ON COMMERCIAL AVIATION SAFETY WINTER 2002 49.pdf · Printed by Woking Print & Publicity Ltd The Print Works, St.Johns Lye, St.Johns Woking, Surrey GU21 1RS Tel: 01483-884884 Fax:

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O N C O M M E R C I A L A V I A T I O N S A F E T Y

ISSUE 49 THE OFFICIAL PUBLICATION OF THEUNITED KINGDOM FLIGHT SAFETY COMMITTEE ISSN 1355-1523

WINTER 2002

22025/Flight Safety Issue 49 4/12/08 15:59 Page 1

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The Official Publication ofTHE UNITED KINGDOM FLIGHT SAFETY COMMITTEE

ISSN: 1355-1523 WINTER 2002 ON COMMERCIAL AVIATION SAFETY

contentsEditorial 2

Chairman’s Column 3

Vertical Situation Display for Improved Flight Safety 4and Reduced Operating Costs

The Boeing Company

Improved Understanding of Human Factors 9Could Reduce Foreign Object Damage

FSF Editorial Staff

Safety Duties Analysed 15

Barlow Lyde & Gilbert

Sharing Safety Lessons 17

Capt. John Marshall

Winter Blues 19

DASC

Space Weather Impacts on Airline Operations 21

Capt. Bryn Jones

Hail Damage! 26

NATS Led Team Wins Aviation Safety Award 27

UKFSC Members List 28

FOCUS is a quarterly subscription journaldevoted to the promotion of best practises inaviation safety. It includes articles, eitheroriginal or reprinted from other sources, relatedto safety issues throughout all areas of airtransport operations. Besides providinginformation on safety related matters, FOCUSaims to promote debate and improvenetworking within the industry. It must beemphasised that FOCUS is not intended as asubstitute for regulatory information or companypublications and procedures.

Editorial Office:Ed PaintinThe Graham Suite, Fairoaks Airport, Chobham,Woking, Surrey. GU24 8HXTel: 01276-855193 Fax: 01276-855195e-mail: [email protected] Site: www.ukfsc.co.ukOffice Hours: 0900-1630 Monday-Friday

Advertisement Sales Office:Andrew PhillipsAndrew Phillips Partnership39 Hale Reeds, Farnham, Surrey. GU9 9BNTel: 01252-642695 Mobile: 07836-677377

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FOCUS on Commercial Aviation Safety iscirculated to commercial pilots, flight engineersand air traffic control officers holding currentlicences. It is also available on subscription toorganisations or individuals at a cost of £12(+p&p) per annum.

FOCUS is produced solely for the purpose ofimproving flight safety and, unless copyright isindicated, articles may be reproduced providingthat the source of material is acknowledged.Opinions expressed by individual authors or inadvertisements appearing in FOCUS are thoseof the author or advertiser and do notnecessarily reflect the views and endorsementsof this journal, the editor or the UK Flight SafetyCommittee.

While every effort is made to ensure theaccuracy of the information contained herein,FOCUS accepts no responsibility for any errorsor omissions in the information, or itsconsequences. Specialist advice shouldalways be sought in relation to any particularcircumstances.

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Editorial

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Reducing the Cost of Ramp Damage

The UKFSC Safety Seminar held on the4th September 2002 entitled “RampSafety Revisited – Chaos or Concerto”looked at the cost of ramp damage, themost common causes and a number ofpossible solutions to the issues involved.Overall the Seminar is considered to havebeen a great success. That being so, onewould expect to see some changes inbehaviour taking place on the ramp, withoperators benefiting from reduced rampdamage. I doubt that there has been anychange at all and unless each and everyair operator, airport and service providermakes a conscious effort to take theinitiative to put in place the necessaryactions to improve ramp safety, there willbe no improvement.

It takes more than some talk at a Seminarto bring about change. If we are seriousabout reducing aircraft damage we haveto change the behaviour of all those whowork on the ramp.

The UKFSC Ground Operations StandingCommittee is currently investigating whatneeds to be done to reduce the amountof damage being caused on the ramp. Itbecame clear from their discussions thatthere is a real need to try to get theindustry to accept and adopt the need fora common aircraft turnaround plan. Thiswould enable ramp service providers togive the required services in the sameorder on every occasion so that provenprocedures could be followed by all

concerned without one organisationcausing hindrance to another.

It is obvious that there is a need for muchimproved supervision on the ramp toensure that the tasks are being donesafely and correctly. Not having arecognised supervisor for the turnaroundmeans that everybody is doing what theywant, when they want and to the standardthey believe to be correct. This has led topoor standards of service, poorco-operation and the inevitable reductionin safety and consequent damage toaircraft, estimated to cost the industrymany millions of pounds each year.

If we are going to reduce the amount ofdamage caused to our aircraft,equipment and personnel on the ramp weare all going to have to take a look at theway our personnel are currently behavingon the ramp and make changes. Weneed to ensure that everybody servicingthe aircraft behaves in the correct manner,follows procedures correctly and has theright attitude to their tasks. Above all weneed to insist on better supervision.

JAR-OPS regulations make the operatorsresponsible for their contractor safety.This means that they need to be payingmore attention to their obligation and toensure that safety audits of the ramp arecarried out more frequently. Shortfalls inperformance must be taken up with theservice providers and corrective action

taken immediately. The sharing of theresults of these audit reports betweenoperators could help to provide a morethorough understanding of where theproblems lie and to ensure that thecorrective action taken is appropriate. For us to be successful in our endeavourto make the ramp a safer and less costlyplace, we will need the support andco-operation of all those organisationsinvolved in the activities on the ramp.

THE UKFSC HAS THE FOLLOWING OBJECTIVES:

■ To pursue the highest standards of aviation safety.

■ To constitute a body of experienced aviation safety personnel available for consultation.

■ To facilitate the free exchange of aviation safety data.

■ To maintain an appropriate liaison with other bodies concerned with aviation safety.

■ To provide assistance to operators establishing and maintaining a flight safety organisation.


Chairman’s Column

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Winter Operations

The summer has gone (with some of uswondering if it was ever actually here) andautumn is already with us, all theindications would seem to point towards abitter winter period throughout Europe.Good news for our children as theprospects of a White Christmas improve,not so good for the grown-ups who’ll haveto shovel the drive clear though. Ourthoughts turn towards that prudentdecision to have the central heatingserviced at the end of the summer period(you have done that haven’t you?) as youretrieve those winter clothes from thewardrobe and put the wellies and shovelinto the car boot.

As your domestic winterisation programmeis now fully under control it’s perhaps anappropriate time to turn our attention tothe winterisation programme going on inour airlines and reflect a little whilst wehave the luxury of time on our side. We areall well schooled in the discipline oflearning, but can you fully recall the detailsof your winterisation programme? Ourchecklists are generally structured forthose items that we do every day, whilstthose once in a blue moon situations aredesignated as memory items. Maybe thiswould be a good time to quietly sit down

and re-examine and reflect on thoseprocedures before you actually need them.

■ What are the effects on performance ofice on the airframe?

■ What are the braking performanceissues of slush, snow and iceoperations?

■ How does ATC actually advise us ofairfield slush, snow, ice and frictionissues and how do we interpret thoseadvisories?

■ What are the latest holdover times?

■ What fluids and what mix are requiredfor our operation, is there an alternativein case we have to divert away fromour usual airfield?

■ When we ask for our aircraft to be de-iced are we specific enough – have werequested wing de-icing or did weneed and ask for wing and airframede-icing?

■ How do we assess the competency ofthose staff assigned to de-icingactivities?

■ Has our Quality department audited allour providers?

■ And when we have been successfullyde-iced are there restrictions on engineor APU bleed air usage for cabin air?

Cold soaking can be a major “gottcha” forwinter operations. Some of the factorsaffecting wing cold soaking are: amountof fuel remaining in the wing, time spent athigh altitude, parking position, exhaustfrom ground equipment, fuel tank locationand time since refuelling. If precipitationfalls within a temperature range between–2° and +15°, on cold soaked wings onthe ground then clear icing can occur.Icing doesn’t have to be symmetrical inform. Clear icing is very difficult to detectvisually, particularly in poor weather andlighting conditions – when you performyour pre-departure walk around at night inmiserable drizzle on the last sector of along day how much access do you reallyhave to inspect the wing upper surfaces?Have the turn around slots been altered toaccommodate the longer pre-flightinspections and de-icing operationsrequired?

Be vigilant, be thorough, remember, it’snot the ice on the wing that will kill you, it’sthe decision to take-off with the ice on thewing that will kill you.

by John Dunne, Airclaims


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Of the more than 200 heavy air transportaccidents involving hull loss or fatalities inthe past 10 years, more than 50 percentwere associated with either controlledflight into terrain (CFIT) or the approachand landing phases of flight (fig. 1). Manyof these accidents involved inadequate orloss of vertical situation awareness byflight crews.

To help prevent CFIT and approach andlanding accidents, Boeing has created aclear graphical picture of the airplanevertical flight path that enhances the flightcrews’ overall situation awareness. Thisvertical situation display (VSD) works inconjunction with the terrain-mappingfeature of the terrain awareness andwarning system (TAWS) (e.g., theHoneywell enhanced ground proximitywarning system) to provide flight crewswith an intuitive presentation of the verticalsituation relative to the surrounding terrainand the final approach descent path. Inaddition to terrain alerting, the TAWSprovides a lateral, or top-down, view ofterrain. The VSD depicts a profile, or sideview, of terrain and flight path data.

The VSD is designed to maximize safetywhile minimizing required changes toairplane hardware and airline flightoperations and training. It also capitalizeson airplane design elements commonacross all Boeing models and can beimplemented within the constraints ofavailable space on existing airplanedisplays.

The VSD will be offered by early 2003 as acustomer option on in-production 737s andby retrofit on 737-600/-700/-800/-900airplanes already in service. Implementationof the system on other Boeing models isunder consideration. The value of theVSD can best be understood through adiscussion of the following:

1. Current method for assessing verticalsituation.

2. Development of the VSD.

3. Display features.

4. Benefits of the VSD.

5. Implementation on Boeing airplanes.

1. Current Method for AssessingVertical Situation

Currently, flight crews must assimilatevertical situation information from varioussources to create a mental picture of thevertical profile. These sources includebarometric and radio altitude readouts,the vertical speed indicator, groundproximity warning systems, terraindepiction systems, and navigation

information from the flight managementcomputer (FMC) and navigation charts.Flight crews usually are very effective atintegrating this information. However, theycan be hard-pressed to formulate andmaintain a completely accurate mentalmodel of the vertical profile, especiallyduring time-critical or high-workloadsituations or during initial training usingvertical navigation (VNAV) systems. Thismakes misinterpretation of the verticalsituation more likely.

During the past several years, variousoptions have been investigated to providevertical situation information on the flightdeck. Although many new technologiespromise to deliver improved overallsituation awareness, significantlyenhancing the safety of the worldwidecommercial airplane fleet will require cost-effective solutions that are relatively easyto retrofit. Presenting flight crews with a

Vertical Situation Display for Improved Flight Safetyand Reduced Operating Costs


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side view of the vertical dimension is onesuch solution - it targets a significant partof the problem yet involves only minorchanges to the airplane and airlineinfrastructure.

2. Development of the VSD

Boeing evaluated various methods ofimproving vertical situation awarenesswith the goal of reducing the overallaccident rate of the commercial airtransport industry. Because themeasurement of vertical awareness issubjective and there is no one-to-onecorrelation between vertical awarenessand accident prevention, Boeing decidedthat measurements of vertical situationawareness alone are insufficient forevaluating the safety of varioustechnologies. Instead, databases - suchas those of airline incident reports and

accident reports for the past 10 years -were used as one source of evaluationcriteria. The incident reports were used toguide the direction of conceptdevelopment, whereas the accidentreports were used to determine theexpected effect of specific concepts onthe accident rate.

In addition, flight crews flew three types ofscenarios in an engineering flight decksimulator that reflected the targetaccident types (i.e., CFIT and approachand landing). The scenarios involved anapproach during which the airplane mustdescend later than normal to intercept theglideslope, an approach with a steepglideslope, and level flight towardmountainous terrain. Flight crewperformance, subjective ratings, andobservations were gathered.

Results showed that the VSD was the

most effective display format in all threescenarios. The least effective display wasa simple three-dimensional (3D)perspective display. The VSD scored highin the areas of early threat recognition,effectiveness when flying steepapproaches, and maintenance of astabilized path.

Based on these results, Boeing chose topursue further development of the VSD asthe most effective and practical optionthat could be implemented in the nearterm. This decision was not meant topreclude further developments in 3Dperspective displays.

Developing a side-view vertical profiledisplay necessitated refinement of thehuman interface requirements. Boeingworked with airlines, suppliers, andregulators to ensure efficient developmentand implementation as well as the


6

establishment and support of an industrystandards team. Human interfacerequirements were refined in the 737engineering flight deck simulator becausethe 737 uses various display types andsizes. Boeing wanted to ensure that anyVSD design could be implemented on themany sizes of electronic displays usedtoday, including the larger ARINC D-size(8- by 8-in) and the smaller ARINC B-size(6- by 7-in) displays.

3. Display Features

A VSD graphically represents a view ofthe vertical profile of the airplane. TheBoeing VSD depicts a swath that followsthe current track of the airplane andtherefore is referred to as a track-typeVSD. When selected by the flight crew, itappears at the bottom of the navigationdisplay (fig. 2).

Figure 3 shows an example of the Boeingside-looking VSD. The basic features ofthis VSD include altitude reference andhorizontal distance scales, an airplanesymbol, a vertical flight path vector, terraindepiction, navigation aids, glideslopedepiction, and various informationselected by the flight crews and FMCsuch as the mode control hand (MCP) -selected altitude, minimum decisionaltitude, and selected vertical speedpredictor.

The development of the VSD formatinvolved a thorough human-centereddesign approach. All the features had tomeet basic flight deck philosophies anddesign guidelines. In addition, becauseclutter always is a concern, each featurewas added only after it was shown toprovide a significant benefit in terms ofenhancing flight crew awareness. Someof these human-centered design

requirements included the following:

■ Information had to be consistent withthat which already appears on otherflight displays.

■ Information had to be intuitive andfollow standard flight informationsystem and navigation displayconventions.

■ The display had to use existingsymbols to as great a degree aspractical.

One issue identified with the track-typeVSD was that flight crews wantedadditional terrain look-ahead in thedirection of a turn. An algorithm wasinvented that expands the swath in thedirection of the turn to give flight crewsthe desired result.

One guiding philosophy was that the VSDmust be intuitive. The swath widthactually is dynamic and varies as afunction of navigation accuracyrequirements and whether or not theairplane is turning. Consequently, theswath is depicted on the lateral displaysimply with two dashed lines. Theinformation contained between these twolines on the lateral view is the informationdepicted on the VSD. This results in adisplay that is more intuitive to flightcrews.

Wherever appropriate, symbols fromother displays were incorporated into theVSD. For example, the symbol for MCP-selected altitude is the same shape asthe corresponding symbol on the primaryflight display altimeter tape.

Although the VSD can be used to assesspath stability, path stability is only part ofthe equation for a stable approach. Theother factor is speed stability. To facilitatespeed stability, a new symbol was


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introduced on the VSD. The range-to-target speed symbol is a green dot thatshows where excess speed will bedissipated along the vertical flight pathvector. If excess speed is not an issue,then the symbol will not appear on thedisplay.

The display remains stable duringdynamic conditions. Flight crews shouldkeep in mind that the VSD is asupplementary display and as such isnot intended for use as the primaryreference during dynamic maneuversand procedures.

Incorporating the VSD does not requireany changes to flight operationsprocedures, except for the addition ofprocedures that apply to the VSD in non-normal conditions. Additions to theairplane flight manual describe thefeatures of the VSD. Flight crews’ trainingregarding the VSD only involves writtenmaterials.

4. Benefits of the VSD

The main benefit of the VSD is improvedsafety. The VSD will give flight crews anintuitive view of the vertical situation justas the current map display provides anintuitive depiction of the lateral situation.In conjunction with the other safetyfeatures of the flight deck, this increasedvertical situation awareness helps preventCFIT and approach and landingaccidents and incidents, thereby furtherdecreasing the already low accident rateof the worldwide commercial airplanefleet.

The VSD depicts terrain information fromthe TAWS or other onboard sources fromanother perspective. The TAWS generatesa lateral view of the surrounding terrainand provides terrain proximity alerting.The VSD depicts the vertical dimension of

the terrain (fig. 4), which will allow crewsto recognize possible terrain conflictsmore readily, before a TAWS alert isgenerated.

The VSD also depicts the final approachsegment of the intended path of theairplane to the runway (fig. 5) therebyassisting flight crews as they establish theglide path. Terrain alerting from the TAWSis disabled gradually during this phase offlight to eliminate nuisance alerts, but theVSD is available full time.

The VSD also complements the increaseduse of constant-angle, area navigation,and required navigation performance(RNP) approaches by providingimmediate validation of the selectedapproach path and allowing full-timemonitoring of the airplane position relativeto the selected glide path. As low-altitude,

in-cloud maneuvering becomescommonplace and RNP criteria allowbetter utilization of restricted airspace, theVSD will serve as an invaluableconfirmation of airplane performance.

The VSD will provide additionaloperational benefits. Earlier recognition ofterrain clearance problems facilitatesmore timely go-arounds and earlier CFITavoidance. In addition, withimprovements in vertical awareness, flightcrews have an improved ability to monitorthe vertical path. Earlier recognition ofunstabilized approaches helps reduce thenumber of go-arounds and missedapproaches. Because many unstabilizedapproach problems are manifestedduring the landing phase of flight, earlierrecognition also should reduce thenumber of hard landings, runwayoverruns, brake fires, and tire failures.


8

This will help reduce airline operatingcosts by extending the life of the air-framestructure, landing gear system. tires, andbrakes and by reducing the airplanemaintenance downtime associated withlanding problems.

Finally, the intuitive nature of the VSD willallow flight crews to assess the verticalsituation quickly, thus reducing overallworkload. Crews will have more timeduring the most critical phases of flight -climb, descent and final approach - tofocus on other routine tasks and handleany unusual circumstances they mayencounter.

5. Implementation on Boeing Airplanes

The VSD has only recently become aviable option for increasing verticalsituation awareness. Three factorsprecluded an earlier introduction of thetechnology. The information presented onthe VSD must be accurate. Accuracyrequires a good terrain database, andthat technology has become available

only recently forcommercialapplications.Second, flight crewsmust have confidencein the accuracy of theposition of the airplanerelative to physicalfeatures. Althoughmost navigationsystems are veryreliable and robust,the advent of theglobal positioningsystem has improvedlateral and verticalaccuracy of theairplane position.

Finally, as a result ofimprovements in

display technology and computationalthroughput, the quantity of displaysymbols is not as limited as it once was.

The VSD was designed for incorporationwithin the constraints of currentproduction models. Implementation on in-production airplanes requires systemchanges to the avionics displays, FMC,and TAWS. For the avionics displays, thedisplay system software must beupdated. The FMC requires a softwareup-grade, and new hardware andsoftware are required for the TAWS. In-service airplanes may require additionalhardware upgrades to allow fullimplementation.

The introduction of new, large liquidcrystal display screens on Boeingairplanes facilitates implementation of theVSD. The VSD also was designed to becompatible with cathode ray tube-basedflight decks. Although Boeing hasfocused on integrating the VSD into theflight deck, a large portion of theworldwide fleet in the next 5 to 10 yearsstill will use electromechanical instrument

flight decks. The VSD can beimplemented on these flight decks as astand-alone display system. These retrofitsolutions are in development.

Boeing has developed the VSD so thatadditional features can be added. Oneexample is the depiction of the verticalprofile along the entire planned flight path.Showing the vertical swath along theplanned flight path of the airplane, insteadof just along the current track, providesseveral benefits. Not only may thisenhance awareness of the vertical mode,but VNAV and lateral navigation conceptsalso may be simplified for training. Otherenvisioned enhancements includeproviding weather and traffic information.

SUMMARY

The VSD is another step on theevolutionary path of flight deck displays.The display is a natural complement toand outgrowth of the lateral moving mapintroduced into commercial fleets in the1970s and 1980s. The VSD can have asignificant and beneficial effect oncommercial air transport safety. Bypresenting the flight crew with a simplegraphical picture of the verticaldimension, vertical situation awarenessis enhanced, which potentially cansignificantly reduce the number of airtransport accidents in the worldwidefleet in a realistic time frame. The VSDcan be implemented without majorairplane hardware changes. The systemwill be offered by early 2003 as acustomer option on in-production 737sand by retrofit on 737-600/-700/-800/-900 airplanes already in service.Implementation of the system on otherBoeing models is under consideration.

Reprinted from AERO magazine bypermission of The Boeing Company


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Foreign object damage (FOD)accidents/incidents have resulted in lossof life and destruction of aircraft, as wellas flight delays and additional work foraviation maintenance technicians andothers. A U.S. Federal AviationAdministration (FAA) report said that onereason for maintenance-related FODoccurrences is the complexity of theaviation-maintenance environment, inwhich maintenance personnel applyspecialized knowledge and skills toconduct controlled procedures insurroundings that include organizationalpressures, environmental pressures andwork pressures.

[FOD is defined as damage to any part ofan aircraft - frequently an engine or aflight control mechanism - that is causedby any extraneous material: the cost ofFOD to the worldwide aerospace industryhas been estimated to be US$4 billionannually.]1

Maintenance personnel may not be ableto anticipate many of the problems thatresult from the complexities of theaviation-maintenance system.

“It is critical, therefore, to have anunderstanding of the human factors of thesystem and to address those humanfactors through both proactive[measures], as well as reactivemeasures,” the report said. “Through agrounded understanding of the humanfactors involved in FOD, the industry canprovide the best guidance to eliminateexisting FOD problems and prevent futureFOD occurrences.”

Many FOD-prevention programsemphasise technical procedures but donot consider human factors related tothose procedures. Therefore, the FAAOffice of Aerospace Medicine conducteda study to identify methods of reducingmaintenance-related FOD occurrences by

applying human factors best practices.2

The report discussed the four causes ofmost FOD in the maintenanceenvironment - poor housekeeping,deterioration of facilities, impropermaintenance and inadequate operationalpractices. The report also discussedinteraction and support of FOD -prevention efforts by management andemployees, FOD awareness, FODtraining, FOD audits and FODinspections.

“These factors, taken together, make upthe proactive measures that can be usedto eliminate and prevent [FOD] in theaviation-maintenance environment,” thereport said.

The report said that an FOD preventionprogram should include precise policiesand procedures that discuss the followingitems:

■ The importance of FOD preventionand how FOD prevention affectssafety, quality, costs and customersatisfaction;

■ The goals of the FOD-preventionprogram and the time required toachieve those goals;

■ The standards that will be used toassess the progress of the FOD-prevention program and to compare itwith similar programs in otherorganizations;

■ The organization of the FOD-prevention program, including howthe program will be managed andwhat support will be available;

Improved Understanding Of Human Factors Could ReduceForeign Object DamageA U.S. Federal Aviation Administration report provides guidelines for reducing maintenance-related foreign object damage through theapplication of human factors best practices.

by FSF Editorial Staff


10

■ The FOD-prevention program’spolicies and procedures, includinghow those procedures will bedisseminated and how improvementsin the process will he achieved;

■ The methods of communicating thesuccesses or failures of the FOD-prevention program to aviationmaintenance technicians and aviationmaintenance managers; and

■ The methods of investigating FODincidents and FOD accidents,including how the occurrences will bereported, what data will be collectedand how the data will be stored andanalyzed.

The report described managementsupport as essential to the success of a

FOD-prevention program and said thatmanagement support should includeadequate funding, appointment of anindividual or group with authority toimplement the program, support for workto eliminate FOD throughout theaerospace industry and support of a“FOD-prevention culture” throughout theorganization.

“The culture of an organization is thecollection of beliefs, norms, attitudes,roles, as well as social [practices] andtechnical practices, that are shared byindividuals within an organization,” thereport said. “A good safety culturefocuses on minimizing dangerous andinjurious conditions that may affect notonly the employees of the organization.A more important result of a good safetyculture is improved safety for the public at

large…

“The aircraftmaintenancetechnician’s attitudestoward FOD will be areflection of thevalues and beliefsthat managementplaces on FODprevention orelimination. …Thus, itis incumbent onmanagement toestablish andmaintain a FOD-prevention culturewithin theorganization.”

The report said thatall maintenancepersonnel shouldreceive training inhow to prevent FOD,including informationabout theorganization’s FOD-

prevention procedures; causes andeffects of FOD; safe working practicesand individual responsibilities; correctstorage, shipping and handling ofmaterial, components, equipment,personal items and tools; accountabilityand control of tools, materials andhardware; vigilance for potential sourcesof FOD; clean-up techniques; andreporting of FOD incidents.

“In addition to the general FOD trainingrequired for all employees, contractorsand subcontractors, the maintenancetechnician should receive additionaltraining focused on the technical aspectsof FOD prevention.” the report said. Theadditional training may discuss correctmethods of cleaning and maintaining fuelfilters and disposing of small pieces ofmaintenance-related material, such aspieces of safety wire.

FOD-prevention training should berequired before maintenance personnelwork on an aircraft on aircraftsubassemblies. Recurrent training alsoshould be required, the report said.

To ensure that all employees develop anawareness of FOD occurrences and theFOD-prevention program, FODannouncements and discussions shouldbe included in meetings, incentiveprograms should be established toreward individuals or departments fortheir efforts to reduce FOD, and FODarticles should be published regularly inthe company newsletter.

The report said that the FOD-preventionprogram should include easilyrecognizable and appropriately sizedFOD receptacles throughout themaintenance facilities. Outdoorreceptacles should be watertight, and allreceptacles should be emptied regularlyand should not be permitted to overflow.

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“There should be regularly scheduledFOD walks of hangar bays, aircraft rampsand aprons,” the report said.“Consideration should be given to usingspecialized brooms, magnets andvacuum-type machines to clear areas.”(Brooms and sweepers should not havemetal bristles, which increase the risk ofFOD.)

The report recommended several clean-up activities for individual maintenancetechnicians, including:

■ Clean the immediate work area whenwork is completed, when work“cannot continue,” at the end of eachshift and before inspection;

■ Pick up debris that might migrate toan inaccessible location or to alocation where the debris would beout of sight. The report said. “If yousee debris, don’t walk over it: pick itup and dispose of it properly”;

■ Do not take food or beverages to thework area; and,

■ Return cleaning equipment and toolsto the proper storage area.

“The fundamental process to prevent[FOD] is to perform all maintenance tasks“by the book,” the report said. “Thisincludes all procedures, from removingexcess grease from a component tocapping all aircraft ports anddisconnected lines with approvedmaterial.”

The guidelines recommended by thereport include the following:

■ Protect equipment that is sensitive toFOD. For example, cover engine inletsand exhausts during maintenance thatdoes not require access to the enginearea;

■ Aircraft undergoing maintenance ormodification and the areassurrounding the aircraft should beinspected and cleaned throughout themaintenance/modification process;

■ If an item is dropped in a “criticalairworthiness area,” the item shouldbe removed before further work isperformed. If the item is not found, theoccurrence should be reported to asupervisor. The item should beaccounted for before the aircraft isreleased for return to service;

■ Every assembly step should includean inspection for extraneous material,and FOD inspections should beperformed before all final closures;

■ Only essential hardware should betaken aboard the aircraft. Tools shouldbe carried and stored in tote trays,sacks or boxes. Tool trays shouldhave lids;

■ Before an engine is started, a FODwalk should be conducted in front ofthe intake area and behind theexhaust area of the engine to ensurethat the areas are free of objects thatcould cause damage;

■ “Check aircraft tires for foreignobjects”;

■ Report damage to pavement; and,

■ Whenever debris is seen, it should becollected and disposed of properly.

The report said that, whenever possible,the packaging of any item used duringmaintenance should be in a color thatcontrasts with the background of themaintenance area. Tools sometimes maybe in colors that blend into thebackground; therefore, tool-controlprocedures should be implemented. The

report said that a written tool inventoryshould be maintained for each tool-storage area, that personnel should beable to identify all tools and trace them totheir assigned storage location and thattools should be transferred from oneindividual to another only with properdocumentation.3

The person responsible for the FOD-prevention program should ensure thatFOD inspectons and FOD audits areconducted regularly, using checklists toverify compliance with FOD-preventionprocedures.

“FOD audits should provide a review ofexisting conditions, as well asrecommendations for improving …debriscontrol,” the report said. “The audit resultsmay be used to develop corrective-actionsprograms and to provide improvements toFOD-training programs.”

When a FOD incident or FOD accidentoccurs, it must be reported promptly andthe circumstances must be reviewed toprevent a similar problem in the future.The report recommended that theindividual or group responsible for theFOD program conduct an investigation,analyze the resulting data and developcorrective actions.

“Human factors should be an integral partof any investigation of any incident oraccident resulting from FOD,” the reportsaid. “Whenever possible, investigators ofa FOD incident or accident shouldconduct an on-site examination. Thiswould include walks through the area ofconcern and interviews with personnelinvolved and [with] other stakeholders.”

The report said that several humanfactors investigative models have beendeveloped for assessing accidents andincidents in aviation maintenance,including the following:


12

■ Maintenance Error Decision Aid(MEDA), developed by BoeingCommercial Airplanes, is designed toinvestigate maintenance errors and toreduce or eliminate the errors byredesigning procedures. MEDA isbased on three principles: “Mechanicsdon’t intend to make mistakes”;“errors result from a variety ofworkplace factors, such as unclearlywritten manuals, poor communicationbetween workers or improperlylabeled parts”; and “management canfix the factors that contribute toerrors”;4

■ Dirty Dozen, developed by GordonDupont in his work with TransportCanada, includes a checklist ofaviation human factors issues that canbe used for training and situational

awareness. The checklist cites 12errors in aviation maintenance thatcan affect safety, including lack ofcommunication, complacency, lack ofknowledge, distraction, lack ofteamwork, fatigue, lack ofassertiveness, stress, lack ofawareness and “norms” (adopting thebehavior of others in the group, evenwhen that behavior is not correct);5

■ SHEL Model, developed by ElwynEdwards and modified by FrankHawkins, describes how the humaninteracts with the system; SHEL is anacronym for software, hardware,environment and liveware (humans).The SHEL model explains how theliveware interacts with the other threeelements, as well as with other humancolleagues;6

■ PEAR Model,developed by MichaelMaddox specificallyfor use in aviationmaintenanceenvironments,emphasizes therelationship betweenindividuals and theother elements of thesystem: PEAR is anacronym for people,environment, actionsand resources. The“people” factorsinclude mentalcapability, physicalcapability, attitude,training, age andadaptability.“Environment” factorsinclude workingconditions such astemperature, noiselevel andorganizationalenvironment.

“Actions” factors include the actionsthat must be taken to complete tasks.“Resources” factors include the tools,computers, information, other peopleand time that are required for peopleto perform actions; and,

■ Human Factors Analysis andClassification System MaintenanceExtension (HFACS-ME), developed bythe U.S. Naval Safety Center, isdesigned to identify human error thatcontributed to aviation maintenanceoccurrences and to use theinformation in the development ofstrategies to prevent such errors.HFACS-ME classifies human error intofour categories - supervisoryconditions, maintainer conditions,working conditions and maintaineracts - to study the relationshipsamong latent failures and activefailures.

The report said that each organizationshould have a form to be used in FODinvestigations and to help organize datafor entry into a FOD database. The formshould be designed to collect data to beused in analyzing the cause of the FODproblem, including a description of theoccurrence, a description of damage, areport on immediate action taken andrecommendations for corrective actions.

By compiling and reviewing the data, theorganization can work to identify and tounderstand the situation that resulted in aFOD occurrence and to implement bestpractices that will prevent FODoccurrences, the report said.

“Once the problem has been defined andthe [investigating] team has anunderstanding of the system, then theycan begin to analyze the information anddata in order to identify the root cause ofthe FOD incident or accident” the reportsaid. “It is possible that an individual -

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13

who intentionally deviated from the safeoperating procedures, recommendedpractices or rules - may have caused theproblem. More than likely, however, theinvestigating team may find weaknessesin equipment design or availability,incorrect or out-of-date operationalprocedures, or lack of awareness andtraining deficiencies. They may even findthat the root cause goes as far back asthe culture of the organization or the lackof management support for FOD-prevention.”

A corrective-action plan should bedeveloped by the individual or groupresponsible for FOD prevention toestablish procedures to ensure that theroot causes of an FOD incident or FODaccident are identified and are correctedpromptly.

A corrective-action plan may include suchitems as documentation of the processesincluded in the investigation of the FODincident or FOD accident; results of theinvestigation and the root-cause analysis;identification of human factors causesand human factors intervention strategies;evaluation of alternative solutions; andassessments of the economic impact ofthe solution, of the solutions regulatorycompliance and the potential for conflictwith other groups or procedures.

If the analysis reveals more than one rootcause of the FOD occurrence, separatecorrective-action plans should bedeveloped for each cause.

The report cited other analyses of humanerror in aviation maintenance that havefound that errors originate from individualfactors or from organizational factors.

The individual factors consisted of thefollowing: physical health, fatigue, timeconstraints, management pressure,complacency, body size/strength,

personal event/stress, workplacedistractions, lack of awareness, lack ofknowledge, lack of communication skills,and lack of assertiveness.7

The organizational factors consisted ofthe following:

■ Hardware/equipment/tools/lack ofresources/inadequate staff;

■ Design/configuration/parts;

■ Maintenance management/leadership/supervision/company policy;

■ Work processes/procedures/information;

■ Error-enforcing conditions/norms/peerpressure;

■ Housekeeping;

■ Incompatible goals;

■ Communication processes;

■ Organizational structures/corporatechange/union action;

■ Training/technical knowledge/ skills;

■ Defenses;

■ Environment/facility; and,

■ Lack of teamwork.8

“Not all FOD errors are due to theindividual, nor are all FOD incidents or[FOD] accidents attributable toorganizational causes,” the report said.“In the past, the focus of a FODinvestigation was on the problem point orthe individual where the active failureoccurred. More recently, however, therehas been a ... shift in FOD investigationsto examine the relevant facts related to

the event and to the background causesor latent failures. Employing a structuredand systematic approach to theinvestigation and root-cause analysis willminimize any potential bias toward theindividual in the corrective-action plan.”

After the FOD error has been categorized,a corrective-action plan can be developed,including human factors interventionstrategies. After the plan has beenimplemented it should be evaluated todetermine whether modifying or eliminatingthe root cause of the FOD has eliminatedthe immediate cause of the FOD andwhether implementation of the planprevented similar recurrences of FOD.

The report recommended the followingguidelines for conducting the evaluation:

■ Incorporate the evaluation into otherroutine proactive FOD-preventionprocedures rather than establishing aseparate group to evaluate the process;

■ Seek opinions from groups rather thanindividuals. The report said thatgroups often provide “more valid andcreative feedback”;

■ Computerize all aspects of theevaluation; and,

■ Ensure that data-collection proceduresare well organized and that thedatabase is designed to allowinformation to be extracted for analysis.

“The elimination of FOD is a continuousimprovement process,” the report said.“Lessons learned can help guide andtune future implementation processes, aswell as help in developing a businesscase to expand the [corrective actionplan] to other parts of the organization.Finally, the evaluation measures can aidin the development of benchmarks forfuture comparisons.”


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[FSF editorial note: This article, exceptwhere specifically noted, is based onGuidelines for the Prevention andElimination of Foreign ObjectDamage/Debris (FOD) in the Aviation-Maintenance Environment ThroughImproved Human Performance. The reportwas written by David C. Kraus of GalaxyScientific and Jean Watson of the AircraftMaintenance Division of the U.S. FederalAviation Administration Flight StandardsService. The 34-page report containsfigures, tables and appendixes.]

Notes

1. “FOD Defined.” FOD News.<www.fodnews.com/fod-defined.html>. June 17, 2002, Theestimate of the cost of foreign objectdamage (FOD) was made by U.S.National Aerospace FOD PreventionInc. (NAPFI), a nonprofit educationorganization established in 1985 towork to eliminate FOD.

2. The guidelines relate only tomaintenance operations and do notdiscuss other causes of foreign objectdamage (FOD), such as bird strikes,animal ingestion, weather-relatedevents, damage from ground-supportequipment and airport operationalpractices. They also do not discussaircraft tire maintenance.

3. Eri, Eulaine. “Sample Tool-control Ten-point Baseline.” National AerospaceFOD Prevention Newsletter. May 1998.

4. Boeing Maintenance Error DecisionAid MEDA. Boeing CommercialAirplane Group. 1994.

5. Dupont, Gordon. “The Dirty DozenErrors in Maintenance.” HumanFactors Issues in Aircraft Maintenanceand Inspection, Meeting 11Proceedings. Washington D.C., U.S.:U.S. Federal Aviation Administration.1997.

6. Hawkins, F.H. Human Factors in Flight.Aldershot, Hampshire, England:Gower Technical Press, 1987.

7. Pakantar Manoj S.; Taylor, James C.“Analyses of Organizational andIndividual Factors Leading toMaintenance Errors.” Paper no. 2001-01-3005. Society of AutomotiveEngineers.

8. Ibid.

Further Reading From FSFPublications

FSF Editorial Staff. “Foreign-objectDamage Cripples Concorde on Take-offFrom Paris.” Accident Prevention Volume59 (April 2002).O’Neill, John F.Jr. “Foreign ObjectDamage: Elimination Should Be a Priorityto Reduce Risks to Personnel andEquipment” Aviation Mechanics BulletinVolume 21 ( March-April 1993).

Reprinted with acknowledgement toFlight Safety Foundation, AviationMechanics Bulletin, July-August 2002.


15

Readers will recall the tragic loss in May1995 of an EMB110 Bandeirante ondeparture from Leeds-Bradford airport.The crew of the UK-operated aircraft lostcontrol of the aircraft in IMC following thefailure of at least one, but possibly both,of the pilots’ attitude indicators (AI).Although the incident was some yearsago, comment is now appropriatebecause the operator sought,unsuccessfully, to recover its losses fromthe aircraft manufacturer (and, initially, thecomponent manufacturer, although thisclaim was discontinued shortly after thetrial started) through the Courts.Judgement was given last year and wefollow up on the previous legal adviser’spromise in FOCUS Issue 45 to say moreabout the case.

The case primarily concerned the dutyowed by a products manufacturer to anoperator when it emerges that equipmentproves unreliable in service. This casefailed, but in addition, the Courtcommented on certain flight operationsissues - specifically issues relating toaircraft handling under limited panel inIMC - which are likely to be of moreinterest to this readership.

The background to the litigation was thatby the time the subject aircraft was built,the manufacturer recognised that theparticular AI fit was unreliable and indeedwas not recommended by thecomponent supplier. A Service Bulletinrecommending installation of a remotegyro (instead of the original panel-mounted installation) was published in1982, about two years after the accidentaircraft was completed. The operatorcontended, first, that the airframemanufacturer should never have used theoriginal installation in an aircraft intendedfor commuter airline use; second, thatoperators should have been warned of itsunsuitability; and third, the Service

Bulletin failed to emphasise theseriousness of the failures of the originalAI installation.

The following factors were important tothe Judge in his decision to reject theclaim.

■ First, while there was abundantevidence of a problem ofunscheduled failures with the originalAI fit, this was not a safety problem.While operators had complainedabout reliability, none had complainedfrom a safety angle and, significantly,none had retrofitted the remote gyroultimately recommended by themanufacturer as the fix to theproblem.

■ Second, the AIs were, formaintenance purposes, “on condition”items. It followed that they could failin service without imperilling theaircraft. Airworthiness regulatorsaccepted this.

■ Third, after the accident, the AAIB hadnot recommended that the SBimplementing the new AI fit be mademandatory, nor had the CAA takenthat course.

So far as flight operations issues areconcerned the flight operations witnesses

accepted that, in the event of a soft AIfailure, professional instrument-ratedpilots should have been able to maintaincontrol of the aircraft. All but one of thosewitnesses agreed that that should havebeen the case even if it was a doublefailure with no standby AI. The Judgeconcluded that the flight crew had failedto perform to the standard reasonably tobe expected, albeit with considerablereluctance given that the crew were notable to explain their conduct in Court.Where the case points up a dilemma is inthe recognition - which the Judge sharedwith the AAIB - of the difficulty ofmaintaining control of the aircraft onlimited panel, particularly in the prevailingweather conditions. Such a task is highlydemanding of a pilot’s skills and in thecase of professional pilots, is neitherretrained nor retested after CPL or ATPLinitial issue. One may therefore concludethat the prudent operator should considera programme of recurrent training if, forexample, its aircraft are not fitted with astandby AI. However, the AAIBrecognised the cost and limitations ofsuch training and clearly took the viewthat the redundancy afforded by twopilots each with a full set of instrumentswas more effective protection and somade no recommendation.

Moreover, the manufacturers did notpursue any suggestion that the operator’s

Safety Duties AnalysedLambson Aviation (Knight Air) and Others v. Embraer and Another High Court of Justice, 11 October 2001


16

training was insufficient; there was nobreach of any legal or regulatoryrequirement in this respect so the Courtwas not in a position to say that theoperator’s practices fell short of thosereasonably to be expected of anyoperator. For this reason, it is difficult todraw any conclusion about the trainingaspect: the Court did not, it appears, hearevidence or argument on the subject, sothis cannot be regarded as a definitiveconclusion.

What the Court did do was to concludethat the Captain was interpolating, inother words trying to continue using his AIdespite knowing that it was not indicatingcorrectly. The Court accepted theexperts’ evidence that it was axiomaticthat if the Captain recognised his AI hadfailed, he should immediately hand overcontrol to the First Officer. Although not amajor factor in his decision, the Judgeconcluded that the crew did not maximisetheir ability to deal with the situation andthis may have been compounded by therelative inexperience in role of both theCaptain and First Officer. That, however,is more a point for the human factorsexperts than for the lawyers.

Some may ask what difference the flightoperations aspects make from a legalperspective. To be brutal, the answer isthat in financial terms it made little

difference: the operator is liable in anyevent to its passengers whether the flightcrew had discharged their duties or not.On these facts, the operator failed todemonstrate that the manufacturer was inbreach of duty, but if the outcome in thatpart of the case had been different, afailure by the flight crew may mean thedifference between the operator’s abilityto recover indemnity in respect ofpassenger claims and the hull loss. Thedifference really lies in the safety of thepassengers.

What then, are the conclusions?

First, at the most general level, it isencouraging that the English Courts candeal with complex technical issues andaddress them, with the rightrepresentation and expert evidence, witha high degree of understanding. Onoccasions in the past this has not beenthe case.

Second, the central legal point to emergeis that liability in negligence arises wherethere is a safety issue. It was this, ratherthan a reliability question, that triggeredthe manufacturer’s duty in tort to theoperator and those on board.

Third, it is critical to remember thatcompliance with a regulatory orcertification standard is not necessarily a

complete answer to a claim innegligence. Those standards will,however, be taken into account whendetermining what it is reasonable torequire of a manufacturer or operator andthus what burden that party mustdischarge to avoid a claim of breach ofduty. If, therefore, you consider thatequipment fit, procedures or whatever donot achieve a high enough level of safety,review and amend them. Do not wait forthe regulator to mandate a particularcourse.

Fourth, the most specific point to emergeis that operators of aircraft of acomparable equipment fit would beadvised to ensure that flight crewoperating procedures make clear that thehandling pilot should hand over controlimmediately a failure of this nature isrecognised.

Finally, no-one should forget that thiscase only considered civil liability; in thefuture, in a political environment in whicha desire to punish the “guilty” becomesincreasingly prevalent, differentconsiderations may come into play.

Simon Phippard - PartnerAerospace DeparmentBarlow Lyde & Gilbert, London

This is an expanded version of an articlewhich appeared, under the heading“Manufacturers’ Duty Analysed” in Issue 7of BLG Aviation News. Copies of thatand other issues are available on line atwww.blg.co/publications.


17

Professor James Reason’s model ofaccident and incident causation andinvestigation has been widely adoptedby the aviation industry. The modelshows that aviation, in common withother high technology, high-riskindustries, has many layers of defenceto prevent accidents from occurring.These defensive layers will, however,have weaknesses in them allowing thedefences to be breached on occasions(an event). Professor Reason makesthese two points:

“ The consequences of an event canvary from the catastrophic to the freelesson. All, however, provide cruciallearning experiences for the system inquestion.”

“The normal run of operations fortunatelyoffers a fairly large number of freelessons in which a defence or barrier isshown to be deficient without adverseconsequences.”

Since the early 1950s, starting with theinvestigation into the De Havilland Cometcrash off the island of Elba, aviation hasshared the safety lessons learnt from itscatastrophic events in the form ofaccident reports published by bodiessuch as the UK’s AAIB. This approach toflight safety, although undeniablyvaluable, is reactive in nature.

In recent years, in order to improve astatic accident rate, aviation has moved inthe direction of pro-active safetymanagement – identifying and mitigatingpotential safety hazards before anaccident occurs. In line with this pro-active approach aviation should alsoshare the safety lessons learnt from itsfree lessons.

Safety lessons are established, accordingto Professor Reason’s model, by

investigating the Active and Latent failuresthat have caused defensive layers to bebreached. Active failures are the errors offront line operators (pilots, air trafficcontrollers and maintenance engineers inthe case of aviation). Latent failures arecaused by the policies, decisions andculture that are an everyday part oforganisational life, e.g. resourceallocation, staff training, documentationprovision and management – staff –management communication. Thepurpose of a safety investigation iscategorically not to apportion blame butto establish the root causes of an eventthereby establishing the safety lessons.

Airlines have a range of safety tools andother sources of information available tothem to help detect and investigate safetyevents. These include:

1. Air Safety Reports (ASRs)

2. Flight Data Monitoring (FDM)

3. Human Factors Reports (HFRs)

4. Crew interviews

5. Engineering data

6. Quality Audit Reports

Not all reported or detected events willrequire a full investigation and resourceswould not permit this anyway. Thereforeevents should be investigated accordingto their perceived risk level, bearing inmind that risk is not just a function of thepotential severity of the outcome but alsoa function of the likelihood of it occurring.If a safety event requires investigationthen all appropriate sources ofinformation should be used to determineboth the Active and Latent failures.The role of front line operators in theinvestigative process is clearly veryimportant as they provide much of theinitial data on which investigations arefounded. They should, therefore, report

Sharing Safety Lessonsby Capt. John Marshall


18

safety events with sufficient breadth anddetail of information as to allow the safetylessons to be established.

A successful safety information sharingscheme must meet certain requirements,which include:

Confidentiality - Aviation safetyinformation can be sensitive in nature andif used in the wrong way, e.g. punitiveaction or sensationalist journalism,potentially damaging to the operator orindividual from where the informationoriginated. A successful safetyinformation sharing scheme must protectthe confidentiality of those involved whileat the same time not diluting the safetybenefits of the information to be shared.

Workload - Airline Flight Safetydepartments are often staffed by pilotswho discharge their flight safety roles ona part-time basis and as a consequencehave a high workload. Therefore asuccessful safety information sharingscheme must not unduly burden staff witheither its administration nor with vastamounts of safety data requiring analysis.

Practical Benefit – The informationshared must be of more than justacademic interest. Shared safety

information should be of practical benefitto the recipient by alerting them topotential safety hazards that they may nothave detected themselves therebyhelping them to prevent an avoidableaccident.

Sharing safety lessons fulfils theserequirements. Firstly, confidentiality neednot be compromised because theinformation does not need to be specificto a particular flight or even a particularoperator. Secondly, safety lessons do notrequire the recipient to carry outsubstantial analysis of data, therebyminimising additional workload. Finally,safety lessons are a readily usable andpractical format of information – therecipient decides if the safety lessons areapplicable to their operation and thentakes appropriate action.

The following is an example of a safetyevent that should be investigated and thesort of safety lessons that might beascertained:

An operator’s FDM programme detects aGPWS event on a glass-cockpit aircraftduring departure from an airport withsignificant terrain in the vicinity. The crewfile an ASR acknowledging a hard GPWSwarning while following FlightManagement Computer navigationdemands on the SID. So far we have littleinformation of practical benefit to otheroperators. However, if the operator’sinvestigation into the Active and Latentfailures determined that the navigationdatabase was incorrect, that the crewhad not checked the database tracksand distances prior to departure, the SIDhad not been monitored with radionavigation data, the departure chart wasdifficult to interpret, and that the companySOP’s were insufficient regardingmonitoring and cross-checking FMCnavigation, then we start to determinesome valuable safety lessons that could

help another operator avoid acatastrophic event.

The medium best suited to sharing safetylessons is the Internet in the form of asecure website hosted by a respectedaviation body. Such a system is alreadyused by some UK FDM operators and isunder development for the UK’sMaintenance Error Management System(MEMS) Project. The Internet has thepotential to distribute flight safetyinformation securely, efficiently and atreasonable cost on a global scale.

We share safety information to preventsomeone else’s accident. Apart from anymoral justification this makes soundcommercial sense. The public perceptionof airline safety is based on the number ofaircraft accidents, not the statistical rateat which they occur. Undoubtedly anairline directly involved in an aircraftaccident will suffer a loss of publicconfidence, at least in the short term.However, if the number of aircraftaccidents lowers the public perception ofairline safety in general, then the airlineindustry as a whole will suffer. Therefore,let us share the safety lessons not justfrom our catastrophic events but from ourfree lessons as well.

About the Author I started my aviation career in 1987 as aFlight Dispatcher for Monarch Airlines. Thefollowing year Monarch selected me forpilot sponsorship. I rejoined Monarch as aFirst Officer in 1989 and have remainedwith them since, latterly as Captain on theA320. I graduated with an MSc in AirTransport Management from CityUniversity in May 2002.


19

Christmas comes but once a year.....andwith it mince pies, Christmas cake, snow,ice, Blacktop tannoys, aquaplaning, fog,immersion suits, high sea states etc etc.Unfortunately, Christmas is a bit late to startthinking about it.

Being the consummate professionals thatyou are, your preparations will havealready begun. Here is a checklist toscan through whilst you make your cup ofcoffee - hopefully it will identify somethingwhich you could improve on.

ON THE GROUND

Clothing

Are you scaled for the correctprotective clothing? If so, get it issuedand wear it. If not, speak to the chain ofcommand to address the problem. DONOT leave it at home, in the locker room,in clothing stores. Make sure that yourwaterproofs are readily available. Alwayswear your waterproofs when it is raining(Sod’s law says that the 2 minute jobalways extends to 20 minutes or more).Wearing bulky gloves inhibits manualdexterity - so leave more time to do a joband tell your supervisor if you cannotcomplete the task in time.

Check your boots have sufficient tread tomaximise traction. HOWEVER treadcollects snow, mud and stones, so stick tothe hard standing and check that the treadis clean before you get into the cockpit.

Out and about

Get out to the line or HAS site early; ifyou rush and slip over you defeat theobject of running and give the hardpressed manpower manager an extraheadache when you reappear in a plastercast.

When marshalling, stand in a sensibleplace where the aircrew can see you,even if their view is restricted. Beprepared for the aircraft to skid. If you getto the aircraft parking area and you findthat it is slippery - get something doneabout it before the aircraft moves on it.

Be on the lookout for ice and snowthat a taxiing aircraft may blow in yourdirection.

Blacktop

Are your personnel familiar with theBlacktop plan? They may have signedas having read, but do they actuallyunderstand how to implement theprocedures? Why not have a briefinggiving examples of how to deal withdifferent situations.

THE LINE

Aircraft do not like being out in thewind and rain. Keep them in the hangaror HAS whenever possible. If you have toleave them outside, keep the canopiesclosed and put the covers on ifpracticable. Whilst there are fewersquashed bugs on the canopies marks arestill caused by de-icing chemicals and dirtywater so they still need to be keptscrupulously clean.

Fit chocks correctly. If the wind isforecast to pick up, other measures maybe required to secure the aircraft.

Drive slowly; assume you are going toskid when you approach the aircraft.

De-ice with the correct fluid; DO NOTchip ice off an aircraft. How are yourstocks of de-icing fluids? Is the de-icing

kit serviceable? Do all your NCOs knowthe techniques for de-icing the aircraft?

Batteries hold their charge less wellin low temperatures. How do youensure that all your ground equipmentbatteries are fully charged?

Have you had all your fireextinguishers checked recently? Themechanism can freeze in very cold weather.

Remember that rubber seals harden incold weather and need special care.

Allow extra time to carry out theaircraft inspection; it takes longer whenit is cold, wet, windy and dark. Payparticular attention to undercarriage bays,undercarriage microswitches, intakes,tyres, control surfaces, pitot heads andstatic vents.

Ice on the aircraft is not acceptable forflight - get the aircraft de-iced.

Have a close look at the undercarriageas the aircraft taxies out. Hydraulic sealsharden in cold weather and may cause ahydraulic leak which will only becomeapparent when the system warms up.Make sure the wheels are actually rotating!

FLYING

Supervisors, remember thatdiversions are sometimes more difficultto come by in poor weather so keep acareful eye on what you have booked. Donot hang on to diversions unnecessarily,other units may be waiting to use them toget a flying state. Keep up to date withthe weather situation and do not rely onthe met office ringing you to warn you ofchanges. Brief the met office on yourrequirements and ask them to keep aneye on areas of concern and inform youas soon as there is a significant change.In allowing flying to take place, are youcontent that the risk involved due to theweather conditions is worth the prize ofgoing flying at that time?

19

Winter Bluesby DASC


Aircrew, are you fit to fly or are youpushing it to make up the numbers?Planning to stay below 10,000 ft isn’t thesolution. If you haven’t experienced ityourself let me assure you that a stickyear or sinus pain is one of the mostdistracting experiences you can havewhen you are flying. What are your rulesabout sickies staying at work to be theauth.....and infect others?

How seriously do you dress to survive?Life in a dinghy in the North Sea at nightin the winter is not that pleasant andrescue may not be instantaneous.

Pay extra attention to the metforecast. Consider not only cloud,visibility and surface wind but also theicing risk, precipitation and the trendsover the flying period. Know where yournearest suitable diversions are that havemore favourable weather andcrosswinds. If you experience weatherdifferent from that which was forecast -tell someone so others can dosomething about it.

Know your aircraft’s anti-icing systemand the limitations on flying in icingconditions. Does your aircraft type have anicing let down technique? If so, revise it.

Is the runway wet? If so, how likely isyour aircraft to aquaplane and at whatspeed? What techniques does youraircraft type require to minimise the risk ofaquaplaning?

Make sure that your approach platesare up to date and be familiar with thembefore the sortie rather than referring to themfor the first time in cloud and short of fuel.

When briefing multi-ship formations,include spacing during taxy, poorweather take-offs, stream intervals for theconditions (noting runway spray, cloudbase and thickness and radar serviceavailable). Does the formation know thetechnique for a snake climb - even if theyexpect to have a radar to lock onto theaircraft in front (radars and other electrical

gadgets invariably fail in poor weather)?Consider low level aborts into thick cloudand nominate individual levels abovesafety altitude. Brief the lost leader incloud drill, making it pertinent for thesortie and do not accept partialknowledge of the drill.

Taxy slowly and well away fromobstacles. Expect slippery surfacesanywhere, especially on the runway andtaxiway markings and especially aftersurfaces have been treated with de-icer.If it is too slippery, stop and inform ATC ofthe problem; if you leave the runway ortaxiway it will be your fault not the fault ofthe Blacktop team, ATC or anyone else.Do not taxy if you cannot see out of thecanopy due to mist or ice.

Know the temperatures and pressuresthat you can expect on engine instrumentsin cold weather. You may have to wait foroil and hydraulic fluid to warm up.

Standing water and slush affects thetake-off and landing performance of anaircraft. Make sure that your calculationsfor take-off and landing distances, abortspeeds etc take the runway condition intoaccount. Know the techniques for takingoff and landing on contaminated runways.

Beware of white out when taking off orlanding vertically onto snow or whenusing reverse thrust.

Whilst airborne, keep track of theweather at your recovery airfield anddiversions. Recover with sufficient fuel forthe procedure required, plus fuel to holdoff. Keep accurately to slot times if theyare in force. Allow extra time and fuel for

larger formations. Make sure that youhave a plan on how and when you aregoing to split for the approach and makesure you give ATC enough notice. If thereare several aircraft in the instrumentpattern, fly standard pattern speeds tofacilitate accurate spacing. Be carefulabout doing pre-landing checks too early;the fuel penalty incurred by the extra dragfrom the undercarriage may run youshort. Fly the approach accurately sothat you are at decision height on speed,on the centreline and on the glidepath sothat you stand the best chance of gettingin on the first approach in marginalconditions. Are the runway approachlights too bright/dim? One R/T call willget them changed for you.

Once on the ground, remember that itis not over until you have crewed out ofthe aircraft and it has been put to bed.Aquaplaning, slippery surfaces and thehazards mentioned above still apply on thetaxi in. Watch out for airfields that were wetwhen you departed at dusk as the coldfront went through and the temperature hasdropped like a stone and those wetsurfaces have miraculously changed intoicy surfaces. This happened at oneparticular RAF station some time ago. Thetemperature drop had gone unnoticed andthe taxiways were not treated. As aTornado from the evening wave taxied inthe pilot noticed that he had little controlover the aircraft. In order to stop theaircraft, the pilot restarted the engine thathad been shut down for the taxy in so thathe could use symmetrical thrust reverse tobring the aircraft to a halt. This was donesuccessfully and the pilot reported hispredicament to ATC. Some minutes later,the engineering recovery team racedtowards the aircraft and narrowly missedcolliding with it when they realised that theytoo had little control of their vehicle!

When it is all over, drive home safely.Manning levels are not helped byRTAs.

20


2121

Space weather impacts on airline operationsby Captain Bryn Jones, Virgin Atlantic Airways Cosmic Radiation Programme Manager

Recent press coverage regardingexposure to increased levels of radiationwhile flying at civil aircraft altitudes due tocosmic radiation, has raised the profile ofan area of space science, known as“Space Weather”, that was previouslymore likely to be linked only with NASAastronauts and the Space Shuttle.However, the fact that the Earth isimmersed in an extremely tenuous bath ofhigh-energy charged particles calledcosmic rays (both galactic and solar inorigin) is but just one of many physicalprocesses going on in near-Earth spacethat can have a direct impact on airlineoperations. Most of the time spaceweather is of little concern in our everydaylives. However, when the spaceenvironment is disturbed by the variableoutputs of the Sun, technologies that wedepend on both in orbit and on the groundcan be affected (See Fig.1). So besidescosmic rays, what are the other SpaceWeather (SW) phenomena that could havea direct impact on airline operations?

What is Space Weather?

Firstly, what exactly do we mean by theterm “Space Weather”? Theinternationally accepted definition is:“Conditions on the sun and in the solarwind, magnetosphere, ionosphere, andthermosphere that can influence theperformance and reliability of space-borne and ground-based technologicalsystems and can endanger human lifeand health”. (From US National SpaceWeather Strategic Plan, August 1995)

Within this definition we include the effectsof Galactic Cosmic Rays (GCRs) thatoriginate from exploding stars outside oursolar system but which also affecttechnological systems, and endangerhuman life and health because their flux ismodulated by solar processes. It is theseGCRs that are the primary source of thecosmic radiation at aircraft altitudes.

Also from this definition we can see thatthe main influence on our SW comes fromour Sun and its own “climate-like”variations, which occur on both the short

term (hours, days) and the long term(roughly 11-year solar cycle). “Storms” inour SW generally follow severe solardisturbances such as Solar Flares on thephotosphere and Coronal Mass Ejections(CMEs) from the outer solar atmosphere.Flares are our solar system’s largestexplosive events, which can be equivalentto approximately 40 billion Hiroshima-sizeatomic bombs. They have lifetimesranging from hours for large gradualevents, down to tens of seconds for themost impulsive events. They releaseultraviolet, x-ray and radio emissions,which can reach the Earth in 8 minutes,producing a temporary increase inionisation in the sunlit hemisphere ofminutes to hours duration called an“ionospheric disturbance”. Large flares,known as Solar Particle Events (SPEs),can release very energetic particles,which then arrive in our atmosphere within30 minutes. The Earth’s magnetic fielddoes offer some protection, but theseparticles can spiral down the field lines,entering the upper atmosphere in thepolar regions where they produceadditional ionisation in the ionosphereand increase the radiation at aircraftaltitudes. Very energetic and intenseevents can also lead to increases at lowerlatitudes.

CMEs are huge bubbles of magnetisedgas that are ejected from the Sun, atseveral million miles per hour, over thecourse of several hours. Theseexplosions of material (equivalent to themass of Mount Everest!) from the Sun’souter atmosphere can also rapidly showerthe Earth with energetic particles andcause severe disturbances in the SolarWind.

The interplanetary medium (orheliosphere – the region of spacedominated by matter from the Sun), onceconsidered to be a perfect vacuum, isnow known to be a turbulent regionFigure 1. A simple illustration of technolo gical systems affected by Space Weather.


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dominated by the solar wind, which flowsat approximately 250-1000km/s (about600,000 to 2,000,000mph). Othercharacteristics of the solar wind (e.g.density, composition, and magnetic fieldstrength) vary with changing conditionson the Sun. The Earth’s magnetic field(similar in shape to the pattern formedwhen iron filings align around a barmagnet) is influenced by the solar wind,becoming compressed in the sunwarddirection and stretched out in thedownwind direction. This creates themagnetosphere, a complex, teardrop-shaped cavity around Earth. Because thesolar wind varies over time scales asshort as seconds, the boundary betweeninterplanetary space and thismagnetosphere is extremely dynamic.

One to four days after a solar disturbancea slower cloud of solar material andmagnetic field reaches the Earth,buffeting the magnetosphere andresulting in a Geomagnetic Storm. The bi-polar magnetic field of the Earth pointsnorth but the field contained within thematerial expelled from the Sun can pointin any direction. When the field isorientated in the opposite direction to thatof the Earth, that is, when it points south,the two magnetic systems interact andthe solar material can enter the Earth’smagnetosphere. These interactions can

produce very largeelectrical currents, of up toa million amperes, flowingthrough the ionosphereand magnetosphere whichcan change the direction ofthe Earth’s magnetic fieldat the surface by up to 1 or2 degrees, mainly in theauroral regions.

Probably the most wellknown effect of thesegeomagnetic storms is theaurora borealis (northern

lights) and aurora australis (southernlights). They occur when energeticparticles, mostly electrons, “rain” downfrom the magnetosphere during episodesof disturbed space weather. The aurorallight is emitted by atmospheric atoms andmolecules that become excited by theclose passage of the electrons. Aurorabegin between 60˚ and 80˚ latitude. As astorm intensifies, the aurora spreadtoward the equator. During an unusuallylarge storm in 1909, an aurora was visibleat Singapore, on the geomagneticequator. The auroras provide prettydisplays, but they are just a visible sign ofatmospheric changes that may wreakhavoc on technological systems.

What are the Impacts?

Hazards to HumansThe principal SW hazard to humans isexposure to Cosmic Radiation, which iscaused primarily by GCRs. Theseenergetic particles start interacting withthe significant atmosphere at around130,000ft causing secondary particles toshower down into the denser atmospherebelow. This “particle shower”, and thecorresponding level of radiation dose,reaches a maximum intensity at around66,000ft (20km) and then slowly drops offby sea level. Dose rates also increasewith increasing latitude reaching a

constant level at about 50˚. The dose rateat an altitude of 26,000ft (8 km) intemperate latitudes is typically up toabout 3 microSv (µSv) per hour, but nearthe equator only about 1 to 1.5µSv/hr. At39,000ft (12km), the values are greater byabout a factor of two.

Typically, a London to New York flight incurrent commercial aircraft accumulates35-45µSv (5-6µSv/hr); however, the phaseof our Sun’s activity cycle can give ± 20%variations in dose from solar minimum tomaximum.

Under present international guidelines,the recommended dose limit for aircrew isa 5-year average dose of 20 mSv peryear, with no more than 50 mSv in asingle year. In the UK an administrativemaximum limit of 6mSv has beenadopted for record keeping purposes,which is still workable with current flightprofiles and annual block hours.However, if future generations of largecommercial aircraft are designed forincreased range or to utilise the availableairspace at higher altitudes, then we canexpect to see significant increases in thedoses (8µSv/hr at 42,000ft, 10µSv/hr at51,000ft). (Note: for a pregnantcrewmember, starting when she reportsher pregnancy to management, her workschedule should be such that theequivalent dose to the child is as low asreasonably achievable and unlikely toexceed 1mSv during the remainder of thepregnancy.)

Figure 2. illustration of some Space Weather phenomena

Figure 3. Example of Space Weather -The Northern Lights or Aurora


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The impact of SPEs can also increase thedose. During the SPE of 1956 it has beenestimated that the radiation dose receivedat 40,000ft (12km) on a transatlantic flightwould have been approximately 10mSv.Such events are extremely rare, butrecent studies of smaller more typicalevents in September and October 1989indicate 2mSv for a similar flight.

Medical research is inconclusive, but thechances of developing cancer as a resultof cosmic radiation is considered to bevery unlikely, as the total career dose isreceived in low doses per flight, andaccumulated slowly over the length of aflying career. It is difficult throughepidemiological studies to find causationof cancer due to cosmic radiation asother lifestyle risk factors exist, particularlywith aircrew.

Radiation Damage to AvionicsAs aircraft avionics continue to useincreasingly smaller electroniccomponents, systems are becoming moresusceptible to damage from the highlyionising interactions of cosmic rays, solarparticles and the secondary particlesgenerated in the atmosphere. The heavierand most energetic particles can depositenough charge in a small volume ofsilicon to change the state of a memorycell, a one becoming a zero and viceversa. Thus memories can becomecorrupted and this could lead toerroneous commands. Such soft errorsare referred to as “single event upsets”(SEU). Sometimes a single particle canupset more than one bit to give what arecalled multiple bit upsets (MBU). Certaindevices could be triggered into a state ofhigh current drain, leading to burn-out andhardware failure; such effects are termedsingle event latch-up or single event burn-out. These deleterious interactions ofindividual particles are referred to assingle event effects (SEE). Satellitesincorporating sensitive RAM chips have

had upset rates from one per day at quiettimes to several hundred per day duringSPEs. In-flight measurements of SEUsensitivity in 4Mb SRAM, produced a rateof 1 upset per 200 flight hours, andagreed well with the expected upset ratevariations due to changing latitude.Research suggests that 100MB SRAM(i.e., laptop) may suffer upsets every 2hrsat 40,000ft, or 1 upset/minute in 1GBSRAM due to the 1989 SPEs. Thisproblem is expected to increase as more,low power, small feature size electronicsare deployed in “more electric” aircraft.

CommunicationMany communication systems utilise theionosphere to reflect radio signals overlong distances. Ionospheric storms canaffect radio communication at alllatitudes. Some radio frequencies areabsorbed, while others arereflected, leading to rapidlyfluctuating signals andunexpected propagationpaths. Solar flare ultravioletand x-ray bursts, solarenergetic particles, orintense aurora can all bringon these conditions. If theeffects become especiallystrong, it can cause a totalcommunications blackout.SPEs produce a particulartype of disturbance calledPolar Cap Absorption (PCA)that can last for many days.When very energeticparticles enter theatmosphere over the polarregions, the enhancedionisation produced at theselow altitudes is particularlyeffective in absorbing HFradio signals and canrender HF communicationsimpossible throughout thepolar regions. At a recentSW conference, several US

air carriers indicated that they havecancelled trans-polar flights due to suchspace weather events.

GPS NavigationThere are now plans to use GPS fornavigating aircraft so that the separationbetween aircraft can be reduced, and toposition the aircraft on approach. Thereare also studies in progress on thelonger-term goal of landing aircraft byGPS. However, the accuracy of the GPSsignal, which must pass through theionosphere, is obviously affected by anyionospheric variations due to solar andgeomagnetic activity. Dual-frequency GPSreceivers actually measure the effect ofthe ionosphere on the GPS signals andcan better adjust to, but not irradicate,these difficult circumstances. This isaccomplished by using a network of fixed

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ground based GPS receivers, separatedby a few hundred km, to derive a map ofthe ionosphere. The map is thentransmitted to the aircraft so that the GPSreceiver on board can make an accurateionospheric correction.

On a smaller scale, irregularities in thedensity of the ionosphere that producescintillations occur in varying amounts,depending on latitude. For example, theequatorial region, (the latitude zone thatspans 15-20˚ either side of the magneticequator) is the site of some of thegreatest ionospheric irregularities, evenwhen magnetic storms do not occur.Seemingly unpredictable episodes ofdensity enhancements in the upperionosphere can occur there in theevening hours and can cause radiowaves to be misdirected. Thesescintillations make GPS operationsdifficult.

GPS signals are generally immune toionospheric changes in response to largeinfusions of x-rays following a solar flare.However, GPS and all other satellites(including communications) must contendwith the detrimental effects the energeticsolar particles have on the on-boardsystems.

Terrestrial WeatherBesides the ionospheric disturbancesdirectly caused by flares and by theauroral particles and currents duringmagnetic storms, the ionosphere exhibitsirregular variations related to thedynamics of the underlying atmosphere.

These depend upon the combination oftraditional “weather” near the ground,which produces waves in the atmospherelike the waves in the deep ocean, and thewinds between the ground and the upper-atmosphere levels that act like a filter tothe passage of those waves. While thisaspect of space weather may appear tohave a non-solar origin, its effects aremost pronounced when the upper-atmosphere winds or lower-ionospherecomposition is enhanced by the energyinputs from the active Sun.

Optical phenomena called “red sprites”and “blue jets” have been observed ataltitudes extending from the tops ofstrong thunderstorms (at around 15-kilometers altitude) to the lowerionosphere (about 95-km altitude).Possibly related to these opticalsignatures, intense electromagneticpulses (10,000 times stronger thanlightning-related pulses) have beendetected over thunderstorm regions bysatellites. These observations suggestthat there may be a stronger connectionbetween global thunderstorm activity andthe ionosphere and upper atmospherethan previously suspected. Interest in theireffects will depend on the future use ofthis region of Earth-space.

A recent NASA-funded Earth Sciencestudy supports earlier findings that theremay be a relationship between increasedcloud cover over the USA and the solarmaximum. Previous studies have shownthat during the solar maximum, the jetstream in the Northern Hemisphere

moves Northward possibly due to theSun’s varying ultraviolet output, whichaffects the ozone production in thestratosphere. When the ozone absorbsultraviolet radiation, it warms thestratosphere, which may affectmovement of air in the tropospherewhere clouds form. It is the jet stream,which plays an important role incloudiness, precipitation and stormformation in the USA. Future studies hopeto establish the mechanisms that may linksolar variability with terrestrial weather.

National Grid & ATC Ground FacilitiesThe enhanced currents that flow in themagnetosphere-ionosphere system duringgeomagnetic storms can affect electricpower systems on the ground. Thesecurrents cause magnetic fieldperturbations on the ground that in turninduce other currents in long transmissionlines. The slowly varying “DC” part of thecurrents can be large enough to causeoverheating and damage to systemsdesigned for “AC”. Disruption of the gridsupplies can adversely affect manyaspects of our daily lives should ablackout result. However, the reliability ofpower supplies to critical ATC groundequipment cannot be overstated. The UKNational Air Traffic Service (NATS) goes toextensive lengths to ensure they haveinstalled adequate redundancy and

Figure 4. Picture of a red sprite and bluejet over a thunderstorm (courtesy of D.Sentman, Geophysical Institute, Universityof Alaska at Fairbanks).


25

backup for failures of the commercial gridsupply. They also depend upon the gridoperators to notify them whengeomagnetic storms threaten the network.

What is the Future?

The need for SW forecasting andreporting has been driven up until now bythe needs of the Space Industry.However, it is now realised that there aremany other different market sectors thatare adversely affected by SW events:power grids, geological prospecting, oiland gas pipelines, railways, defence, riskand insurance, tourism and of courseaviation. There are National SpaceWeather Programmes underway in theUSA and Japan, with the EuropeanSpace Agency (ESA) undertakingextensive work assessing the need for aseparate European SW capability. The

requirements of the different SW users inEurope are currently being assessed viavarious ESA or EC funded researchprogrammes and collaborations, and thisincludes the SW impacts on airlineoperations.Initial reports state that with all futuretechnological and operationaladvancements, the civil aviation industrywill begin to see an increasing risk fromSW, and will therefore, need to utilise andintegrate SW information services into thedaily operation. To assess the SW riskcorrectly an industry-biased educationalOutreach Programme is being developed.This should then lead to the identificationof relevant expertise within the industry toliase with the SW science community todraw up the requirements of a SpaceWeather European Network (SWENET).However, one important consideration, isthat due to the nature of aviation, any SWnetwork or service would need to be

internationally co-ordinated and undergoregulatory (CAA, FAA, ICAO, etc) approvalin a similar manner to current terrestrialweather services.

Further InformationThe author is currently participating in EUand ESA SW research and can providefurther information upon request (contactCaptain Bryn Jones on +44 (0)1293444907 or [email protected] [email protected].)

Some useful websites are:

www.spaceweather.com- general SW newswww.estec.esa.nl/wmwww/wma/spweather- ESA SW sitewww.sec.noaa.gov- US Space Environment Center

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Hail Damage!

The effect of hail can be somewhatstartling. “Storm chasing” is big in theStates. It is not common in the airlineworld. Guidance information stronglyadvises avoiding storms by considerablemargins.

In June 2002 an Airbus A320 enteredwhat appeared to be insignificant high-level cloud. What came out the otherside of the cloud was quite unexpected!

At approximately 1650 UTC whilst on thereturn sector of a flight to Greece theaircraft entered the top of aCumulonimbus cloud formation. Theaircraft suffered considerable damage asa result of hail within the weather system.The crew of this aircraft did notdeliberately fly into a storm! The aircraftwas in the cruise at 36000ft south east ofPrague in the Czech Republic. Visibilitywas good and both pilots could clearlysee the ground and were flying in goodvisual meteorological conditions.

The aircraft subsequently entered somehigh-level cirrus cloud. Light turbulencewas experienced and the captain electedto switch on the seat belt sign. The levelof turbulence increased from light tomoderate. The cabin crew were advisedto take their seats and as this instruction

was carried out the aircraft experiencedsevere turbulence.

The aircraft’s autopilot was doing areasonable job of controlling the aircraftuntil the severe turbulence hit. Thecaptain elected to disengage theautopilot and manually set the aircraftattitude in an attempt to stabilise theattitude & speed.

The pilots stated that this was the mostsevere turbulence they had experienced.The aircraft then entered an intense hailshower. Both main windscreens crackedand crazed over. The hail -storm wasover almost as quickly as it started andhad quite an effect on the aircraft. Theweather radar was selected on as theaircraft entered the cirrus cloud. Theradar screen showed some “red” areas. From the Flight data Analysis the aircraft

was in the storm activity for a little over aminute. The flight crew was surprised atthe reception inside what appeared to beinsignificant high-level cloud. Both pilotshad experienced the initial conditionsmany times in the past with little effect. The crew had a slightly differentexperience in the cabin. The impressionwas one of being on a roller coaster ride.The turbulence was the worst the cabinsupervisor had experienced. Theextremely bumpy ride came out ofnowhere and given the smooth outboundsector the crew were not expecting anyproblems. The CS was in the cabinassisting a customer that had been feelingunwell. The noise was horrendous and thecrew considered that the noise was similar

to that of the landing gear being lowered.

It would be very easy to speculate about thecauses of this incident. It is the honestreporting on the behalf of the crew that isreally important and gets the safetymessage across. It is a dormant evil thatinhibits full and free confession, which aprofessional may make for the good ofsafety.

So what caused this pounding by hail?

In simple terms the pilots involved did notselect the weather radar on prior toentering the high cirrus cloud. They werecaught out by what was hidden within!The crew of this aircraft performedextremely well given the circumstances. Itis easy to concentrate on what wentwrong and lose sight of the safetybenefits that come out of the situation!

■ The locked flight deck door was not abarrier to good CRM. The crewworked well throughout this incidentand the flow of information from theCaptain was tremendous.

■ The company has a strong supportteam in place and was in a greatposition to offer assistance andcounselling to both crew andcustomers.

Worth a read: AIC 72/2001 Effect ofthunderstorms and associated Turbulenceon aircraft operations.


27

NATS Led Team Wins Aviation Safety Award

An industry wide team led by NationalAir Traffic Services has won an award for‘an outstanding contribution to AviationSafety’ from the Guild of Air TrafficControllers.

Paul Jones, team leader, said that theupdated booklet ‘Aircraft Emergencies –Considerations for Controllers’represented a huge effort over a shortperiod of time by the team who took onthe challenge on top of their ‘day jobs’.

Richard Daswson, President of GATCOpresented the award to the team at aGala dinner on the 12th of October at theBotley Park Hotel near Swanwick.

The booklet will shortly be distributed toall UK controllers regardless of whetherthey work for NATS. The new updatedversion has been totally rewritten tochange the focus, introduce new materialincluding human factors and introducesome general ‘rules of thumb’.The team (pictured left to right – John

Dunne Chairman UK Flight SafetyCommittee, Jane Gothard NATS, MikeDawson NATS, Paul Jones NATS, NigelSelf British Airways, Susie Foley NATS,and Alan Evans Mytravel) also includedSimon Searle GO, Brian Connolly BritishAirways and Alison MacMaster NATS whowere unable to attend the presentation.


28

Full members

ChairmanAirclaimsJohn Dunne

Vice-Chairmanflybe. british europeanStuart McKie-Smith

TreasurerAir 2000Capt. Martin Pitt

External Affairs OfficerRAeSPeter Richards

Aer LingusCapt. Tom Croke

Aerostructures HambleDr. Marvin Curtiss

AIG AviationJonathan Woodrow

Air ContractorsCapt. Tony Barrett-Jolley

Air MauritiusCapt. Francois Marion

Air ScandicPaul Ridgard

Air SeychellesCapt. Curtis Allcorn

Air Transport AvionicsColin Buck

ALAEDave Morrison

Astraeus LtdCapt. Nick Carter

BAA plcFrancis Richards

BAC ExpressCapt. Steve Thursfield

BAE SYSTEMS Reg. A/CDan Gurney

BALPACarolyn Evans

bmi regionalCapt. Steve Saint

British AirwaysSteve Hull

British Airways CitiExpress LtdCapt. Ed Pooley

British InternationalCapt. Terry Green

British Mediterranean AirwaysRobin Berry

CAADave Lewis - MRPSChrys Hadjiantonis - Safety Data Dept.Brian Synnott - Flight OperationsAlison Thomas - Intl. Services

Cardiff International AirportGraeme Gamble

CargoLuxCapt. David Martin

Cathay PacificCapt. Richard Howell

Channel ExpressRob Trayhurn

CityJetCapt. Mick O’Connor

Cougar LeasingShaun Harborne

DHL AirPeter Naz

DragonairAlex Dawson

Eastern Airways UK LtdCapt. Jacqueline Mills

easyJetCapt. Tim Atkinson

Emerald AirwaysCapt. Roley Bevan

European Aviation Air CharterDavid Wilkinson

EVA AirwaysAlex Reid

Excel AirwaysPeter Williams

FlightLineCapt. Derek Murphy

GAPANCapt. Chris Hodgkinson

GATCORichard Dawson

Goodrich Control SystemsKeith Joyner

Independent Pilots AssociationCapt. Mike Nash

Irish Aviation AuthorityCapt. Bob Tweedy

JMC AirlinesCapt. Graham Clarke

LAD (Aviation) LtdSteve Flowers

LoganairDoug Akhurst

London City AirportSimon Butterworth

London-Manston AirportWally Walker

Maersk AirCapt. Christopher Morley

Manchester Airport plcPeter Hampson

Middle East AirlinesCapt. Mohammed Aziz

Monarch AirlinesCapt. Gavin Rowden

MyTravelCapt. Tom Mackle

NATSPaul Jones

PrivatAirCapt. Boris Beuc

RyanairCapt. Gerry Conway

Members ofTHE UNITED KINGDOM FLIGHT SAFETY COMMITTEE


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SBACJohn McCulloch - SecretariatVic Lockwood -FR Aviation

ServisairEric Nobbs

Shell AircraftCliff Edwards

The Boeing Co.Edward Berthiaume

Virgin Atlantic AirwaysCapt. Jason Holt

Willis AerospaceIan Crowe

Group members

bmi british midlandCapt. Ian Mattimoe

bmi british midland Eng.Peter Horner

Bristow HelicoptersCapt. Derek Whatling

Bristow Helicopters Eng.Richard Tudge

Britannia AirwaysJez Last

Britannia Airways Eng.Adrian Vaughan

CHC ScotiaCapt. David Bailey

CHC Scotia Eng.Colin Brown

EurocypriaCapt. Constantinos Pitsillides

Cyprus AirwaysCapt. Spyros Papouis

FLS Aerospace (IRL)Frank Buggie

FLS Aerospace (UK)Andrew Hoad

flybe. british europeanStuart McKie-Smith

flybe. british european eng.Chris Clark

Ford AirF/O Paul Stevens

Ford Motor Co. EngSteve Laven

GB AirwaysCapt. Aaron Cambridge

GB Airways Eng.Terry Scott

KLM ukDean Godfrey

KLM uk Eng.Andy Beale

Lufthansa Cargo AGCapt. Nigel Ironside

Condor/Lufthansa & CityLine

MODDASC Col. Arthur GibsonDASC Eng.HQ STC MOD - Sqn Ldr Jeff Collier

RAeSPeter Richards

RAeS Eng.Jack Carter

Co-opted Advisers

AAIBPhil Gilmartin

CHIRPPeter Tait

GASCoJohn Campbell

Royal Met. SocietyDr John Stewart


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