AeroSafety World - April 2009
Cessna 303 Crusader · Training Manual
Overview
This document is the April 2009 issue of AeroSafety World, a publication by the Flight Safety Foundation. It focuses on aviation safety, providing insights and updates relevant to flight crews and operations personnel. The content includes safety management tools, risk assessment guidelines, and various safety-related articles. While it does not specifically serve as a training manual for the Cessna 303 Crusader, it contains valuable information that can be beneficial for pilots and aviation enthusiasts interested in safety practices and operational procedures.
- The FSF Aviation Department Tool Kit is essential for flight crews.
- Economic downturns do not necessarily lead to a decline in safety if proactive measures are taken.
- Safety alerts and recommendations are crucial for maintaining operational safety.
- Participation in aviation safety events is encouraged for continuous learning.
- Environmental concerns are increasingly relevant in aviation discussions.
Document
Source
Originally published by flightsafety.org. Sprinkle hosts a reference copy with an added summary, specifications and searchable full text.
Document details
- Type
- Training Manual
- Year
- 2009
- Pages
- 68
- File size
- 5.0 MB
- Publisher
- flightsafety.org
Common. Rarer than 2% of the aircraft models we track.
Most owners only have the POH. Here's the essential set for the Cessna 303 Crusader.
- Pilot's Operating Handbook / AFM
- Checklist
- Maintenance Manual
- Parts Catalog (IPC)
- Systems & Wiring
- Service Bulletins
- Type Certificate (TCDS)
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In this document
Safety Management Tools
The document discusses various safety management tools developed through years of aviation safety audits. It emphasizes the importance of having these tools on the minimum equipment list for flight crews and operations personnel. The FSF Aviation Department Tool Kit is highlighted as a valuable resource, providing templates for flight operations and safety manuals.
Economic Impact on Safety
The president's message addresses concerns about whether safety will decline due to economic downturns. It reflects on past experiences, noting that proactive safety measures can maintain safety standards even during challenging economic times.
Upcoming Aviation Safety Events
The document lists several upcoming aviation safety events and seminars, encouraging participation from industry professionals. These events focus on various aspects of aviation safety, including accident investigation and operational safety.
Safety Alerts
The publication includes safety alerts regarding specific aviation incidents and recommendations from safety boards. These alerts serve to inform operators and crews about potential risks and necessary precautions.
Environmental Concerns in Aviation
An editorial discusses the aviation industry's response to environmental concerns, particularly regarding emissions and climate change. It emphasizes the need for a balanced approach to safety and environmental responsibility.
Safety notes
- Safety management tools should be included in the minimum equipment list.
- Operators must stay informed about safety alerts and recommendations.
Full document text
APRIL 2009 The JouRnAL of fLIghT SAfeTy foundATIon AeroSafety w o r l d WINDSHIELD CRACK MISHANDLED MANAGED TO NEAR DISASTER DISTRACTED VIGILANCE news helicopters Collide BLACKLISTS oversight With a Bite STORIES FROM THE BACK Cabin Safety Symposium RESET CIRCUIT BREAKER? fatal Lack of Maintenance Safety tools developed through years of FSF aviation safety audits have been conveniently packaged for your flight crews and operations personnel. These tools should be on your minimum equipment list. The FSF Aviation Department Tool Kit is such a valuable resource that Cessna Aircraft Co. provides each new Citation owner with a copy. One look at the contents tells you why. Templates for flight operations, safety and emergency response manuals formatted for easy adaptation to your needs. Safety-management resources, including an SOPs template, CFIT risk assessment checklist and approach-and-landing risk awareness guidelines. Principles and guidelines for duty and rest schedul- ing based on NASA research. Additional bonus CDs include the Approach and Landing Accident Reduction Tool Kit; Waterproof Flight Operations (a guide to survival in water landings); Operator’s Flight Safety Handbook; Turbofan Engine Malfunction Recognition and Response; and Turboprop Engine Malfunction Recognition and Response. “Cessna is committed to providing the latest safety information to our customers, and that’s why we provide each new Citation owner with an FSF Aviation Department Tool Kit.” — Will Dirks, VP Flight Operations, Cessna Aircraft Co. MEL item FSF member price: US$750 Nonmember price: US$1,000 Quantity discounts available! For more information, contact: Feda Jamous, + 1 703 739-6700, ext. 111 e-mail: jamous@flightsafety.org Here’s your all-in-one collection of flight safety tools — unbeatable value for cost. | 1 www.flightsafety.org | AeroSAfetyworld | april 2009 president’sMeSSAge there are a couple of tough questions that keep coming up during every stop I make. One of the toughest is whether safety is going to suffer as a result of the economic downturn, and what we can we do about it. Here are some of the best answers I can come up with. This year is not off to a good start. The trend lines for accident rates are flattening out, and may even be starting to rise. In addition, North America and Europe have suffered seven air car- rier major accidents since August. It is too soon to assume we are entering a “dark age” for safety, but recent events cannot be ignored. On a more positive note, I’ll point out that we have empirical proof that economic stress does not have to result in a decline in safety. The period fol- lowing the attacks of Sept. 11, 2001, despite most of the airlines in the United States filing for bankruptcy protection at least once, was the safest in U.S. com- mercial aviation history. Here is how I explain it: First, I have to credit the extraordinary tenac- ity and professional integrity of the people on the line who ran the system every day while watching their dreams of prosperity and retirement slip away. Second, many carriers, especially the big ones, really caught on to the idea that predictive safety systems and protected reporting systems were good for the bottom line as well as good for safety. Next, I have to point out that the regulators did some things that worked. This was the era when risk-based surveillance really took hold. The regulators had enough access to information about the operators to make informed decisions about who needed more attention and who needed less. The regulators didn’t go soft; they just got smarter. When an operator failed to get the safety message, these gatekeepers were able to focus on the at-risk operators until they either got it right or went out of business. Can we expect the same positive scenario around the world now that we have an even deeper recession? That depends on a lot of vari- ables, so let me offer a short checklist to consider your risk: • Do you have an experienced and dedicated workforce that can stay professional in spite of economic distractions? • Does your airline really understand that proactive safety and reporting systems are essential to its business? • Do you have a competent and capable regu- latory authority that can intelligently target risks? • Can your regulator act without fear of po- litical interference and be able to present grounding as a credible threat? • Is the relationship between the regulator and the industry open, effective and appropriate, or is it a game of hide and seek? History tells us that a strong operator some- times can stay safe without a strong regulator, but if your experience shows a weakness in both, we could be in for a rough year. William R. Voss President and CEO Flight Safety Foundation Bad times safety in 2 | flight safety foundation | AeroSAfetyWorld | april 2009 features 12 Helicoptersafety | Distracted 17 seminareASS | Beyond Compliance 20 Coverstory | Knock Yourself Out 30 Cabinsafety | Symposium Highlights 34 trafficControl | TCAS II Version 7.1 Approval 39 flighttraining | Back to the Drawing Board 42 Strategicissues | Blacklist Reasoning 46 MaintenanceMatters | Circuit Breaker Threats departments 1 president’sMessage | Safety in Bad Times 5 editorialpage | Green and Safe 8 safetyCalendar | Industry Events 9 inBrief | Safety News 20 AeroSafetyWorld 12 30 contents April2009 Vol 4 issue 4 AeroSafetyWORLD telephone: +1 703.739.6700 William R. Voss, publisher, FSF president and CEO voss@flightsafety.org J.A. Donoghue, editor-in-chief, FSF director of publications donoghue@flightsafety.org, ext. 116 Mark Lacagnina, senior editor lacagnina@flightsafety.org, ext. 114 Wayne Rosenkrans, senior editor rosenkrans@flightsafety.org, ext. 115 Linda Werfelman, senior editor werfelman@flightsafety.org, ext. 122 Rick Darby, associate editor darby@flightsafety.org, ext. 113 Karen K. Ehrlich, web and print production coordinator ehrlich@flightsafety.org, ext. 117
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Ann L. Mullikin, art director and designer mullikin@flightsafety.org, ext. 120 Susan D. Reed, production specialist reed@flightsafety.org, ext. 123 Patricia Setze, librarian setze@flightsafety.org, ext. 103 Editorial Advisory Board David North, EAB chairman, consultant William R. Voss, president and CEO Flight Safety Foundation J.A. Donoghue, EAB executive secretary Flight Safety Foundation Steven J. Brown, senior vice president–operations National Business Aviation Association Barry Eccleston, president and CEO Airbus North America Don Phillips, freelance transportation reporter Russell B. Rayman, M.D., executive director Aerospace Medical Association www.flightsafety.org | AERoSAfEtyworld | april 2009 | 3 25 foundationfocus | FSF–I Is 20 29 smokefirefumes | U.S. and Canadian Events 50 Datalink | Tanzania’s Runway Game 53 Infoscan | From Ideal to Real in the Cockpit 57 onRecord | ‘Salvaged’ Approach Ends Badly We Encourage Reprints (for permissions, go to <www.flightsafety.org/asw_home.html>) Share Your Knowledge if you have an article proposal, manuscript or technical paper that you believe would make a useful contribution to the ongoing dialogue about aviation safety, we will be glad to consider it. send it to director of publications J.a. donoghue, 601 Madison st., suite 300, alexandria, Va 22314-1756 Usa or donoghue@flightsafety.org. the publications staff reserves the right to edit all submissions for publication. Copyright must be transferred to the foundation for a contribution to be published, and payment is made to the author upon publication. Sales Contacts Europe, Central USA, Latin America Joan daly, joan@dalyllc.com, tel. +1.703.983.5907 Northeast USA and Canada tony Calamaro, tcalamaro@comcast.net, tel. +1.610.449.3490 Subscriptions: subscribe to AeroSafety World and become an individual member of flight safety foundation. one year subscription for 12 issues includes postage and handling — Us$350. special introductory rate — $310. single issues are available for $30 for members, $50 for nonmembers. for more information, please contact the membership department, flight safety foundation, 601 Madison st., suite 300, alexandria, Va 22314-1756 Usa, +1 703.739.6700 or membership@flightsafety.org. AeroSafety World © Copyright 2009 by flight safety foundation inc. all rights reserved. issN 1934-4015 (print)/ issN 1937-0830 (digital). published 12 times a year. suggestions and opinions expressed in AeroSafety World are not necessarily endorsed by flight safety foundation. Nothing in these pages is intended to supersede operators’ or manufacturers’ policies, practices or requirements, or to supersede government regulations. About the Cover Beech King air suffered from a cracked windshield poorly handled. © Chris sorensen photography 34 39 Asia Pacific, Western USA pat walker, walkercom1@aol.com, tel. +1.415.387.7593 Regional Advertising Manager arlene Braithwaite, arlenetbg@comcast.net, tel. +1.410.772.0820 42 Managing your air safety risk... ...has its rewards. Safety Management • Safety reporting module integrates incident data across all departments • Risk assessment calculates and guides decision-making to resolve incidents • Automatically trigger corrective actions from incidents • Schedule and execute safety audits (IOSA) across multiple departments • Consolidate and standardize document control and training across the organization Quality Management Quality Management • Risk assessment determines critical vs. non-critical events, guides decisions • Schedule and track maintenance and equipment calibration • Powerful reporting tool with over 50 reports out-of-the-box • Over 20 integrated modules available: • Incidents • Document Control • Employee Training • Corrective Action • Audits • Calibration & Maintenance • Centralized Reporting... and more! Supplier Management Supplier Management • Foster collaboration with suppliers and contractors • Create visibility into supplier quality and supplier safety • Supplier rating automatically updates scorecards based on quality/safety events Integrated Approach • Integration of Quality, Safety, Environmental, and Supplier data across the enterprise • Holistic Integrated Airline Management System v i s i t o u r w e b s i t e f o r a f r e e a u t o m a t e d d e m o c a l l f o r a f r e e l i v e d e m o n s t r a t i o n w w w. e t q . c o m / a i r s a f e t y maintenance LOW RISK HIGH RISK HIGH RISK flight ops in-flight safety | 5 www.flightsafety.org | AeroSAfetyworld | april 2009 editoriAlpage environmental activists around the globe have aviation in their sights and the industry must respond. In many ways, the current uproar about aviation’s contribution to global climate change mirrors past outbursts about aviation safety; some were justified, others were vastly overblown. Everything connected to aviation, the highly visible and singular activity that it is, gets an exaggerated public response. We’ve found that being defensive about undeserved safety criticism doesn’t get a lot of traction with a disturbed public. While presenting our case as best we can, in the end we must have a positive response to the public concern. And so it goes with emissions: Pro- testing that aviation’s contribution to the world problem is minimal won’t win the day. Even less productive is trying to ar- gue the existence of climate change. In the end we just have to suck it up and make a good-faith effort to improve, making certain that we blow whistles, wave our hands and issue press releases with every step taken toward being carbon neutral. Meanwhile, we also have to be tem- pered in our rush to greenness. We can- not let our zeal to be Earth-friendly diminish our safety focus. This is not to point a finger at any aspect of the drive toward carbon neutrality; I’ve seen noth- ing that is an obvious risk. However, one only needs to look at the recent surprising developments with frozen ice crystals blocking the fuel flow on Rolls-Royce– powered Boeing 777s to get some idea of how complicated it will be to fully test and clear for use the alternative fuels now in development. When a jet fuel that has been in use for so many decades suddenly presents new, odious failure modes, it raises the question: How well do we need to test the new fuels? Experts speaking at the recent Avia- tion and Environment Summit in Geneva predicted that sustainable biofuels could be ready for commercial aviation opera- tions within five years. Where are these fuels coming from? Numerous sources are candidates. In addition to fuels from feed grains, there are fuels being tested made from plants including camelina, jatropha and halophytes, fuels from cel- lulosic material remain a possibility, and in the longer term fuel produced by algae may become available. Efforts using feedstock to produce alcohol initially were welcomed until it was noted that these sources compete with human food, and their production requires a lot of carbon generation. Sud- denly they came to be considered more of a hazard than a solution. The viability of the other candidates depends on how readily they can be produced and turned into fuel with minimal negative effects. It may be that these new fuels are a direct swap for Jet A, but I doubt it. There are bound to be differences. In automo- tive fuels, the 15 percent ethanol content added in many areas of the United States reduces emissions without harming the engine, but the energy content of the mix is several percentage points lower than pure gas of the same octane rating. In an automobile, this is not an issue. However, every point counts in calculating aircraft performance. I am not criticizing the biofuel effort. Fossil fuels are finite resources; renewable energy sources must be developed, even more so now to answer the call to stem the rate of climate change. But concern about the biofuel effort is an example of the care that must be exercised as we travel the road to a green aviation industry. J.A. Donoghue Editor-in-Chief AeroSafety World green and safe MemberGuide Flight Safety Foundation Headquarters: 601 Madison St., Suite 300, Alexandria, VA, 22314-1756 USA tel: +1 703.739.6700 fax: +1 703.739.6708 www.flightsafety.org Member enrollment ext. 105 Ann Hill, director of membership hill@flightsafety.org Seminar registration ext. 101 Namratha Apparao, membership services coordinator apparao@flightsafety.org Seminar sponsorships ext. 105 Ann Hill, director of membership hill@flightsafety.org Exhibitor opportunities ext. 105 Ann Hill, director of membership hill@flightsafety.org FSF awards programs ext. 111 Feda Jamous, accountant jamous@flightsafety.org Technical product orders ext. 111 Feda Jamous, accountant jamous@flightsafety.org Library services/seminar proceedings ext. 103 Patricia Setze, librarian setze@flightsafety.org Web Site ext. 117 Karen Ehrlich, web and print production coordinator ehrlich@flightsafety.org Regional Office: GPO Box 3026 • Melbourne, Victoria 3001 Australia Telephone: +61 1300.557.162 • Fax +61 1300.557.182 Paul Fox, regional director fox@flightsafety.org Amy Beveridge, event manager beveridge@flightsafety.org OFFicErS and STaFF Chairman, Board of Governors Amb. Edward W. Stimpson President and CEO William R. Voss General Counsel and Secretary Kenneth P. Quinn, Esq. Treasurer David J. Barger adMiniSTraTivE Manager, Support Services Linda Crowley Horger FinanciaL Chief Financial Officer Penny Young Accountant Feda Jamous MEMbErShip Director of Membership Ann Hill Membership Services Coordinator Namratha Apparao Membership Services Coordinator Ahlam Wahdan cOMMunicaTiOnS Director of Communications Emily McGee TEchnicaL Director of Technical Programs James M. Burin Technical Programs Specialist Norma Fields Technical Specialist/ Safety Auditor Robert Feeler Manager of Aviation Safety Audits Darol V. Holsman Past President Stuart Matthews Founder Jerome Lederer 1902–2004 FligHt SAFety FoUndAtion | AEroSAFEtyWorld | April 2009 Flight Safety Foundation is an international membership organization dedicated to the continuous improvement of aviation safety. Nonprofit and independent, the Foundation was launched officially in 1947 in response to the aviation industry’s need for a neutral clearinghouse to disseminate objective safety information, and for a credible and knowledgeable body that would identify threats to safety, analyze the problems and recommend practical solutions to them. Since its beginning, the Foundation has acted in the public interest to produce positive influence on aviation safety. Today, the Foundation provides leadership to more than 1,170 individuals and member organizations in 142 countries. Serving Aviation Safety interests for More than 60 years Flight Data Services (USA) Telephone: +1 (602) 387-4961 Fax: +1 (602) 387-5001. Flight Data Services (UK) Telephone: +44 (0)1329 223663 Fax: +44 (0)1329 223664. Flight Data Services (UAE) Telephone: +971 4 3132717 Fax: +971 4 3132718. Flight Data Services are members of the Flight Safety Foundation, the National Business Aviation Association, the European Regions Airline Association, the United Kingdom Flight Safety Committee and AFRASCO. The World’s Leading FOQA/FDM Service Provider www.c-foqa.com Choose the C-FOQA service that meets international mandatory requirements 8 | flight safety foundation | AeroSAfetyWorld | april 2009 ➤ safetycAlendAr Aviation safety event coming up? Tell industry leaders about it. If you have a safety-related conference, seminar or meeting, we’ll list it. Get the information to us early — we’ll keep it on the calendar through the issue dated the month of the event. Send listings to Rick Darby at Flight Safety Foundation, 601 Madison St., Suite 300, Alexandria, VA 22314- 1756 USA, or <darby@flightsafety.org>. Be sure to include a phone number and/ or an e-mail address for readers to contact you about the event. APRIL 14–15 ➤ Helicopter Safety and Operations Management Forum. Aviation Week Management Forums. San Diego. Helen Kang, <helen_kang@aviationweek.com>, <www.aviationnow.com/forums/helimain.htm>, +1 212.904.6305. APRIL 20–21 ➤ Regional Air Safety Seminar: Air Accident Investigation in the European Environment. European Society of Air Safety Investigators. Hamburg, Germany. Anne Evans, <aevans@aaib.gov.uk>, +44 1252 510300. APRIL 20–MAY 1 ➤ Advanced Accident Prevention and Investigation Course. Southern California Safety Institute and Czech Republic Ministry of Transport. Prague. Sharon Morphew, <registrar@scsi-inc.com>, <www. scsi-inc.com/Prague%20Announcements. html>, 800.545.3766, ext. 104; +1 310.517.8844, ext. 104. APRIL 21–23 ➤ 54th annual Corporate Aviation Safety Seminar (CASS). Orlando, Florida, U.S. Namratha Apparao, <apparao@ flightsafety.org>, <www.flightsafety.org/ seminars.html#cass>, +1 703.739.6700, ext. 101. APRIL 25–26 ➤ Regional Advanced Airport Safety and Operations Specialist School. American Association of Airport Executives. Buffalo, New York, U.S. Stacey Renfroe, <stacy.renfroe@aaae.org>, <www.aaae.org/ meetings/meetings_calendar/mtgdetails. cfm?MtgID=090416>, +1 703.824.0500. APRIL 26–28 ➤ 4th CANSO Asia Pacific ANSP Conference. Civil Air Navigation Services Organisation. Singapore. Marc-Peter Pijper, <marcpeter.pijper@canso.org>, <www. canso.org/Canso/Web/events/asia+pacific>, +31 (0)23.568.5386. APRIL 27–MAY 1 ➤ Survival Factors in Aviation Accidents Course. U.S. National Transportation Safety Board. Ashburn, Virginia, U.S. <trainingcenter@ntsb.gov>, <www.ntsb.gov/tc>, +1 571.223.3900. APRIL 27–28 ➤ Safety and Training Summit 2009. Rotor & Wing. Denver. Randy Jones, <rjones@accessintel.com>, <www. safetyandtrainingsummit.com>. APRIL 28–30 ➤ World Aviation Training Conference and Tradeshow. Halldale Media Group. Orlando, Florida, U.S. Fiona Greenyer, <fiona@halldale.com>, <www.halldale.com/ WRATS.aspx>, +44 (0)1252 532000. APRIL 30 ➤ Annual Dinner/Meeting. International Society of Air Safety Investigators, Mid-Atlantic Region. Herndon, Virginia, U.S. Ron Schleede, <ronschleede@cox.net>, +1 703.455.3766. MAY 3–7 ➤ Annual Scientific Meeting. Aerospace Medical Association. Los Angeles. Dr. Russell B. Rayman, <rrayman@asma.org>, <www. asma.org/meeting/index.php>, +1 703.739.2240, ext. 103. MAY 4–6 ➤ 6th International Aircraft Rescue Fire Fighting Conference and Exhibits. Aviation Fire Journal. Myrtle Beach, South Carolina, U.S. <avifirejnl@aol.com>, <www. aviationfirejournal.com/myrtlebeach/index. htm>, +1 914.962.5185. MAY 4–7 ➤ Aging Aircraft 2009. Universal Technology Corp. Kansas City, Missouri, U.S. Jill Jennewine, <jjennewine@utcdayton.com>, <www.agingaircraft2009.com/index.html>, +1 937.426.2808. MAY 5–7 ➤ Technical Symposium. Air Traffic Control Association, U.S. Federal Aviation Administration and U.S. National Aeronautics and Space Administration. Atlantic City, New Jersey, U.S. Claire Rusk, <claire.rusk@atca.org>, <www. atca.org>, +1 703.299.2430. MAY 6–7 ➤ Bird Strike Prevention Forum. Aviation Week Management Forums. Chicago. Helen Kang, <helen_kang@aviationweek.com>, <www.aviationnow.com/forums/birdmain.htm>, +1 212.904.6305. MAY 11–12 ➤ Risk Management Course. ScandiAvia. Stockholm. Morten Kjellesvig, <morten@scandiavia.net>, <www.scandiavia.net/ index.php/web/artikkel_kurs/risk_management_ course/>, +47 91.18.41.82. MAY 12–14 ➤ EBACE2009. European Business Aviation Association and National Business Aviation Association. Geneva. <info- eu@ebace.aero>, <info-us@ebace.aero>, <www.ebace.aero/2009>, +32 2.766.0073, +1 202.783.9000. MAY 12–14 ➤ Safety Manager Course. Aviation Research Group/U.S. Denver. Kendra Christin, <kchristin@aviationresearch.com>, <www.aviationresearch.com/press_detail. asp?id=46>, +1 513.852.5110, ext. 10. MAY 21–22 ➤ Waypoint AirMed and Rescue. Waypoint. Oxford, England. <info@ airmedandrescue.com>, <www.airmedandrescue. com>, +44 (0)117 922 66 00, ext. 2. JUNE 2–4 ➤ 2009 Europe/U.S. International Aviation Safety Conference. European Aviation Safety Agency and Hellenic Civil Aviation Authority. Athens, Greece. Ross Inwood, <athens2009@easa.europa.eu>, <www.easa. europa.eu/conf2009>, +49 221 89990 2041. JUNE 3–4 ➤ Flight Simulation Conference: Towards the Edge of the Envelope. Royal Aeronautical Society. London. <conference@ aerosociety.com>,<www.aerosociety. com/conference/indexconf.html>, +44 (0)20 7670 4345. JUNE 9–11 ➤ Aviation Ground Safety Seminar. National Safety Council, International Air Transport Section. Bournemouth, England. B.J. LoMastro, <B.J.LoMastro@nsc.org>, <www.nsc. org>, +1 630.775.2174. JUNE 10–11 ➤ CAE Flightscape Users Conference. CAE Flightscape. Ottawa. <info@ flightscape.com>, <www.flightscape.com/about/ conferences.php>, +1 613.225.0070. JUNE 15–21 ➤ International Paris Air Show. Gifas (Groupement des Industries Françaises Aéronautiques et Spatiales). Paris Le Bourget. <siae@salon-du-bourget.fr>, <www.paris-air- show.com>, +33 (0)826 465 265. JUNE 15–18 ➤ Human Factors Initial and Train-the-Trainer Courses. The Aviation Consulting Group. Phoenix. Bob Baron, <tacg@ scccoast.net>, <www.tacgworldwide.com/ humanfactorstraining.htm>, 800.294.0872, +1 954.803.5807. JUNE 25–27 ➤ 14th Annual Flight Attendants Conference. National Business Aviation Association. New Orleans. Jay Evans, <jevans@nbaa.org>, <web.nbaa.org/events/ fac/2009>, +1 202.783.9353. | 9 www.flightsafety.org | AeroSAfetyworld | april 2009 inBrief acomponent on Boeing 777 Rolls- Royce RB211 Trent 800 series engines should be redesigned to eliminate the possibility of an icing buildup similar to those that have been cited in two engine thrust rollbacks in 2008, the U.S. National Transportation Safety Board (NTSB) says. In safety recommendations to the U.S. Federal Aviation Administration (FAA) and the European Aviation Safety Agency (EASA), the NTSB also said that after the redesign of the fuel/oil heat exchanger (FOHE) is complete, opera- tors should be required to install the new system on affected 777s at the next main- tenance check or within six months. Rolls-Royce has indicated that redesign already has begun and that the system should be ready for installation within 12 months, the NTSB said. In issuing its recommendations, the NTSB cited the Jan. 17, 2008, crash of a British Airways 777-200ER just short of the landing runway at London Heathrow Airport after a flight from Beijing. One person was seriously injured and 12 received minor injuries in the crash, and the airplane was substantially damaged. The U.K. Air Accidents Investigation Branch (AAIB) said in preliminary reports that an accumulation of ice on the FOHE restricted the flow of fuel to the engines, resulting in a dual-engine thrust rollback. The NTSB also cited a Nov. 26, 2008, incident involving a single-engine thrust rollback in a Delta Air Lines 777 dur- ing the cruise segment of a flight from Shanghai, China, to Atlanta. The flight crew performed Boeing’s published pro- cedure to recover engine performance and resumed normal flight. Since the incidents, Boeing has developed additional procedures for dealing with the problem, and the FAA and EASA have incorporated those pro- cedures into airworthiness directives. “While the procedures may reduce the risk of a rollback in one or both engines due to FOHE ice blockage, they add complexity to flight crew operations, and the level of risk reduction is not well established,” the NTSB said. “And because the recovery procedure requires a descent, the aircraft may be exposed to other risks such as rising terrain or hazardous weath- er, or the inability to achieve maximum thrust during a critical phase of flight, such as during a missed approach.” As a result, the NTSB said a redesign of the FOHE was “the only acceptable solution” to the safety risk. Because two similar events occurred within one year, without corrective ac- tion, NTSB Acting Chairman Mark V. Rosenker said, “We believe that there is a high probability of something similar happening again.” Component Redesign Sought the Spanish aviation accident investigation body has recommended that Boeing be required to include in vari- ous information manuals instructions on dealing with overheating of the ram air temperature probe while an airplane is on the ground. The Comisión de Investigación de Accidentes e Incidentes de Aviación Civil cited the Aug. 20, 2008, crash of a McDonnell Douglas MD-82 after takeoff from Madrid-Barajas Airport. The crash killed 154 people, 18 were seriously injured, and the airplane was destroyed. Before takeoff, the crew had returned to the gate so the overheated temperature probe could be examined by mainte- nance personnel, who disabled the circuit breaker that supplied power to the probe. A preliminary investigation found that the airplane’s flaps and slats were not in takeoff configuration, “re- sulting in the failure of the airplane to climb properly,” and that the crew did not receive an automated takeoff configuration warning during the takeoff roll, the commission said. The commission said that the steps that should be taken to find the cause of high ram air temperature indications on the ground are not specifically cited in the manufacturer’s main- tenance manuals, and that airworthiness instructions do not address two possible problems involving temperature probe heat- ing: improper heating on the ground and no heat while airborne. The commission recommended that the European Aviation Safety Agency and the U.S. Federal Aviation Administration require Boeing to add relevant information to the aircraft main- tenance manual, troubleshooting manual and fault isolation manual. Overheated Temperature Probe U.S. National Transportation Safety Board © Javier Pedreira/flickr safety news 10 | flight safety foundation | AeroSAfetyworld | april 2009 inBrief Certain light emitting diode (LED) lighting systems are not visible through night vision goggles (NVG), and NVG users should exercise caution when flying near areas where these lighting systems may be operating, the U.S. Federal Aviation Administration (FAA) says. The FAA cited a report issued in 2008 by the Canadian Air Force Directorate of Flight Safety, which identified the problem, which involves some obstruction light- ing systems that use red LEDs. The lights are visible to the naked eye but not through NVGs. “Aviation Red light ranges from about 610 to 700 nanometers (nm), and NVGs approved for civil aviation … are only sensitive to energy ranging from 665 to about 930 nm,” the FAA said in Safety Alert for Operators, No. 09007. “Because LEDs have a relatively narrow emission band and do not emit infrared energy like incandescent lights, it is possible for them to meet FAA requirements for Aviation Red but be below the range in which NVGs are sensitive.” NVG Alert the U.S. Federal Aviation Adminis- tration (FAA) has issued a policy change to prevent operators from claiming that the applicable operating rules for their aircraft have been changed by obtaining supplemental type certifi- cates (STCs) that reduce the aircraft’s maximum zero fuel weight (MZFW). The FAA said it is “aware that persons have obtained STC or amended TC [type certificate] approvals to change an aircraft’s FAA-approved limitation and then use the approvals to change the applicability of operating rules they operate under. The STC (or amended TC) may or may not actually make a change to the aircraft.” Because the changes are not changes in type design, the original TC still determines whether the aircraft is operated under U.S. Federal Aviation Regulations Part 125 or less stringent regulations, the FAA said. Zero Fuel Weight Changes the Italian flight safety board, the Agenzia Nazionale per la Sicurezza del Volo (ANSV), says it has established a new “effective spirit of cooperation” with the Italian Ministry of Justice for the investigation of aviation accidents. “In particular, the Ministry of Justice invited the directors of public prosecutions with the appeals courts to stipulate that, in the case of an accident involving an aircraft and immediately following the event, in compatibility with search and rescue activities, there shall be no tampering with or alteration of evidence before the ar- rival of the assigned ANSV investigators,” the ANSV said. According to the agreement, the recovery of wreckage also should be coordinated with the ANSV. The ANSV statement followed criticism by aviation safety organizations, including Flight Safety Foundation, of pros- ecutors in Italy and France for their interference in accident investigations in both countries. The investigations involved the Nov. 27, 2008, crash of an Air New Zealand Airbus A320 off the coast of France and the Feb. 7, 2009, crash of a Cessna Citation in Rome. Seven people were killed when the A320, on a post-maintenance test flight, plunged into the Mediterranean Sea during an approach to Perpignan Airport. Two pilots — the only people in the Cita- tion — were killed after encountering a thunderstorm after departure from Rome to pick up personnel for an emergency medical services flight. Flight Safety Foundation said in late February that in- vestigations of both accidents had been delayed “because law enforcement authorities seized vital evidence before safety investigators could examine it.” Some of the evidence was sub- sequently returned to investigators. “Unless there is evidence of sabotage, law enforcement and judicial authorities need to step aside, allow accident investiga- tors immediate access to the wreckage and to surviving crew and passengers, and let safety professionals do their job,” said Foundation President and CEO William R. Voss. “To prevent another tragedy, it’s far more important that we learn what hap- pened and why than to build a criminal case.” Investigative Cooperation © Andrei Dimofte/Wikimedia © iStockphoto | 11 www.flightsafety.org | AeroSAfetyworld | april 2009 inBrief aRINC has launched an air-ground data link communications service in Brazil that covers all major South American air routes. GLOBALink/VHF ACARS is being carried over the Brazilian Department of Airspace Control’s air and ground facilities. … Airservices Australia plans to upgrade three of its air traffic control towers with technology provided jointly by Nav Canada and Sensis Corp. The upgrade is intended to provide controllers with immediate access to flight data and voice communications, and to monitor the airports and their surrounding airspace, Nav Canada said. Correction … The source was cited incorrectly for Table 1 on p. 35 of the February issue of ASW. The correct source is: Lambregts, A.A.; Nesemeier, G.; Wilborn, J.E.; Newman, R.L. “Airplane Upsets: Old Prob- lem, New Issues.” Paper presented at American Institute of Aeronautics and Astronautics Modeling and Simulation Technologies Conference and Exhibit, Aug. 18–21, 2008. AIAA 2008-6867. In Other News … Compiled and edited by Linda Werfelman. southwest Airlines will pay a $7.5 million civil penalty to re- solve U.S. Federal Aviation Administration (FAA) enforce- ment actions for operating 46 airplanes on 59,791 flights without performing required inspections for fatigue cracking in the fuselage, the FAA says. The penalty could double if Southwest does not perform 13 safety improvements outlined in an agreement with the FAA. Those improvements include increasing the number of on-site technical representatives for heavy maintenance ven- dors, granting FAA inspectors improved access to information used to track maintenance activities, rewriting FAA-approved manuals and designating a quality assurance manager who does not have responsibility for air carrier certification. The penalty stemmed from what the FAA said was South- west’s failure, during parts of 2006 and 2007, to comply with a 2004 airworthiness directive that required repetitive inspections of some fuselage areas to detect fatigue cracks. When the penalty was first proposed, Southwest said that the missed inspections were “one of many routine and redundant inspections” involving “an extremely small area in one of the many overlapping inspec- tions” aimed at early detections of fatigue cracking. “This agreement furthers aviation safety by requiring im- portant improvements to the airline’s safety program,” FAA Act- ing Administrator Lynne A. Osmus said. “Some of those safety measures exceed FAA regulations.” Multimillion-Dollar Penalty Japanese accident investigators inspect the wreckage of a FedEx McDonnell Douglas MD-11 cargo plane that crashed on landing at Narita International Airport east of Tokyo on March 23. The two pilots — the only people in the airplane — were killed. © Kyodo/Associated Press © Brian Futterman/Wikimedia 12 | flight safety foundation | AeroSAfetyWorld | april 2009 HeLICoPtersafety five television news-gathering helicopters were maneuvering to cover a police chase in Phoenix on July 27, 2007, when two of the aircraft — both Eurocopter AS 350B2s — collided over a downtown park as their pilot-reporters were describing the events occurring on the ground. The crash killed the two pilot-reporters and two news photographers and de- stroyed both helicopters. The U.S. National Transportation Safety Board (NTSB), in its final report on the accident, said that the probable cause was the failure of both pilots to see and avoid the other helicopter, and “contributing to this failure was the pi- lots’ responsibility to perform reporting and visual tracking duties to support their station’s ENG [electronic news gathering] operation.” The report identified as a contribut- ing factor “the lack of formal procedures for Phoenix-area ENG pilots to follow Ross D. Franklin/Associated Press DistracteD BY LINDA WERFELMAN The pilots of two TV news helicopters were busy with news-reporting duties in the seconds before their midair collision in Phoenix. Helicopter Position Information Channel 15 1245:19, 2,200 ft Channel 15 1245:24, 2,200 ft Collision Channel 15 1245:50, 2,300 ft Channel 15 1245:54, 2,300 ft Channel 15 1245:59, 2,300 ft Channel 3 1245:25, 2,000 ft Channel 15 1246:08 Channel 3 1246:05 Channel 3 1245:45, 2,000 ft Channel 3 1246:00, 2,100 ft 1245:27 1245:02 Truck stops here 1246:05 1245:38 1245:51 1244:43 Notes: Altitude was not available for position reports immediately before the collision. Yellow line indicates path of truck. Source: U.S. National Transporation Safety Board; Aerial photograph, Google Earth Figure 1 | 13 WWW.flightsafety.org | AeroSAfetyWorld | april 2009 HeLICoPtersafety regarding the conduct of these operations.” Visual meteoro- logical conditions prevailed when the midair collision oc- curred at 1246 local time, about 23 min- utes after a police he- licopter contacted air traffic control (ATC) to join the pursuit by police on the ground of a suspect accused of stealing a pickup truck, backing it into a police vehicle and then fleeing in the truck. Over the next 22 minutes, pilots of the five news helicop- ters also checked in with ATC and headed for the area of the police chase. In accordance with informal procedures, the six helicopter pilots shared an air-to-air radio frequency to report their positions and their intentions. The accident helicop- ters — from Channel 3 and Channel 15 — had audio-video recording systems, and the information recorded by those systems was analyzed in the accident investigation. At 1238, the Channel 15 pilot was recorded telling the other pilots that he was flying at 2,200 ft, and the Channel 3 pilot said that his helicopter was at 2,000 ft (Figure 1). “According to the Channel 3 and 15 audio recordings, about 1241:02, the Channel 15 pilot stated, ‘I’ll just kinda park it right here.’ About 1241:18, the Channel 3 pilot broadcast, “OK, I’m gonna move.’ Between about 1241:22 and about 1241:26, the Channel 15 pilot stated, ‘where’s three?’ … ‘like how far?’ … and ‘oh jeez.’ The Channel 15 pilot then transmitted, ‘Three. I’m right over you. Fifteen’s on top of you.’ After- ward, the Channel 3 pilot questioned which helicopter Channel 15 was over, to which the Channel 15 pilot responded, ‘I’m over the top of you.’ About 1241:34, the Channel 3 pilot indicated that he was operating at 2,000 feet. About 1242:25, the Channel 3 pilot stated to the Channel 15 pilot, ‘OK. … I got you in sight,’ to which the Channel 15 pilot responded, about three seconds later, ‘got you as well.’” These comments — about four minutes before the collision — were the last in which the two pilots coordinated their helicopters’ positions or intentions. The video recordings from the he- licopters showed that, during those four minutes, both helicopters continued to change position. The report said that the suspect stopped the stolen vehicle about 1246:05, and in a broadcast recording that began at 1245:43, the Channel 3 pilot said, “Looks like he [the suspect] is starting to run. … Looks like he’s gonna try and take another vehicle … looks like they’ve got him blocked in there, but he did get ... ” The Channel 3 report then ended “suddenly, with an unintel- ligible word,” the NTSB said. An accident investigator photographs the wreckage of one of two TV news helicopters that crashed to the ground in a downtown Phoenix park after a midair collision. Four people were killed in the 2007 crash. 14 | flight safety foundation | AeroSAfetyWorld | april 2009 HeLICoPtersafety The Channel 15 pilot, in a live broad- cast that began at 1246:03, said, “He [the suspect] has stopped … now it’s a foot chase. Now he’s in another vehicle … doors open police … oh jee.” That report also ended suddenly, the NTSB said, and audio recordings from both helicopters indicated that the midair colli- sion occurred about 1246:18. Both helicopters plunged to the ground in a city park, and the pilot of a third ENG helicopter told ATC there had been a midair collision. The Channel 3 pilot, who in September 2006 reported having 13,579 flight hours, received a commercial pilot certificate with a rotorcraft-helicopter rating on Aug. 24, 1987. He also held a certified flight instructor certificate with a rotorcraft-helicopter rating and a second-class medical certificate. He was a backup pilot under contract to Channel 3 and a part-time employee; the station’s chief pilot said that the accident pilot had flown 79 flights and 124 flight hours for the station between Jan. 2 and July 5, 2007. The accident pilot also worked full time for Westcor Aviation in Scottsdale, Ari- zona, as director of operations and a charter pilot; the operator said the accident pilot had flown 88 hours for the company in 2007. The Channel 15 pilot, who had 8,006 flight hours — all in helicopters, including 907 hours in AS 350B2s — received a commercial pilot certificate with a rotorcraft-helicopter rating on Dec. 7, 1990. He held a second-class medi- cal certificate with a waiver for defective color vision; the NTSB report said that the deficiency was not a factor in the accident. The pilot was hired in October 2005 by U.S. Helicopters, which had a contract to provide helicopter service to Channel 15. He flew an average of 45 hours per month for the station and did no other flying for U.S. Helicopters, the report said. The Channel 3 helicopter had an ENG moni- tor near the instrument panel that displayed four scenes simultaneously: the station’s current broadcast, the video being recorded by the helicopter’s photographer and two other scenes selected by the pilot-reporter. The Channel 15 helicopter had a similar monitor that displayed one scene at a time. The Channel 3 helicopter was equipped with an L-3 Communications SkyWatch SKY497 traffic advisory system that provided aural traf- fic warnings via the pilot’s headset, displayed traffic on a Garmin GNS 430 navigation unit and provided 20- to 30-second warnings of aircraft that were on a collision path. “The system issued an aural alert when air- craft entered a cylinder of airspace surround- ing the pilot’s aircraft that had a horizontal radius of … 1,216 ft [371 m] and a height of plus or minus 600 ft [183 m],” the report said. Manufacturer’s guidance said that after hearing an alert, the pilot should look for the traffic and comply with right-of-way procedures. The guidance material also noted that an alert is generated only when the collision threat is first detected and that it is possible for the alert to be “inhibited.” Channel 3’s chief pilot told investigators that the system had been functioning when he flew the helicopter earlier on the day of the accident. He also said that, in situations in which “a lot of traffic (was) in close,” the volume of the aural alert was turned down to ensure that the pilot could hear radio transmissions on the commu- nications frequency. Channel 15’s helicopter had no on-board traffic advisory system, the report said. In addition to their use of the shared air-to- air frequency and their scans of the TV display screens in the cockpit, the pilot-reporters monitored the Phoenix air traffic control tower Pat Shannahan/Associated Press Pilots of the two TV news helicopters had traded information about the positions of their aircraft several times, but investigators say the last exchange came about four minutes before their midair collision. The Eurocopter AS 350 is a light five/six-seat utility helicopter first produced in October 1977 by Aerospatiale as the AS 350B. The Aerospatiale helicop- ter division and the MBB (Messerschmitt-Bolkow-Blohm) helicopter division merged to form Eurocopter in 1992. Several versions have been produced since the first AS 350Bs, which were powered by a 478 kw (641 shp) Turbomeca Arriel 1B turboshaft engine and a main rotor system comprising three fiberglass blades. The next version was the AS 350BA, with larger main rotor blades and an increased takeoff weight. Current versions include the AS 350B2, certified in 1989, and the AS 350B3, first certified in France in 1997. The AS 350B2 has a 546 kw (732 shp) Arriel 1D1 engine, a maximum cruise speed of 134 kt at sea level and a maximum takeoff weight of 2,250 kg (4,960 lb) or 2,500 kg (5,512 lb) with an external load. The AS 350B3 has a 632 kw (847 shp) Arriel 2B engine, maximum cruise speed of 140 kt at sea level and a maximum takeoff weight of 2,250 kg, or 2,800 kg (6,173 lb) with an external load. Source: Jane’s All the World’s Aircraft Eurocopter AS 350 | 15 www.flighTsafeTy.org | AeroSAfetyworld | april 2009 HelicoptersafeTy frequency on another radio, commu- nicated with their station news depart- ments on a third radio and talked with their photographers over an intercom, the report said. ‘Adequate’ Communication Radar data showed that the Channel 15 helicopter had been between 2,000 and 2,200 ft and entered a climbing right turn in the seconds before the crash; the last radar return showed the heli- copter at 2,300 ft. At the same time, the Channel 3 helicopter, which had been at 2,000 ft, turned right; the last radar return showed the helicopter at 2,100 ft. As part of the investigation, NTSB representatives met with Phoenix ENG helicopter pilots, who said that com- munication between the accident pilots had been “adequate” during the police chase. They also noted that, at the time of the accident, all operators except one used pilot-reporters to fly their aircraft; the exception was a station that employed a reporter-photographer. However, the pilots told investiga- tors that they sometimes lost sight of other helicopters because the aircraft paint schemes “tended to blend in with the desert landscape and vegetation.” They recommended the use of high- visibility paint schemes for main rotors and tail rotors, and light-emitting diode (LED) anti-collision lights to improve helicopter conspicuity. Neither accident helicopter had these features. The chief pilot for Channel 3 told investigators that, since the accident, pilots of the ENG helicopters have had “a lot more” air-to-air communication, describing the location of their helicop- ters and acknowledging the positions of others. “He also stated that, in a static situa- tion, such as a building fire, no helicop- ters would change position until all of the pilots responded and that, in a dynamic situation, such as a car chase, the pilots would constantly communicate with one another and confirm each other’s posi- tions,” the report said. “He further indi- cated that the pilots were providing more distance between each other’s helicopters and were asking the photographers more often to check clearances (separation) with other helicopters.” The two accident pilots were experienced in helicopter operations in general and ENG operations in AS 350B2s in the Phoenix area in par- ticular, the report said. Both also were experienced in simultaneously flying their helicopters and reporting. “Many of the tasks that the pilots were performing during the accident flight — such as flying the helicopter, operating the radios and initiating communications — were well-learned skills that would have been performed without much cognitive or physical © Benjamin Russell/Airliners.net 16 | flight safety foundation | AeroSAfetyWorld | april 2009 HeLICoPtersafety effort,” the report said. “However the two helicopters collided without either pilot detecting the impending hazard. Thus, even for experienced pilots, the ability to shift attention among compet- ing task demands may break down under high workload conditions and can lead to a narrowing of attention on a specific task.” A review of audio recordings showed that the accident pilots did not use the air-to-air frequency to report their positions as often as the ENG pilots participating in the post-accident interview had thought, the report said. “It is difficult to determine the extent that the Channel 3 and [Channel] 15 pilots’ reporting duties contributed to the breakdown in each pilot’s aware- ness of the other helicopter,” the report said. “The additional tasks of directly observing activities on the ground and providing narration could have affected the pilots’ ability to maintain their helicopter’s position or track the other helicopter’s positions. From about 1245:43 (Channel 3) and about 1246:03 (Channel 15) to the time of the collision, the pilots were continuously reporting the events as they unfolded, which nar- rowed the pilots’ attention to the ground and away from other tasks, such as maintaining the helicopters’ stated posi- tion and altitude and scanning the area for potential collision hazards. “Even with the limited evidence to determine the extent that the pilots’ ENG-related duties affected their ability to see and avoid the other helicopter, the circumstances of this accident dem- onstrated that a failure to see and avoid occurred about the time that a critical event of interest to the ENG operations (the carjacking) was taking place on the ground. … It is critical for ENG pilots to be vigilant of other aircraft during close-in operations and not to divert their attention to a non-flying-related task or event.” The NTSB also cited a report filed with the U.S. National Aeronautics and Space Administration Aviation Safety Reporting System (ASRS) — one of 18 reports of near-midair collisions involving ENG helicopters — in which the pilot described how he inadver- tently allowed his helicopter to descend toward a police helicopter because his “hectic” workload had distracted him from altitude awareness. “The midair collision in [Phoenix] and the near-midair collisions described in … ASRS reports demonstrate the haz- ards involved in conducting ENG opera- tions with multiple aircraft nearby,” the report said. “The safety board concludes that the Channel 3 and 15 pilots’ report- ing and visual tracking duties immedi- ately before the collision likely precluded them from recognizing the proximity of their helicopters at that time.” Aftermath After the accident, both Channel 3 and Channel 15 modified their flight opera- tions. The Channel 3 news helicopter is now staffed by two pilots — one to handle flying and the second to handle news reporting. The Channel 15 helicopter pilot no longer has reporting duties; the helicopter carries a photog- rapher to obtain video. In February, the Helicopter Associa- tion International (HAI) approved a new Broadcast Aviation Safety Manual developed along the lines of many of the NTSB safety recommendations issued as a result of the accident investigation. The 10 safety recommendations included a call for the U.S. Federal Aviation Administration (FAA) to re- quire ENG operators to assign report- ing duties to “someone other than the flying pilot, unless it can be determined that the pilot’s workload would remain manageable under all conditions,” and to require high-visibility blade paint schemes and high-visibility anti-colli- sion lights on ENG aircraft. Other recommendations said the FAA should develop standards for helicopter cockpit electronic traffic advisory systems to notify pilots of the presence of nearby aircraft, and require that the systems be installed in ENG aircraft; host annual ENG helicopter conferences to discuss relevant issues, and, based on those discussions, de- velop agreements specifying minimum horizontal and vertical aircraft separa- tion requirements; and incorporate in- formation from the HAI safety manual into an FAA advisory circular. Other recommendations — su- perseding similar recommendations issued in 2003 — call for requiring the installation of a “crash-protected flight recorder system” on new and existing turbine-powered, non-experimental, non-restricted-category aircraft that are not equipped with a flight data recorder and cockpit voice recorder and that are operated under U.S. Federal Aviation Regulations Parts 91, 121 or 135. The recorder should record cockpit audio, if a cockpit voice recorder has not already been installed, as well as “a view of the cockpit environment to include as much of the outside view as possible” and flight data, the NTSB said. Since 2004, the NTSB has included similar recommendations on its “most wanted” list of transportation safety improvements. This article is based on U.S. National Transportation Safety Board (NTSB) Accident Report NTSB/AAR-09/02, “Midair Collision of Electronic News Gathering Helicopter KTVK- TV, Eurocopter AS350B2, N613TV, and U.S. Helicopters Inc., Eurocopter AS350B2, N215TV, Phoenix, Arizona, July 27, 2007.” Jan. 28, 2009. Flight Safety Foundation and Eurocontrol at the seminar announced that two Eurocontrol officials, Radu Cioponea and Tzvetomir Blajev, have been seconded to Flight Safety Foundation for two years to serve as Foundation Fellows campaigning to educate prosecutors about the negative consequen- ces of post-accident criminal prosecutions and interfering with the immediate safety investigation of accidents. — JD Targeting Safety Criminalization | 17 www.FlightsaFety.org | AeroSAfetyworld | april 2009 seminarseASS “aviation safety is not that good so far this year,” said William R. Voss, president and chief ex- ecutive officer of Flight Safety Foundation, opening the 21st European Aviation Safety Seminar in Nicosia, Cyprus. We need to work harder to improve safety, Voss said, to fulfill “our promise to the public that we are not waiting for the next accident.” A successful safety system depends on “a competent and effective regulator” operating free of political interference that establishes a close relationship with its operators. Further, experience has shown that networks of airlines provid- ing oversight functions for each other, and regulators auditing each other around the world, produce an intercon- nected process that can continue to protect safety should a regulator or an airline begin to fail, Voss said. Inter-airline safety oversight, airlines working together, also was suggested by Tomislav Gradisar of Croatian Airlines as a way of getting around regulators’ lack of resources, trained personnel and scope — regulators are restricted to judging based on what regulations require and nothing more. He said that while regulators may be able to define and quantify the organizational structure and data gathering elements of a safety management system, the status of a firm’s safety culture “is hard or impossible to check. It is impossible to revoke an oper- ating certificate because a company has a low safety culture,” Gradisar said. An inter-airline system has “adequate finances, adequate human resources and [potentially] unlimited scope.” However, there also exists a commercial bias in such a system: “They want to make it work. This is better, but not good enough.” Beyond Compliance By J.A. Donoghue Seminar speakers stress the need to exceed basic requirements. 18 | seminarsEass flight safety foundation | aErosafEtyWorld | april 2009 Conventional regulators need to be over- hauled by the addition of a dedicated oversight agency with access to a “registry of experts” drawn from the industry to conduct audits, Gradisar said. There also need to be added analysis and database functions to help the industry “to move beyond compliance.” The resulting system can allow auditors to look be- yond the regulations, and make a clear assess- ment of the state of an operator’s safety culture. Robert Sumwalt, member of the U.S. National Transportation Safety Board, was clear on the sub- ject of safety culture: “If you think you have a good safety culture you are almost certainly mistaken. A safety culture is a journey, not a destination… . Safety has to start at the top of the organization and permeate throughout.” NTSB investigates many accidents in which “the most common link is the attitude at the top of the organization.” Sumwalt cited the crash of a Cessna 310 (see story, p. 46) where “management commitment was not there. They did not have the policies and procedures in place to keep an unairworthy aircraft from becoming airborne with a known and unresolved discrepancy.” Also cited by Sumwalt was a company that gave maneuver guides only to its chief pilot and in- structors, an airline that permitted crews to use an automated system for the first time in line service and a regional airline that had no way of knowing if procedures had been followed other than that the airplane “arrived on time and took off on time.” Sumwalt said, “You track engine health with multiple gauges. Wouldn’t you like to have mul- tiple sensors to keep informed about the health of your safety culture? You have these sensors, your employees.” Nick Mower, vice president technical servic- es for the European Regions Airline Association, said there is a need for the European Aviation Safety Agency to strengthen its safety focus and establish priorities, instead of devoting too much time to transcription and documentation. “EASA has yet to develop a clear safety road- map,” he said. Part of the problem is that EASA regulations lack “teeth” due to the weakness in the legislation that established EASA, and lacks a European Union–wide aircraft registry. The absolutely essential nature of data to the safety process was highlighted by Eric Merckx, deputy director, air traffic management pro- grams, Eurocontrol: “It is criminal if you don’t share [safety information]. Indications are that only 20 percent of incidents are being reported [because] air traffic controllers and pilots are still afraid to report out of fear of criminal prosecution. We need to tell prosecutors how important reporting is to protect passengers.” (See “Targeting Safety Criminalization,” p. 17) “Safety has stopped improving since about 2003,” according to his analysis of data, said David Learmount, operations and safety editor, Flight Group. “We need to go beyond compli- ance. Excellence, rather than just staying within the law, must be the objective.” An example of this failure to reach beyond the rules is the industry’s failure to adopt jet upset training despite a Boeing study that clearly showed the training benefits, he said. “There is no requirement to provide such training; we need to go beyond compliance,” he repeated. Another operational element that needs to be examined is the psychology behind pilots’ actions during non-revenue flights, Learmount said, Mower (left), Learmount and, from left, Gradisar, Vecko, Dick van Eck (air traffic controller, The Netherlands), and Rausel. | 19 www.FlightsaFety.org | AeroSAfetyworld | april 2009 seminarseASS pointing at the Air New Zealand/XL Air Airbus A320 accident during acceptance testing off the coast of France. In addi- tion, he said, “we have to do more study of pilots flying highly automated aircraft,” noting the possible role automation played in the crash of a Turkish Airlines Boeing 737-800 just short of the runway at Amsterdam Schiphol Airport. Learmount also charged that the in- dustry, “despite the respite granted by the economic downturn, has taken its eye off the ball dealing with the shortage of trained labor,” a refrain echoed by Emile Rausel, director of training engineering at ATR. Rausel pointed out that pilot skill levels must cope with increased aircraft automation, especially in emer- gency situations, congestion, accelerated training and minimal recurrent training. Part of this economic pressure for regional airlines is having to cope with training programs developed by and for major carriers that focus on full flight simulators (FFS) with motion despite the relative scarcity of FFS for regional aircraft. Also, there are increased re- quirements for mandatory exercises in the same amount of simulator time. The result, Rausel said, is “cockpit proficiency is decreasing.” In addition, operators found that “students starting in the ATR did not have adequate skills; they needed more [simulator] time.” However, while an FFS costs as much as an ATR 42, a new high-capability fixed base training device (FFT-X) has been developed that costs about $4 mil- lion that, in a modified training program that adds a few weeks to the introductory training process, allows pilots to develop a much deeper understanding of aircraft systems, Rausel said. These new simula- tors, deployed in a network of training centers, have been accepted for recurrent training in Poland, Italy, Venezuela and New Zealand, while France, the United Kingdom, Brazil, Oman and Fiji have ac- cepted them for checking and recurrent training. Call sign confusion leads pilots to deviate from air traffic control (ATC) clearances, said Richard Lawrence, de- Richard Lawrence, de- e- puty manager, Eurocontrol contingency planning project. A Eurocontrol study showed that call sign confusion usually involves two or more aircraft from the same company, with 14 percent of con- fusions resulting in an altitude deviation. Only the French air navigation service provider, Direction des Services de la Navigation Aérienne, had a program to de-conflict call signs until Eurocontrol last year launched a three-stage, three- year program that intends to eliminate 80 percent of call sign similarities that lead to confusion events, Lawrence said. A major element in the effort is push- ing call signs away from numbers-only into an alphanumeric combination. Attention also is being paid to the last letter of the call sign, often the key to a confusion incidence, designing flight number scheduling schemes to keep identical “last letter” call signs out of the same airspace. Up to 50 percent of all traffic alert and collision avoidance system (TCAS) resolution advisories (RAs) are unneces- sary and can be a significant nuisance, said Martin Vecko, director of flight safety at CSA Czech Airlines. These unnecessary RAs can create aircraft han- dling problems by over-responding pilots, a pilot input opposite to the RA and even the reduction in separation with aircraft not involved in the initial encounter. Many of these unnecessary RAs are triggered by the high vertical speed of aircraft climbing or descending to an altitude that will not cause a conflict, but sets off the look-ahead feature of TCAS. TCAS is a valuable tool and its warnings must always be acted upon immediately, leaving event evaluation for later, he said, but the system would be safer overall if unnecessary RAs can be reduced. The problem, Vecko said, is that modern aircraft have normal climb rates well in excess of the rate that will not trigger an RA. While Eurocontrol recommends a rate of 1,000 fpm in the last 1,000 feet of the climb, and Interna- tional Civil Aviation Organization sug- gests 1,500 fpm, the vertical speeds in any autoflight mode available on CSA’s 737s and A320s, based on a flight data monitoring study, “are significantly higher than the recommended values.” At present the best solution is for pilot intervention into the autoflight settings to manually reduce the climb rate, “but the reduction must be timely,” Vecko said, with hope that eventually manufacturers can modify the autoflight altitude capture laws. Also possible is a redesign of TCAS logic (see story, p. 34) or new ATC route systems that avoid simultaneous horizontal and vertical aircraft convergence, Vecko said. Given the time required to redesign systems, Vecko recommended that pilots “push one more button before leveling off ” as the best approach to take today. The development of a landing overrun risk assessment index through a joint airline, university and Nether- lands’ National Aerospace Laboratory (NLR) effort was described by Gerard van Es from the NLR Air Transport Safety Institute. He said that data show that overruns are a rising proportion of total accidents. Using data from 182 overrun accidents and quick access recorder data from 14,000 landings, the team constructed a risk index that involved as many as 35 risk factors. The Landing Overrun Risk Index (LORI) has been successfully demonstrated and is available to help manage the risk of an overrun, van Es said. 20 | flight safety foundation | AeroSAfetyWorld | april 2009 Coverstory 20 | the Raytheon King Air B200 was cruising at 27,000 ft when the pilots heard a loud snap and saw a web of cracks appear in the left windshield. Procedures for dealing with a shattered windshield were not on the one-page collection of truncated checklists aboard the airplane. Fearing groundlessly that the wind- shield might blow out, the pilot depressurized the cabin. Both pilots then donned their oxygen masks — but failed to notice that the oxygen system shutoff valve was closed. With the cabin depressurized and no oxygen flowing into their masks, the pilots momentarily lost consciousness. The King Air descended out of control for about five minutes, losing 17,600 ft of altitude. The windshield held, but the tail was shredded as aerodynamic loads reached at least 4 g — that is, four times standard gravita- tional acceleration — during the uncontrolled descent and the pilots’ eventual recovery from the dive. Damage was substantial, but the pilots escaped injury and were able to land the air- plane without further incident. In its final report, the U.S. National Trans- portation Safety Board (NTSB) said that the probable cause of the accident was the “pilot’s poor judgment before and during the flight, in- cluding turning the oxygen system ready switch KnocK Yourself out BY MARK LACAGNINA Overreaction to a shattered windshield led to loss of consciousness and control. © John Taylor | 21 coverStory www.flightSafety.org | AeroSAfetyworld | april 2009 [i.e., the shutoff valve] to the ‘OFF’ position after he conducted the preflight inspection and using an unapproved checklist, which did not provide guidance for a fractured windshield and resulted in his depressurizing the airplane.” This statement of probable cause, how- ever, did not result from consensus among the NTSB’s five members. A dissenting statement was filed by one member who contended that the shattering of the windshield resulted from a design defect and should have been cited as a contributing cause of the accident. Another safety board member concurred. Positioning Flight The accident occurred on Feb. 2, 2007, during a positioning flight from Rogers, Arkansas, to Staunton, Virginia, in visual meteorological conditions. The report said that the King Air was operated by the Assembly of God. The pilot, 31, was employed as a company pilot. He held an airline transport pilot certifi- cate and had 4,048 flight hours, including 110 hours in type. “The pilot completed a flight review during B200 training at SimCom Inter- national on Aug. 24, 2006,” the report said. “A noncompany pilot, who had not attended or completed a training course or received a checkout for Raytheon … King Air 200 air- planes, was asked by the company pilot to accompany him on the flight so that the non- company pilot could accumulate flight time.” The copilot, 28, had commercial pilot and flight instructor certificates with multiengine airplane ratings. He had 2,806 flight hours, in- cluding 557 hours in multiengine airplanes and 28 hours in the King Air. The airplane was manufactured in 1998 and had accumulated 1,835 service hours. “The pilot’s windshield … was installed at the time of the airplane manufacture and subsequently had not been overhauled or repaired prior to the ac- cident,” the report said. “There were no previous reports of delamination or cracking.” ‘Don’t Tear It Up’ The King Air departed from Rogers Municipal Airport at 0839 local time. The report said that cockpit voice recorder (CVR) data indicated that the pilot left the cockpit shortly after the airplane was established in cruise flight at 27,000 ft at about 0900. The pilot said that he was going to “fetch the trash can” and told the copilot, “Don’t tear it up while I’m gone.” About four minutes later, the CVR recorded the sound of a very loud snap and the copi- lot calling the pilot’s name. “[This] indicated that the company pilot was not in the cockpit when the windshield fractured because he was emptying trash in the cabin,” the report said. “This action showed poor judgment, consider- ing the noncompany pilot was not qualified in the airplane.” After the copilot called his name, the pilot said, “What did you break?” The inner ply of the left windshield had shattered. According to the B200 airplane flight manual (AFM), this is an abnormality, not an emergency: Although small particles may sepa- rate from a shattered inner ply, the windshield is designed to remain in place. The “Abnormal Procedures” section of the AFM includes a checklist titled “Cracked or Shattered Windshield.” A note at the top of the checklist says, “The following procedure © John Taylor The King Air’s tail was extensively damaged during the uncontrolled descent and the pilots’ recovery from the upset. The shattering of the inner ply of the left windshield was traced to a fracture within the glass. 22 | flight safety foundation | AeroSAfetyWorld | april 2009 Coverstory should be used when one or more cracks occur in the inner or outer ply of the windshield. The procedure is also applicable if the windshield shatters. This usually occurs in the inner ply and is characterized by a multitude of cracks which will likely obstruct the crewmember’s vision and may produce small particles or flakes of glass that can break free of the windshield.” The checklist procedure comprises the fol- lowing actions: • Maintain an altitude of 25,000 ft or lower “if possible.” • Maintain a cabin differential pressure of 2.0 psi to 4.6 psi during cruise and descent.1 • Depressurize the cabin before landing. The checklist also includes the following “in- flight considerations”: • “Visibility through a shattered windshield may be sufficiently reduced to dictate fly- ing the airplane from the opposite side of the cockpit; • “Precautions should be taken to prevent particles or flakes of glass from a shattered inner ply of the windshield from interfer- ing with the crew’s vision; • “A cracked outer windshield ply may dam- age operating windshield wipers; • “Windshield heat may be inoperative in the area of the crack(s); [and,] • “The structural integrity of the windshield will be maintained.” The checklist refers the user to the “Limitations” section of the AFM for postflight considerations. Basically, the airplane can be flown for up to 25 hours after cracks appear in either the inner ply or the outer ply of the windshield. However, if both plies are cracked or if an inner ply has shat- tered, the windshield must be replaced before further flight.2 Homemade Checklist The pilots did not consult the AFM after the windshield shattered. “An unapproved document, not derived from the AFM, that contained several checklists was found on the airplane,” the report said. “The company pilot stated that he used this document and that it ‘came with the airplane.’ The document did not include a checklist ad- dressing a cracked or shattered windshield.” The pilot told investigators that he depres- surized the cabin because he did not know what had caused the windshield to shatter and whether it would remain in place. This indicates that the pilot did not know that the shattered windshield did not present an in-flight emer- gency and that there was no need to depressur- ize the cabin, the report said. Raytheon King Air 200B © Mick Bajcar/Airliners.net Beech Aircraft began deliveries of the Super King Air 200 in 1974. The airplane shares the same basic fuselage with the King Air 100 but has a longer wing, a T-tail and more powerful engines — 850-shp (634-kW) Pratt & Whitney PT6A-41s. Raytheon acquired Beech in 1980 and shortly thereafter introduced the B model with PT6A-42 engines, which provide improved cruise performance and a higher — 6.5-psi — maximum cabin-pressurization differential. The prefix “Super” was deleted from the names of the 200-, 300- and 350-series King Airs in 1996. In standard configuration, the King Air B200 accommodates a pilot and seven passengers, and has a maximum takeoff/landing weight of 12,500 lb (5,670 kg), a maximum cruise speed of 289 kt, a service ceil- ing of 35,000 ft or 21,735 ft with one engine inoperative, and a range of 1,461 nm (2,706 km) at 25,000 ft. Hawker Beechcraft, formed in 2007, currently produces the King Air 200GT and 350 models. Source: Jane’s All the World’s Aircraft King Air B200 Oxygen System Forward pressure bulkhead Oxygen pressure gauge Crew mask Passenger mask outlet Shutoff valve Shutoff valve control Aft pressure bulkhead Oxygen cylinder High-pressure line Low-pressure line Control cable Source: U.S. National Transportation Safety Board/Susan Reed Figure 1 | 23 WWW.flightsafety.org | AeroSAfetyWorld | april 2009 Coverstory After the pilot selected the pressurization “DUMP” switch, the copilot said, “We need to go on oxygen.” The pilot replied, “Yeah.” They donned their oxygen masks but found that oxygen was not flowing into the masks. “Can’t get no oxygen,” the pilot said. “I ain’t getting no oxygen. … You got oxygen?” That was the last statement recorded by the CVR. “After this time, the only crew noise was the sound of the copilot breathing erratically,” the report said. Shutoff Valve Shut The pilot told investigators that he pulled the oxygen-system control knob on the left side of the center console to open the shutoff valve on the oxygen cylinder, which places the oxygen system in the ready mode, but “it was hard to pull and did not seem to engage properly.” The oxygen cylinder is located behind the aft cabin firewall. The oxygen system shutoff valve on the cylinder is connected to the cockpit control knob by a cable (Figure 1). Opening the shutoff valve is among the actions specified by the “Before Start” checklist — as well as by sev- eral emergency checklists — in the AFM, but it was not included in the truncated “Before Start” checklist that the pilots were using. “Oxygen will flow to each mask only if the oxygen tank shutoff valve is in the ‘OPEN’ posi- tion,” the report said. The pilot told investigators that he opened the shutoff valve during preflight preparation to check that the oxygen system was functional but then closed the valve because he was concerned that the oxygen would be depleted if the valve remained open. After the accident, the oxygen shutoff valve control knob was found in the “OFF” posi- tion. “Functional testing of the oxygen system revealed normal operation,” the report said. “The unapproved-checklists document did not include the instruction to leave the oxygen sys- tem on. Regardless, the pilot stated that he knew the approved checklist stated to leave the oxygen system on but that he still chose to turn it off. The pilot exhibited poor judgment by using an unapproved, incomplete checklists document and by knowingly deviating from approved preflight procedures.” The report said that the pilots likely either forgot to open the oxygen system shutoff valve after depressurizing the cabin or lost conscious- ness before they could do so. ‘Not Thinking Clearly’ The pilot said that soon after he depressur- ized the cabin, he developed tunnel vision and 24 | flight safety foundation | AeroSAfetyWorld | april 2009 Coverstory had trouble thinking clearly.3 He told investigators, “The last thing I remem- ber, although not clearly, at this phase of flight was beginning an emergency descent. I disengaged the autopilot and pitched down but never made it to reducing power to idle or extending the landing gear.” Only two air traffic control (ATC) radar data points were recorded dur- ing the uncontrolled descent. The first showed the King Air at 25,400 ft at 0917:45; the second showed the airplane at 7,800 ft at 0922:59. The pilot told investigators that he did not remember clearly what hap- pened when he regained consciousness. “I remember the airspeed pegged, so I immediately reduced power to idle and began pitching toward a level attitude slowly,” he said. “Due to very limited vision from oxygen deprivation, a shat- tered windshield and a failed attitude in- dicator, overcoming disorientation was very difficult. After an unknown amount of oscillations, satisfactory control of the aircraft under present conditions was obtained at approximately 7,000 ft.” He declared an emergency with ATC and requested, and received, vectors to the nearest suitable landing site, Cape Girardeau (Missouri) Regional Airport. “Although the aircraft was difficult to control, a successful landing was made with no injuries sustained,” the pilot said. The fact that the airplane had been subjected to aerodynamic loads of at least 4 g was established by the position of the CVR impact switch. The switch, which was found open, is designed to open au- tomatically — and deactivate the CVR so that data are preserved — if the airplane is subjected to an acceleration force of 4 g. “On-scene examination of the airplane noted that approximately two- thirds of the left horizontal stabilizer and elevator were separated from the airplane, and two-thirds of the right el- evator was separated but attached at the inboard hinge,” the report said. “The left and right wing [skins] were wrin- kled. The left pilot windshield outer and inner plies were intact. The inner ply exhibited a shattered appearance with a crack at the lower right-hand corner of the windshield.” In addition, the rear fuselage was buckled. ‘Possible Anomaly’ The windshield, which consists of ther- mally tempered glass plies with a vinyl layer between them, was examined by the Research Laboratory Materials Integrity Branch at Wright-Patterson Air Force Base in Ohio. “There was no evidence of fractures or any other damage on the windshield’s outboard surface or within the outer glass ply,” the report said. The shattering of the inner pane was traced to a “peel chip fracture” at the bottom center of the pane. “Scan- ning electron microscope examinations conducted of the glass fracture at the peel chip initiation revealed evidence of the initiation at a possible anomaly in the glass,” the report said. The windshields installed in King Airs were redesigned in 2001 to incorporate a urethane layer between the vinyl interlayer and the inner glass ply that relieves stresses on the glass ply. “No known similar fractures have occurred in the newly designed windshield,” the report said. “The manufacturer chose not to issue a service bulletin for a retrofit of the new windshield design in airplanes manufactured before 2001 because the fracture of one pane of glass is not a safety-of-flight issue.” ‘Not an Aberration’ NTSB member Deborah Hersman did not agree with the probable-cause statement approved by the majority of the board members. Board mem- ber Robert Sumwalt concurred with the dissenting statement that she included in the public docket for the investigation. Hersman pointed to 160 service difficulty reports (SDRs) of King Air windshield fractures that were submit- ted to the U.S. Federal Aviation Admin- istration (FAA) between 1995 and 2007. “In a number of the cases cited in the SDR data, the crew failed to take the appropriate action,” she said. “So, while this crew’s reaction to their fractured windshield was poor, it was not neces- sarily an aberration. “The fracturing of the windshield on this aircraft, which was due to a design defect, set in motion the crew’s reaction that led to the accident. If the windshield had not failed, the crew would not have had the occasion to take any responsive action, appropriate or otherwise, and this accident would not have occurred. For that reason, I believe the fracturing of the windshield should be cited as a contributing cause of this incident.” The report was based on a limited investigation of the accident, and no rec- ommendations were issued by NTSB. This article is based on NTSB accident report no. CHI07LA063, issued on Nov. 20, 2008, and on public docket no. 65268. Notes 1. The checklist notes that with a cabin differential pressure of 4.6 psi at 25,000 ft, cabin altitude is approximately 10,500 ft. Maximum differential pressure is 6.5 psi. 2. A special permit can be requested from the FAA to conduct a ferry flight to a repair station. 3. According to the FAA, loss of peripheral vision and impaired decision-making ability are symptoms of hypoxia, or oxygen deficiency; time of useful consciousness at 27,000 ft is about 90 seconds. | 25 www.flightsafety.org | AeroSAfetyworld | april 2009 foundAtionfocus the life of an organization, like that of a person, should not be viewed apart from the social and political periods to which they belong. At the end of the 1980s, perestroika and glas- nost became powerful influences on the course of events in our society. After dozens of years behind the “Iron Curtain,” our society began to move more freely than before, and international contacts multiplied. At the same time, the avia- tion community, as with society in general, felt something unseen and unknown coming. But only the people at the top knew that serious problems were at hand. Oil prices were plummeting, and the state budget was in great disarray. Many thought that state flight safety programs were facing a financial guil- lotine. Aviators concerned with safety were writing letters of alarm to Mikhail Gorbachev, then premier of the Union of Soviet Socialist Republics (U.S.S.R.), but they received only formal replies. Despite these concerns, other actions were at work. The Soviet government sent a delega- tion to the United States to discuss with the State Department and Federal Aviation Administration (FAA) the possibility of commencing operations from North America to Southeast Asia via routes over the U.S.S.R. If this possibility could be real- ized, the world of international air traffic would be changed dramatically, with great reductions in en route time and cost. It so happened that while those of us in the delegation were in New York City, visiting the FAA air route traffic control center, we met John Enders, president and chief executive officer of Flight Safety Foundation (FSF). An engag- ing and experienced engineer, air safety expert and former aviator, John briefed us on how the independent Foundation originated in 1947 and subsequently expanded its operations to enhance flight safety worldwide. He encouraged us to con- sider this as a model for the U.S.S.R. in address- ing aviation safety challenges. After returning to Moscow, we shared the idea of setting up a similar organization with prominent FSF-I awards ceremony at Petrovsky Palace, Moscow, 1997. Standing: Valery Shelkovnikov, FSF-I president. 20From its birth in the last years of the U.S.S.R., FSF–I advanced to hosting the International Air Safety Seminar. Flight SaFety Foundation– international iS 20 BY VALERY SHELKOVNIKOV AND DMITRI TARASEVICH 26 | flight safety foundation | AeroSAfetyworld | april 2009 foundAtionfocus figures in Soviet aviation. Ivan Mashkivskiy, chair- man of the State Safety Oversight Agency; Tatiana Anodina, head of one of the principal research and development institutes; Air Force Maj. Gen. Alexey Mayorov, Premier Gorbachev’s chief pilot; Air Force Col.-Gen. Ivan Modiaev, First Deputy Air Force General Staff; Gennady Bocharov, prominent journalist and member of the Writers Union; and many others enthusiastically supported this idea. It seems that some had nurtured similar thoughts for many years. All of them joined a new steering committee that was set up to devise a way of bringing these ideas to reality. Everybody understood that: First, even the most developed state aviation system is not in a position to cover the entire spectrum of problems; Second, state organizations are not flexible and proactive enough; and, Third, state personnel, being dependent on numerous other government bodies, may not demonstrate independent, objective and unbi- ased approaches to developing permanent safety solutions. Our lawyers quickly advised us of the difficul- ties we faced in forming such an organization. There was no law in the U.S.S.R. that would allow for the creation of a public organization. Some- body told us that even the powerful Communist Party, as a de facto “public organization,” had been illegally functioning for more than 70 years; life was not simple. It was Gennady Alferenko, a young, joyful and adventurous character, and president of the Social Innovation Foundation of the U.S.S.R., who provided us with a means of achieving our goals. In love with aviation, he promptly helped us to draft papers necessary for joining his Foundation under the name “Associa- tion Flight Safety Foundation U.S.S.R. (AFSF- USSR)” and his huge official stamp breathed life into our organization. We were the ninth group existing under his approval umbrella. After that, no matter whether public organization legislation existed in the U.S.S.R., we were allowed to open bank accounts. The principal goals of our new organization were almost 100 percent modeled on the Flight Safety Foundation as described to us by John Enders. We undertook to communicate safety information; award aviators for heroism, bravery and resourcefulness; advocate flight safety and international experience; hold international flight safety workshops; and perform other initiatives to instruct our nation’s aviation personnel and inform the international community about Soviet aviation. The first person to react to media information about our new association was Anna Pavlovna Smirnova. She wrote: “My sons, accept three rubles in the enclosed envelope. I am retired and that is all I can do for you. Fight for flight safety. My only son was killed in an air accident.” After reading this message, we realized in our hearts the serious responsibility we had taken upon our shoulders. Cooperation with the Foundation had become our priority. Unique information on ac- cident prevention from the Foundation was dis- seminated among our corporate members. We organized a number of joint international flight safety workshops, awarded Russian aviators both with the Association’s and FSF’s awards. Helicopter test pilot Anatoly Grischenko was the first Russian to receive the highly esteemed FSF Heroism Award, the Graviner Sword, for his rescue operations at the Chernobyl nuclear reactor accident site in Ukraine. The award was presented posthumously to his wife at Flight Safety Foundation’s International Air Safety Seminar in 1990. Innokenty Tsivilev, a Mil Mi-8 Alexander Neradko, director of Russian Federation Air Navigation Authority (left), with Stuart Matthews, FSF president and CEO, Moscow ALAR workshop, 2003. Shelkovnikov and Tarasevich’s comprehensive account of FSF-I’s beginning and growth noted the influence and support of Flight Safety Foundation (FSF) in nurturing FSF-I. Here’s how it happened: In 1980, FSF’s board of governors wanted to broaden the organization’s membership. It then stood at about 150 organizations, but all were outside the Communist Bloc. Since the FSF charter called for fostering the safety of civil air transportation worldwide, that implied sharing operational safety information and practices among all operators. Efforts began to bring the General Administration of Civil Aviation of China (CAAC) and the Union of Soviet Socialist Republics (U.S.S.R.) Ministry of Aviation into dialogue with the Foundation through our seminars, forums and publi- cations, and to share knowledge and lessons learned with them. Correspondence began in 1982 with the U.S.S.R. minister of aviation, Marshal Bugayev, as well as with the CAAC through its New York office. We invited each to send representatives to FSF international seminars and become ac- quainted with our work, aiming to bring them into full membership. Neither the U.S.S.R. nor China well understood the Foundation’s charter as an indepen- dent, non-government and non-profit international organization, or its mode of operation. Meanwhile, we sent com- plimentary copies of our safety bulletins to both CAAC and the U.S.S.R. The Internet did not exist at the time. Eventually, a teletype reply ar- rived from Marshal Bugayev. Soon, the U.S.S.R. sent two representatives, Nicolai Safranov of the State Supervisory Committee and Yuri Kostev of the Gromov Flight Research Institute, to our 1988 International Occupant Safety Conference and Workshop in Arlington, Virginia, U.S. We had intensive discus- sions with them about the Foundation’s organization and operation. A Soviet air traffic control delegation led by Valery Shelkovnikov was visiting the U.S. Federal Aviation Administration (FAA) at the time of our conference, and Safranov and Kostev briefed Shelkovnikov about the Foundation on their return flight to the U.S.S.R. Shortly, we received a message from Sergei Tcheremnykh, on behalf of Shelkovnikov, that began mutually supportive efforts by suggesting a meeting, facilitated by the FAA, at the New York Terminal Radar Approach Control. We described our organiza- tion, means of funding, collaborative information exchange with members, feedback through industry advisory committees and other administrative matters, hoping it would serve as a template for them. Soviet participation in our seminars began with our 1989 42nd interna- tional seminar in Athens, where Drs. Krylyk and Mirinov presented a paper on catastrophic risk. Russian delega- tions have attended and participated in our seminars ever since. In 1990, FSF General Counsel Bob Gray and I met with senior Russian avia- tion experts and visited many depart- ments and institutions in Moscow and Leningrad to explain the FSF concept and to urge Soviet support for their own fledgling foundation. Our subsequent visits included lectures to officials, students and industry leaders about aviation safety and how it was practiced in the West, emphasizing that we would provide help as they proceeded with their own approaches to safety improvement, and eventually in joint sponsorship of safety colloquies and workshops throughout the new Commonwealth of Independent States. Stuart Matthews, FSF president and CEO, and I maintained vigorous sup- port of and cooperation with our FSF-I friends, which continues under the cur- rent president and CEO, William R. Voss. — John Enders John H. Enders is former president, CEO and vice chairman, Flight Safety Foundation, and honorary president, FSF-I. Afterword | 27 www.flightSafety.org | AeroSAfetyworld | april 2009 foundAtionfocuS transport helicopter flight engineer, was the second Russian recipient, in 1997. These activities made the Association highly visible in the aviation community, and drew support from industry, govern- ment and individuals. The number of corporate members quickly grew to 100. The first Association revenue was used to disseminate more than 1,000 copies of the International Civil Aviation Organization (ICAO) Accident Preven- tion Manual among Russian aviation organizations. We knew that only about 50 copies of this vitally important report describing modern concepts and accident prevention methods had been sent to Russia from ICAO headquarters, and could be found only on the desks and bookshelves of the “big shots,” while those who vitally needed this information, the operations personnel, were deprived of it. That is why we considered this move as a type of “missionary” work aimed at en- larging the circle of like-minded persons and raising safety awareness among them. As a result, many aviators began to speak our common safety language and, more importantly, to apply the principles it described. In 1990, responding to a request of the Federation of Amateur Pilots of the U.S.S.R., our Association organized and led a seven-light-plane formation flight over an adventurous and challenging route: Moscow-Siberia-Alaska-Canada- Seattle and return to Moscow. The 28 | flight Safety foundation | AeroSAfetyworld | april 2009 foundAtionfocuS flight was a success and took a month and a half. Our purpose was to attain some familiarity with U.S. general aviation activities. Although the flight was sponsored by Russian businessman and amateur pilot Grigory Komarenko, without the assistance rendered by our friend and former FAA administrator, the late U.S. Navy Vice Admiral Donald D. Engen, we would never have been able to make it. His authority helped us to solve all the problems of coordination with U.S.- Canadian North American Aerospace Defense Command systems in order for us to be able to cross the U.S.S.R.-U.S. border in the Bering Strait area. Later he demonstrated to us the democratic approach to airspace use. We had never seen such freedom of operations, even in Europe. In October 1991, a “miracle” hap- pened. The first deputy to the Minister of Jurisdiction granted registration documents to our organization. We were overwhelmed with joy! We had become a legitimate organization in the eyes of the government. As far as we know, it was some time later that the powerful Communist Party of the U.S.S.R. was similarly registered! On Dec. 8, 1991, the U.S.S.R. collapsed. In 1993, miraculously, the shelling of Parliament and attempted coup did not end in disaster. In 1998, we saw financial default. Not only were private persons within our corporate membership victimized, but institutions were badly affected. But we followed author Alexander Solzhenitsyn’s admonition: “Do not trust, do not be scared, do not ask for a favor,” and continued to work. We were not afraid of contacting people at the top and criticizing, and we never took a single ruble from the state budget. Every year we organized the awards ceremony for aviators from the Commonwealth of Independent States (C.I.S.) member states. Together with ICAO, the International Air Transport Association (IATA), the Foundation and the FAA, we continued holding work- shops and disseminating unique materi- als pertaining to international flight safety experience. In cooperation with the U.S. National Aeronautics and Space Administration Aviation Safety Report- ing System (ASRS), we established a similar voluntary reporting system. Finnair became the first interna- tional airline to join our Association, making a significant contribution by supporting flight safety workshops, including those in Finland. The Anglo- Continental Education Group in Eng- land contributed heavily to the training of Russian and C.I.S. aviators and air traffic control personnel in English language proficiency, later joining our organization. Our Association’s chair- men and the members of our board of governors exercised wisdom as their decisions and initiatives contributed to stable and efficient operations through many years of safety enhancements in this country. We cannot overestimate the important role in flight safety promotion played by the Civil Aviation magazine, the AviaSoyuz magazine, and the Vozdushny Transport newspaper. Tirelessly, John Enders traveled all over the U.S.S.R. and C.I.S., lecturing on the most pressing issues of accident prevention and safety management. Ten years later, taking due account of their inputs into establishing our organization, we decided to elect Enders the Association’s honorary president and Mashkivskiy as chairman emeritus. With Enders’s retirement from the Foundation, a new and energetic succes- sor president, Stuart Matthews, contin- ued an excellent relationship with us, did a lot to improve it and suggested that the Association should be an FSF “sister organization.” This initiative consider- ably enlarged our international contacts aimed at information exchange. Recently, William R. Voss, succeeding Matthews, continued the cooperation. We held extremely important international workshops at the begin- ning of the 21st century to discuss the FSF ALAR Tool Kit and controlled flight into terrain workshops designed to combat the principal “killers in aviation.” The FSF 58th annual Interna- tional Air Safety Seminar in Moscow in November 2005, a joint meeting of the Foundation, IATA and the Inter- national Federation of Airworthiness, became a high point of our activities. Despite a cold and frozen Moscow, the theme “Safety Is Everybody’s Business” attracted about 500 participants. Our cooperation with the Founda- tion goes on. Bill Voss often comes to Russia to organize and take part in important conferences. His messages in AeroSafety World are translated into Russian and have become very popular among the Russian aviation community. The international financial crisis we currently face is an opportunity for clever and talented people to demon- strate their abilities. Understanding this, we shall survive and continue our efforts to enhance aviation safety. Valery Shelkovnikov is the former president, Flight Safety Foundation–International. Dmitri Tarasevich is the former vice-president, Flight Safety Foundation–International. We had become a legitimate organization in the eyes of the government. | 29 www.flightsafety.org | AeroSAfetyworld | april 2009 smokefirefumes Selected Smoke, Fire and Fumes Events in the United States and Canada, December 2008–March 2009 Event Date Flight Phase Event Airport Event Classification Event Sub-classification Aircraft Model Operator Name Dec. 2, 2008 Climb Return to airport, unscheduled landing Smoke in cockpit EMB-145 American Eagle Airlines Crew reported on climb-out strong odor of smoke in cockpit. Dec. 3, 2008 Climb Unscheduled landing Smoke in cockpit EMB-120ER SkyWest Airlines Burning odor in cockpit and cabin accompanied by smoke. Dec. 3, 2008 Cruise Unscheduled landing Smoke in cockpit Boeing 757 Delta Air Lines Flight crew reported smoke and fumes in the flight deck. Dec. 6, 2008 Climb Unscheduled landing Smoke in cockpit B-100 Corporate During climb crew noticed odor of electrical smoke in cockpit. After leveling off, cabin crew noticed odor of smoke in cabin. O2 masks donned. Dec. 8, 2008 Climb Teterboro, New Jersey (TEB) Diversion, unscheduled landing Smoke in cabin Cessna 750 Corporate Deptarting TEB flight crew reported at 40,000 ft smoke in the cabin, diverted to Port Columbus, Ohio (CMH) Dec. 9, 2008 Takeoff Emergency landing, return to airport Smoke in cabin Boeing 737 Airtran Airways Upon takeoff flight attendants reported smell of smoke in cabin. Dec. 10, 2008 Cruise Milwaukee, Wisconsin (MKE) Unscheduled landing Smoke in cockpit B-1900 Corporate On departure pilots reported smoke smell and sparks near the bottom of the first officer’s windshield. Dec. 11, 2008 Climb Houston, Texas (IAH) Return to airport, unscheduled landing Smoke in cabin, smoke alert EMB-145XR Continental Express Airlines Crew reported a lavatory smoke warming in flight. The cabin filled with smoke minutes after takeoff. Dec. 18, 2008 Cruise San Juan, Puerto Rico (SJU) Diversion, unscheduled landing Smoke in cockpit Boeing 737 Delta Air Lines Burning smell in cockpit at cruise, diverted to SJU. Dec. 21, 2008 Climb Return to airport, unscheduled landing Smoke in cabin Boeing 737 Aerovías de México Aircraft returned due to smoke in the cabin. Dec. 22, 2008 Cruise Unscheduled landing Smoke in cockpit Falcon 50 Executive Jet Aviation Smoke in cockpit originating from center console/FMS. O2 masks donned. Dec. 24, 2008 Cruise Lexington, Kentucky (LEX) Diversion, unscheduled landing Smoke in cabin EMB-145LR Chautauqua Airlines Crew reported a smoke smell from emergency row. Flight diverted. Dec. 24, 2008 Cruise Return to airport, unscheduled landing Smoke alert, smoke in cabin, odor in cockpit CL-600 Chautauqua Airlines In flight, the crew reported a lavatory s
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