
Untiring Efforts
BY MARIO PIEROBON
Fatigue among maintenance technicians can be mitigated by fatigue reporting, bio-mathematical models and shift-change management.
I
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n April 2010, after a base maintenance check at Exeter, England, a Bombardier DHC-8102 was flown uneventfully to East Midlands Airport to be repainted. During the return ferry flight to Exeter, the right engine developed a significant oil leak and lost oil pressure, so the flight crew shut the engine down. Subsequently, the crew noticed the left engine also leaking oil, with a fluctuating oil pressure, so they diverted to Bristol, where they landed safely. The oil leaks were traced to damaged Oring seals within the oil cooler fittings on both engines. Both oil coolers had been removed and refitted during the maintenance at Exeter. It was
probably during re-installation that the O-ring seals were damaged.1 During the investigation carried out by the U.K. Air Accidents Investigation Branch (AAIB), it was found that over the 17-week period leading up to the end of a C-check, one of the maintenance technicians working on the aircraft had worked an average of 57 hours per week, which was nine hours per week more than allowed by the European Working Time Directive (WTD). The investigation also found that during the 10 days prior to the aircrafts arrival at Exeter, the same technician had averaged 15.7 work hours per day, resulting in the 11-hour
whanwhana/iStockphoto
MAINTENANCEMATTERS
post-shift rest entitlement in the WTD being significantly curtailed. The technician reported that he did not consider himself fatigued during this period. However, he also said that during the leak checks on the incident aircraft he felt tired and had a lot on his mind, trying to get the aircraft ready for its scheduled painting slot, although it was not an unusual level of tiredness.2 The AAIB said that a technician tasked to work a 10-day period, with just one day off in the middle, averaging 15.7 hours per day, is a safety concern, particularly if not monitored by the approved maintenance organization (AMO). The AAIB also noted that the AMO involved in this occurrence had no policy on the maximum hours for a technician to work in any 24-hour period and relied on every technician and manager, after undergoing human factors/ performance training, to communicate to their supervisors the risk of fatigue. The AAIB said that individuals who have undergone this training probably will be very responsible and will request time off when they feel that they need it. However, for some individuals this may not be the case, particularly when they have a strong desire to complete the job they have started and when there is a financial incentive to work longer hours, the report said.3 According to the AAIB, there is also evidence from fatigue research that people are not very good at detecting their degradation in performance as they become fatigued. Therefore, the responsibility for managing fatigue should belong to the AMO and not just the individual. The AAIB, however, notes that in Europe Part 145 (Annex II to Commission Regulation [EC] No 2042/2003) states that the AMO needs to take human performance limitations into account when planning maintenance tasks and, although not specifically stated, this should include maintenance technician fatigue. However, the acceptable means of compliance (AMC) and guidance material (GM) to Part 145 currently do not explain how this should be accomplished.4 In response to a safety recommendation issued by the AAIB following this serious incident, EASA in early 2013 published a Notice of
Proposed Amendment (NPA) to EU Regulation 2042/2003 on continuing airworthiness to add AMC and GM in Part 145 on how approved maintenance organizations should manage and monitor the risk of maintenance technician fatigue as part of their requirement to take human performance limitations into account.
Working Time Directive

Unlike aircraft crewmembers whose duty time is regulated by ad hoc and specific regulation, aircraft maintenance engineers duty time is standardized and regulated by the generic and rather vague Council Directive 2003/88/EC (the WTD), which leaves the door open to many interpretations and exceptions, says Marco Giovannoli, an aircraft systems engineer at Etihad Airways and a fatigue and safety specialist. The directive contains many opportunities for derogation, or exception, which maintenance organizations can use to circumvent the limits. The directive states that derogations may be made from the rest periods in the case of activities involving the need for continuity of service or production, particularly in industries where work cannot be interrupted on technical grounds. Also, derogations may be made by collective workforce agreements. Even without the derogations, the WTD has been interpreted by some to mean that the minimum daily rest period of 11 hours means providing 11 hours of rest after a working period that could be up to 24 hours. Therefore, maintenance organizations need to have clear fatigue management plans that monitor their staff working hours and working patterns to reduce the risk of fatigue-related maintenance errors. The published NPA (2013-01) is actually attempting to standardize across Europe the interpretation of the working time directives for aircraft maintenance operations. With NPA 2013-01, EASA is filling a regulatory gap compared with other aviation regulatory environments such as Canada and the United States. According to the AAIB, Transport Canada has published two NPAs (2004-047 and 2004049) which propose requirements for an AMO to
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MAINTENANCEMATTERS
manage fatigue-related risks through a safety management system (SMS). To support these proposed regulations, Transport Canada has published guidelines for a fatigue risk management system (FRMS) that provides a method for quantifying fatigue risk on a numerical scale using knowledge of working hours and rest periods. The AAIB also found that the U.S. Federal Aviation Administration (FAA) has set up a maintenance fatigue working group to review the need for regulatory limits on working hours for maintenance technicians.5 organizations can draw from already produced research in relation to flight crews fatigue, including the FRMS Implementation Guide for Operators jointly released by the International Air Transport Association, the International Civil Aviation Organization and the International Federation of Air Line Pilots Associations in 2011. However, there are inherent differences between aircraft maintenance technicians work, working environment and associated fatigue issues and those of flight crews. It becomes necessary for a maintenance organization planning an FRMS to properly consider the maintenance-specific fatigue issues. fatigue issues. In this situation, the NPA is going to play an important role, as it requires a rule-enforcing effort from European NAAs for fatigue management. More important, however, is going to be the actual cultural transformation within maintenance organizations themselves. Aircraft maintenance engineers should be encouraged to report to supervisors their degraded performance caused by fatigue, and they should not face veiled threats of repercussions from their managers, says Giovannoli. Nowadays if a pilot reports fatigue, [the reporting] is considered professional, conversely an engineer calling in fatigued may be demonized. For fatigue to be consistently reported, technicians need a better understanding of their fatigue performance limitations. There is a strong subjective component concerning fatigue, and therefore it is important to clearly illustrate the various indicators and symptoms of fatigue and the possible methods of offsetting it, such as caffeine, which normally is the common counteracting method used by aircraft maintenance engineers, says Giovannoli. Technicians should be advised about correct sleep practices and good health. Recommended levels of physical activity should be regularly practiced and a balanced way of life should be followed. Moreover, managers and supervisors should be properly trained to perceive fatigue symptoms and be empowered to take corrective actions, even if these could be perceived as detrimental to organizational productivity, he said.
Fatigue Risk Management

EASAs new requirements for fatigue risk management are part of a larger rulemaking effort related to SMS in maintenance and continuing airworthiness management organizations. Approved maintenance organizations are going to be required by EASA to implement an FRMS. An FRMS needs to be carefully planned. To some extent, maintenance Vigilance Decrement Over Time
90 80 Vigilance e ectiveness % 70 60 50 40 30 20 10 0 10 20 30 40 60 70
Reporting Fatigue
Fatigue should be a joint concern of technicians, organizations and national aviation authorities (NAAs). Without proper and effective oversight by aviation authorities, maintenance organizations may not have a strong enough incentive to monitor and mitigate
90
100 110
120
130 140
Time (min)
Source: Australian Transport Safety Bureau
Vigilance Issues
Vigilance decrement is a form of short-term fatigue to which aircraft maintenance technicians are highly susceptible, especially during inspection
Figure 1
20 |
MAINTENANCEMATTERS
tasks. This form of fatigue should be particularly monitored by AMOs. Alan Hobbs, in a report issued by the Australian Transport Safety Bureau, discussed vigilance issues. During the Second World War it was found that after about 20 minutes at their posts, radar operators became much less likely to detect obvious targets, he said. This problem applies to many monitoring tasks where the search targets are relatively rare. Aircraft inspection, the checking of medical X-rays and quality control inspection in factories are areas where vigilance decrements may occur6 (Figure 1, p. 20). Vigilance decrement applies particularly to detection tasks where the person is required to passively monitor a situation that is boring and monotonous, such as inspecting large numbers of turbine blades. The limiting factor is the ability to keep attention on the task. For example, during the visual inspection of an aircraft, a maintenance worker may look directly at a defect, yet if their attention is occupied with other demands, the defect may not be recognised. In general, inspection tasks that involve variety and regular breaks are less likely to suffer from vigilance decrement.7 Giovannoli, however, recognizes such models intrinsic limitations, as they do not consider the workers individual variables and the conditions around him, such as task difficulties, working conditions and perception of fatigue, which may drastically increase the individuals actual level of fatigue. It is recommended to integrate a bio-mathematical model in a widerranging FRMS, he said. However, available models should be carefully considered and validated before implementation. One example of guidance for the selection of bio-mathematical models suitable for fatigue risk management in aviation maintenance has been provided by the Australian Civil Aviation Safety Authority (CASA). In its publication, Bio-Mathematical Fatigue Modelling in Civil Aviation Fatigue Risk Management, CASA identifies opportunities for integrating models into a holistic FRMS while developing management systems and a corporate culture that understand the uses and limitations of qualitative/ quantitative model predictions, use their outputs with caution and in the context of other operational opportunities and constraints, and adopt complementary multi-layered strategies to proactively identify and manage fatigue risk.9 CASA also discusses key factors to consider when selecting and applying a bio-mathematical fatigue model. These include the type of data to be used as inputs, the physiological factors described by the model components, types of output predictions and their relevance to task risks or other outcome variables, data used for validation and their level of equivalence to the operational environment and subject population, and the interpretation of predictions for use in decision making. CASA states that all these factors must be considered, relative to the specific operational environment for their intended use.10 In the application guidance material, CASA provides an overview of six bio-mathematical models from commercial and academic organizations together with their related products and services. CASA also provides a feature comparison table and a discussion of features in the context of commercial aviation applications. A software model that has been developed explicitly for flight crew fatigue monitoring should not be selected, as it may not allow for proper collection and elaboration of relevant information in a maintenance environment.
Shift Work and Maintenance Errors

According to a study by Dawson and Reid, Recent research has shown that moderate sleep deprivation of the kind experienced by shift workers can produce effects very similar to those produced by alcohol. After 18 hours of being awake, mental and physical performance on many tasks is affected as though the person had a blood alcohol concentration of 0.05 percent. Boring tasks that require a person to detect a rare problem, like some inspection jobs, are most susceptible to fatigue effects.11 Studies have shown, Hobbs said, that 24-hour circadian rhythms influence human error, with many aspects of human performance at particularly low levels in the early morning. Memory and reaction time are at their worst at around 0400, and the chance of error is increased. There appears to be an increased risk of maintenance errors on night shifts.12 Hobbs said, It has been found that when maintenance technicians
Bio-Mathematical Fatigue Models

Several software models are available from vendors as practical tools for estimating work-related fatigue associated with shift workers duty schedules. Some of the models can be used with any duty schedule, in which hours of work (i.e., start/end times of work periods) are the sole input. The main advantage of bio-mathematical fatigue models is that they allow the generation of qualitative and quantitative forecasts of human fatigue based on a set of equations.8
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MAINTENANCEMATTERS
are experiencing sleepiness, they are at increased likelihood of errors involving failures to carry out intentions, such as memory lapses and perceptual errors.12 Sleepiness, however, seems to be less likely to lead to mistakes of thinking such as procedural misunderstandings.13 constantly changing, Giovannoli said. Direction and speed of rotation can affect the adaptation to rotating shifts. Direction of rotation means the order of changes to shifts. Two common types of rotation are forward, when rotation is day to evening to night; and backward, when rotation is day to night to evening. Speed of rotation means the number of consecutive working days before a shift change. The current fatigue science literature reports that a rapid (two to five days) forward-rotating shift system reduces mental and physical performance degradation and enables faster recovery of both sleep and social activities. In contrast, the fast backward-rotating shift system is linked with reduced physical and psychological health and higher fatigue.16 Night shift should not last more than 10 hours including overtime and two consecutive night shift blocks in a row should not be allowed; with not more than eight night shifts in every month, says Giovannoli. Furthermore, night shift should not be extended beyond 0800 and after a night shift block, two days off should be granted, to provide enough rest time before the next shift, which in the forward rotation is a morning shift. The ideal of a totally non-fatigued technician may not be achievable in the actual workplace, yet avoiding adverse outcomes of fatigue on safety and productivity should be the objective while implementing an FRMS. Empowering fatigue reporting, using bio-mathematical fatigue models and properly managing work shifts are valuable strategies for targeted fatigue risk management in maintenance organizations.
Mario Pierobon works in business development and project support at Great Circle Services in Lucerne, Switzerland.
Notes
1. U.K. Air Accidents Investigation Branch (AAIB), AAIB Bulletin 6/2011. 2. AAIB. 3. AAIB. 4. AAIB. 5. AAIB. 6. Hobbs, Alan. An Overview of Human Factors in Aviation Maintenance. Australian Transport Safety Bureau, AR 2008 055. December 2008. 7. Hobbs. 8. Australian Civil Aviation Safety Authority (CASA). Bio-Mathematical Fatigue Modelling in Civil Aviation Fatigue Risk Management Application Guidance. 2010. 9. CASA. 10. CASA. 11. Dawson, D.; Reid, K. (1997). Equating the performance impairment associated with sustained wakefulness and alcohol intoxication. Journal of the Centre for Sleep Research, 2, 1-8. Cited in Hobbs (2008). 12. Hobbs, Alan. An Overview of Human Factors in Aviation Maintenance. ATSB Transport Safety Report Aviation Research and Analysis Report AR 2008 055, December 2008. 13. Hobbs, A.; Williamson, A. (2003). Associations between errors and contributing factors in aircraft maintenance. Human Factors, 45, 186-201. Cited in Hobbs (2008). 14. Hobbs, Alan. An Overview of Human Factors in Aviation Maintenance. ATSB Transport Safety Report Aviation Research and Analysis Report AR 2008 055, December 2008. 15. Hobbs. 16. Vangelova, Katia. The Effect of Shift Rotation on Variations of Cortisol, Fatigue and Sleep in Sound Engineers. Industrial Health, 46, 490493 (2008); cited in Giovannoli, Marco, Fatigue Monitoring to Improve Productivity and Safety in Aviation Maintenance. City University London (2008).
Twelve-Hour Shifts
Twelve-hour maintenance shifts are becoming increasingly common, Hobbs said. In some cases, a companys move to 12-hour shifts is driven by employee preference rather than management pressure. When compared with eight-hour shifts, 12-hour shifts offer certain advantages, such as less commuting time over the course of a week, more days off, and the opportunity to complete more work in each shift, with fewer handovers of tasks between shifts. Although workers tend to be more fatigued at the end of a 12hour shift than at the end of an eighthour shift, they sometimes report fewer health problems and better sleep on a 12-hour shift pattern than when on an eight-hour pattern.14 At present, there is no conclusive evidence to indicate that extending the duration of shifts from eight to 12 hours will increase the probability of accidents or injuries. Nevertheless, 12-hour shifts may not be appropriate in all cases. Whenever a change is being made to 12-hour shifts, it is essential to evaluate the effects of the change on worker well-being and work quality. Quite possibly, the most significant effects of 12-hour shifts would show themselves on the journey home rather than at work.15
Rotating Shifts
Rotating-shift workers may never entirely become accustomed to a work schedule, because the timing of shifts is
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FLIGHTDECK
Despite frequent warnings, an actual shortage of airline pilots would be the first since the 1960s.
Short Supply
BY LINDA WERFELMAN
T
Spiritartist/iStockphoto
he often-forecast shortage of U.S. airline pilots may finally come to pass, fed by a perfect storm of increasing demand for new pilots, mounting retirements by babyboomer pilots and declining interest among young people in airline careers, industry experts say. A recent study by researchers from several U.S. universities reinforced the conclusions of Boeings 2012 projection that the next two decades will bring an unprecedented demand for new pilots. Filling those jobs may not be easy, the university study said. The study forecast the hiring of more than 95,000 pilots in the United States over the next 20 years as a result of the combined effects of new aircraft growth, pilot retirements and pilot attrition from the industry for reasons other than retirement, as well as government regulations especially rest and duty time requirements that will limit the
number of hours pilots may work that may lead to an increase in the number of required new pilots.1 The Boeing study had forecast a need for 460,000 new pilots worldwide by 2032, including 69,000 in North America (Figure 1, p. 24). The Asia Pacific region will account for about 40 percent of the total worldwide need; that number will include 71,300 in China alone. The study cautioned that, in many regions of the world, a pilot shortage is already here and noted that the Asia Pacific region, in particular, is experiencing delays and operational interruptions due to pilot scheduling constraints.2 The university study, which was conducted at the request of an aviation industry stakeholders group, acknowledged the failure of frequent past warnings of an impending pilot shortage to come to fruition, as well as confusion about exactly what constitutes a shortage.
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FLIGHTDECK
Does pilot shortage refer to a situation where the lack of available qualified pilots results in operational disruptions, such as changes in schedule or reduction of flights? the studys authors asked. Using this definition, the last pilot shortage occurred in the 1960s. In this era, it was noted that thousands of hours of flights by major airlines had to be canceled and operations adjusted due to the unavailability of qualified pilots to hire. Or does a pilot shortage mean a lowering of hiring requirements to dip into the next wave of applicants who, of course, still meet FAA [U.S. Federal Aviation Administration] requirements but are not at the top of the flight experience hierarchy? There is evidence to support this was the case at the regional carriers in the most recent hiring wave of 2007 and 2008. Typically, U.S. airlines have found enough qualified pilots by hiring retired military pilots and others from civilian sources. What is different now? the study asked before outlining several new considerations: Recent limited hiring at major airlines; An increase in retirements from major airlines over the next few years; Expansion of airlines; A smaller number of new flight instructors who say they want careers with the airlines; and, A legislative requirement for airline pilots to possess airline transport pilot (ATP) certificates which typically require 1,500 flight hours. The hiring of pilots for major airlines stimulates demand for pilots throughout the industry, the study said, adding that the unanswered question now is whether hiring over the next few years will provide enough of a stimulus to develop an adequate, continuous supply of pilots. About 45,000 pilots are expected to retire from major airlines in the next 20 years, and with 18,000 current regional pilots, the industry will face a shortfall unless a significant number of new pilots enter the work force, the study said. Current projections indicate there will be disruptions in the pilot labor supply unless industrymarket fundamentals change, more pilots can be enticed into an airline pilot career or the regulatory environment changes, the report said. A status quo projection indicates that there will be a shortage of around 35,000 pilots (Figure 2, p. 25).
A status quo projection indicates that there will be a shortage of around 35,000 pilots.
CFI Survey
The university study included a survey of certified flight instructors (CFIs), gauging their interest in an airline career, Kent Lovelace, chairman of the Department of Aviation at the University of North Dakota and one of the studys authors, said during a panel discussion in May at the Regional Airline Associations (RAAs) annual meeting in Montreal. Its not so much how many pilots are out there, but how many want to pursue the career, Lovelace said, noting that many CFIs trained in the United States plan to return to their native countries to continue their aviation careers. The survey, administered to 1,636 CFIs, found that 54 percent are planning on an airline career. Nine percent of those questioned said they had abandoned their interest in a career with the airlines because of the
Forecast New Pilot Demand Through 2031

8% 9% 3% 3%
Region Asia Paci c Europe North America Latin America Middle East CIS Africa Total
Pilots 185, 600 100,900 69,000 42,000 36,100 11,900 14,500 460,000 15%
40%
22%
CIS = Commonwealth of Independent States
Source: The Boeing Company
Figure 1
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FLIGHTDECK
Forecast Yearly and Cumulative Shortages of Pilots to Sta the US Airline Fleet Forecast Shortages of Pilots to Staff the U.S. Airline Fleet
4,000 3,500 Yearly number of pilots 3,000 2,500 2,000 1,500 1,000 500 0 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 Yearly shortage Cumulative shortage 40,000 Cumulative number of pilots 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0
Source: Higgins, James; Lovelace, Kent; Bjerki, Elizabeth et al. An Investigation of the United States Airline Pilot Labor Supply. 2013.
Figure 2 requirement for first officers to possess an ATP. An additional 33 percent said the requirement had prompted them to reconsider their plans to fly for the airlines. The requirement included in a 2010 law left room for exceptions to the 1,500-flighthour requirement for military pilots and for new pilots who graduate from four-year colleges with aviation degrees (ASW, 12/12, p. 43). The specifics of those exceptions will be clarified in a rule expected to be issued later this year by the FAA. The numbers of CFIs hoping for airline careers are dramatically lower than they have been in the past, Lovelace said, noting that 10 or 15 years ago, 75 to 90 percent of those questioned said that they wanted to fly for an airline and they knew which airline and which equipment. Today, Lovelace told the RAA, if you convince 100 percent of those [the 54 percent] to pursue an airline career, you dont have a supply problem. Nevertheless, he added, airlines must actively persuade new pilots to join their ranks. A major issue is the cost of flight training and of accumulating enough flight hours to be employable, Lovelace said. The study added that an airline job might be more attractive if those costs could be reduced through scholarships,
programs that provide funding in exchange for future employment or gateway programs that show a clear path from early pilot training to airline employment. Lovelace noted that many potential pilots also want to maintain connections with their friends and communities, and many fear that an airline pilots schedule would preclude them from doing so; that concern might be more difficult to address.
A Shrinking Pool
In the short term the next five to 10 years major airlines are unlikely to experience a shortage, the university study said. But it added that supply problems may have an impact at regional airlines, which will have to actively compete for a shrinking pool of qualified pilots, the study said. It is not clear whether all the regional airlines will be successful in attracting an adequate number of qualified applicants, he said.3 If they are not, the study predicted, the most likely consequence would involve the industry reducing its schedule. In particular, smaller communities served only by regional airlines could experience airline disruption or even a suspension of service. Another factor not specifically considered in the university study was that
Smaller communities served only by regional airlines could experience airline disruption or even a suspension of service.
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FLIGHTDECK
non-U.S. air carriers, which also will be eager to hire qualified pilots, may decide to aggressively compete and employ lower-time, entry-level pilots. Darrin Greubel, manager of line operations for ExpressJet, told the RAA that the decline in the number of pilots leaving the U.S. military for airline jobs, the increasing number of retirements as airline pilots reach the mandatory retirement age of 65 and regulatory changes are adding to pressure on the pool of employable pilots. Weve heard this [shortage warning] a dozen times in the past, and weve always worked it out, Greubel said, adding that this round of warnings is based on more complete data. Today you can talk to the majority of people, and they will say, I believe in it this time. I see the supply issue; I see the demand issue. Its time to act upon this. provide a defined pathway for a student to reach a major airline. She said the participating airlines benefit from the steady stream of qualified pilots who typically work as flight instructors in the gateway program until they accumulate between 800 to 1,200 flight hours and then are hired as first officers at Cape Air (or ExpressJet, a newcomer to the program), where they work until they have 2,000 to 3,000 hours and an airline transport pilot certificate and are eligible for job interviews with JetBlue. About 150 pilots have participated in the program, and the first eight are now first officers at JetBlue, Poppe said. More than 20 are flying with Cape Air, she said. the left seats at the regional airlines and any seat at the majors. However, even with a glut of pilots, it may become difficult to fill the right seat of some regional carriers with pay scales below poverty wage.
Hard Time
Greubel, however, said the pilot shortage is already here. Theres a hard time finding 1,500hour pilots and filling classes. Thats already becoming a challenge, he said. And its starting to become a challenge for simulator vendors who sell sim time and say they arent selling as much because they cant find the pilots. It [the shortage] is here now, today. Its only going to get worse. What is most needed, Allen said, is a thorough collection and analysis of data and a healthy discussion of the issue to determine the likelihood of a pilot shortage. What Im afraid of, he said, is that we will have a problem and well be too late with recognition and too late to fix. Notes
1. Higgins, James; Lovelace, Kent; Bjerki, Elizabeth et al. An Investigation of the United States Airline Pilot Labor Supply. 2013. 2. Boeing. 2012 Pilot and Technician Outlook. <boeing.com/assets/pdf/commercial/aviationservices/brochures/ PilotTechnicianOutlook.pdf>. 3. The authors said their analysis did not consider the likely effects of new flight and duty time regulations in the United States, the prospect of non-U.S. carriers hiring U.S. pilots or an additional decline or increase in the number of new pilots who decide against an airline career. 4. Harrison, Brant. Pilot Demand Projections/ Analysis for the Next 10 Years. Audries Aircraft Analysis. 2013.
Skeptical Voices
Not everyone is convinced that a shortage of pilots will materialize in the United States. John Allen, director of the FAA Flight Standards Service, told the World Aviation Training Conference and Tradeshow (WATS 2013) in Orlando, Florida, U.S., in April that while some studies warn of a looming shortage, others express confidence that market forces will resolve any potential shortage and that there is a robust commercial certificated pilot inventory that would cover the need for ATPs in the future. Brant Harrison, a pilot for a large U.S. airline who has conducted his own industry analysis to forecast pilot demand over the next decade, predicted that regional airlines in the United States will experience little growth over the next 10 years and may experience significant reductions.4 As a result, his analysis said, it was highly unlikely any significant pressure will be felt for finding pilots to fill
Airline Solutions
Air carriers themselves are beginning to develop solutions to the problem, Greubel said, citing new cooperative programs involving universities, regional operators and major airlines. One such program is the Aviation University Gateway, operated by JetBlue Airways in cooperation with Cape Air, ExpressJet, Embry-Riddle Aeronautical University, Auburn University, Jacksonville University and the University of North Dakota. The program, begun in 2008, is designed to identify potential pilots and provide them with academic training, a flight instructors job, regional airline experience and ultimately an airline pilots job at JetBlue. Krista Poppe, a captain with Cape Air and manager of the program, told the RAA conference that the goal is to
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FLIGHTOPS
ICAO moves closer to finalizing pilot training standards and guidance to reduce risk of loss of controlin flight.
Enough
BY WAYNE ROSENKRANS
Susan Reed
f they accept the recent consensus of pilottraining specialists on defenses against loss of controlin flight (LOC-I), civil aviation authorities could reap the benefits of updated guidance on best practices by the end of 2013 and templates for changing regulatory requirements by late 2014, says Henry Defalque, technical officer, licensing and operations, Air Navigation Bureau, International Civil Aviation Organization (ICAO).
TALK
He offered a preview of the pending ICAO standards and recommended practices for airplane upset prevention and recovery training (UPRT) including their estimated time of arrival in April during the World Aviation Training Conference and Tradeshow (WATS 2013) in Orlando, Florida, U.S. The changes are significant inroads to resolving the contentious issues involved in LOC-I in commercial air transport operations, Defalque said.
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address LOC-I. ICATEE had input into LOCART, and after an initial organizational meeting and six monthly meetings during 2012, LOCART joined with a U.S. Federal Aviation Administration aviation rulemaking committee in January in producing a report on solutions that would aid the ICAO Secretariat in proposing Annex 1 pilot licensing proposals and Annex 6 Part I UPRT training requirements, he said. In late April this year, ICAO presented its final draft proposal for the ICATEE-derived Manual on Aeroplane Upset Prevention and Recovery and corresponding regulatory amendments to a final LOCART meeting to begin the process of peer review for this manual. About 100 reviewers have two months to comment on it, and then we will finalize everything, Defalque said in April. ICAOs timetable calls for publishing the Manual on Aeroplane Upset Prevention and Recovery by the end of 2013. Timing of approval of ICATEEs amendment to ICAO Doc 9625 is contingent on completion of review for ICAO by the Royal Aeronautical Societys International Committee on Flight Simulation Training Device Qualification, he said. That should be published by ICAO in the first quarter 2014, he said. This amendment focuses on additional aerodynamic modeling for UPRT that enables introduction of additional pilot tasks, new functions and tools for instructor operating stations, and specification of which maneuvers should not be trained in an FSTD to avoid negative training. The ICAO Air Navigation Commissions first review of the new ICAO regulatory provisions the UPRT- related requirements for licenses, training programs and PANS-TRG was set for June 6, Defalque said, adding, Afterwards, [they] will be disseminated to
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Airplane Upset Recovery Training Aid
LOC-I was a little bit under the radar until a few years ago, when awareness of the accident numbers increased, especially awareness that about 80 percent of LOC-I accidents were fatal. The safety priority of this accident category then officially increased to no. 1 for the agencys technical officers, he said. ICAO has 200 people conducting its entire technical work program, half of those technical officers. So the agency showed openness to participating in external initiatives and receiving expert advice by creating a temporary Loss of Control Avoidance and Recovery Training (LOCART) committee of civil aviation authorities; by receiving input from the Royal Aeronautical Societys International Committee for Aviation Training in Extended Envelopes (ICATEE), which began its work in May 2009; and by reference to the 2008 version of the Airplane Upset Recovery Training Aid, an advisory document updated twice since 1998 by Airbus, Boeing Commercial Airplanes and Flight Safety Foundation (see Airplane Upset Recovery Training Aid Remains Relevant, p. 30).
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Particularly for the LOCART issue, we decided to go for the low-hanging fruits the pilot training, Defalque said. There are other issues with loss of controlin flight, and that will be a long-term assignment for another group at ICAO. From those sources, we developed and will run annex and [Procedures for Air Navigation Services: Training (PANS-TRG)] proposals through a very complex adoption and approval process. ICATEE delivered its draft manual on UPRT to ICAO in December 2012 with a companion proposal to amend ICAO Doc 9625, Manual of Criteria for the Qualification of Flight Simulation Training Devices [FSTDs], Volume I Aeroplanes. ICAOs 50-member LOCART group was prompted by an October 2011 European Aviation Safety Agency conference on LOC-I, in which participating regulators realized that everybody was going his own way, and this is a new issue and we needed harmonization, Defalque said. By some counts at that time, about 18 separate organizations or initiatives were under way worldwide to
FLIGHTOPS
states and all international organizations for comments. They have four months to comment, and then we will have a final review in November 2013. Its very tight according to ICAO schedules, but if we make it, it will be applicable in November 2014. Otherwise, it will be delayed by one year. The expected changes to Annex 1 only affect airplane pilots. First, we want to emphasize that the main focus of our action is toward the prevention of upset, he said. We hope to avoid the need for recovery. For the commercial pilot license [CPL] there is a recommendation for the applicant to receive, in actual flight, upset prevention and recovery training. For the multicrew pilot license (MPL), minor wording changes add prevention to the existing description of upset recovery and refer to the new manual and to PANS-TRG revisions. ICAO made the CPL changes a recommended practice because a standard would have required existing pilots to comply within five years by receiving training in a single-engine propeller airplane, which was not deemed feasible for several reasons. That makes no sense, and that would tremendously overdrain the training capability, so we are limited to a recommended practice, he said. For a type rating for a multicrew aircraft, the applicant shall have, for the issue of an airplane category type rating, received upset prevention and recovery training. The guidance material explains FSTD UPRT for a pilots type rating. If there is no FSTD for the airplane type, however, other LOC-I mitigations should be adopted, but never including UPRT on the actual airplane. Its too dangerous, he said. Annex 6 changes are expected to require a UPRT ground trainingflight training program for pilots flying as part of flight crews in commercial air transport operations. An air transport pilot, even if [he/she] is already current and he hasnt had upset recovery training in the past, would be getting that training under the operators training program, Defalque said. The expected new UPRT-related chapter in PANS-TRG has six new sections, including ICAOs official philosophy of UPRT. It should be competency-based, he said. There is an addition [covering] the knowledgebased training because knowledge has been identified as generally deficient in many instances of accidents involving loss of control. Aircraft manufacturers agreed to a set of upset recovery techniques and FSTD training scenarios which we introduced with an introductory paragraph in the appendixes. We are strongly advocating that there would be no civil aviation authority flight check or FSTD check. The competency-based training must be conducted in an approved training organization which would be overseen by the authority but would be responsible to ensure the competency of the trainee after the training period. Other changes cover the regulatory templates for states and expected state regulatory oversight, single-pilot UPRT on an airplane, MPL UPRT in a generic FSTD and type-specific UPRT in a type-specific FSTD. Also covered is instructor qualification for on-airplane UPRT and FSTD UPRT.
Words of Caution
Averting a global divergence among civil aviation authorities in implementing complex UPRT requirements was not the only concern when they, ICAO leaders and other stakeholders compared notes in 2011. Another major issue was the risk of negative training of pilots. Civil aviation authorities and industry must be cautious about promoting training in an FSTD unsuitable for the task, Defalque said. It is really critical. On-aircraft training can lead to negative training if the difference in behavior and control capabilities of a light aircraft and a transport heavy jet aircraft is not recognized. To introduce additional training maneuvers, FSTD modeling may be required to change, and those maneuvers that we want to introduce need additional work if they bring the
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Airplane Upset Recovery Training Aid Remains Relevant
hen the U.S. Federal Aviation Administration (FAA) in July 2010 published an Information for Operators bulletin (InFO 10010) titled Enhanced Upset Recovery Training, the objective was to highlight the availability and merits of the Airplane Upset Recovery Training Aid for all air operators under Federal Aviation Regulations Parts 91K, 121, 125 and 135, and Part 142 pilot training centers. The first version of the Training Aid was published in 1998 by an FAA-industry work group co-chaired by Airbus, Boeing and Flight Safety Foundation. This comprehensive package was updated in 2004 and 2008 the latest version covering high-altitude stalls and remains available at <flightsafety. org/archives-and-resources/ airplane-upset-recovery-training-aid>.
The FAA strongly recommends incorporation of applicable sections into training programs, the InFO says. Although the work group was primarily focused on large aircraft, many of the same aerodynamic principles apply to smaller swept-wing turbine aircraft. Several presenters at the World Aviation Training Conference and Tradeshow (WATS 2013) likewise urged airline training managers worldwide to know and apply the Training Aids content while anticipating new documents from the International Civil Aviation Organization (ICAO) and regulators. During the past four years, however, the Royal Aeronautical Societys International Committee for Aviation Training in Extended Envelopes has created an enhanced sequel to the Training Aid (ASW, 6/11, p. 24; 10/11, p. 36; 6/12, p. 16) and delivered this Manual on Aeroplane Upset Prevention and Recovery to ICAO for scheduled release by the end of 2013. ICAO plays a critical role given the past reticence of some training organizations. For example, an FAA aviation rulemaking committee found that more than 60 percent of U.S. airline training managers surveyed before the InFO was published were unaware of the Training Aid, said Lou Nmeth, a captain and chief safety officer, CAE. [The Training Aid] is a very valuable document a fundamentally sound document, he told WATS attendees. [The] Training Aid is still very valid and should be used. He attributed signs of limited adaptation
partly to the economically tough environment in which some organizations have been hard-pressed to justify airline pilot training enhancements that exceed current regulatory requirements. Its an excellent document, but it is not a regulatory requirement, he said. So in defense of training departments that dont know about it and havent used it, since its not a regulatory requirement, it gets overlooked when people are developing training. [The work group had] urged the regulator to adopt [the Training Aid] as a regulatory standard and it was not. Frank Cheeseman, chairman, Human Factors and Training Group, Air Line Pilots Association, International, and an Airbus A320 captain for United Airlines, called it concerning that some training organizations have professed that they are unaware of this resource. There are two revisions out there that hopefully worldwide are being used in your training programs, he told the conference. One of the task force members present cited another reason. Some of the training managers reviewed the [Training Aid] and then said, Were not doing anything thats in conflict with it, so we dont have to change what were doing, said John Cox, a captain and CEO of Safety Operating Systems. Had it gone regulatory, it could have been more effective. It sits quietly on a lot of desks and gathers dust which was never the intent. I would encourage you to use it. WR
simulator outside the FSTD normal training envelope. So these are the words of caution. Finally, ICAO had to grapple with the controversial issue of the relative value of civilian airline pilots experiencing inverted flight, or roll beyond 90 degrees, as part of UPRT. He said about 90
30 |
percent of the training can be completed without this. What is currently recommended by ICATEE is that the optimum solution for upset prevention and recovery training for the CPL and MPL that is, on an airplane involve exposure to inverted flight, he said. For us
inverted flight exposure is a Cadillac solution to loss of control in flight, but it is not possible for most states. For the CPL, we cannot do it, but for the MPL because it is an integrated training program involved with an operator with fairly expensive setup cost we still recommend it.
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FLIGHTOPS
He said this conclusion about limited infrastructure was reached after studying a year-old ICAO database of the aircraft registry data of states, covering 38 member states at the time. Of those 38 states, 60 percent did not have a single civil aerobatic aircraft, he said. The [database search] restriction was that aircraft needed two seats to have an instructor, and shouldnt be kit-built. Sunjoo Advani, chairman of ICATEE, reminded the audience, however, of the impressions that research had left on participants and the urgency for the full scope of solutions to be implemented in the near future. ICAOs imminent Manual on Aeroplane Upset Prevention and Recovery serves as a regulators handbook for the quality assurance of upset prevention and recovery training programs and standardizing instruction, Advani said. The Royal Aeronautical Society launched the ICATEE task force because in a 2009 conference we identified that loss of control is not really effectively trained, and in some cases, ineffectively trained; despite the good intentions of many people, it was being incorrectly trained by some. Training had been focusing on unusual attitudes rather than the full range of upsets, and limitations in capabilities of FSTDs were not considered adequately. Prevention became a high priority of the committee, but even that had to be explained at first with unsettled terminology. What is an upset? Advani said. We go from normal flight to an upset to a loss of control situation. We can prevent the upset, and if an upset occurs, we can recover from it to prevent loss of control. In an upset event, you can end up in a stall. You can end up in an unusual attitude. It can lead to a spin; it can end up overstressing the aircraft and you may [not] end up recovering. So we want to reduce these risks. Part of the challenge has been explaining the effects of the stall and post-stall aerodynamics. The red or danger zone on a graphed coefficient of lift/angle-of-attack curve shows that in that post-stall region, aircraft response to normal control inputs tends to be confusing for pilots without UPRT training, and may exceed control recoverability. In real operational conditions in this region of the envelope, pilots could experience reduced roll stability, reverse roll control, stall g-breaks and other anomalies, he said. If youre in a swept-wing aircraft and you encounter stall toward the tips, you could end up having a change in the pitching moment that can catch you off guard, he said. Possible uncommanded roll could occur if one wing were to stall. You can end up with tailplane blanketing [normal airflow over the horizontal tail disrupted by disturbed airflow from the wings and fuselage], which can again cause a surprising condition. We saw this occur in the Colgan Air accident where all of these things started to occur in a rapid fire, confusing the pilots and causing them to apply controls which they were not prepared for. ICATEE also became concerned about inadequate pilot currency in practical aspects of aerodynamics theory that are seldom applied in line operations. We have the requirement to maintain airmanship knowledge, but where is that knowledge? Advani said. When we [talked] to pilots, the average pilot seems to have a degradation of that knowledge and a degradation of skills. What we see in all upset events is the response of the pilot to an unexpected situation to startle, to being frozen, to actually having a loss of cognitive control, of understanding the situation and being able to interact appropriately. The working group believes that it pushed the frontiers of UPRT knowledge, training and technology, Advani said. Were developing new ideas, new concepts, really understanding what goes on [not only] in the airplane and the aerodynamics, but also in the mind.
ICATEE Perspectives
Now that ICATEE has submitted the deliverables on its agenda, the members remain available to advise on the implementation phases of other organizations.
What we see in all upset events is the response of the pilot to an unexpected situation to startle, to being frozen, to actually having a loss of cognitive control, of understanding the situation and being able to interact appropriately.
Wayne Rosenkrans
Advani
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FLIGHTOPS
ell phones and other portable electronic devices (PEDs) have introduced a 21st century twist to the distractions that can permeate pilot decision-making processes, and more should be done to prevent their use during critical phases of flight and ground operations, Chairman Deborah Hersman of the U.S. National Transportation Safety Board (NTSB) says. Hersman spoke during an NTSB hearing on the Aug. 26, 2011, crash of a Eurocopter AS350 B2 that ran out of fuel and crashed 1 nm (2 km) from the Midwest National Air Center in Mosby, Missouri, U.S., during a multi-leg flight. The crash killed the pilot of the Air Methods helicopter, flight nurse, flight paramedic and patient.
The 2011 crash of this Air Methods EMS helicopter prompted calls for an expanded ban on cell phone use during flight and safety-critical ground operations.
n w o d n k o i c t a c r C Distra on
g usin s t ft pilo rcra i n on a a b n he le a nd t whi e t s x e e s urpo ts to p n l a a on Bw pers NTS r e o h f T es hon p .| l l ce tion a r e op is in
BY LINDA WERFELMAN
Gary Arbach|Dreamstime.com
Mark Shashek
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The NTSB said probable causes of the crash were the pilots failure to confirm that the helicopter had adequate fuel on board to complete the mission before making the first departure, his improper decision to continue the mission and make a second departure after he became aware of a critically low fuel level, and his failure to successfully enter an autorotation when the engine lost power due to fuel exhaustion.1 Among the contributing factors was the pilots distracted attention due to personal texting during safety-critical ground and flight operations, the NTSB said (see Dissenting Opinion, p. 36).2 The agency said its investigation of the accident prompted its issuance of nine safety recommendations, including four dealing with use of PEDs (ASW, 6/13, p. 10). The recommendations call on the U.S. Federal Aviation Administration (FAA) to prohibit flight crewmembers in U.S. Federal Aviation Regulations Part 135, commuter and on-demand, and Part 91 Subpart K, fractional ownership, operations from using PEDs for nonoperational use while at their duty station on the flight deck while the aircraft is being operated. Other recommendations say the FAA should require Parts 121 (air carrier), 135 and 91 Subpart K operators to inform pilots during initial and recurrent training of the detrimental effects associated with nonoperational use of PEDs, and ensure that their procedures prohibit nonoperational use of PEDs by operational personnel during flight and safety-critical periods on the ground. In addition, the NTSB recommended that Air Methods, which strengthened its prohibitions on cell phone use after the accident, further expand its ban on the use of PEDs during flight to include safety-critical ground activities such as flight planning and preflight inspection.
Timeline of Pilot Communications, Including Inspection

Local Time 1400 1415
Personal text message sent Personal text message received Personal telephone call
S R
R R R R R R R R R R R R R R R R R R
1430
S S S S S
Helicopter inspected and returned to serv ice
1445 1500
1515
1530
1545 1600
Phone: 15521553 Pilot exchanges brief telephone calls with work friend
1615
1630
1645
RR S S RR SS R R SS RR R S R R R RR R S
Phone: 16381643 Pilot receives telephone calls from work friend
1700
Source: U.S. National Transportation Safety Board
Figure 1 by personal issues his wifes pregnancy, his fathers recent heart surgery, his commute to a base at St. Joseph, Missouri, after moving to a new city and his cell phone conversations and text messages with a colleague with whom he was to have dinner after his shift ended. The pilot needed to focus his attention away from personal issues when performing safety-related tasks, but at such times, both
flight flightsafety safety foundation foundation | AeroSafetyWorld | July 2013
Uncharacteristic Failure
NTSB investigators said the pilots colleagues told them it was uncharacteristic that he failed to recognize that the helicopter lacked the fuel to complete the planned mission. The accident report said that the former military helicopter pilot might have been distracted
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a complete preflight inspection, but they could have distracted the pilot, the report said. The pilot either did not perform a preflight inspection or performed an incomplete inspection, the report said, citing his unawareness of the helicopters low fuel and his failure to sign off certain entries in maintenance records and the daily flight log. The records showed that text messages also were sent from the pilots cell phone while the helicopter was in flight, including several sent during the accident leg of the mission (Figure 2). Company procedures prohibited pilots from using, or even turning on, cell phones during flight operations, the report said.
Timeline of Pilot Communications, Including Flight

Local Time
Personal text message sent Personal text message received Personal telephone call Radio communication
S
R
1700
1715
R S R S R
Radio: 17201721 Flight follower calls to confirm weather, then LifeNet accepts the accident trip Radio: 17291730 Pilot reports airborne, two hours of fuel St. Joseph to Bethany flight (1729)
1730
1745
R S Phone: 17591806 R S Radio: 18121813 R S Pilot reports airborne RR S on accident leg R S
1800
Pilot reports on ground, landed at 1758, short of fuel
Flight Plans
The original plan called for a two-part flight from the St. Joseph base at Rosecrans Memorial Airport to Harrison County Community Hospital in Bethany to pick up a patient and then continue to Liberty Hospital in Liberty, Missouri. While in Bethany, the pilot told his companys communication specialist that he had realized about halfway through the first leg of the flight that the helicopter did not have as much fuel as he had thought. Rather than continue to Liberty, which was 62 nm (115 km) southwest, he decided to stop in Mosby, along the same route but 4 nm (7 km) closer. The pilot sent all of his in-flight texts after he recognized the low-fuel state the last one about 20 minutes before the accident, the report said, noting that the pilot did not respond to two subsequent incoming text messages. There is no evidence that the pilots airborne texting activities directly affected his response to the engine failure, the report said. However, the personal texting activities would have periodically diverted the pilots attention from flight operations and aeronautical decision making. At a minimum, the pilots attention would be diverted for the amount of time it took to read and compose messages. Further, from a control usage standpoint, to send a text, the pilot would require at least one hand to be temporarily removed from active control of the helicopter.
1815
1830
Accident flight (1811) R S R Radio: 1827 Flight follower calls to confirm R that airport is standing by with fuel
1845
Source: U.S. National Transportation Safety Board
Time of accident (1841)
Figure 2 before departure and during the mission, he engaged in personal texting activities, the report said, adding that investigators examined the pilots cell phone records to see whether distraction caused by the pilots personal electronic communications could have played a role in his incomplete preflight inspection (Figure 1). The records showed that the pilot sent and received text messages and phone calls throughout the day, including a number of texts shortly after 1400 local time, when a maintenance technician said he and the pilot began a walk-around inspection of the helicopter as the helicopter was being prepared to return to service. The pilot first responded to the texts after 1430 a delay that indicated that the texts did not necessarily preclude the performance of
flightsafety.org | AeroSafety World | July 2013
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Degraded Performance
The report called the pilots personal texting a source of distractions and interruptions, citing research3 that has shown that distractions and interruptions decrease cognitive capacity, reduce the processing of potentially relevant information and can cause information in working memory to be confused or forgotten. These effects degrade performance of complex tasks and increase the likelihood of decision errors. Time pressure, which the pilot faced when deciding to continue the mission, can exacerbate this effect by restricting opportunities to weigh potentially relevant cues and consider alternative courses of action. a notice of proposed rule making (NPRM) earlier this year to prohibit Part 121 flight crewmembers from using PEDs for personal purposes while at their duty station on the flight deck while an aircraft is being operated. A final rule is expected after the FAA has reviewed public comments on the proposal. The FAA said the rule was intended to ensure that certain nonessential activities do not contribute to the challenge of task management on the flight deck and do not contribute to a loss of situational awareness. The NPRM cautioned that a loss of situational awareness can lead to critical consequences, such as missing information from one source when concentrating on another source, altitude or course deviations, dominance of visual cues to the extent that pilots may not hear certain aural warnings, misinterpreting ATC [air traffic control] instructions or experiencing task overload. As an example, the NPRM cited an Oct. 21, 2009, incident in which a Northwest Airlines Airbus A320 bound from San Diego to Minneapolis flew 150 nm (278 km) past its destination because the pilots were using their personal laptop computers to retrieve information as they discussed the airlines crew scheduling process.4 In the final report on that incident, the NTSB said the pilots had allowed this conversation to monopolize their attention and thus lower their capacity to monitor their radio communications, notice the lack of contact [with ATC] and recognize, via airplane instruments, the flights progress. The pilots failed, over a period of about 75 minutes, to respond to numerous radio calls from air traffic controllers in the Denver Air Route Traffic Control Center (ARTCC) and the Minneapolis ARTCC, the report said. While the laptops were open, they blocked the pilots views of some flight and navigation displays, the report said, adding, The computers not only restricted the pilots direct visual scan of all cockpit instruments but also further focused their attention on nonoperational issues, contributing to a reduction in their monitoring activities, loss of situational awareness and lack of awareness of the passage of time. The pilots missed alerts from the aircraft communication addressing and reporting system (ACARS) and messages about their aircrafts position, and as they neared Minneapolis, they had not entered landing data in the flight management computer, the report said. The pilots stated that their first indication of anything unusual with the flight was when they received a call from a flight attendant inquiring
flight flightsafety safety foundation foundation | AeroSafetyWorld | July 2013
Earlier Events
The FAA acting in response to a 2012 law that called for a crackdown on the use of PEDs on the flight deck issued
Dissenting Opinion
he U.S. National Transportation Safety Board (NTSB) was not unanimous in its belief that the use of a portable electronic device (PED) by the pilot of the accident helicopter contributed to the crash. In dissenting remarks, board member Earl Weener said that, by emphasizing the role of the pilots use of a PED, the final report on the accident provides a distraction from other critical safety issues identified and supported by the investigation. Weener added that the PED was only one of many distractions for this pilot that day. As ill-advisable and disconcerting as his actions may be with regard to his PED use, the report fails to make the case for attributing the causes or contributing causes of this accident to distraction based explicitly on use of the device. The pilots flawed aeronautical decision making is the fundamental issue, which goes well beyond his decisions regarding cell phone use. It is the root cause of this accident. Weener said the accident pilot demonstrated poor judgment several times including by failing to complete the preflight inspection and the beforetakeoff confirmation checklist, and by exhausting the fuel supply rather than conducting an emergency landing. Once the pilot made his decision to proceed with this mission, he added, nothing was going to deter him from his course, regardless of whether he used a cell phone. LW
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officers cellular phone during a takeoff roll just before reaching the airplanes takeoff decision speed, the NTSB summarized in its report on the Colgan accident. The SAFO stated that the ring tone was a distraction to the flight crew and could have resulted in an unnecessary rejected takeoff.6 Notes
1. NTSB. Crash Following Loss of Engine Power Due to Fuel Exhaustion; Air Methods Corporation; Eurocopter AS350 B2, N352LN; Near Mosby, Missouri; August 26, 2011, Aircraft Accident Report NTSB/ AAR-13/02. April 9, 2013.
The AS350 was about to land for refueling when it ran out of fuel and crashed 1 nm (2 km) from the runway in Mosby, Missouri.
U.S. National Transportation Safety Board
about their arrival, the report said. The captain said that he then saw that there was no flight plan information on his multifunction control and display unit and that the navigation display showed the airplane was nearing Duluth, Minnesota, and Eau Claire, Wisconsin both of which were beyond Minneapolis. The report said that they then contacted ATC to report that they got distracted, and weve overflown Minneapolis. Were overhead Eau Claire and would like to make a one-eighty. In response to questions from Minneapolis ARTCC, they said they had experienced cockpit distractions. Later, they told incident investigators about their laptop-enhanced conversations. At the time of the incident, the airline had a policy prohibiting use of PEDs on the flight deck.
Texting During Taxi

The NPRM also cited the circumstances preceding the Feb. 12, 2009, crash of a Colgan Air Bombardier Q400 near Buffalo, New York, U.S.,
flightsafety.org | AeroSafety World | July 2013
noting that, during the taxi phase of the flight, the first officer sent a text message on her personal cell phone another example, the FAA said, of the potential for such devices to create a hazardous distraction during critical phases of flight.5 Although the airplane was not moving when the first officer sent her text message, the NTSB noted that FAA Advisory Circular (AC) 91.21-1B, Use of Portable Electronic Devices Aboard Aircraft, issued in 2006, says that cell phones will not be authorized for use while the aircraft is being taxied for departure after leaving the gate. Colgans policy conformed to the guidance contained in the AC. FAA Safety Alert for Operators (SAFO) 09003, Cellular Phone Usage on the Flight Deck, issued five days before the Colgan crash, also cautioned flight crewmembers about the hazards of leaving cell phones turned on during critical phases of flight. The SAFO was the result of an inspectors observation of a ring tone/ warbling sound coming from a first
2. The NTSB also cited as contributing factors the pilots degraded performance due to fatigue, the lack of a company policy requiring an operational control center specialist to be notified if a helicopter was low on fuel and the lack of practice representative of an actual engine failure at cruise airspeed in the pilots autorotation training in the accident make and model helicopter. 3. The NTSB cited The Effects of Interruptions, Task Complexity and Information Presentation on Computer-Supported Decision-Making Performance, written by Cheri Speier, Iris Vessey and Joseph S. Valacich and published in 2003 in Decision Sciences Volume 34 (4): 771797. 4. NTSB. Accident report no. DCA10IA001. Oct. 21, 2009. 5. NTSB. Loss of Control on Approach; Colgan Air Inc., Operating as Continental Connection Flight 3407; Bombardier DHC8-400, N200WQ; Clarence Center, New York; February 12, 2009, Aircraft Accident Report NTSB/AAR-10/01. Feb. 2, 2010. The crash killed all 49 people in the airplane and one on the ground. In the final report, the NTSB said the probable cause of the accident was the captains inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. 6. Ibid.
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Continuous
Inexpensive alternatives to step-down, nonprecision approach procedures reduce risk of CFIT accidents.
he fact that a couple of enhancements to the designs of nonprecision instrument approaches date back to the 1970s should not deter their use whenever feasible as a countermeasure to controlled flight into terrain (CFIT), says Hugh Dibley, a former international airline captain who currently trains Airbus A320 flight crews. He recently has begun to advocate a wellknown mitigation comprising the combination of constant-angle, nonprecision approaches that have distance-measuring equipment (DME) aligned with the final approach course and a standard operating procedure (SOP) that calls for flight crew use of the DME distance altitude tables on the associated charts to check aircraft altitude at prescribed distances from the runway threshold. In the early 1970s, British Airways introduced constant-angle descents beginning at about 7,000 ft over the center of London into London Heathrow Airport by adding DME navigational aids (transponders) to instrument landing systems (ILS) and new procedures and training in order to reduce aircraft noise level, fuel burn and risk. I was surprised recently, when training with a crew, how their company said, Oh, we dont
use constant-angle, we still use dive-and-drive [stepped/step-down fixes] for our nonprecision approaches, Dibley said in April during his presentation to the World Aviation Training Conference and Tradeshow (WATS 2013) in Orlando, Florida, U.S. In fact, two airlines where he recently conducted training had the same practice, and one of the type-rated pilots told him that this practice was consistent with his training for a U.S. A320 type rating, Dibley said. Part of Dibleys surprise was that some companies today see no problem with dive-and-drive approaches, despite the wealth of safety data analysis available and the wide awareness of the CFIT risk (Figure 1, p. 39). Thats what spurred me to start to talk about this, he added. His basic premise is that any transport category aircraft currently operating can fly a constant-angle approach using a DME aligned with the runway. A lot of us had been doing this on hand-flown Boeing 707s when we had no flight directors, no autopilot, no nothing, he said. Some flight operations/training managers and regulators reject what may seem like an anachronistic change during a transitional period when the aviation industry has focused heavily on satellite-based communication, navigation
Gorshkov13 | Dreamstime.com
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STRATEGICISSUES
Descent
BY WAYNE ROSENKRANS
and surveillance, he said. However, in doing so, they overlook a low-cost defense that can be part of the solution to an apparent resurgence of CFIT accidents (ASW, 2/13, p. 18). A groundproximity warning system (GPWS) or terrain awareness and warning system (TAWS) also is a critical defense, but one designed to be a backup system while the known risks of nonprecision approaches are mitigated separately, he said. Constant-Angle vs. Step-Down Final Approach Discrepancy
TW 3.9 nm D (MAPt) 0.6 nm Altitude (ft)
A Bit of History
Although the 707 was the first large commercial jet Dibley flew, he began to conduct constantangle, nonprecision approaches on 747s in the 1970s. So you dont need a lot of sophisticated equipment to do the much safer constant-angle, nonprecision approaches, he said. Moreover, according to his research, some of the practices involved remain relevant to todays advanced transport aircraft for example, to the threedimensional, flight management systemgenerated landing system (FLS) on the new A350. In the history of instrument approach design, the ILS with a nominal 3-degree glideslope and associated fixes/marker beacons, was regarded soon after wide introduction as five times safer than the normal step-down approaches, he said. In the 1970s, we had DMEs throughout the industry an accuracy of 0.1 nm [0.2 km], so you immediately could start doing a constantangle descent to within 30 ft. He noted similarities to required navigation performance (RNP) systems. Given the constant-angle approaches that already had been introduced at Heathrow in the 1970s, Dibley said that he had been disappointed to learn of the CFIT accident involving a Trans World Airlines 727 in December 1974 during a nonprecision approach to Washington Dulles International Airport.2 I thought, Why on Earth were they so low? he said. It so happened on 747s at the time I was operating a route DetroitWashington London, and I personally always did a nonprecision approach using our little slide-rule because it was very easy, especially on that particular approach onto [Runway] 12, which is the most
1,350
uo u 3 s des .0 ce O de nt cia gre n l es al a na pp l ap roa pro ch ach Co nti n
1,000
MDA 620 ft above MAPt 494 ft GND 262 ft THR + 50 ft Runway 09 3 4 Distance to runway threshold (nm) 2 1 0
CFIT = controlled flight into terrain; GND = runway threshold elevation above sea level; D (MAPt) = missed approach point distance from runway threshold; MDA = minimum descent altitude; THR+50 ft = threshold-crossing 50 ft above ground level; TW = compass locator Note: Investigators studying flight data from an uneventful approach conducted about two weeks before the Afriqiyah Airways Airbus A330 CFIT accident on May 12, 2010, noticed that for the Runway 09 Locator approach procedure at Tripoli [International Airport, Libya], the calculated glideslope on final approach for a continuous descent final approach is 3 degrees. Contrary to what is published, the descent begins after crossing TW.
Source: Libyan Civil Aviation Authority
Figure 1
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anything. They probably descended a bit early, he said, and during the goaround, the airplane nearly struck palm trees before the crew returned to the airport and conducted a safe landing. It got our attention, and the approach procedure was revised to follow a 3-degree path, he said. British Airways revised approach chart established the initial approach fix at 4,000 ft and added DME distancealtitude tables to be monitored per SOP; this action resolved the problem. By the 1980s, many European airlines had adopted, and they continue to use, constant-angle, nonprecision approaches tailored to their operational objectives and risk analyses, Dibley said. Examples of charts from KLM Royal Dutch Airlines contained an easy-to-use DME distancealtitude table designed so that the nonprecision approach and corresponding ILS glideslope share the same descentangle profile. If the glideslope becomes inoperative, the flight crew can continue the descent without reverting to dive-and-drive, he noted. In the 1980s, Airbus came along with the A320 [and] automatic constant-angle descent approach, which could be done through the FMGC [flight management guidance computer or] selected manually using flight path angle and a table, Dibley said. Despite those technological advances, dive-and-drive continued to influence the CFIT toll. Around 2000, the FAA supported constant-angle, nonprecision approaches, but only in the context of RNP avionics, one of the foundations for building the U.S. Next Generation Air Transportation System (NextGen). Dibley said that the reluctance of civil aviation authorities to promote wider use, especially in some developing
Constant-Angle Descent, Nonprecision Approaches Mitigate Multiple Risks

Stepdown/Dive-and-Drive Descent Pro le
Unstable approach Pilot needs pitch, thrust and ap changes Risk of hard landing or runway overrun Flying level pitched up at MDA obtaining visual reference causes late dive at the runway with hard or deep landing and runway overrun Variable pro le Leading to unstable approaches MDA
Missed step has caused CFIT accidents Charts were misread so pilot ew into an obstacle
-3
DA
Constant-Angle Descent Pro le

Stable approach Landing con guration, no pitch/thrust changes
Nonprecision approach minimums may be reduced
MDA
-3
DA
CFIT = controlled flight into terrain; DA = runway threshold crossing matches decision altitude/height of a standard precision approach; MDA = minimum descent altitude Note: Analyses of CFIT accident and incident data for decades have generated an expert consensus that constant-angle descent, nonprecision approaches help pilots maintain a stable flight path and significantly reduce their workload.
Source: Hugh Dibley
Figure 2 efficient approach. As a result of that, the [U.S. Federal Aviation Administration (FAA)] mandated that GPWS should be fitted to all U.S.-registered airplanes. What if theyd said, If theres a DME in line with the runway, a nonprecision approach has got to be a constant-angle approach. Sometimes, mitigation of risks involved in a step-down, nonprecision approach (Figure 2) has been accomplished after a near-CFIT scenario, such as when airline flight crews flew
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a VOR/DME (VHF omnidirectional range/DME) approach at Kuala Lumpur, Malaysia, in the mid-1970s. We had a very close call which concentrated our minds in British Airways, Dibley said. The aircraft would start the approach at 2,500 ft 13 [nm; 17 km] from the field. It was a black-hole approach with no visual cues. In the serious incident, the flight crew of the 747, with no vertical guidance method in use, descended to minimum descent altitude, but could not see
STRATEGICISSUES
countries, warrants reconsideration in light of CFIT data today. toward the runway on a 3-degree slope. Therefore, once you see the runway, youve then got to pitch down, reconfigure the airplane perhaps, and perhaps dive at the runway. Its not a safe, easy situation. Youre configuring the airplane late, quite often reading checklists right down to the last moment. He points out several accidents that exemplify such risk factors in his full presentation <halldale.com/wats2013/world-airline-pilot-proceedings#. UbCcTJXYl5g>. Serious incidents also have involved flight crews recognizing the situation because of a GPWS or TAWS warning, or an intervention dependent on air traffic control (ATC) radar monitoring. If pilots lack a DME distancealtitude table or approved equivalent device, they can do a simple altitudedistance computation to monitor the correct altitudes over fixes along their constant 3-degree descent path. He referred to the circumstances of the Korean Air 747 CFIT accident in Guam in August 1997 for demonstration purposes.1 Its much easier to have a device which gives you a direct DME-toaltitude display, he said. He cited a U.S. National Aeronautics and Space Administration study that found that most mentally computed descent profiles are not optimum, and he also cited one serious incident in which CFIT was averted by a crewmembers mental computation, yet the computation result actually was in error. table checks during nonprecision and precision approaches alike. Dibley cited, for example, one case of an aircraft avionics system coupling to an ILS glideslope that was in test mode, resulting in an automated descent below the correct descent angle until a third pilot recognized the 1,000-ft discrepancy from his own mental calculations, and called for a go-around. The flight crew then landed safely. The incident report questioned, however, why the flight crew had not recognized the discrepancy by using the DME distancealtitude table on the approach chart. Flight crews need to check their height at some stage of an ILS, normally at the outer marker, to check that they have the QNH (barometric setting for the altimeter to show altitude above mean sea level) set correctly, Dibley said. The advantage of having a table is you can do it at any time, he said. You might be just having to change ATC frequencies or something as you pass the outer marker. Temperature-related altitude errors also become obvious by this consistent practice. In another example, a CFIT accident occurred on a nonprecision approach that had been developed partly to achieve noise-mitigation objectives at night, using a 3-degree descent angle that intercepted a steeper 3.7-degree visual approach slope indicator. So the captain started off and got too low, but the first officer looking at that chart had no way of monitoring the descent profile, Dibley said. Dibleys subsequent simulator reenactment of the accident scenario found that a 3.7-degree constant-angle approach could have been flown easily as an Airbus managed approach (that is, selected flight angle) or by hand-flying, while monitoring with the table in either case.
Dive-and-Drive Risks
Mitigation of unstable approaches has been a focal point of global aviation industry safety initiatives for at least 20 years as evidenced, for example, by extensive related content in Flight Safety Foundations 2010 Approachand-Landing Accident Reduction [ALAR] Tool Kit Update <flightsafety. org/current-safety-initiatives/approachand-landing-accident-reduction-alar/ alar-tool-kit-cd>. Without mentioning whether he was familiar with the ALAR Tool Kit as a whole, Dibley criticized one of the safety analyses the tool kit contains (Killers in Aviation: FSF Task Force Presents Facts About Approach-and-landing and Controlledflight-into-terrain Accidents, Flight Safety Digest, Volume 17, NovemberDecember 1998January-February 1999) for insufficient emphasis on the use of DME distancealtitude tables on approach charts. He concurred with FSF research and other studies that regard conventional step-down nonprecision approaches as inferior to precision procedures, adding that dive-and-drive procedures are prone to becoming unstabilized because of the inherent level of difficulty. Its quite easy to make a mistake when youre doing a step-down or dive-and-drive, Dibley said. You have to pitch down which involves level-off, changing configuration and thrust and that can lead to an unstable approach, which we all know is not a good idea. You can miss one of the steps and a number of accidents resulted from that. Similarly, if you dont do it correctly youll end up flying level, pitched up and not pitched down
WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JULY 2013
CFIT Continues
Lessons from commercial air transport CFIT accidents and relevant incidents from those of the 1970s to the May 2010 Afriqiyah Airways crash (see Fatal Hesitation, p. 12) underscore the value of the DME distancealtitude
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CFIT Accident Profile Involves Unstabilized Approach Despite Constant-Angle, RNAV/GNSS Procedure
IAF IF LHRWI FAF LHRWF MAP LHRWM
3500
LHRWD LHRWE LHRWG
124 2500 2200
3.49 2860
124
340
2115 1600
Forecast cloud top Forecast cloud base
2060
1600
5
MDA 0
MAP THR 12 ELEV 46
NM FM 17 MAP
12
3.6
0.45
CFIT = controlled flight into terrain; ELEV = elevation; FAF = final approach fix; FM = from; IAF = initial approach fix; IF = intermediate fix; MAP = missed approach point; MDA = minimum descent altitude; NM = nautical miles; RNAV/GNSS = area navigation/global navigation satellite system; THR = runway threshold Note: An experienced pilot with a history of noncompliance with standard operating procedures, an inexperienced and nonassertive copilot, excessive airspeeds and descent rates during a nonprecision approach in bad weather, and the operators disregard of its own rules and training standards were found to have played roles in the May 7, 2005, crash of a Fairchild Metro 23 in Queensland, Australia (ASW, 6/07, p. 32).
Source: Australian Transport Safety Bureau (ATSB)
Figure 3 In April, he reviewed reports for nine of the most recent CFITs that could have been prevented by Enhanced Ground Proximity Warning Systems (EGPWS). These were identified in the database maintained by Don Bateman, Honeywell corporate fellow and chief engineertechnologist for flight safety systems. Dibley found that in five of these CFITs, DME was available while constant-angledescent approach charts were not. Some investigations into the influence of nonprecision approach designs have revealed discrepancies in procedure design (Figure 3), he said, bolstering the argument for tables as a situational awareness tool. The important thing is that the distance-altitude tables are essential, but they must be clear, and the crew must know exactly what theyre meant to be checking, Dibley said. So long as nonprecision approaches must be conducted to minimums based on barometric altitudes, even flight crews operating the latest transport category airplanes must at some stage to do a distance-to-altitude check on
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the glideslope during your approach to confirm the QNH, he said, referring to the A350 FLS as an example. If the systems are downgraded in some way be it from the GPS [global positioning system] or the aircraft systems youre going to go back to raw data. At some stage, the crew may need just altitude-DME information to carry out a constant-angle approach, so tables will be used for the foreseeable future. What do we need to do now? Well, educate those who are unaware of constant-angle approach benefits. Emphasize that we can implement it immediately on any aircraft at effectively no cost. We must train the crews properly, of course, but theres very little training involved, frankly. If authorities are slow to approve, give them a suitable stimulus. Help produce the simplest, clearest approach profiles and minimize the number of approach options. Notes
1. In this case, the DME navigational aid (transponder) was sited along the approach course 3.3 nm (6.1 km) from the
runway threshold. Therefore, for example, the correct altitude for the airplane at the 5-nm DME fix (9.3 km) for a 3-degree angle of descent (300 ft/nm) and (310-ft DME crossing height) would be: (5+3.3) x 300 + 310 = 2,800 ft. 2. The NTSBs final report said the probable cause was the crews decision to descend to 1,800 ft before the aircraft had reached the approach segment where that minimum altitude applied. The crews decision to descend was a result of inadequacies and lack of clarity in the air traffic control procedures which led to a misunderstanding on the part of the pilots and of the controllers regarding each others responsibilities during operations in terminal areas under instrument meteorological conditions. Nevertheless, the examination of the plan view of the approach chart should have disclosed to the captain that a minimum altitude of 1,800 ft was not a safe altitude. Among three contributing factors, the report said, two were: the issuance of the approach clearance when the flight was 44 miles from the airport on an unpublished route without clearly defined minimum altitudes; and inadequate depiction of altitude restrictions on the profile view of the approach chart for the VOR/DME approach to Runway 12 at Dulles International Airport.
DATALINK
BY WAYNE ROSENKRANS
Veer-Offs and Overruns

A fresh analysis of NLR data sources compares business aircraft runway excursions with their airline counterparts.
I
4.0 3.5
Runway excursions per million ights
n recent years, business aircraft have experienced runway excursions at a higher rate than commercial air transports, says Gerard van Es, senior consultant for flight operations and safety, Air Transport Safety Institute, National Aerospace Laboratory of the Netherlands (NLR). His studys starting point was the runway excursion rate per million flights for the last three calendar years (Figure 1). What Ive compared here is commercial operations with business operations business jets, business turboprops worldwide, he said. [NLR] looked at accidents,
Runway Excursion Rate Comparison

Business Commercial
3.0 2.5 2.0 1.5 1.0 0.5 0.0 2010 2011 Year 2012
Notes: NLRs business dataset for this analysis included worldwide accidents, serious incidents and incidents for turbine or turboprop-powered business aircraft with more than one engine, used in business flight operations. NLRs commercial dataset comprised transport category aircraft in commercial airline operations.
Source: National Aerospace Laboratory of the Netherlands (NLR)
Figure 1
incidents, serious incidents, minor incidents, and tried to be as complete as possible. In these three years, its almost a factor of two as between commercial operations and business operations. Looking at the analysis of runway excursions, in business operations versus commercial operations, NLR essentially saw the same causal factors. We saw them with the same frequency in the major accidents and the serious incidents, van Es said. Differences in exposure to factors such as unstable approaches, fast landings and high tail wind landings increase the risk of an excursion. NLR found that such causal factors occurred, or occurred more frequently, among business aircraft operated in a business environment than those in airline operations. Presenting his findings in April during Flight Safety Foundations Business Aviation Safety Seminar in Montreal, he acknowledged limitations of data mining from international sources to study off-side excursions (veer-offs) and off-end excursions (overruns) with known causes. Taxiway excursions were not considered, and all events selected for the dataset involved either turbine or turboproppowered types with more than one engine. Next he focused on runway-overrun accidents in 20082012 for these two industry segments. Again, you see a similar trend, van Es said. You see that the aircraft operated in a business environment have a higher rate. However, the difference in rates was smaller for the
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DATALINK
distribution indicated little difference between the two indusWet/contaminated runway try segments related Long landing to flight phase or type Fast approach/touchdown of runway excursion. Crosswind Both [industry segSystem failure ments] have a very Tail wind Incorrect use of stopping devices similar distribution, Tire failure and in both, the landAquaplaning ing phase is the most Abort/reject after V1 takeo critical phase. [Its] Hard landing where the majority of Commercial Business High on approach the excursions occur, 45% 0% 5% 10% 15% 20% 25% 30% 35% 40% van Es said. Figure 2 shows Share of all excursions with known causal factors leading causal factors V1 = maximum speed in the takeoff at which the pilot must take the first action (e.g., apply brakes, reduce thrust, deploy speed assigned by the acbrakes) to stop the airplane within the accelerate-stop distance Notes: System failure included known causal factors such as hydraulic system failure or antiskid system failure. NLRs business cident investigation dataset for this analysis included worldwide accidents, serious incidents and incidents for turbine or turboprop-powered boards, civil aviation business aircraft with more than one engine, used in business flight operations. NLRs commercial dataset comprised transport category aircraft in commercial airline operations. authority investigaSource: National Aerospace Laboratory of the Netherlands (NLR) tors and aircraft manufacturers; none were Figure 2 assigned by NLR. At the top of the list is whats on the runway and five-year period of excursion accidents than for what it is doing to your tires, he said. A wet the different sources in the 20102012 dataset. or contaminated runway in this case means a The reason for that is not very clear, he lower friction than expected contributed to said. It could be coincidence. It could be due to the accident. the fact that the [business aircraft] excursions The figures data also showed proportions are mitigated more by all kinds of things like of excursions among business operators and RESAs [runway end safety areas] runway airlines alike that could be attributed to fast strips that are much better organized. approach/touchdown, crosswind and system Business aircraft operators want to mitigate runway excursion risks simply because, as in air- failure in fact, differences in distribution of causal factors were small and similar in freline operations, such events represent a signifiquency. Failure to initiate a go-around also was a cant portion of all takeoff and landing accidents, common element. he said. Moreover, damage to aircraft occurred One caveat to this data interpretation, van in about half of the excursions studied, and the Es said, citing one example, is the absence of U.S. National Transportation Safety Board rates information about standard operating procethe prevention of runway excursions among its dures (SOPs) in effect. We can say Yes, the fast top six safety priorities within the risk domain approach contributed to the accident, but maybe of business aircraft operations, he said. there was no SOP for the crew to adhere to, he All told, NLRs data sample for this analysaid. So to them, it was a fast approach but not sis comprised about 1,600 occurrences that a necessity to do a go-around. Thats why you break down as accidents, serious incidents dont see [a direct cause] but you see here eleand incidents all of them events for which ments that justify, in hindsight, a go-around. investigations have been completed. The data Causal Factors in Runway Excursions Studied, 20102012
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DATALINK
In his effort to overcome this limitation, he turned to data on relative exposure to wellknown risk factors. What I mean by exposed is How often do you do landings in tail winds on wet runways? If you do it more, you are exposed more to the risk factor, so there is a probability that operational risks are more related to this factor. Data collected by NLR primarily from flight data monitoring (FDM) programs in Europe and from flight operational quality assurance (FOQA) programs in North America enabled deeper analysis of recorded parameters related to the landing phase. Obtaining such data for business aircraft operations proved difficult, however. We did manage to get data in a reasonable amount, which we could compare to the commercial operations, but its not as complete in terms of the amount, van Es said. There are not millions of flights. There are tens of thousands of flights. Van Es had intended to mine these data partly to identify differences in excursion scenarios for wet and contaminated runway operations. We have no good data from the flight data or any other data to make an estimate or an analysis of how often business operators are exposed to these kinds of conditions, he said. But looking a little bit deeper, we know [from flight data] and we also know from runway excursion accidents, that business aircraft can be operated at smaller, more remote airports, airports that may be less sophisticated in their surface-monitoring system. In other words, they may lack systems in which trained observers visit the runway surface and accurately measure and report conditions. Related risk factors are less-than-optimal maintenance checks of runway surface condition, significant exposure to operations with snow on the runway and marginal snow-removal equipment for runways. more than 15 kt in excess of target approach speed). We found that it was three to five times more likely, when compared to the commercial operations, that the fast speed condition existed in business aircraft operations. In commercial operations, we saw roughly between 1 percent and 8 percent of all their approaches were unstable. In business operations we saw a range as low as 1 percent, but it can also be as high as 14 percent. Theres a very low go-around rate after an unstabilized approach. We see roughly numbers in the 1 to 2 percent range for go-arounds in the business operations. What often happens is that the approach is unstable at 1,000 ft, but the crew manages by speed brakes or whatever to get it back on line at 500 ft, and for the pilot, there is no reason to abort the landing, then go into a go-around. Its still an unstabilized approach, and if it was in IMC [instrument meteorological conditions], it would have justified a go-around. In NLRs methodology for this analysis, a long landing was defined as a touchdown more than 2,400 ft (732 m) from the runway landing threshold, and flight crews of business Runway Excursions Involving aircraft conducted Long Landing, 20102012 about eight times the number of long Business landings (Figure 3) compared with their airline counterparts, Commercial he said. What we dont 20% 0% 5% 10% 15% know in these data Share of all excursions at least from the with known causal factors business operations, is Notes: Long landing in the NLR analysis, sometimes called how long the runways long flare or deep landing, means the touchdown point was more than 2,400 ft (732 m) beyond the runway threshold. were, van Es said. Such landings were about eight times more likely in Pilots can say, Well, I business aircraft operations. NLRs business dataset for this analysis included worldwide accidents, serious incidents have a longer runway; and incidents for turbine or turboprop-powered business that justifies maybe a aircraft with more than one engine, used in business flight operations. NLRs commercial dataset comprised transport longer landing. They category aircraft in commercial airline operations. also have to keep in Source: National Aerospace Laboratory of the Netherlands (NLR) mind that if you operFigure 3 ate a small aircraft
Fast and High

The NLR analyst also searched for evidence of unstabilized approaches. Looking at unstabilized approaches and excursions, the key issues are fast and high approaches, van Es said (ASW, 5/13, p. 34; fast means crossing the runway threshold
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like a Cessna Citation on a runway thats set up for a [Boeing] 747, and you fly the PAPI [precision approach path indicator lights], you always land longer because the PAPI is set up for the 747. Many pilots dont realize that and they are landing much longer than performance calculations assume. NLR also studied runway length as a variable in takeoffs and landings, but found it was not significant in this part of the issue analysis. A similar question whether the width of the runway was causally relevant in veer-off events involved looking at data that showed business aircraft flight crews typically operating on runways narrower than those used by airline flight crews. The important factor here was airplane wheel track, the distance between the outer edges of the main gear, relative to runway width. If you have a commercial aircraft, the wheel track runs typically between 5 and 14 m [16 and 46 ft], he said. Typical aircraft wheel track that theyre using in business operation is between 2.5 and 6.0 m [8.2 and 19.7 ft]. Citing an indirectly relevant regulation, which sets a maximum limit of 9-m [29.5-ft] for landing gear deviation from the runway centerline after an engine failure, he said that a typical business aircraft doesnt need that much of a wider runway to comply with this. He cited Australia as a state with strict regulations applicable to business aircraft operating on runways defined as narrow, while most states only specify corrections to minimum control speeds and maximum allowable crosswind conditions applicable to transport category aircraft.
Tail Wind Realities

Figure 4 shows, as a percentage of total FDM/FOQA flights, a relatively higher incidence of tail wind operations involving business aircraft flight crews than airline crews. Particularly, if you look at the very high ones, more than 10 kt [of tail wind, the difference is] significant, and to operate beyond 10 kt means that you have to have a separate certificate for a Part 25 certified aircraft because you get 10 kt as a standard, van Es said. Im not aware if there are many business aircraft that have this certificate or operators that use this [exception to the rule].
No Crosswind Surprises
Lacking any risk-exposure data about business aircraft encounters with strong gusty crosswind conditions during business operations (ASW, 4/13, p. 39), NLR compared conditions during actual runway veer-offs and overruns with the corresponding fleet-type data for maximum demonstrated crosswinds on a dry runway as a function of the year of aircraft certification. Looking at the average over all these years, event rates are a little bit higher on the data from airline passenger aircraft, but there is no huge difference, van Es said. They come up in the same numbers: [operating within] what they are demonstrated to be capable to handle, he said. What business aircraft operators often will find, however, is that a combination of strong gusty crosswinds with a contaminated runway sets up an unacceptable risk. That combination is a very tricky one. Its not part of the official certification, he said, leaving operators and pilots with only advisory material to make correct judgments about the risk level. Sometimes there are statements in the operating manual saying, Extreme care should be taken when landing in crosswind on a contaminated runway. That doesnt help me. I need some guidance, I need a number. Which crosswinds can this aircraft handle under these conditions?
Runway Excursions Involving Landing With Tail Wind, 20102012

35%
Share of all excursions with known causal factors
Commercial Business
30% 25% 20% 15% 10% 5% 0% 20 15 15 10 50 10 5 Tail wind (kt) 05
510 1015 1520 2025 2530 3035 Head wind (kt)
Notes: Tail wind landings were most prevalent during business aircraft operations in the NLR comparison. NLRs business dataset for this analysis included worldwide accidents, serious incidents and incidents for turbine or turboprop-powered business aircraft with more than one engine, used in business flight operations. NLRs commercial dataset comprised transport category aircraft in commercial airline operations.
Source: National Aerospace Laboratory of the Netherlands (NLR)
Figure 4
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INFOSCAN
Progress, Within Limits

A GAO report says the FAA is making tradeoffs to reap earlier benefits of NextGen.
BY LIN DA WER FEL M A N
REPORTS
GAO
April 2013 United States Government Accountability Office
Report to Congressional Requesters
NEXTGEN AIR TRANSPORTATION SYSTEM FAA Has Made Some Progress in Midterm Implementation, but Ongoing Challenges Limit Expected Benefits
NextGen Air Transportation System: FAA Has Made Some Progress in Midterm Implementation, but Ongoing Challenges Limit Expected Benefits.
U.S. Government Accountability Office (GAO). GAO-13-264. April 2013. 71 pp. Appendixes, figures, tables. Available from GAO at <gao.gov>.
GAO-13-264
his report, written at the request of members of the U.S. House of Representatives Committee on Transportation and Infrastructure, examines challenges facing the U.S. Federal Aviation Administration (FAA) in its implementation of the Next Generation Air Transportation System (NextGen). NextGen an overhaul of air traffic control procedures featuring satellite-based surveillance, performance-based navigation (PBN) and data link communications is intended to enhance safety in the National Airspace System, reduce delays, save fuel and lower carbon dioxide emissions. During the midterm of the NextGen implementation process, from 2013 through 2018, the FAAs efforts are focusing on establishing PBN procedures at key airports, using currently available technologies in the hope that some of the benefits of NextGen can be realized now. To deliver benefits more quickly, FAA made tradeoffs in selecting sites and in the scope of
proposed improvements, the GAO report said. For example, FAA is not implementing procedures that will trigger lengthy environmental reviews. These tradeoffs will likely limit benefits from these PBN initiatives early in the midterm. FAA also has made some progress in other key operational improvement areas, such as upgrading traffic management systems and revising standards to improve aircraft flow in congested airspace. However, FAA has not fully integrated implementation of all of its operational improvement efforts at airports. Because of the interdependency of improvements, their limited integration also could limit benefits in the midterm. The report noted that the FAA is proceeding with NextGen implementation by using long-established processes and requirements that have made the U.S. airspace among the safest in the world. Nevertheless, because some of those processes are lengthy and complicated, progress toward implementation has been slow, the report said. The process of developing PBN and other new flight procedures was identified several years ago as a challenge, and the FAA has since begun streamlining the procedures. There is no estimate of how much time will be saved, however.
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The report said the agency is developing NextGen performance metrics, but data that would demonstrate its progress are limited. Information is incomplete on the midterm improvements and their benefits at selected airports, and airlines and others lack access to needed information to make fully informed investment decisions, the report said. The report recommended that the FAA better integrate NextGen efforts, develop processes for selecting new PBN procedures and ensure that stakeholders have needed information on NextGen progress to facilitate investment decisions.
A Review of the Effectiveness of Emergency Locator Transmitters in Aviation Accidents

Australian Transport Safety Bureau (ATSB). AR-2012-128. May 2013. 23 pp. Appendix, figures, photographs, table. Available from ATSB at <atsb.gov.au/publications>.
ccident investigators and others in the aviation community have for years expressed concern about the effectiveness of airframe-mounted emergency locator transmit ters (ELTs), which are designed to activate automatically after a crash. This report discusses the findings of ATSB researchers, who examined the agencys data and found that ELTs function correctly in 40 to 60 percent of accidents in which their activation would have been expected. They also reviewed search and rescue (SAR) records maintained by the Australian Maritime Safety Authority and found that ELT activation accounted for the first notification of an accident in about 15 percent of cases. These activations were considered responsible for saving about four lives per year, the report said. The report found a number of factors that were responsible in accidents in which the ELTs did not function properly. Among those factors were not selecting the ELT activation to armed before flight, incorrect installation, flat [depleted] batteries, lack of waterproofing, lack of fire protection, disconnection of the
co-axial antenna cable from the unit during impact, damage and/ or removal of the antenna during impact and an aircraft coming A review of the effectiveness of to rest inverted after emergency locator transmitters in Insert document title impact. aviation accidents The report cited several accidents involving ELT issues, including improper installation, separation of an ELT from the aircraft during the accident, destruction of an ELT by a post-impact fire, and failure of a waterdamaged ELT. The report said that when ELTs are installed correctly, they should operate in high g-force accidents. It suggested the use of ELTs equipped with a global positioning system (GPS) receiver to enhance the accuracy of their position-reporting. Newer ELTs with 3-axis g switches may improve chances that the unit will activate after impact, the report said. It is important to remember that ELTs are an important safety device, not only for aircraft occupants but also for SAR personnel, the report said. Even if an aircraft is destroyed in an accident and the occupants are deceased, a functioning ELT helps SAR in minimising search times, risk to rescue personnel and use of SAR resources. The report cited data showing that, of 442 SAR operations associated with aircraft emergencies between June 1999 and December 2012, 68 operations benefited from the detection of an activated ELT or PLB [personal locator beacon], resulting in 52 lives saved during this period.
Location | Date Research Investigation ATSB Transport Safety Report [Insert Mode] Aviation Research Occurrence Investigation Investigation XX-YYYY-#### AR-2012-128 Final 21 May 2013
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INFOSCAN
Federal Aviation Administration
Development and Utility of the Front Line Managers Quick Reference Guide
DOT/FAA/AM-13/10. McCauley, Darendia; Peterson, L. Sarah; King, S. Janine. U.S. Federal Aviation Administration (FAA) Office of Aerospace Medicine. May 2013. 18 pp. Appendix, tables. Available from the FAA at <www.faa.gov/ data_research/research/med_humanfacs/oamreports/2010s/ media/201310.pdf>.
DOT/FAA/AM-13/10 Office of Aerospace Medicine Washington, DC 20591
Development and Utility of the Front Line Managers Quick Reference Guide
Darendia McCauley L. Sarah Peterson Civil Aerospace Medical Institute Federal Aviation Administration Oklahoma City, OK 73125 S. Janine King Xyant Technology, Inc. Oklahoma City, OK 73125
May 2013
Final Report
his document was developed to examine the effectiveness of the Front Line Managers Quick Reference Guide (QRG), a resource guide to help front line managers (FLMs) in air traffic control operations more effectively supervise their employees while enhancing safety and communication. It also serves as training support, when other training opportunities may not be readily available, the document says. The QRG itself was developed, in part, with input from studies conducted by Booz Allen Hamilton to identify the best practices of FLMs in promoting safety and therefore to mitigate operational incidents and runway incursions throughout the National Airspace System. To assess the usefulness of the QRG, the FAA Civil Aerospace Medical Institute and the FAA Air Traffic Organization developed and administered a survey of FLMs. A copy
of the survey, which received responses from about 850 individuals, is included as an appendix. Survey results showed that 82 percent of respondents considered information in the QRG somewhat or very appropriate to their jobs, and more than half said they would probably or definitely use the QRG for reference. ELECTRONIC MEDIA
The U.S. Federal Aviation Administration (FAA) North Atlantic (NAT) Resource Guide for U.S. Operators.
<www.faa.gov/about/office_org/headquarters_offices/avs/offices/ afs/afs400/afs470/media/NAT.pdf>
FAA NAT Resource Guide for U.S. Operators

Emphasis Items Initiatives NAT Airspace References Com / Nav / Surveillance (CNS) Inspector Guidance
Caption describing picture or graphic.
Version 13.5 Reviewed Monthly
This resource document consolidates U.S. and International guidance for U.S. operators. Please direct questions regarding NAT operations to your Regional (AXX-220) NextGen Special Areas of Operation (SAO) Specialist. Contact us via email with your questions and comments pertaining to this PDF document.
Contact US Send Comments Frequently Asked Questions Acronyms
Video: Track Wise New York 50/30/30 Notice SAFO 13004

NAT OPS Bulletin 2013-001, Information & Guidance for Data Link Oceanic Clearance Delivery in Santa Maria FIR
! NEW
he FAA maintains this guide for U.S. operators of aircraft in NAT airspace the most-traveled oceanic airspace in the world, with about 450,000 flights in 2011. The guide, in Adobe portable document format (PDF), brings together multiple sources of domestic and international regulatory guidance relevant to flight operations in NAT airspace, the FAA says. This guide provides operators and FAA inspectors an easy one-stop access to multiple sources of information used to promote the highest standards of horizontal and vertical navigation performance and accuracy in the NAT. Documents contained in the guide discuss flight planning, weather deviation and strategic lateral offset procedures procedures that enable flight crews on some aircraft to fly on a track parallel to an airway centerline, 1.0 or 2.0 nm (1.9 or 3.7 km) to the right. The guide is updated monthly and to provide the most current information for mitigating large height deviations and gross navigation errors in the NAT, the FAA said. A large height deviation is defined as a deviation of 300 ft or more from an assigned altitude/flight level; gross navigation errors are deviations of 25 nm (46km) or more.
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Automation Surprise
The captains reaction to an unexpected autopilot pitch change resulted in an unsafe descent.
BY MARK LACAGNINA
The following information provides an awareness of problems that might be avoided in the future. The information is based on final reports by official investigative authorities on aircraft accidents and incidents.
JETS
Go-Around Delayed
Boeing 777-300. No damage. No injuries.
he tower controller at Melbourne Airport in Victoria, Australia, noticed that the 777 was lower than it should have been and advised the flight crew to check their altitude. Receiving no immediate response, the controller told the crew to go around. However, nearly a minute elapsed before the aircraft began to climb. The crew completed the go-around and landed without further incident. During its investigation of the incident, the Australian Transport Safety Bureau (ATSB) determined that the pilot-in-command (PIC) may not have fully understood some aspects of the aircrafts automatic flight control systems and probably experienced automation surprise when the autopilot commanded an unexpected pitch change during the nonprecision approach. Moreover, the ATSBs final report said that the crews delay in complying with the controllers go-around instruction could have resulted in a more hazardous situation if, for instance, the instruction had been issued because of terrain or traffic, rather than because the aircraft was unusually low on final approach. The incident occurred the night of July 24, 2011, during a passenger flight to Melbourne from Bangkok, Thailand. The first officer was the pilot flying.
The 777 was nearing Melbourne at 6,000 ft when the approach controller told the crew to descend to 3,000 ft and issued a vector to establish the aircraft on the VOR (VHF omnidirectional range) approach to Runway 34. Weather reports indicated that visual meteorological conditions existed at the time and visibility was reduced to about 8 km [5 mi] due to rain showers, the report said. The wind was reported to be from the north at about 20 kph [11 kt]. The descent was conducted with the autopilots lateral navigation (LNAV) and vertical navigation speed (VNAV SPD) modes selected, and with 230 kt and 3,000 ft set in the mode control panel (MCP). In [VNAV SPD] mode, the autoflight system acted to maintain the selected airspeed of 230 kt and limit the descent to not below 3,000 ft, the report said. The published minimum altitude between the initial approach fix and the intermediate approach fix was 3,000 ft. However, the aircrafts flight management computer (FMC) had computed a final glide path that began at 3,440 ft, to enable descent on a constant 3-degree glide path, rather than the consecutive step-downs at the intermediate approach fix and the final approach fix, to the minimum descent altitude (MDA). The 777 was descending through 3,300 ft as it neared the intermediate approach fix, and the
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autopilot automatically changed from the VNAV speed mode to the VNAV flight path mode, to follow the computed approach path. As the FMC- calculated approach path altitude was about 3,400 ft and above the aircrafts current altitude, the [autopilot] commanded a pitch-up to level flight for interception of the required approach path, the report said. Although the flight crew had conducted similar coupled approaches before, the pitch-up in this case apparently was more pronounced. While the [PIC] reported that he had not observed this type of [autopilot] behaviour before, it was possible that during previous approaches, the aircraft was already on or above the required approach path, the report said. In that case, any pitch change would have been minimal. The PIC apparently was expecting the aircraft to level off at 3,000 ft, and the unexpected pitch-up at 3,300 ft caused him to suspect a fault in the autopilot VNAV mode. He reacted by setting 2,000 ft and 190 kt in the MCP and selecting the autopilot flight change mode. While it was likely that those actions were intended to arrest the pitch change and continue the descent, they were symptomatic of automation surprise on the part of the PIC, probably due to a lack of [autopilot] mode appreciation, the report said. In flight change mode, the autopilot adjusts the pitch attitude to maintain the speed selected on the MCP. In that mode, the aircrafts rate of descent is unrestricted and therefore may be significantly higher than that required for an instrument approach, the report said. To maintain the selected airspeed of 190 kt down to 2,000 ft, the autothrottle reduced engine thrust to flight idle. At this point, the crew inadvertently set 970 ft (the MDA) in the MCP, which
caused the aircraft to prematurely descend below 1,950 ft, the published minimum altitude between the initial approach fix and the final approach fix. Shortly thereafter, the PIC established radio communication with the airport tower controller and reported the airport in sight. The tower controller cleared the crew to conduct a visual approach if the aircraft was established on the precision approach path indicator (PAPI) glide path and was inside the circling area. At the time, the aircraft was below the PAPI glide path and nearly 2 nm (4 km) outside the circling area. The PIC momentarily lost sight of the runway when the aircraft encountered a rain shower. He then noticed four red PAPI lights, indicating that the 777 was substantially below the 3- degree glide path, and told the first officer to stop the descent. The first officer disengaged the autopilot and leveled the aircraft. About the same time, the tower controller observed both visually and by radar that the aircraft was low on the approach and asked the flight crew to check altitude, the report said. Four seconds later, the controller instructed the crew to climb, go around, carry out missed approach Runway 34, to which the flight crew responded climbing. The aircraft was still outside the final approach fix and at 984 ft (966 ft below the minimum segment altitude) when the controller issued the instruction to go around. Although the missed approach procedure called for an initial climb to 4,000 ft, the aircraft climbed only to about 1,200 ft. About 50 seconds later, the controller asked the crew to confirm that they were conducting a go-around. The PIC replied, We are climbing. We are maintaining 1,200.
The tower controller again told the crew to go around. The PICs response was mostly incomprehensible but included the words on visual approach. Negative, the controller said. Missed approach Runway 34. Climb to 4,000 ft. The crew complied with the instruction, conducted another VOR approach with the autopilot LNAV and VNAV modes engaged and landed the aircraft on Runway 34. The report said, This occurrence highlights the risks inherent in the conduct of nonprecision approaches and reinforces the need for flight crews to closely monitor the aircrafts flight path to ensure it complies with the prescribed procedure. Noting that errors in the use of automatic flight control systems have been identified as causal factors in 20 percent of approach-and-landing accidents worldwide, the report said, Modern air transport aircraft are equipped with ever-increasing levels of automation that, when used appropriately, can greatly reduce flight crew workload. While flight crews retain the option of flying the aircraft manually, the use of automation is generally preferred and often provides increased levels of safety and efficiency. To effectively manage the aircraft and flight path, however, flight crews need to maintain a thorough understanding of the relevant automatic flight systems. The airline responded to the incident by issuing a notice to flight crews emphasizing the importance of constant-angle nonprecision approaches and adherence to published minimum safe altitudes. Other actions included a review of the training in support of nonprecision approaches and the provision of additional information relating to the use of the aircrafts autopilot/ flight director system, the report said.
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Sickened by Mysterious Odor
examinations in a Frankfurt hospital, with no abnormal results. A further examination of the aircraft revealed nothing about the source of the odor. This event thus joins a growing number of cases in which there has been a similar lack of conclusive evidence as to the cause(s) of aircraft cabin air quality issues, the report said. Although research has shown that cabin air can be contaminated by the pyrolysis (thermochemical decomposition) of engine and auxiliary power unit lubricants, in tests where measurements of contaminants have been taken, the concentration is invariably well below internationally agreed levels for occupational exposure, the report said. an examination by aircraft rescue and fire fighting personnel, the aircraft was towed to a gate, where the 49 passengers deplaned. Maintenance personnel found that a brake pressure plate and rotor had failed. Separated brake parts were also found on the landing runway, the report said. Further examination of the incident brake and four other brakes revealed that they all contained varying levels of oxidation development. The report concluded that the oxidation that had caused the brake rotor to overheat and fail had not been detected by the operators maintenance personnel. Investigators found that the operator had received details of a maintenance procedure developed by the brake manufacturer that involved the use of a fingernail or plastic tool to check brake rotors for oxidation. The operator developed and provided related training to its maintenance personnel based on the manufacturers procedures, the report said. However, interviews with airline and contract maintenance personnel revealed that they were not familiar with the inspection and were not issued the plastic tool. Subsequently, the brake manufacturer and operator provided additional related training to the operators maintenance personnel, and the operator stocked their maintenance system with the specified tool.
Airbus A321-131. No damage. No injuries.
he A321 was descending through 12,000 ft to land at London Heathrow Airport the morning of Oct. 21, 2012, when the flight crew detected a strong odor causing throat and eye irritation. The copilot soon became dizzy and nauseous. The commander used the interphone to call the purser, who confirmed that there was also an odour in the cabin and that she was experiencing the same symptoms as the copilot, said the report by the U.K. Air Accidents Investigation Branch (AAIB). Both pilots donned their oxygen masks, and a request was made to air traffic control (ATC) for priority landing clearance. After an uneventful approach, the aircraft landed within 1015 minutes of the onset of the smell, the report said. The aircraft was halted on a parallel taxiway, and the engines and air conditioning were shut down. After shutting the engines down, the situation in the cabin improved, although a few [of the 139] passengers reported light throat irritation. However, the copilots dizziness and nausea persisted, and several other crewmembers continued to experience eye and throat irritation. As a result, the entire crew were sent to a local hospital for examination, the report said. They were released after several hours, by which time their condition had improved and the results of blood tests, taken earlier, produced no medical findings. An examination of the A321s engines, air conditioning system, galleys and lavatory revealed nothing to explain the odor or the illness it had caused. After the recirculation and avionics filters were replaced, the aircraft was released for a ferry flight to its home base in Frankfurt, Germany. The crew received medical
Oxidized Brakes Overheat
Embraer 145. Minor damage. No injuries.
fter touching down at Chicago (Illinois, U.S.) OHare International Airport the morning of June 3, 2011, the flight crew experienced the sensation that one brake pedal had fully released momentarily. An airport traffic controller saw a puff of smoke emerge from the main landing gear and asked the crew if a tire had burst. Directional control was maintained during the landing roll, and the crew taxied the EMB-145 to a holding pad. Braking action diminished as the taxi progressed, said the report by the U.S. National Transportation Safety Board (NTSB). When stopped on the pad, it was discovered that the emergency brake would not hold the aircraft stationary. In addition, the crew received messages warning of brake hydraulic system failure, as well as a report by a flight attendant that smoke was seen on the right side of the aircraft. The crew shut down the engines and started the auxiliary power unit. After
Control Lost in Wind Shear
Learjet 35. Substantial damage. No injuries.
s the Learjet neared Opa-Locka (Florida, U.S.) Executive Airport the afternoon of July 12, 2011, the automatic terminal information service broadcast indicated that visual meteorological conditions prevailed at the field, with surface winds from 340
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degrees at 4 kt. The flight crew prepared for a visual approach to Runway 12. At the time, terminal doppler weather radar data indicated strong convective activity northwest of the airport. The data also identified possible microbursts and diverging winds near the surface, the NTSB report said. As the crew conducted the visual approach, the tower controller made several announcements about an area of weather about 5 mi (8 km) wide with light-to-moderate precipitation that had moved onto the airport. A special weather observation indicated that the direction of the surface winds varied between northwest and northeast, and that the velocity had increased to 15 kt, with gusts to 20 kt. The Learjet was about 30 ft above the runway when it encountered wind shear. It rolled left, and indicated airspeed decreased about 20 kt. As the pilot attempted to regain control of the airplane, the right wing tip made contact with the runway surface, the report said. After touchdown, the pilot applied differential engine power and aggressive flight control inputs to stay on the runway. The airplane was substantially damaged, but none of the four occupants was injured. After taxiing to the ramp and shutting down the engines, the pilots found that the right wing tip tank had separated and was hanging by the lower wing skin, the report said.
TURBOPROPS
Gusts Were Nasty
ATR 72-212. Destroyed. No injuries.
he aircraft was on a scheduled flight with 21 passengers and four crewmembers from Manchester, England, to Shannon (Ireland) Airport, which had strong, gusty winds from the northwest, good visibility, a few clouds at 1,000 ft and a broken ceiling at 1,300 ft. The flight crew was cleared to conduct the instrument landing system (ILS) approach to Runway 24, which was 3,199 m (10,496 ft) long. (Shannons secondary runway, 13-31, had recently been closed and converted to a taxiway.) During the approach briefing, the commander, the pilot flying, said that she intended to add 15 kt to the normal approach speed and touch down at the end of the runway touchdown zone, to avoid mechanical turbulence created by a hangar near the runway threshold, said the report by the Irish Air Accident Investigation Unit (AAIU). As the crew began the approach, the tower controller advised that occasional moderate turbulence was observed and forecast in the touchdown zone of Runway 24. The winds had been reported from 300 degrees at 20 kt, but
during the approach, the velocity increased to 24 kt, with gusts to 32 kt. The controller also passed this information to the crew. The commander told investigators that the gusts were nasty when she flared the ATR for landing. The aircraft touched down on the nose wheel, bounced and touched down again, harder. The crew initiated a go-around and requested vectors for another ILS approach to Runway 24. During this second approach, landing turbulence was again experienced, the report said. Following bounces, the aircraft pitched nosedown and contacted the runway heavily in a nosedown attitude. The nose gear collapsed, and the aircraft nose descended onto the runway. There were no injuries, but the aircraft was deemed to be damaged beyond economical repair. AAIU concluded that the probable cause of the accident was excessive approach speed and inadequate control of aircraft pitch during a crosswind landing in very blustery conditions. Although the commander had planned to conduct the approach at 107 kt, the indicated airspeeds on touchdown were 139 kt and 140 kt, respectively. This was partly due to the pilot flying increasing torque after flaring and partly due to the prevailing gusty conditions, the report said.
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The copilot had made no airspeed callouts during either approach, and the commander had not requested them. A lightly loaded aeroplane at [indicated airspeeds] well above [the calculated approach speed] does not tend to touch down after the flare, the report said. At such speeds, the aeroplane has to be flown onto the runway; then, it can tend to bounce due to excessive lift still being generated by the wings. off and on. However, they later told investigators that they did not place the generator switches in the RESET position. The crew adhered to established communications-failure procedures and circled Cambridge Airport while attempting to manually extend the landing gear. The report noted that the captain neglected to pull the landing gear relay circuit breaker, as required, and that the copilot stopped operating the alternate gear- extension handle after feeling resistance to its movement. The crew then conducted a no-flap landing. The aircraft touched down gently at approximately 100 kt, the report said. Almost immediately after touchdown, the landing gear started to collapse. The commander shut down the engines and feathered the propellers as the aircraft settled onto its belly cargo pod and main landing gear doors. The pilots and the two technical crewmembers evacuated without injury after the King Air came to a stop on the runway. It was not possible to determine the cause of the electrical failure, the report said. Although, due to their proximity, it is possible that the ignition-and-engine-start switches could have been operated by mistake instead of the anti-ice switches. This action would have caused the generators to go off-line. If the generators had gone off-line for some reason, resetting them might have restored electrical power. A possible explanation for the landing gear collapse was that the crew ceased operating the alternate extension handle before the landing gear was fully extended, the report said. The electrical failure meant that the crew had no indication of the landing gear position and therefore could not confirm that the gear was down and locked prior to landing.
Inadvertent Prop Overspeed
Bombardier DHC-8-315. No damage. No injuries.
Electrical System Fails
Beech B200 King Air. Substantial damage. No injuries.
he crew was returning to Cambridge (England) Airport after completing a communicationsrelay mission in support of the Olympic Games the afternoon of July 28, 2012. While conducting the Descent checklist, the copilot, the pilot flying from the left seat, noticed that the fuel gauges read zero. At the same time, ATC told the crew that Mode C transponder replies no longer were being received. After the commander replied that they likely had an electrical system problem, ATC received no further radio transmissions from the aircraft. Over the next two to three minutes, the pilots experienced a progressive failure of all of the electrical equipment, with the exception of the left instrument panel electronic flight information system display, the AAIB report said. This remained powered by a backup power supply. Other components, including the standby compass, also remained operational. The report said that there was no checklist for a total electrical system failure. Among their troubleshooting actions, the pilots selected the alternate inverter and turned the battery switch and both generator switches
he first officer, the pilot flying, had his hand on the power levers during a flight idle descent to land at Weipa, Queensland, Australia, the night of Dec. 6, 2011. When the aircraft encountered turbulence, the first officer inadvertently lifted one or both of the flight idle gate release triggers and moved the power levers below the flight idle gate, the ATSB report said. Both propellers exceeded the maximum limit by more than 300 rpm briefly before the first officer, hearing the beta warning horn and the increased propeller noise, moved the power levers back above the flight idle gates. The propellers returned to the normal controlled operating rpm, the report said. The aircraft subsequently was landed without further incident in Weipa, where maintenance personnel found no damage to the engines or propellers. Noting that many Dash 8-100, -200 and -300 series aircraft do not have a means to prevent inadvertent or intentional movement of the power levers below the flight idle gates in flight, the report said, This design limitation has been associated with several safety occurrences. At the time of the incident, beta-lockout modifications had been mandated by aviation authorities in Papua New Guinea and the United States. Transport Canada subsequently announced its intention to issue an airworthiness directive requiring such modifications in all Dash 8-100, -200 and -300 aircraft.
54 |
ONRECORD
PISTON AIRPLANES
Engine-Out Control Loss
Cessna 421C. Destroyed. Seven fatalities. he 421 was en route at 21,000 ft from St. Louis, Missouri, U.S., to Destin, Florida, the afternoon of July 9, 2011, when the pilot declared an emergency due to a rough-running right engine and diverted the flight to Demopolis (Alabama) Municipal, an uncontrolled airport about 10 nm (19 km) away. A few minutes later, the pilot told ATC that he had shut down the right engine. The airplane was at 17,000 ft when it reached the airport, and the pilot continued the descent while circling the field. The airplane descended through 2,300 ft when it was abeam the runway threshold on the downwind leg of the traffic pattern, the NTSB report said. ATC radar contact was lost when the airplane was at 700 ft (600 ft above ground level) and about 3 nm (6 km) from the approach end of Runway 22. The airplane was configured for a singleengine landing and was likely on or turning to the final approach course when it rolled and impacted trees, the report said. The airplane came to rest in a wooded area about 0.8 mi [1.3 km] north of the runway threshold, inverted, in a flat attitude. A majority of the airplane [was] consumed by a postcrash fire. All seven occupants were killed.
Investigators determined that the right engine had failed because of a fatigue fracture of one of the teeth on the camshaft gear. The remaining gear teeth were fractured in overstress and/or were crushed due to interference contact with the crankshaft gear, the report said. Spalling observed on an intact gear tooth suggested abnormal loading of the camshaft gear; however, the origin of the abnormal loading could not be determined.
Distracted by Chatter
Beech 58 Baron. Substantial damage. No injuries. he pilot was conducting the Before Landing checklist on approach to the airport in Sugar Loaf Mountain, Michigan, U.S., the afternoon of July 10, 2012, when he became distracted by a conversation between his two passengers. Earlier in the flight, the pilot briefed his passengers about having a sterile cockpit environment during the landing phase of flight, but the conversation did not cease, the NTSB report said. The pilot did not complete the checklist and neglected to extend the landing gear. He told investigators that he did not hear the gear-warning horn. Before he realized that the gear was still up, the airplane impacted the runway, sustaining substantial damage to the fuselage during the wheels-up landing, the report said.
HELICOPTERS
Mist Shrouds Unmarked Tower
Bell 206B. Destroyed. Two fatalities.
he pilot was repositioning the JetRanger from North Bay to Kapuskasing in Ontario the afternoon of July 23, 2010, in preparation for sightseeing flights the next day. Another company pilot was aboard as a passenger. The Transportation Safety Board of Canada (TSB) determined that the pilots preflight review of weather conditions had been inadequate and that he was not aware of deteriorating conditions along the route. Data recovered from the global positioning system (GPS) receiver indicated that the helicopter was flown at progressively lower altitudes
and that higher terrain was encountered as the visual flight rules flight progressed. The helicopter was about 52 ft above the ground when it struck an unmarked and unlighted 79-ft radio tower located atop a hill and descended to the ground near Elk Lake about 72 minutes after departing from North Bay. Reduced visibility likely obscured the tower and reduced the available reaction time the pilot had to avoid the tower, the TSB report said. Because the tower was not depicted on the VNC [visual navigation chart] or GPS, the pilot was not likely aware that it existed. The report noted that the GPS receivers database had not been updated.
| 55
ONRECORD
Preliminary Reports, May 2013

Date May 2 May 3 May 4 May 5 Location Catskill, New York, U.S. Chorgolu, Kyrgyzstan Newtok, Alaska, U.S. Valencia, Venezuela Aircraft Type Grumman G-44 Widgeon Boeing KC-135R Stratotanker Cessna 207A Learjet 60 Aircraft Damage substantial destroyed substantial destroyed Injuries 1 fatal 3 fatal 4 minor 2 fatal
Witnesses saw the seaplane maneuvering low over the Hudson River before it struck the water and sank. The airplane, operated by the U.S. Air Force, struck mountainous terrain during a local flight from Bishkek-Manas International Airport. The airplane was on a scheduled passenger flight when it crashed about a mile from the airport during a visual approach in fog. Instrument meteorological conditions prevailed when the Learjet crashed in a residential area about 3 km (2 nm) from the runway during final approach. A building and six vehicles were damaged, but no one on the ground was injured. May 7 May 8 May 8 La Junta, Colorado, U.S. Wamena, Indonesia Honolulu, Hawaii, U.S. Bell 206L-1 British Aerospace 146-200QT Robinson R22 Beta substantial destroyed substantial 3 none 1 serious 1 minor, 1 none The helicopter struck terrain after tail rotor control was lost during an aerial observation flight. Oil barrels were being unloaded with a forklift when a fire erupted and engulfed the aircraft. The engine lost power during an aerial photography flight. The helicopter skidded into a parked vehicle during the subsequent autorotative landing on a road. May 13 McMinnville, Oregon, U.S. Learjet 35A substantial 3 none The Learjet overran the runway after the thrust reversers and the wheel brakes malfunctioned on landing during a postmaintenance repositioning flight. The squat switches on both main landing gear were found loose. May 16 May 16 May 16 May 16 Shenyang, China Mon Hsat, Myanmar Jomsom, Nepal Floriston, California, U.S. Harbin Yunshuji Y-12 Xian MA60 de Havilland Twin Otter Cessna 421C destroyed substantial destroyed destroyed 1 serious, 2 minor 2 serious, 53 minor/none 6 serious, 15 minor 1 fatal The aircraft crashed on a road shortly after taking off for a cloud-seeding flight. The left main landing gear collapsed after the aircraft overran the runway on landing. The Twin Otter veered off the runway on landing, traveled down an embankment and came to a stop on a river bank. While descending in visual meteorological conditions (VMC) to land in Reno, Nevada, the pilot reported that the airplane was in a spin. The 421 then struck mountainous terrain. May 23 May 24 Krakow, Poland London, England Piper Seneca Airbus A319-131 destroyed NA 3 fatal 80 none VMC prevailed when the Seneca struck a mountain at 5,600 ft during a personal flight from Poznan, Poland, to Bratislava, Slovakia. The A319 was departing from London Heathrow Airport when the fan cowl doors on both engines separated, damaging the airframe and causing fuel and hydraulic leaks. The crew shut down the right engine due to a fire while returning to land at Heathrow. May 24 May 24 Jalal-Abad, Kyrgyzstan Johnstown, New York, U.S. Antonov 2R Piper Seneca II destroyed destroyed 3 fatal 3 fatal The aircraft crashed under unknown circumstances during a fumigation flight to combat locusts. The airplane was on a volunteer medical transport flight from Boston to New York when it entered an uncontrolled descent, broke up in flight and crashed in a reservoir. May 26 May 27 May 27 May 31 Port-au-Prince, Haiti Eisenach, Germany Simikot, Nepal Wamena, Indonesia Boeing KC-137E Piper Twin Comanche Cessna 208B Caravan British Aerospace ATP substantial destroyed substantial substantial 143 none 1 fatal 11 none 3 none The transport, operated by the Brazilian air force, veered off the runway during a rejected takeoff due to an engine fire. The aircraft crashed out of control shortly after takeoff. The Caravan veered off the runway and struck a ditch after the right tire burst on landing. The nose landing gear collapsed when the cargo aircraft veered off the runway on landing.
NA = not available This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed.
56 |
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AeroSafety

A330 CFIT IN TRIPOLI

CAUSAL FACTORS FROM LIBYAN CAA

66th annual International Air Safety Summit

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