Aviation Safety Letter

Over the course of the last few years, TCCA has undergone a fundamental change in its approach, and in the industry you’ve surely noticed this change. Today, we’re working differently than we did a few years ago and we’re already seeing international recognition for the approach we are taking. Safety Management Systems (SMS) mandates a reporting culture and also encourages employee feedback. Our inspectors conduct SMS assessments to verify that the SMS concept is working in practice, not just in theory. These inspections include numerous interviews with company employees and managers, which is something we have never done before. Results show that Canadians are indeed best served by this modern safety culture. We continue to work hard every day to refine our practices and further advance an already exceptional air safety system. We are also collaborating with industry stakeholders and we are very pleased to see so many taking initiative, such as developing guidance material, to strive for the highest level of safety. The move to a systems-based approach to safety has been no small task. SMS implementation for Canada’s large airlines was a major undertaking and it took time to get things working effectively. While smaller operators may be less complicated, the sheer volume of them operating across the country is immense, which demands that we are fully ready before we begin SMS implementation for this sector of the aviation industry. It’s very important to us to get it right, and I truly appreciate our stakeholders’ understanding as we work to find the best way forward in modernizing aviation surveillance. Internal quality assurance at Transport Canada After seeing the benefits of applying a systems-based approach to the industry, we were confident that we here at TCCA could also benefit from this type of thinking. We began developing our own integrated management system (IMS), which is helping us put in place the right systems and processes to get things done more effectively and efficiently. At its core, IMS is a quality management system. It involves documenting all of the policies, practices, procedures, and controls that guide and support the Civil Aviation Program, and it’s allowing us to experience benefits similar to those achieved by the industry’s safety management systems. Ultimately, this is about establishing consistency and effectiveness in our program’s delivery across the country. This means the industry can expect to receive a consistent level of oversight from TC, whether its operations are based in Halifax, Whitehorse, or Victoria. Reorganizing to serve Canadians better Just as we’re working to achieve efficiencies in the industry and in our own processes and procedures, we also want to be sure our organization is an efficient and effective one. In short, we’re making sure we have the right people in the right places to meet TCCA’s aviation safety oversight commitments. We’re integrating TCCA’s functions and being as cost effective and efficient as possible while staying true to our mandate of maintaining a high level of aviation safety in Canada. Martin Eley 4 ASL 1/2012 To the Letter To the Letter Pre-Flight Pre-Flight Guest Editorial Guest Editorial Pre-Flight Pre-Flight The reorganization project is called the National Organization Transition Implementation Plan (NOTIP). The team leading this transition is close to realizing its goal of implementing the design of a modern organization that easily facilitates the application of TCCA’s business model, the introduction of SMS, and the implementation of our own IMS. We’re making every effort to recruit and retain employees that have crucial competencies, as well as maintaining corporate memory. What’s more, the standard work descriptions being created by the transition team will provide consistency, which again means the industry can expect to receive a consistent, efficient oversight from TC across the country. In closing As Gerard McDonald, Assistant Deputy Minister of Safety and Security, stated in the previous issue’s editorial, “Canada has one of the safest aviation systems in the world.” He and I both feel this is something to be proud of and something to drive us forward to reach new goals. In the business of safety, we can never afford to become too comfortable or complacent, even when the level of safety is already high. We must always reach higher and ask ourselves, “how can we continue to improve,” and “how can we make sure our system stays safe despite increasing volume?” At TC, we are committed to driving the level of aviation safety even higher by modernizing the way we do things. By evolving our approach to safety oversight, re-evaluating our own policies and procedures, and reshaping our organization, we’re confident we’re ready to meet the challenges of the ever-developing aviation sector. Be assured that we will continue to work with our industry partners to maintain the exceptional level of aviation safety Canadians already enjoy, as safety is a responsibility we all share. Martin J. Eley Director General Transport Canada, Civil Aviation Celebrate Canada's Air Transportation Safety, Strength and Success! www.tc.gc.ca/aviation-day NATIONAL AVIATION DAYFEB 23 ASL 1/2012 5 pre-flight The SMS Approach to Dangerous Goods in a 705 World ........................................................................................... page 5 COPA Corner—Electrical Fires Do Happen................................................................................................................. page 6 Emergency? Let Air Traffic Services Know..................................................................................................................... page 8 The SMS Approach to Dangerous Goods in a 705 World by Daniel Sylvestre, Civil Aviation Safety Inspector, National Operations, Civil Aviation, Transport Canada In 2005, the National Operations Branch, along with the rest of Civil Aviation, started the Safety Management System (SMS) certification of the air operators assigned to the Branch’s Airlines Division, with final assessments completed in 2009. While there were massive efforts by both the air operators and Transport Canada (TC) to bring a successful completion to this new system, we cannot forget that day-to-day operations continued. The air operators continued to fly and TC continued with certification and surveillance activities, including activities related to the safe transport of dangerous goods by air. As the transport of dangerous goods by air affects everybody in the air operators’ activities, such as flight operations, cabin safety, passenger handling, ground handling, cargo operations and the shipments of maintenance spares, the oversight strategies often had to be customized. In addition, the safe transport of dangerous goods involves many laws and regulations, among them the Civil Aviation Regulations (CARs), the Transportation of Dangerous Goods Act (TDGA) and associated Regulations (TDGR), and by reference, the International Civil Aviation Organization’s (ICAO) Technical Instructions for the Safe Transport of Dangerous Goods by Air. To date, we have every indication that the implemented SMS strategies worked, allowing us to review the best practices that made it possible. We believe that one of the key ingredients to its success was that whenever a new process was initiated or developed, we returned to the SMS principles identified in TC’s documents. One of the key principles, and the cornerstone of the air operator’s SMS, is the non-punitive reporting policy. An air operator must have a policy signed by the accountable executive that would prevent any reprisals against anyone who reports any error, omission or incident committed without malice or not while under the influence of drugs or alcohol. This results in the gathering of intelligence of what is really happening. In addition, with the air operator conducting an investigation, the root causes of the error, omission or incident can be identified, eliminated or mitigated to prevent the probability of a repeat. The TDGR and ICAO’s Technical Instructions for the Safe Transport of Dangerous Goods by Air require that an air operator reports various types of occurrences to the State of Authorities (TC) such as: • dangerous goods incidents and accidents; and • undeclared or mis-declared dangerous goods in cargo or passengers’ baggage. Using the same policy of “non-punitive reporting” required by the air operator’s SMS, we have applied these principles in handling all the reports from air operators. When an air operator reports occurrences to TC, they must provide, within a 30-day time frame, the probable root cause(s), and short- and long-term corrective action plans and means to ensure that the corrective action plans are effective. To date, we have reviewed over 460 of these occurrences. Such a high number of reports demonstrates that the non-punitive reporting system works. The collecting of this information has allowed us to: • develop a database of occurrences and associated corrective action plans (CAP); • develop a database of articles containing dangerous goods intercepted in passengers’ or crew members’ baggage; • identify the current issues faced by the air operators; • share with all air operators the best practices to improve safety; and • develop proposals to revise and improve the TDGR. Naturally, whenever material is shared with all air operators, ICAO’s Code of Conduct on the Sharing and Use of Safety Information is followed and any information, such as the identity of the air operators, is removed to prevent a misuse of the information. The intelligence obtained has been quite important in improving domestic and international regulations. Since 2004, National Operations, Airlines Division has been providing a technical advisor to the member representing Canada at the ICAO Dangerous Goods Panel (DGP). Issues or difficulties identified through the occurrences reported by the air operators are then converted into working papers proposing revision to the TDGR. We have been successful in the approval of many proposals Pre-Flight Pre-Flight Pre-Flight Pre-Flight 6 ASL 1/2012 and the implementation of many changes to international regulations, including: • the requirement that hidden dangerous goods notices contain pictograms for foreign speakers; • an authorization to carry onboard life- saving devices such as automated external defibrillators (AED), nebulizer, and continuous positive airway pressure (CPAP) containing large lithium batteries; and • a reformatting of the list of articles containing dangerous goods in a table format to simplify information retrieval. The analysis of the data has also allowed us to identify where the surveillance activities must be concentrated. Changes have also been made to the oversight activities. When performing a process inspection at an airport, the air operator’s dangerous goods coordinators are invited to participate. By performing such joint activities, we are able to share knowledge, discuss issues and develop possible corrective options when non- compliances are observed. When a finding is issued, it is against the air operator’s system for not discovering the non-compliance. In order to assist air operators, on a monthly basis, the Branch publishes and communicates to all the dangerous goods coordinators of an air operator, a dangerous goods profile that lists all the contact information, air operator’s variations, approved training programs and publications, and all the expected corrective action plan(s) and their due dates. In addition, the Branch provides a list of all the latest revisions to regulatory and non-regulatory publications. This successful approach has been shared with other states, through the assistance of TC’s International Operations, by providing training to dangerous goods inspectors from other civil aviation authorities including Bahamas, Bangladesh, Cambodia, China, Fiji, Hong Kong, Indonesia, Laos, Macao, Mongolia, Philippines, Seychelles, Singapore, South Korea, Sri Lanka, Thailand and Vietnam. Safety management principles can be applied to any activity to reduce the risk associated with that activity. The application of SMS principles in the oversight of dangerous goods has proven to be a success story that is sure to be repeated in other sectors as well. As we continue to move forward, it is the culture change and knowledge that will facilitate the successful implementation of SMS. Pre-Flight Pre-Flight Pre-Flight Pre-Flight Others 18.10% Lighters 38.21% Aerosols 21.57% Adhesives 4.20% Battery 3.11% Cartridges 3.66% Chemicals 5.67% Cylinder 2.74% Outdoor Equipment 2.74% Figure 1: Proportion of dangerous goods in articles intercepted in passenger or crew baggage in the last 12 months Invest a few minutes into your safe return home this winter... ...by reviewing section RAC 2.7 of the Transport Canada Aeronautical Information Manual (TC AIM), titled “Low Level Controlled Airspace.” ASL 1/2012 7 Pre-Flight Pre-Flight Pre-Flight Pre-Flight COPA Corner—Electrical Fires Do Happen by Dale Nielsen. This article was originally published in the “Chock to Chock” column of the February 2010 issue of COPA Flight, and is reprinted with permission. Smoke in the cockpit could be the result of an electrical fire. The acrid smell of an electrical fire is very distinctive, but any smoke from the area of the instrument panel, circuit breaker panel or any panel with a number of electrical switches should be considered an electrical fire. An electrical fire is a critical emergency. The Cessna 172 was on a local VFR flight when the pilot squawked 7700 and returned for landing. After landing, the pilot reported smoke in the cockpit and a radio failure. An RV 7 pilot saw sparks and smoke coming from under the instrument panel. He declared an emergency, shut down the electrical system and returned for landing. After landing, there were no longer any sparks coming from under the instrument panel and the smoke had dissipated. An inspection revealed that a hose clamp had come loose, allowing a metal hose ducting in air from the outside to come in contact with a fuse bus, causing a short. A Cessna 172R was on a local training flight when the crew noticed smoke and fumes in the cockpit. They declared an emergency, shut down all electrical systems and returned for landing. An inspection by an AME revealed a faulty landing light switch. An instructor and student in a Cessna 152 were leaving the control zone on a local training flight when both began to smell smoke and noticed a light haze in the cockpit. The instructor then noticed the radio lights begin to flicker. He received a slight electrical shock when he attempted to select the radio to “Off ”. The Battery Master Switch was selected “Off ” and the smoke dissipated rapidly. The instructor then used his cell phone to get clearance to return to the airport and land. He did not declare an emergency. The tower controller did however contact the airport emergency services to stand by. Maintenance personnel discovered that the starter bendix had not disengaged after engine start. The overheated starter caused the aircraft electrical system to overheat, causing the smoke and haze. Ten minutes after departing from the airport, the Cessna 172 cockpit filled with smoke. The pilot turned the Battery Master Switch “Off ” and used his cell phone to declare an emergency and to get clearance to return to the airport for landing. During the return, the pilot reported that the smoke had dissipated, but wanted his emergency status to remain in effect. A maintenance inspection revealed a short from a bare wire. In the first incident, we don’t know from the report if the pilot shut down his electrical system. All of the other pilots did. From previous aircraft incident/accident reports, we know that people may become incapacitated by electrical smoke in less than 3 minutes. Electrical smoke is toxic. It is imperative to turn the Master Switch “Off ” immediately when electrical smoke is detected or suspected. All of the pilots declared an emergency, either verbally or with the transponder, except the C–152 instructor, and he should have. Fortunately, the tower controller did it for him. You may not know it, but you may be partially incapacitated. The electrical fire checklist in most aircraft read as follows: • Turn off the battery/alternator master switches. • Don an oxygen mask if one is available. • Turn off all electrical switches. • If the smoke or fire persists, use the fire extinguisher, then ventilate the cabin. • Essential electrics can be selected back on one at a time, while watching for a re-occurrence of the smoke or fire. “Essential” is a key word here. After an electrical fire, only select “On” those electrical services that are essential for getting the aircraft to the nearest airport. Be prepared to re-select a service back “Off ” immediately if the smoke or fire returns. Troubleshooting to find the source of the fire must be left for the maintenance people with fire trucks standing by, especially if we have used up our one-shot fire extinguisher. What is essential in an aircraft in VFR conditions? Nothing. The engine will run perfectly well without any electrical services. We can continue to our destination or to an alternate uncontrolled airport and complete a NORDO procedure. If we have a cell phone on board, we can use it to get clearances for control zone entry and for landing as did two of the pilots mentioned above. In IFR conditions, we may require a radio or navigation aid. We must only turn on what we absolutely require, and then only after some thought as to where the smoke may have come from, and after checking for popped circuit breakers. 8 ASL 1/2012 Pre-Flight Pre-Flight Pre-Flight Pre-Flight Damage caused by fire in the cockpit of a King Air 100. Photo : www.pirep.org Pilots employed in commercial operations are now required to annually review the use of circuit breakers as the result of electrical fires that have occurred when pilots repeatedly pushed in popped circuit breakers. The Transport Canada (TC) recommendation and the industry policy is if the electrical system protected by the popped circuit breaker is not necessary for the remainder of the flight, it is not to be reset. If the system is considered to be necessary, one reset is permitted. The breaker is not to be reset if it pops again. The incidents described above occurred in 2009. Electrical fires do happen. As we can see, following correct procedure will get us home safely in the event we encounter an electrical fire or smoke. Fly safely. Dale Nielsen is an ex-Armed Forces pilot and aerial photography pilot. He lives in Abbotsford, B.C., and currently flies MEDEVACs from Victoria in a Lear 25. Nielsen is also the author of seven flight training manuals published by Canuck West Holdings. Dale can be contacted via e-mail: dale@flighttrainingmanuals.com. To know more about COPA, visit www.copanational.org. Emergency? Let Air Traffic Services Know by the Safety Management Planning and Analysis Division, NAV CANADA Recent discussion in aviation safety forums and with the pilot community suggests that some pilots may not understand the importance of letting air traffic services (ATS) know when they are concerned about the safety of their flight. What’s an emergency? There are many different reasons why a pilot may be concerned with safety. Some of these may sound familiar: • you have mechanical problems or malfunctioning avionics; • you’re concerned about low fuel; • while you are flying VFR, the cloud bases come down and you’re forced to climb through an overcast layer in order to reach VFR over-the-top conditions; • you’re a VFR pilot flying above scattered cloud conditions that unexpectedly change to overcast, without time for you to descend; • yourself or a passenger become ill in-flight; or • you’re lost. NAV CANADA air traffic controllers and flight service specialists provide assistance to pilots in these types of situations. But we need to know that you are experiencing an emergency! What does a controller or flight service specialist do when a pilot issues a Mayday or a Pan Pan? The word “MAYDAY” spoken at the start of communication identifies a distress message that indicates that the aircraft is threatened by serious and/or imminent danger and requires immediate assistance. The words “PAN PAN” identify an urgency message concerning the safety of an aircraft or other vehicle, or some person on board or within sight, which does not require immediate assistance. Timely notification of ATS personnel about an emergency or potential issue that may impact flight safety is critical. Once a controller or specialist is made aware, there are a number of different actions that they may take depending on the nature of the situation: • Priority of service – Given that they are aware that a situation exists, ATS personnel can better prioritize the level of assistance that may be required, offering direct routes or assistance in planning for alternate destinations. • Coordination with other ATS units – A flight service station (FSS) or control tower may contact the area control centre for radar ASL 1/2012 9 Pre-Flight Pre-Flight Pre-Flight Pre-Flight EMERGENCY COMMUNICATIONS As soon as there is any doubt as to the safe conduct of a flight, immediately request assistance from ATC. Flight crews should declare the situation early; it can always be cancelled. • A distress call (situation where the aircraft requires immediate assistance) is prefixed: MAYDAY, MAYDAY, MAYDAY. • An urgency message (situation not requiring immediate assistance) is prefixed: PAN PAN, PAN PAN, PAN PAN. • Make the initial call on the frequency in use, but if that is not possible, squawk 7700 and call on 121.5. (Note: 121.5 is not available or monitored via PAL or RCO facilities. Only tower and FSS personnel monitor 121.5 during hours of operation.) • The distress/urgency message should contain (at a minimum) the name of the station addressed, the call sign, nature of the emergency, fuel endurance, persons on board and any supporting information such as position, altitude (climbing/descending), speed, heading and pilot’s intentions. Minimum fuel advisory As per the TC AIM (RAC 1.8.2), pilots may experience situations in which delays caused by traffic, weather or any other reason result in the pilot being concerned about the aircraft’s fuel state upon reaching destination. In such cases, the pilot may declare to ATC that a MINIMUM FUEL condition exists. This declaration results in ATC taking specific actions as per RAC 1.8.2 and alerts them that an emergency situation could develop. ‘Fuel emergency’ and ‘fuel priority’ are not recognized terms. On reaching an emergency situation with respect to the aircraft’s fuel state, flight crews should declare a PAN or MAYDAY to be sure of being given the appropriate priority. assistance or to coordinate between IFR and VFR aircraft (special VFR authorization). – Controllers may coordinate the use of additional airspace, protecting emergency climbs or descents by blocking altitudes or diverting other traffic as necessary. • Notifying outside agencies – Relaying information to a company dispatch or maintenance may yield assistance to the pilot or flight crew in resolving in-flight issues. • Notifying emergency services – ATS personnel will do this either directly with local emergency services or through the destination unit, keeping in mind that in many smaller locations, emergency services are not on site, therefore increasing response times. Failure to notify ATS about an emergency or potential problem may result in a delay in having the appropriate responders available. If you’re in doubt about the safety of your flight, let ATS know as soon as possible. You can always cancel later. ICAO proposed changes Finally, the International Civil Aviation Organization (ICAO) is proposing amendments to Annex 6 and PANS-ATM regarding fuel management for implementation on November 15, 2012. These changes include the introduction of new fuel-related terms and phraseology that differentiate MINIMUM FUEL from a FUEL EMERGENCY. It is expected that Canada will comply with the amendment. An appropriate notification will be forthcoming as well as amendments to ICAO and Canadian publications once the changes are finalized. 10 ASL 1/2012 flight operations Worthwhile Reading: The 1999 Transport Canada Evaluation of Stall/Spin Accidents in Canada........................ page 10 Focus on CRM—Emotionally Enabled .......................................................................................................................... page 16 Worthwhile Reading: The 1999 Transport Canada Evaluation of Stall/Spin Accidents in Canada by the Standards Branch, Civil Aviation, Transport Canada The following article is from the 1999 Transport Canada (TC) evaluation of stall/spin accidents (TP 13748E), which had been prepared by human factors specialist Jim McMenemy, and Civil Aviation Inspector Brian Penner. This research was done to guide decision-makers regarding whether or not TC should keep spin recovery as part of the private pilot flight test. This study was referred by the Transportation Safety Board of Canada (TSB) in their Final Report A02O0287, relating to an accident on September 7, 2002, involving a Cessna 172 in an attempt for the “impossible” 180° turn back to the runway (a lake in that case). This accident was featured in Aviation Safety Letter Issue 1/2005. This study was also instrumental in developing Stall/Spin Awareness–Guidance Notes–Private and Commercial Pilot Training (TP 13747E), which are found on our Web site to this day. While we certainly encourage readers to revisit the documents referred above, we publish here the analysis that preceded them. We feel this professional research is not only informative and practical reading for all pilots, but that it also deserves to be shared. It should also provide context and arguments for those of you who debate the 180° turn back to the runway in the event of an engine failure after takeoff. —Ed. An Evaluation of Stall/Spin Accidents in Canada (TP 13748E, 1999) Canada is the last major aviation country to test spins on the private pilot flight test. The spin hasn’t been required in primary training in the United States since 1949. It is not required in the JAA standard adopted in Europe, nor is it required in private pilot training in either Australia or New Zealand. Other aviation authorities have moved to a model of stall/spin awareness in the hope of focusing the training on recognition of situations that could lead to an inadvertent stall and spin. In addition to the fact that Canada’s major aviation partners do not include the spin in either training or testing for the private pilot licence (or, for that matter, the commercial pilot licence), it is becoming increasingly difficult to obtain new aircraft that are certified for spins. To support flight training development and be sure that Canada was moving in the right direction, it was decided to examine the safety record related to stall and spin accidents in general aviation aircraft in Canada. This evaluation, which reviews Canadian stall/spin accidents over the last ten years, was launched in the hope that it would help everyone understand the reality of these accidents and determine whether changes to training may be effective in advancing safety. One fact that emerges clearly in this study is this: “One feature that stands out in all except one of the 39 stall/spin accidents examined is that knowing how to recover from the stall or spin was of no benefit to the pilots in these circumstances. They stalled at altitudes so low, that once the stall developed, a serious accident was in progress. Safety will be advanced therefore by preventing stalls and spins.” To some degree, the way spins are taught in the current syllabus may even create risk by fostering the illusion that real spins are typically entered from a classic, power- off clean stall and, for some aircraft, a lot of effort is needed to initiate and maintain the spin. However, such apparently docile aircraft spin quite differently when fully loaded, when they are operated outside the utility category, and in the real world the spins that kill tend to be entered at low altitude and in situations that don’t resemble the classic clean stall and don’t give enough room to recover. Some occur when speed is allowed to decay on approach and when a cross-control situation develops. Some occur when full power has been applied in an overshoot. Some occur in an attempt to turn back to the airport when the engine fails immediately after takeoff. In these situations, the development of the spin is sudden and aggressive, unlike anything the pilot might have seen in training. If the Canadian approach to spin training and testing has left us with a continuing concern about the numbers of fatal stall/spin accidents, would we do better with a stall/spin awareness model? In the United States, where stall/spin awareness has been used for years, spins still account for roughly 12 percent of general aviation accidents and 25 percent of the fatal accidents. In Canada, the stall/spin accident rate is not appreciably different from the American experience. Ten years ago, the spin-related accident rates in Canada varied from a low of 0.8% to a high of 2.4% whereas in the United States the rate varied from a low of 1.3% to a high of 2.4% (TSB, 1987). Comparison of different statistical environments is always difficult—Canada and the United States count and define Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations ASL 1/2012 11 Debrief Regulations and You Debrief rief" Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations things differently—but there is not a significant difference in the stall/spin accident rate between the two countries. Canada is not gaining an obvious safety dividend from the current approach to spin training and testing. This 2006 crash was a case of mishandling of the aircraft, resulting in an aerodynamic stall, followed by a spin. Method The first step was to identify the accidents relevant to the question at hand. A key word search was conducted on the TSB database to identify stall and spin accidents over the past ten years in Canada. A total of 39 stall/spin accidents involving single-engine or light twin-certified aircraft were identified. TSB occurrence reports and occurrence briefs were obtained. There is a tendency to consider accidents to be events. They are events, often tragic events, but, if your goal is accident prevention, accidents are better understood as processes, the results of a series of events, conditions, and human actions/decisions with decidedly negative outcomes. Understanding the processes that lead to accidents and incidents is a vital step in identifying changes that will prevent or mitigate the negative outcomes. To arrive at a common understanding of the factors that lead to accidents, it was important to apply a standardized approach to analyzing occurrences to identify the causal and contributing factors for each occurrence reliably and accurately. The Civil Aviation Human Error Model and its companion analytic process were used to analyze the accidents. The aim is to identify and analyze the unsafe acts and unsafe conditions which contributed to the accident. When the factors that lead to unsafe acts or errors are understood, it is possible to identify interventions which have the potential to reduce the number or severity of accidents. Results The Civil Aviation Human Performance/Human Error model was used to analyze each occurrence. In every case at least one unsafe act or error was identified. In some cases the background data were not sufficient to support a complete analysis and identify the antecedents or contributing factors. In most cases, however, the model helped understand the accident and identify factors that contributed to the mishap. The occurrences broke down into three principal groups: a. stall or spin accidents resulting from aircraft handling (27); b. stalls or spins following engine failure (9); and c. stalls or spins resulting from loss of control in IMC (3). Handling Accidents Twenty-seven accidents resulted from mishandling the aircraft into an aerodynamic stall. These accidents resulted in 26 fatalities and 16 serious injuries. In two cases, it appears that the engine was not producing full power but the aircraft was capable of controlled flight and the stall was avoidable. In all cases, the stall, which sometimes precipitated a spin or wing drop, occurred at low altitude and at low airspeed. The stalls and spins occurred at a height where recovery was very difficult and probably impossible. Sixteen stalls resulted from turning at low airspeed, 10 occurred in straight ahead flight, and one inverted spin developed when the pilot was practising aerobatics at about 1 500 ft AGL. Most of the 27 handling accidents happened during the takeoff/initial climb-out or approach phase. There were 13 stalls during the climb-out after taking off and at least six of these occurred during a low speed, low altitude turn. Five stalls, all in turns, occurred during the approach/landing phase, most often on turning base to final. One practice overshoot ended in a stall when the instructor waited too long to take control and the airspeed fell too low. Three of the en route accidents occurred in mountainous terrain. A navigational error led to a very difficult situation in one of them. Better mountain flying technique might have prevented all three accidents. At the moment of impact, damage and injury might have been reduced if the aircraft had been under control rather than stalled. Two pilots were flying while intoxicated. One spin occurred during acrobatic practice. The spin occurred at about 1 500 ft and using the approved recovery technique might have prevented or reduced the severity of the accident. One accident happened when an unqualified instructor was teaching slow flight below the 12 ASL 1/2012 manufacturer’s recommended altitude and did not apply the correct recovery procedure. Several seaplane pilots made what are, in retrospect, obvious planning errors by taking off toward rising terrain with insufficient room to clear terrain or not accounting for downdraft conditions when taking off from steep banked lakes. These errors are obvious now, but probably were not apparent to the pilots involved until it was too late. Contributing factors include human visual limitations. People are not able to judge absolute distances. This makes judging how far away an obstacle is very difficult, especially when the field of vision is flat and featureless, like a body of water. It is possible that some pilots, due to perceptual limitations misjudged the distance available and did not recognize the problem until it was too late. Downdraft occurring as the aircraft approached a shoreline and drift illusion appear to have taken three pilots by surprise. Lack of awareness and not being prepared to cope with the effect led to stalls and crashes. Two float-equipped aircraft stalled and crashed when the pilots undertook instructional or check flights with no rear seat control column installed. The instructor/check pilot was, therefore, unable to exert any control when the front seat pilot mishandled the aircraft. In some cases, heavy, possibly even overweight aircraft may have contributed as well. Lack of experience flying aircraft near, or at, maximum gross weight, in one case with an external load, may have led to the pilots being surprised at the effect that fuel weight and loads had on aircraft performance. The importance of weight and balance calculations was emphasized by the fact that at least one aircraft was flown with the centre of gravity aft of the design limit. Currency, supervisory factors and the importance of developing and ensuring compliance with standard operating procedures were all identified as contributory factors. The young glider tow plane pilot who took an unauthorized passenger, flew a low pass over the field, and stalled in a steep climbing turn was in violation of several rules. Standard operating procedures can contribute consistency, but in commercial operations those with supervisory responsibilities must be vigilant in promoting compliance. Several of the pilots who mishandled their way into stalls were not current on their aircraft. One private pilot, demonstrating his aircraft to a potential purchaser, had flown only ten hr in the previous 12 months. He climbed out too steeply after takeoff, airspeed decayed and the aircraft stalled. Several other private pilots were either low time pilots, flew infrequently, or both. Skill decay is likely to affect such pilots if any unusual circumstances requiring quick assessment of the situation and rapid accurate decisions should arise. Accidents following engine failure Nine accidents resulted from stalls/spins following engine failures. Two of the aircraft were twins and the rest were single-engine. Preventing engine failure is the best way to reduce this type of accident and several of the engine failures could have been prevented. Losing power, however, is not always preventable. It is a critical emergency and effective management of the situation is essential to achieve the best possible outcome. Poor maintenance, fuel contamination, and taking off with insufficient fuel led to preventable engine failures. In one case, a pilot had a rough running engine. He landed, removed the engine winterizing kit, and tried to conduct a test flight. The engine failed shortly after takeoff. One engine failure resulted from using contaminated fuel. The pilot in that instance continued the flight after two partial power losses. Two pilots took off with so little fuel on board that the engine stopped on climb-out. Another crash was traced to poor maintenance. An accident may be inevitable after an engine failure but the task of the pilot is to minimize personal injury and damage to the aircraft. Losing control of the aircraft is the worst possible outcome after losing power. Regardless of the fact that some of the engine failures were preventable, inadequately coping with the situation is an even more serious failure. All of the engine failures occurred at low altitude so that recovery from a stall or spin was impossible. It is vital therefore, in such situations that control be maintained and the aircraft not stall. All nine stalls/spins resulted from mishandling the aircraft in an emergency and most of the problems can be traced to poor decisions. At least eight out of these nine did not follow approved procedures. Deviations include basic items such as failing to raise the landing gear and not flying recommended airspeed. Five pilots stalled after turning back to the runway following an engine failure after takeoff. Loss of control in instrument meteorological conditions (IMC) Three accidents resulted from loss of control in IMC. In one case the pilot, after being warned about the weather, still went flying and, in fact lost control of the aircraft three times and recovered, but continued the flight. He apparently did not recover the fourth time and perished. This is the only stall accident examined which involved a high altitude stall. Another pilot had made several Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations ASL 1/2012 13 Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations attempts over a period of days to deliver his passengers but was prevented by weather. Pressure to complete the job and a forecast of improving conditions at destination may have lured him into the attempt. The aircraft stalled and spun to the earth from tree top height resulting in three serious injuries. The final accident also involved passengers. The aircraft stalled at very low height. Weather information may have been lacking as the nearest observation site was 60 miles away. Discussion One feature that stands out in all except one of the 39 stall/spin accidents examined is that knowing how to recover from the stall or spin was of no benefit to the pilots in these circumstances. They stalled at attitudes so low that once the stall developed, a serious accident was in progress. Safety will be advanced therefore by preventing stalls and spins. In this section of the paper we will continue the analysis of the unsafe acts which caused or exacerbated the accidents and begin the task of identifying potential countermeasures which could be implemented in training and flight testing. Currency and skill decay Different types of skills, once learned and not practised for periods of time, will degrade at different rates. Continuous movement skills, such as steering, guiding or tracking are relatively impervious to decay. Decision making, recalling bodies of knowledge and skill at tasks which require verbal communication between people, however, are subject to fairly rapid decay if not practised.1 A measurable skill decrement at information processing and communication tasks can be apparent in a couple weeks if the skills are not practised. The pilot who has not flown for a period of several weeks or months could be misled in certain situations. Such a pilot might expect that there has been some degradation in skill, but once in the aircraft, find that the stick and rudder skills are fairly intact. During a routine flight, there might not be much demand for problem solving and the pilot might conclude that no serious skill decay has occurred. In fact, the skill decay is hidden and may not become apparent until the pilot is faced with an emergency or complex situation. 1 Rullo, JoAnn C.; McDonald, L. Bruce. Factors Related to Skill Degradation and Their Implications for Refresher Training. Paper presented to the 34th Annual Meeting of the Human Factors Society. 1990. To preclude this, infrequent fliers should engage in a periodic review or refresher activity to ensure that the relevant knowledge is available for recall and the information processing and decision-making skills stay sharp. Aircraft handling Aircraft handling is a psychomotor skill involving both mental and physical components. The mental skills involve information processing and decision making while the physical skills involve eye-hand-foot coordination, and aircraft extensive practice, the control skills can become so well learned that the normal adjustments that are required to maintain or change attitude or direction can be accomplished without conscious thought. This does not imply a lack of attention, but is, in fact, a very efficient and effective way of handling well-learned, often complex tasks. Departures from the normal, well-practised routines involve a greater degree of conscious cognitive activity. Most of the situations a qualified pilot encounters are resolved at the rule- based level of performance. The most important factor in arriving at the correct action is accurate recognition of the situation. Exposure to situations teaches us to recognize similar conditions when we encounter them again. Training teaches us how to deal with those situations. Repeated practice allows us to incorporate the required action into a routine which can be accomplished, virtually on automatic, without consciously thinking through all the steps. Examination of the stall/spin accidents leads us to conclude that a significant number of pilots failed to recognize the symptoms of a developing aerodynamic stall. This is based on an assumption that no one would willingly enter a stall at a height which precludes recovery. It is possible, in some cases, to identify potential distractors which, by occupying the pilot’s attention, may have prevented recognition of the developing stall. In other cases, it is likely that one or more aspects of the situation were not familiar. Since the pilot had never seen such a situation, he/she did not recognize the condition or the solution. Stall and spin training for the private pilot’s licence (PPL) begins with briefings and discussions on the ground so that the student pilot understands what is happening and how to deal with it. In the air the aircraft is stalled, typically straight ahead with power off. The stalls that led to the accidents were not entered that way. Most of “During a routine flight, there might not be much demand for problem solving and the pilot might conclude that no serious skill decay has occurred. In fact, the skill decay is hidden and may not become apparent until the pilot is faced with an emergency or complex situation.” 14 ASL 1/2012 the stalls leading to accidents occurred at low altitude, taking off or landing when airspeed is significantly less than cruise. If a pilot’s experience does not go beyond the basic straight-ahead, power-off stall and spins, it is very possible that the pilot will not recognize the situation and therefore will not take action in time to prevent the full stall. Every pilot needs to know how to recover from a stall, but the accident record indicates that there are instances where recovery is impossible. Therefore, in these circumstances, early recognition and stall avoidance is even more important than being able to recover. To maximize the likelihood that a pilot will recognize the symptoms of a stall in other than straight-ahead, power- off conditions, student pilots should be exposed to the variety of stall initiation possibilities. They should learn to recognize the flight conditions that make stalls most likely and to take appropriate action to avoid the stall. To ensure that pilots can recognize the hazard and avoid the stall, the skills should be evaluated in the private pilot flight test. They must also learn that if a crash is inevitable, a controlled collision with terrain is far preferable to a stall or spin. Coping with emergencies There are two types of skills which are both of critical importance when coping with emergencies: cognitive skills and motor skills. The cognitive skills are the mental activities relating to assessing the situation and selecting or developing the plan or course of action. The motor skills relate to controlling the aircraft to accomplish the plan. The brain is a single-channel processor. This means that people can only consciously solve one problem at a time. If the motor or aircraft control skills are well learned, to the point that a pilot can perform them automatically, without conscious thought, then decision- making capacity is not being used on aircraft control tasks. This capacity is then available for assessing the situation, monitoring progress towards the goal, problem solving, or communicating. In an emergency situation, such as an engine failure, acute stress will have predictable physiological and behavioural effects. Heartbeat and respiration rate increase. Attention often narrows down to one or two apparently salient features of the situation. This narrowing of attention often leads to problems because so much attention is devoted to one aspect of a situation that other important features, such as decaying airspeed, are not noticed. The normal scan of the instruments and the environment will become more rapid, but more superficial. People become susceptible to particular kinds of error at times of acute stress. Historically, the forced landing is the most difficult exercise on PPL flight tests. This is understandable because it is a complex exercise and the situation, even in a practice environment, is inherently stressful. Although the requirement to perform a forced landing occurs rarely, the consequences of inadequate performance are dire and it is illogical to conclude that after the granting of a licence, skill at the task will improve, or even be maintained without practice. Three measures are worth consideration to improve performance in forced landing situations. The first is to examine the task to identify all the component skills and practise each of these in isolation until proficiency is achieved. Then, the individual skills can be integrated. This approach is often used by flight instructors, but perhaps the practice could be improved by redefining the component skills and specifying the level of proficiency required before integrating the components. The second measure is to practise the skills often, both before and after earning a licence. Forced landing skills would be an ideal candidate for inclusion in a periodic review, should such an initiative be adopted. Thirdly, to ensure that the student is aware of the stall hazard and appropriate preventive measures during forced landing, stall/spin recognition training must include situations, such as descending turn stalls, than can be encountered during forced landings. Take-off planning on floats A number of float-equipped aircraft stalled during the climb-out after taking off because the pilot had selected a take-off route which was inadequate for the conditions. The human visual system is not capable of judging absolute distances. Seaplane training should include information on how susceptible we are to misjudging distances and techniques to ensure the adequacy of a take-off area. Effects of weight and balance Typically in flight training the aircraft will carry no more than the student, an instructor, and fuel. The student pilot learns about weight and balance, but learning about it and the experience of flying a heavy aircraft may be very different. It may be advisable for pilots to actually experience flying and manoeuvring an aircraft at or near its maximum gross weight in controlled conditions. Having had the experience, a pilot may be more able to recognize the change in handling characteristics and avoid stall conditions. Turn back after takeoff Several stalls occurred when the pilot decided to turn back to the runway when the engine failed. Typically, guidance on this topic recommends that the pilot land Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations ASL 1/2012 15 Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations straight ahead unless the aircraft has enough altitude to make the turn back to the runway. This constitutes a “fuzzy rule”. That is, the rule requires interpretation, but the rule provides little or no guidance in making that interpretation. How much altitude is enough? Is it always the same? What variables may affect the requirement? The pilot is better off not having to consider these questions. Lives would be saved if the guidance required no thought or assessment. If an engine failure after takeoff results in an accident, the pilot is at least eight times more likely to be killed or seriously injured turning back than landing straight ahead. The easiest decisions to make are those which are prescriptive. As soon as the situation is known to exist, the procedure to follow is defined. Engine failure after takeoff should be such a decision. Drift illusion All pilots learn about drift illusion, but without experience, it is difficult to understand how compelling an illusion can be. Exposing the students to drift illusion so that they can learn to recognize and cope with it is difficult and potentially dangerous. Simulation may be an effective and safe alternative for teaching about drift illusion. Consideration should be given to developing better ways to teach student pilots about illusions. EXECUTIVE SUMMARY Pilots must be taught to recognize and recover from the onset of a stall/spin situation. Prevention must be the aim and the key to prevention is recognition. Skill in recovery from stalls is needed, especially stalls in those situations that lead to a wing drop and autorotation requiring immediate, precise, and confident handling. Once the spin develops, as this study shows, the situation is too often an accident in progress. Canada’s insistence that we continue to include spins on the private pilot flight test, including assessing the ability to ENTER a spin, has not given us a safety benefit over other countries that have moved away from this requirement. Results of instructor flight tests, and flights with instructors conducted on refresher courses in the past, tell us that some instructors may not be skilled at teaching the advanced stalls that will prepare pilots to recognize the onset of a stall/spin situation. We have to bring the skill level of ALL instructors to the point where they can confidently show their students, at altitude, how mishandling during events such as a forced landing, a turn to final approach, an overshoot, or attempting to return to the runway after a power loss after takeoff, can lead to an overwhelming emergency at low levels. They need to be able to teach their students how to recognize these situations. They need to be able to teach their students how to recover from these stalls as soon as the wing drops and before autorotation develops. Removing the spin from private pilot training is not the solution that Canada should be embracing, but a move toward the stall/spin awareness emphasis seen elsewhere is recommended provided that the following steps are taken: 1. Replace the spin on the private pilot flight test with a second stall, an advanced stall. 2. Place more emphasis on the proficiency of private pilot students in recognizing and recovering from advanced stalls. 3. Give examiners better guidance on how to test the advanced stall. 4. Require that spins and the correct recovery technique continue to be demonstrated during private pilot training. 5. Sample the advanced stall more heavily on instructor rating flight tests. 6. Emphasize the teaching of advanced stalls on instructor refresher courses. 7. Continue to require spin training and testing for commercial pilots but use the development of the integrated commercial program to give more specific recommendations for improvement. 8. Enhance training in the teaching of spins and advanced stalls during instructor rating training. 9. Continue to sample the teaching of spins and advanced stalls on instructor rating flight tests. 16 ASL 1/2012 Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations Emotionally Enabled by Shari Frisinger. This article was originally published in the August 2010 Issue of Aero Safety World, and is reprinted with permission of the Flight Safety Foundation. We watched in astonishment when Chesley Sullenberger in early 2009 skillfully piloted US Airways Flight 1549 to a safe landing in the Hudson River, and listened in horror a month later when we heard of Colgan Air Flight 3407 crashing into a Buffalo, New York, U.S., suburb. Among the factors that caused one perfectly good aircraft to fall out of the sky, killing 50 people, while another very crippled aircraft made a safe water landing that resulted in only a few minor injuries, technical flying skills obviously play a major role. However, success or failure to a large degree can be linked to the captain’s ability to control his own emotions in order to think clearly, while being aware of the crew’s emotional and mental states. When the role pilots play in aircraft incidents and accidents is considered, the initial focus of the U.S. National Transportation Safety Board (NTSB) and many analysts is on the technical abilities of the pilots: When was their last recurrent training? How many flight hours did they have in the aircraft type? How many total hours of flight experience?1 But some time ago it was realized that technical skills are not the only desirable traits a captain should have. Many years ago, airlines implemented cockpit resource management (CRM) techniques to enhance crew coordination. This new concept was partially based on a U.S. National Aeronautics and Space Administration investigation that discovered a common theme in many accidents—failure of leadership and ineffective crew interaction. 1 Helmreich, R.L.; Merritt, A.C.; Wilhelm, J.A. “The Evolution of Crew Resource Management Training in Commercial Aviation.” The International Journal of Aviation Psychology. Jan. 1, 1999. CRM focused on how the crew interacted in the cockpit, not necessarily on acceptable or appropriate cockpit behaviors. During the first decade of CRM use, it morphed into crew resource management, to include helping all crewmembers work more effectively as a team, improving situational awareness and providing techniques to break the error chain. CRM has become a training mainstay. To date, CRM has included only the technical skills and thinking abilities— analytical, conceptual and problem solving. However, research beginning in the 1980s demonstrated that emotions greatly influence a person’s cognitive abilities. To be effective, the next level of CRM needs to include more of the “people” side—self-confidence, teamwork, cooperation, empathy and flexibility in thoughts and actions. A major factor in maintaining the safety of the crew and passengers is the combination of the leader’s objective thought process and his or her emotional awareness. The word “emotion” may conjure up negative elements that tend to degrade safety: anger, fear, crying, shouting and other unhelpful behaviors, but everyone every day experiences more subtle varieties of emotion.2 In the cockpit this might include satisfaction for having achieved a smooth landing, pride in maneuvering around turbulence, excitement in getting desirable days off, irritation when plans don’t work out, and sometimes annoyance with others. Regardless of the situation, there always exists some degree of emotional response, and emotions are simply another 2 Goleman, D. “What Makes a Leader?” Harvard Business Review. Jan. 1, 2005. Focus on CRM For the next few issues, the ASL will feature a series of articles dedicated to crew resource management (CRM) awareness. In response to Transportation Safety Board of Canada (TSB) Recommendation A09-02, Transport Canada (TC) agreed to require commercial air operators regulated under subparts 703 and 704 of the Canadian Aviation Regulations (CARs) to provide contemporary CRM training to their pilots. It was decided that in consultation with industry stakeholders, TC will develop an updated CRM training requirement for 703 and 704 operators, which will also apply to single-pilot operations. Since CRM is not a static concept, but rather an evolving science, TC will also enhance or replace the current CRM training requirement for 705 operators, and consider harmonization with the recently released final FAA rule Amendment No. 135-122, Crew Resource Management Training for Crewmembers in Part 135 Operations. A focus group will tackle these issues, and progress updates will be published in the ASL. Our first feature article on CRM is entitled “Emotionally Enabled” and was written by Shari Frisinger. It was previously published by the Flight Safety Foundation. ASL 1/2012 17 Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations “Emotional Intelligence” means being aware of an entire crew’s mental state, not just your own. type of information that must be considered in making effective decisions, especially in a team environment. A high degree of situational awareness relies on a person being attentive to the environment. Internal situational awareness consists of understanding one’s own emotions and emotional triggers. External situational awareness involves insights into team members’ moods and unspoken communication, and appropriately addressing them. The cornerstones of emotional intelligence (EI) are consciousness of one’s thoughts and moods, of how the behaviors resulting from those impact and influence others, and of the moods and behaviors of others.3 People with a high level of EI recognize and control their own emotional outbursts, step back from the heat of any situation, analyze it objectively and take the appropriate action that produces the most desirable results. A person’s perception of reality shapes emotions and feelings, and these drive thoughts and behaviors. Status quo is maintained until new strong feelings are experienced. Simply being unhappy in a job is usually not enough to warrant a change. Getting passed over for a promotion, accompanied by the belief that the decision was wrong, usually sparks anger and an active job pursuit. The amygdala is the part of the brain that controls a person’s level of emotional reactivity. It never matures, and, if left unchecked, it can bring chaos to a life. To compound the problem, the human brain instinctively cannot distinguish between a real threat and an imagined one. Sitting in a theater, watching a panoramic or 3-D movie, the sudden loud sound of an airplane approaching will make most people reflexively duck. Intellectually, they know the airplane is not real, but the emotional brain hears the loud sound and tells the body it needs to avoid getting hit. When a situation changes, the emotional brain determines if the stimulus causing the change is a threat. If a threat is sensed, awareness becomes heightened and physiological changes take place to cope with this new danger. Adrenaline is released to pump the heart faster and prime the muscles for action. If the situation is later deemed to not be a threat, logic and objectivity take over again, but it takes four hours for the adrenaline to dissipate from the body. 3 Mayer, J.D.; Salovey, P.; Caruso, D.R. “Emotional Intelligence: Theory, Findings, and Implications.” Psychological Inquiry. Jan. 1, 2004. Today’s fears, threats and dangers are not unlike those of prehistoric man. A flight department manager who needs to justify the expenses of his department can experience the same “fight or flight” reaction that the caveman did when faced with a saber-toothed tiger. A similar reaction occurs when people feel their reputation or credibility is threatened. Fear and stress envelop thinking and people overfocus on a narrow selection of solutions, disregarding alternative approaches. When people allow their stressed brains to overtake thoughts, the perspective narrows and the main focus becomes escaping from the situation. Unable to think of alternatives, they don’t see the “big picture” or question assumptions. At this level of thought, perception of the complexity of the situation becomes paralyzing, and the focus is on current limitations. Remember the last time you became angry during an argument? It probably wasn’t until later, after you could see the situation without emotion, that you thought of several obvious points that could have helped your case. These become apparent because your rational mind was back in control. Your primary focus, in the midst of that argument, was to defend yourself. Success is more assured when this emotionally downward-spiraling thinking is halted and the problem is addressed more creatively. The captain in the Colgan Air 3407 accident chose the “flight” reaction; he chose to avoid a developing situation.4 When the first officer brought up the icing conditions — “I’ve never seen icing conditions. I’ve never deiced. I’ve never seen any, … I’ve never experienced any of that” — the captain’s response was, “Yeah, uh, I spent the first three months in, uh, Charleston, West Virginia and, uh, flew but I — first couple of times I saw the amount of ice that that Saab would pick up and keep on truckin’ … I’m a Florida man … .” Then he added, “There wasn’t — we never had to make decisions that I wouldn’t have been able to make but ... now I’m more comfortable.” The captain was still unaware of what was rapidly developing around him, chatting while the aircraft’s airspeed rapidly decayed. His failure to quiet his instinctive emotions narrowed his perception to the point that airspeed, one of the most basic elements of flying an airplane, no longer had his attention. There were few instances when the captain referred to the first officer’s health. He did not ask how she felt about her ability to perform her flight duties, even though she sneezed twice and six minutes later, she mentioned her ears. Basic understanding of CRM and crew performance should have tipped off the captain that the first officer was 4 NTSB, Colgan Air 3407 cockpit voice recording. www.ntsb.gov/Dockets/Aviation/DCA09MA027/418693.pdf 18 ASL 1/2012 Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations not feeling well that day and her performance could be negatively impacted. A person with higher EI could have recognized that, and probably would have been empathic to her condition and her inability to actively participate as a viable crewmember. The captain told stories for most of the flight. At one point, he rambled for over three minutes while the first officer only said 34 words, most of which were “yeah” and “uh-huh.” Research on how the mind processes information has revealed that people can only consciously execute one task at a time, and unconsciously perform one additional task. When driving in heavy traffic or merging onto a freeway, are you able to continue your conversation? Your mind moves from the conversation you were having to looking at traffic, calculating vehicle speeds and analyzing the best opportunity to speed up and merge. Your automatic mind does not have the ability to safely handle non-routine driving tasks. A classic example is United Airlines Flight 173, a McDonnell Douglas DC-8, which in 1978 was destroyed when it crashed during an approach to Portland (Oregon, U.S.) International Airport.5 The captain’s intense preoccupation with arranging for a safe emergency landing prohibited him from considering other anomalies. His concentration was so focused on the emergency landing checklist that he did not modify his plans when the first officer and flight engineer twice warned him about their airplane’s dwindling fuel supply. Ten people were killed when the aircraft crashed into a wooded area due to fuel exhaustion. The NTSB said, “The probable cause of the accident was the failure of the captain to monitor properly the aircraft’s fuel state and to properly respond to the low fuel state and the crewmembers’ advisories regarding fuel state. … His inattention resulted from preoccupation with a landing gear malfunction and preparations for a possible landing emergency.” This accident was one of the key events driving the adoption of CRM in airline training. Contrast the reactions and situational awareness of the Colgan and United crews to those of the captain of the US Airways A320 that landed in the Hudson River. Sullenberger kept his emotions under control and remained focused on doing his job—to safely land the plane. The captain’s words “my airplane” when he took over the controls after the bird strike could have been trigger words, 5 Aviation Safety Network. www.aviation-safety.net/database/record.php?id=19781228-1 words to focus on, snapping his rational brain into action and putting him into a safety frame of mind. He repeated the commands from the first officer, indicating that during those critical seconds there was no room for any misunderstanding. This flight crew’s emotional intelligence was as good as it gets, which enabled their processing information quickly and using every resource available to them at the time. The captain of United Airlines Flight 232, a McDonnell Douglas DC-10 that in 1989 attempted to land in Sioux City, Iowa, U.S., with catastrophic hydraulic and flight control systems failures, could have reacted to his challenges by becoming indecisive, shutting out the crew or dictating orders to them.6 If he had responded in any of these ways, the captain would have reflected the emotional pressures he was experiencing, and, as a result, his crew would have had his pressures added to their own. Instead, he worked as part of the crew, alternating between giving direction and explaining his actions and taking input from anyone in the cockpit, including a training pilot. Emotions are contagious, and the strongest expressed emotion will be felt unconsciously by others and mimicked. In this case, the captain’s calm demeanor was mirrored by the crew and they were able to contain their emotional reactivity. Aviation history is overflowing with accidents due to pilot error. Many of them could have been avoided if the crews were more aware of their own emotional reactivity and those of the others. Captains infected with “captainitis” are so absorbed in their own world that they lose their situational awareness. The captain in Colgan Air 3407 was self-absorbed, talking about himself for nearly 20 minutes of the last 40 minutes of the flight, missing a number of clues that eventually led to the crash; on the other hand, the captain of US Airways 1549 maintained his composure throughout his short flight and focused on every element of the emergency. Why is EI relevant? The Center for Creative Leadership found that the leading causes of failure among business executives are inadequate abilities to work well with others, either in their direct reports or in a team environment. Another study of several hundred executives revealed a direct correlation between superior performance and executives’ ability to accurately assess themselves. What actions demonstrate an increased level of EI? • When crewmembers voice their concerns in a calm, firm manner, giving evidence to back up those concerns; 6 Aviation Safety Network. www.aviation-safety.net/investigation/cvr/transcripts/ cvr_ua232.pdf ASL 1/2012 19 Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations • When leaders acknowledge the atmosphere and question crewmembers in a non-defensive manner to determine the causes of the uneasiness; and, • In a crisis or stress situation, when leaders maintain their composure and communicate more frequently and more calmly with the crew. There are several techniques that can raise your level of EI: • Be aware of the thoughts going through your mind. Are they stuck in the past and wallowing in problems, or are they focused on the future and actively looking for solutions? Once we choose negative thoughts, they can very easily spiral downward, the cycle descending into hopelessness. • Acknowledge your emotions. Remember they are neither good nor bad, they are what they are. Next, identify these emotions: Angry? Irritated? Defensive? Disappointed? Guilty? Frantic? Miserable? Naming your emotions makes them less abstract and helps release their influence on you. It becomes easier to detach yourself and think objectively. • Look back over your previous reactions. How could you have made a better choice? What information and alternatives are clear now that weren’t at that time? As we frantically search for quick solutions to rectify the situation, we automatically use the techniques that we have used before, whether they are the best choice or not. Our mind is not free to explore new alternatives. • Put yourself in the other person’s position. How would you react if you were on the receiving end of your emotions? The other person’s brain will send him through the same fight/flight/freeze reaction that yours is experiencing. Imagine both people fighting for their pride or their reputation—chances are slim that the discussion will end well. Leaders need a considerable amount of cognition.7 The ability of the leader to broaden his or her focus from technical and task-related activities to include an awareness of the moods of the crew is critical to success. It would benefit all parties to know which skills in specific circumstances are most appropriate. A leader’s behaviors directly affect the team’s disposition, and the team’s disposition drives performance. When the leader can analyze and manage his or her own emotional reactivity, the team members can more easily manage their own emotions. How well the leader performs this can have a direct effect on the safety and morale of the crew. Shari Frisinger, president of CornerStone Strategies, www.sharifrisinger.com, is an adjunct faculty member in the Mountain State University Aviation Department and School of Leadership and Professional Development. 7 Helmreich et al. ANNOUNCEMENT New Application Forms for all Flight Crew Permits and Licences Transport Canada (TC) has replaced the current Application for Flight Crew Permits form (TP 26-0194) with 12 individual application forms specific to the individual permit or licence. TC regional licensing offices will still accept the use of the old application form until further notice. NEW application forms have the following features: • available on the TC Flight Crew Licensing Web site and in the TC Forms Catalogue; • available in English and French; • detailed application guidelines provided; • available in PDF format; • completed online or manually; • electronically saveable; and • letter size for printing on a home printer. Emphasis has been placed on applicants to ensure that they have met all the Canadian Aviation Regulations (CARs) licensing requirements prior to submitting the application to TC. For additional information, please see Advisory Circular 401-002: Application Form Guidelines for Permits and Licences www.tc.gc.ca/eng/civilaviation/opssvs/managementservices-referencecentre-acs-400-menu-479.htm. TC Forms Catalogue: wwwapps.tc.gc.ca/Corp-Serv-Gen/5/Forms-Formulaires/search.aspx. For further clarification, please contact a TC regional licensing office. 20 ASL 1/2012 maintenance and certification Air Intake Filters: Technologies Used to Keep Contaminants Out ............................................................................... page 20 Fuel Tank Safety and Electrical Wiring Interconnection Systems—Considerations for Transport Airplane Modification and Repair Designs............................................................................................ page 22 Floats—a Seasonal Problem ............................................................................................................................................ page 24 Air Intake Filters: Technologies Used to Keep Contaminants Out by Ronald Donner, Editor, Aircraft Maintenance Technology (AMT) on-line magazine (www.amtonline.com). This article originally appeared in the May 2010 issue of AMT magazine and is reprinted with permission. Keeping dust from reaching the internal workings of any reciprocating engine is critical. According to publications from both Lycoming and Continental unfiltered air contains contaminates which are very abrasive to engines, especially reciprocating engine cylinder walls and piston ring faces. If a worn, poorly fit, or poorly functioning inlet air filter allows as much as a tablespoon of abrasive dirt in the cylinders, it will cause wear to the extent that wear to internal parts of the engine will prematurely occur and an overhaul will be prematurely required. For most general aviation (GA) aircraft powered by reciprocating engines there are four different technologies currently in use to protect today’s reciprocating engines. These four technologies can be further broken down into two different categories: “dry media” and “wet media.” Let’s take a closer look at these two basic types of inlet air filters. We’ll begin with the dry media filter. As its name implies “dry media” filters feature a filtering medium that—well, is dry. A dry media filter does not require the use of oil as part of the filtering process. Historically, the filtering media has been made using cellulose or paper fibers. Today a large portion of these filters have a man-made synthetic fiber, or fiberglass as the filtering media. This media, regardless of the material type, is then pleated into the “accordion” shape to make the filter. The filter media is then encased in a frame designed to fit the specific engine and aircraft application. This style of filter is currently found on multiple GA reciprocating engine aircraft applications. Next is the wet media filter, which is the other popular filter technology which is found in use on GA aircraft today. Wet, as its name implies, is a type of media that requires a tacky oil to be applied to a substrate to act as the dust trapping agents. The substrate is most commonly either a foam pad or pleated cotton gauze. Typically this filter substrate alone offers only a limited portion of filtration protection. However, once tacky oil is applied to the substrate the effectiveness increases dramatically. Wet media filters require that oil is always present on the substrate in order to ensure the best filtering action. Consequently as the filter media dries out, the efficiency of these filters becomes modified. In some cases wet media filters will require that oil is re-applied as part of the normal servicing for the aircraft. Additionally, care must be taken to not wash away the oil from the foam pads. The following is a general description and guidelines to follow when inspecting and servicing induction air filters: Dry media filters Dry media filters can be either a cellulose or synthetic media. The tight weave of the media traps particles by sieving the dust contaminates. The pleated style of the media maximizes the surface area of the filter providing the engine maximum area to breathe. Most GA original equipment manufacturers (OEM) use a dry media pleated filter on their equipment. The dry media pleated filters are designed to offer long life, approximately 500 flight hours or three years of service, and they can be cleaned up to five times before replacing them. Cleaning can be initially performed by using compressed air to expel any dust and particulate that has been trapped in the filter pleats. Once all of the dust and particulate has been blown away, you should hold the filter up to a light source and inspect the condition of the media for deterioration. If the media is in satisfactory condition, further cleaning can be accomplished by washing the filter in a solution of water and general purpose low-suds detergent. After washing, the filter should be dried and once again inspected for contamination and general condition. The following steps can be used as a guide when servicing the dry media filter: 1. Remove the filter and inspect for damage or deterioration. 2. Pre-clean using compressed air to blow off the dust and particulate. 3. Wash and soak with water and detergent. 4. Rinse the filter. 5. Dry the filter. 6. Re-inspect and re-install. Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations ASL 1/2012 21 Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations The tight weave of the dry media traps particles by sieving the dust contaminates. Photo: Donaldson Aerospace and Defense Group Wet media filters Wet media filters generally fall into two different classifications: oiled foam and oiled cotton gauze. The oiled foam style filters contain a low-cost replaceable pad, which is saturated with tacky oil that provides its filtration efficiency. The foam pads are contained inside of a filter frame for easy removal and replacement. These foam pad wet media filters have been primarily an aftermarket part, approved for installation by way of a supplemental type certificate (STC). The foam pads are required to be replaced on a regular basis, typically every 100 flight hr or when 50 percent of the surface is covered with contaminants or debris. The cost of the replacement foam filter pads are low and this type of air intake filter is popular on many GA aircraft models. There really is no maintenance servicing for this style of wet media foam pad filter—only remove and replace. The other wet media technology is the gauze-pleated filter. This media consists of layers of surgical cotton gauze that is pleated between wire screens and then coated with oil. This technology has migrated into the GA aircraft industry from the automotive industry. The highly permeable cotton gauze is used to support tacky oil to provide its filtration efficiency. The gauze-pleated wet media filters have also been an aftermarket part, approved for installation by way of an STC. The following steps can be used as a guide when servicing the wet gauze-pleated filter: 1. Remove the filter and inspect it for damage or deterioration. 2. Gently tap filter on a hard surface to remove loose dust that will easily fall off the filter. 3. Apply the cleaner to clean side of filter. 4. Apply the cleaner to dirty side of filter. 5. Let the cleaner soak for 10 min. 6. Rinse with water. 7. Dry the filter without accelerated drying methods. 8. Re-oil the filter substrate. 9. Let sit for approximately 20 min and check for oil coverage. 10. Re-oil any areas of the filter that were initially missed. 11. Continue steps 5 through 7 until a uniform colour covers the entire filter media. The cleaning procedures for this type of filter are recommended every calendar year or every 100 flight hr, and can be cleaned up to 25 times or a maximum of 2 500 flight hr. Wet media, as its name implies, is a type of media that requires a tacky oil to be applied to a substrate to act as the dust trapping agents. Photo: Donaldson Aerospace and Defense Group No matter which type of air intake filter is used, when operating a reciprocating engine-powered aircraft in sandy or dusty conditions, it may be necessary to service the air intake filter(s) much more frequently—even daily. Use only the cleaning procedures, cleaning fluid, and the correct type of re-oiling fluid that are recommended by the filter manufacturer or aircraft maintenance manual. Failure to follow the required cleaning instructions on any type of air intake filter can lead to poor filtering efficiency which can eventually lead to premature wear and damage of internal engine parts. 22 ASL 1/2012 Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations When choosing an air intake filter system for your customer’s aircraft, consider all of the options. Calculate the initial costs, the cost of ongoing filter servicing tasks, and the cost of ongoing element replacement. Some air intake filter systems have service bulletins and airworthiness directives requiring certain maintenance actions. More information regarding care and servicing of air intake filters can be found by contacting the manufacturer of the aircraft and engine. Information for this article was provided by Scott Petersen, Account Manager for the Donaldson Company’s Aerospace and Defense Group. Fuel Tank Safety and Electrical Wiring Interconnection Systems—Considerations for Transport Airplane Modification and Repair Designs by Blake Cheney, Manager, Domestic Regulations, Aircraft Certification Standards, Civil Aviation, Transport Canada The business of modifying and repairing transport category airplanes can be complex. A spectrum of engineering design challenges related to any specific modification or repair necessarily compete with the business realities of financial and time constraints. As always, it is necessary to be wary of aircraft level risks that may be inadvertently introduced with the installation and integration of new design changes to any aircraft. Accident examples have raised awareness regarding the need for new best practices to protect against aircraft level safety risks associated with modification (and repair) of fuel tank systems, including adjacent areas, and the installation and maintenance of electrical wiring interconnection systems (EWIS). EWIS is defined in Airworthiness Manual (AWM) 525.1701 as “any wire, wiring device, or combination of these, including termination devices, installed in any area of the airplane for the purpose of transmitting electrical energy between two or more intended termination points.” EWIS does not include electrical equipment or avionics qualified to acceptable environmental conditions and testing procedures, portable electrical devices that are not part of the airplane’s type design, or fibre optics. Electrical wiring interconnection systems (EWIS) In the United States, the Federal Aviation Administration (FAA) has codified these best practices under Special Federal Aviation Regulation (SFAR) No.88 and 14 CFR 26.11 Enhanced Airworthiness Program for Airplane Systems (EAPAS). In particular, these requirements apply to transport category, turbine-powered airplanes with a type certificate issued after January 1, 1958, that, as a result of the original certification or a later increase in capacity, have: (1) a maximum type-certificated passenger capacity of 30 or more; or (2) a maximum payload capacity of 7 500 lbs or more. In the case of fuel tank systems, a worldwide effort by transport airplane design approval holders (DAHs) to re-evaluate their designs has resulted in the development and promulgation of numerous design changes and Instructions for Continued Airworthiness (ICA) (including Limitations), most importantly by airworthiness directives (AD). Much knowledge of the specific vulnerabilities of fuel tank system designs with respect to the development of ignition sources was gained through this safety exercise. New best practices are now recognized as necessary to minimize the development of fuel tank system ignition sources stemming from possible heat sources, electrical arcing (including lightning- induced arcing), or mechanical sparking (each arising from normal operation, single failures or combinations of failures that are not extremely remote). In the case of EWIS, DAHs had to make a similar large-scale effort to evaluate the need for, prepare, and make available any additional maintenance and inspection tasks, developed using the Enhanced Zonal Analysis Procedure (EZAP) methodology, that may be required for the EWIS. The EZAP is an analytical procedure that identifies the physical and environmental conditions in each zone of an airplane, analyzes the effects of these conditions on EWIS, and assesses the possibilities for smoke and fire. From EZAP analysis, maintenance tasks can be developed to detect EWIS degradation issues, prevent ignition sources and minimize possibilities for combustion by minimizing accumulation of combustible materials. The resulting EWIS EZAP ICAs are to be presented in ASL 1/2012 23 Flight Operations Maintenance and Certification Maintenance and Certification Flight Operations the form of an appropriate informational document and will be easily recognizable as EWIS ICA. The goal of the resultant enhanced cleaning and inspection tasks is to have fewer EWIS failures, which leads to safer operation. During the zonal inspections, EWIS would be checked for unacceptable conditions, including: • wire bundle chafing, sagging or improper attachment and securing; • wire damage (obvious damage due to mechanical impact, overheat, localized chafing, etc.); • wiring protection sheath/conduit deformity or incorrect installation; • contamination, such as dust and lint accumulation, surface contamination by metal shavings/swarf, and liquids; • deterioration of splices, whether from production or previous repair; • inappropriate repairs (e.g. incorrect splice); • grommets missing or damaged; • lacing tape and/or ties missing/incorrectly installed; and • wires riding on, or inadequate separation from, fluid lines. Most manufacturers will conduct the EZAP through the Maintenance Review Board (MRB) process (using MSG-3 v2005.1 or a later version). However, Supplemental Type Certificate (STC) applicants will likely conduct the EZAP by other means outside the MRB process, such as via a Maintenance Type Board (see TP 13850). Typically, Transport Canada Civil Aviation (TCCA) aircraft evaluation or regional maintenance inspectors would participate in and/ or review the results of the EZAP, with input from headquarters or regional aircraft certification engineers. The EWIS ICA would be included in an approved section of the ICA document(s) pertinent to each design approval. Once generated, these EWIS ICAs are required to be placed in Canadian commercial air operator-approved maintenance schedules, pursuant to CAR 605.86, to meet the requirements of Standard 625, appendices C and D. These wiring lessons have been learned and documented as recommendations from the Transportation Safety Board of Canada’s (TSB) investigation into the Swissair 111 accident. Among other findings, the TSB asserted that wiring discrepancies found on many aircraft reflected a shortfall within the aviation industry in wire installation, maintenance, and inspection procedures. In particular, the TSB identified that: • current maintenance practices did not adequately address wiring components; • wiring inspection criteria were too general; • maintenance instructions did not describe unacceptable conditions in enough detail; and • airplane wiring needed to be considered as a discrete system and given the same level of scrutiny as other airplane systems. Wire chaffing issue To ensure that the achieved safety objectives of the fuel tank system and EAPAS industry-wide safety reviews and retrofits are maintained for the operational life of the reviewed airplane models, we need to ensure that future design changes do not degrade the achieved level of safety in the fleet. On a go-foward basis, the FAA is applying the fuel tank system and EWIS EZAP ICA requirements to all new design changes to transport category airplanes, pursuant to specific regulations. These requirements may be over and above the requirements of 14 CFR Part 25/AWM 525, or those otherwise established in the airplane’s basis of certification. Transport Canada (TC) and the European Aviation Safety Agency (EASA) are also applying these same design requirements for new design approval applications, citing that the design may have (unsafe) features that were not foreseen in the existing certification basis; for that reason, it establishes these new design requirements as applicable standards for a design approval application. Moreover, there are existing requirements that provide that there may not be design features or details that experience has shown to be hazardous or unreliable. Further, in view of the hundreds of ADs issued to correct in-service deficiencies relating to fuel tank safety, failure to follow the revised “best practices” would be considered an unsafe feature or characteristic, and on that basis TCCA or EASA may refuse to issue the design approval. EASA has further clarified in NPA 2007/01 that it supported the retrospective design reviews and would send letters to request review of ICA to incorporate 24 ASL 1/2012 results of EZAP by DAH holders. ADs would be issued to non-cooperative DAHs, pursuant to the EASA Implementing Rule (IR) 21A.3B(c)(1). In addition, pending modification of type certificate data sheets, generic special conditions quoting the relevant paragraphs of CS-25 as modified by the EWIS NPA will be systematically issued for approvals of modifications affecting EWIS when application is after the amendment to CS-25 (September 5, 2008). As in Canada, any EWIS ICAs developed under the EZAP must be placed in European operators’ maintenance programs, pursuant to IR Part-M.302. Each new design change that may affect the airplane fuel tank system should not introduce additional fuel tank ignition hazards to those that may already be present in the unmodified design. The design change applicant must demonstrate compliance with the design standards of AWM/FAR/CS 525/25.981(a), (b) and Appendix H525/25.4 (change 525-11, equivalent to FAR Amdt. 25-102). Similarly, for each aircraft zone containing EWIS that is affected by the design change, especially where the characteristics of the zone (e.g. susceptibility to systemic accumulation of dust and lint, proximity to hydraulic and mechanical flight controls, zone density) may be affected, it must be determined whether any specific EWIS ICA may be required, using the EZAP methodology in accordance with AWM Appendix H525.5(a)(1) and (b) (change 525-16, equivalent to FAR Amdt. 25-123). These actions are the cumulative result of past experience and in-depth reviews. They are intended to promote safety of the transport airplane fleet through certification and continued airworthiness processes. Floats—a Seasonal Problem The following article was originally published in Aviation Safety Maintainer Issue 1/1988, and is republished in this issue for its pertinence to this day. Spring is fast approaching and, with the melting of ice on lakes and rivers, aircraft owners and operators scramble to change over from winter ski and wheel kits to floats or amphibious landing gear. A search through some accident files suggests this can spell big trouble for the unwary AME after installation of an unserviceable or incorrect kit. Accidents caused by faulty float or amphibious gear maintenance include those of an amphibious Cessna 185 that flipped onto its back during a water landing. This acc