- ISSUE 1/2008
- Copyright and Credits
- Guest Editorial
- To the Letter
- Flight Operations
- Recently Released TSB Reports
- Maintenance and Certification
- Accident Synopses
- Regulations and You
- Pilots Beware: Geese Are in the Air
- Aviation Safety in History
- Take Five: Snow Landing and Take-off Techniques for Helicopters
- Full HTML Version
- PDF Version
- Blackfly Air
- NAV CANADA Adopts International Best Practices
- COPA Corner-Buzzing at a Fly-In Is Illegal
- Battery “Bewareness”
- Facing Conflict Within a Non-Punitive Safety Management
- Cabin Safety: Alcohol Alert
In today’s global aviation industry, it is critical to share data and information between aviation organizations in order to streamline and standardize air traffic control procedures encountered by aircraft crossing multiple international boundaries.
Taking this idea a step further, in 2005, NAV CANADA’s ATS Standards and Procedures established a working group whose mission was to review existing international procedures that could potentially reduce delays or fuel burn with a view to implementing them in Canada.
In order to quickly benefit from these procedures, rather than “re-invent the wheel,” NAV CANADA set out to adopt existing international procedures wherever possible, on the condition that they demonstrated an acceptable safety record, and were adaptable to the Canadian regulatory climate.
Before adopting an existing international procedure as its own, NAVCANADA conducts a rigorous safety review of the procedure and the context in which it is used in the host country. This safety review begins with a thorough examination of all existing written documentation, including a review of any applicable regulatory material. Then, any existing safety analyses that the host country is able to provide are reviewed, and any operating irregularities involving the procedure are examined.
At that point, visits to the countries in question are scheduled. Training facilities may be visited prior to individual site visits to better understand the nationally mandated application of the procedure.
Site visits involve watching the actual procedure in action and talking to front-line staff and management regarding any concerns they may have about the procedure. It is not uncommon to receive suggestions from operational staff as to how the procedure might be improved.
Next, draft Canadian procedures are designed and subjected to a national hazard identification and risk analysis (HIRA) process involving operational air traffic controllers, pilots, and airline operators. The procedures are then subject to a second “operational level” HIRA at an initial trial site to determine if there are any site-specific issues to take into consideration before implementation.
Mitigations are put in place, where possible, for hazards that are identified. If mitigations are not possible, then the actual procedure is re-considered. Just such a case occurred when NAV CANADA considered introducing conditional instructions into Canada.
Before the trial begins, air operators and pilots will be advised of the new procedures through an aeronautical information circular (AIC). Implementation of the new procedures is monitored by national and local management on an on-going basis, and is overseen during regular visits by NAV CANADA ATS Evaluations and Investigations inspectors.
Once the trial has been successfully completed, the procedures are subject to a HIRA at any additional sites under consideration for implementation.
To date, this process has been successfully used in the implementation of multiple landing clearances at five major airports in Canada, as well as the development of new visual separation procedures soon to be introduced at various sites across the country.
A very similar process has been used for several years by NAV CANADA, when introducing homegrown procedures.
If you would like more information on the safety analysis process for the introduction of new operational procedures, please contact Randy Speiran, Manager, ATS Standards and Procedures, NAV CANADA by e-mail, at firstname.lastname@example.org, or by phone, at 613-563-5659.
So, you are coming into a fly-in, and you decide to do a low approach, make a high-speed pass down the runway, and then pull up before joining the circuit. You see that there are lots of people there because the fly-in was widely advertised in town. Oh well, who is it going to hurt; you aren’t breaking any rules, are you? Maybe you had to pull up and go around anyway, right? Canadian Aviation Regulation (CAR) 603.01 states:
“No person shall conduct a special aviation event unless the person complies with the provisions of a special flight operations certificate-special aviation event issued by the Minister pursuant to section 603.02.”
Was your buzz job a special aviation event? The term “special aviation event” is defined in CAR 101 as:
“An air show, a low level air race, an aerobatic competition, a fly-in or a balloon festival.”
Was your buzz job an air show? The term “air show” is also defined in CAR101:
“An aerial display or demonstration before an invited assembly of persons by one or more aircraft.”
Was your buzz job a demonstration? If you did not perform a standard approach, a normal overshoot and climb-out, followed by a normal cross-wind and then down-wind, it could easily be established that you were performing a demonstration, and therefore, an air show that was in direct contravention of CAR 603.01 because you did not have an operations certificate. Note that the assembly of persons just has to be invited, not “paying.”
Buzzing is not only old hat, but unprofessional, illegal, and dangerous.
CAR 103.08 lays out the penalties for non-compliance with the CARs. Violations of CAR 603.01 carry a maximum penalty of a $3,000 fine for individuals and $15,000 if a company owns your airplane.
If Transport Canada (TC) thinks that your “buzz job” was a hazard in addition to an illegal air show, then you could also be charged under CAR602.01, which states:
“No person shall operate an aircraft in such a reckless or negligent manner as to endanger or be likely to endanger the life or property of any person.”
CAR 103.08 specifies the maximum penalty for that offence as $5,000 for individuals and $25,000 for corporations.
Pilots who feel the need to show off are imperilling the very existence of fly-ins in Canada. TC inspectors have informed COPA that some pilots are acting recklessly at fly-ins in the name of showing off, and consequently, TC has been pressing for more control over fly-ins. COPA has been opposing more control by TC over fly-ins, but every time another pilot cannot resist the urge to show off it makes COPA’s arguments less effective. The end result may be that fly-ins will disappear in Canada, buried under a mountain of paperwork requirements that will make them impossible to hold.
If that happens, it could be because some pilots couldn’t just show up at a fly-in and land their plane-they had to show-off and “buzz” the airport. Please think about the consequences, and if you see someone showing off, urge them to stop for the sake of our freedom to fly. For more information on COPA, visit http://www.copanational.org/.
Fires can potentially erupt from lithium batteries in-use and carried onboard aircraft.
The following is an excerpt from an article published in the July/August 2007 issue of FAA Aviation News. It was written by Terry Pearsall, an Aviation Safety Inspector with the General Aviation and Avionics Branch in Flight Standards Service’s Aircraft Maintenance Division, and adapted for the Aviation Safety Letter (ASL) by Roger Lessard, Civil Aviation Safety Inspector, Dangerous Goods Standards, Standards, Civil Aviation, Transport Canada.
Portable equipment manufacturers and the general public alike are using lithium batteries to power the latest notebook computers, DVD players, digital cameras, portable drills, cellular phones, and many more devices like these. In portable equipment, lithium batteries provide hours more capacity than their predecessor power sources of lead oxide, nickel cadmium, alkaline, and other disposable batteries. The weight savings and increased capacity lithium batteries provide, however, do not come without risks of fire that can erupt from mishandling or misuse.
Presently, users of this technology, ranging from wireless telephone manufacturers to the electric vehicle industry, have noted significant safety concerns regarding the use of these types of batteries. In December 2005, the U.S. Federal Aviation Administration (FAA) first learned of fires erupting from laptop batteries and issued Safety Alert for Operators (SAFO) 05008. Subsequently, Transport Canada published Commercial and Business Aviation Advisory Circular (CBAAC) No. 260 in March 2007, alerting crew members to be aware of the potential for smoke emission and fire propagation from high-energy batteries of any kind.
By design, all batteries operate through a controlled chemical reaction to generate an electrical current and transmit power through terminals made of a conductive metal. It is their capacity to perform that basic function that makes them useful; but, if not properly handled, designed, or manufactured, it poses a risk of overheating and fire. The newest generation of batteries using lithium metal (Li) or lithium ion (Li-Ion) technology pose particular risks, based on their energy density and chemistry, and because fires involving these batteries are more difficult to extinguish or suppress. Even nickel cadmium and nickel metal-hydride batteries can generate large amounts of current and heat when short-circuited.
The Transportation of Dangerous Goods Regulations (TDGR) forbid the transportation of electrical devices that are likely to create sparks or generate a dangerous quantity of heat, unless packaged in a manner that precludes such an occurrence. Passengers carrying batteries or electrical devices in carry-on or checked baggage are responsible for ensuring that the appropriate steps are taken to protect against dangerous levels of heat that can be generated by inadvertent activation or short-circuiting of these devices while in transport. The following precautions should be taken:
- Keep batteries installed in portable electronic devices. When replacing with a spare battery during flight, handle batteries with care and pack used batteries safely.
- Pack spare batteries in carry-on baggage.
- Keep spare batteries in the original retail packaging.
- If original packaging is not available, use a sturdy, re-sealable plastic bag and cover the battery terminals with insulating tape, such as electrical tape.
- Do not carry on board a plane recalled, damaged, or counterfeit batteries. Passengers should only use batteries purchased from reputable sources. Cordless power tools, for instance, should be packed in a protective case, with a trigger lock engaged.
- Always ensure that the battery or spare battery is the type and model specified by the manufacturer of the device it will be used to power.
As with any product, manufacturing defects can also cause safety problems. Manufacturers have voluntarily recalled over 10 million lithium-ion batteries in the last few years. Information about recalled batteries can be found on the manufacturer’s Web site or from the Health Canada Consumer Product Safety Web site (www.hc-sc.gc.ca/cps-spc/index_e.html).
Example of a battery-operated portable drill inappropriately packaged in checked baggage
There are ancillary hazards from transporting lithium batteries in cargo containers aboard aircraft. A number of incidents recently reported in the United States sparked the FAA Office of Aviation Research to conduct a series of tests to assess the flammability characteristics of non rechargeable lithium batteries. The results of the tests indicate that:
- A relatively small fire source is sufficient to start a primary lithium (metal) battery fire.
- None of the fire-extinguishing agents, including Halon 1301, currently in use within cargo compartments on U.S. commercial aircraft, is effective in extinguishing primary lithium fires.
- The ignition of a primary lithium battery releases burning electrolyte, which can perforate cargo liners and propagate a fire to other locations in the passenger compartment.
The FAA researchers tested batteries from a number of manufacturers. They found that:
“A relatively small fire source is sufficient to start a primary lithium battery fire. […] Halon 1301, the fire suppression agent installed in transport category aircraft, is ineffective in suppressing or extinguishing a primary lithium battery fire. Halon 1301 appears to chemically interact with the burning lithium and electrolyte, causing a colour change in the molten lithium sparks, turning them a deep red instead of the normal white. This chemical interaction has no effect on battery fire duration or intensity. The air temperature in a cargo compartment that has had a fire suppressed by Halon 1301 can still be above the autoignition temperature of lithium. Because of this, batteries that were not involved in the initial fire can still ignite and propagate. The ignition of a primary lithium battery releases burning electrolyte and a molten lithium spray. The cargo liner material may be vulnerable to perforation by molten lithium, depending on its thickness. This can allow the Halon 1301 fire suppressant agent to leak out of the compartment, reducing the concentration within the cargo compartment and the effectiveness of the agent. Holes in the cargo liner may also allow flames to spread outside the compartment. The ignition of primary lithium batteries releases a pressure pulse that can raise the air pressure within the cargo compartment. The ignition of only a few batteries was sufficient to increase the air pressure by more than one pound per square inch(psi)[6.9kilopascals(kPa)] in an airtight 10-meter-cubed pressure vessel. Cargo compartments are only designed to withstand approximately onepsi[6.9kPa]differential. The ignition of a bulk-packed lithium battery shipment may compromise the integrity of the compartment by activating the pressure relief panels. This has the same effect as perforations in the cargo liner, allowing the Halon 1301 fire suppressant to leak out, reducing its effectiveness.”
Manufacturers of batteries and consumer products, as well as airlines, testing laboratories, emergency responders, the law enforcement community, and others, continue to respond to real incidents and accidents caused by Li and Li-Ion battery malfunctions. Fortunately, in all of the reported incidents, crew members were able to successfully locate the source of the smoke or fire and combat it effectively with the equipment and techniques available to them. Nevertheless, over the next few months Transport Canada and other International Civil Aviation Organization (ICAO) Dangerous Goods Panel members will discuss the issues and actions to enhance battery transportation safety.
In the meantime, airlines are reminded of their existing obligations under the TDGR and Transport Canada policies.
Click on image to enlarge
There seems to be an assumption among academics and regulatory bodies that there is a critical mass of people in the aviation community who will face conflict through open, proactive self-reporting. Conflict is defined as tension between the values and expectations of a regulatory standard, and the reality within a protective and productive business environment. Self-reporting is understood as a quality of the safety culture that is the foundation for a safety management system (SMS).
The concept of culture, that is, human activity and the structures that give activity significance, establishes a system of choices, goals, and actions. In an attempt to establish a uniform standard of activity within the aviation community, a model of a just and safe culture has been proposed by academics, such as James Reason, and regulatory bodies, such as Transport Canada.
The concept of a just culture will be discussed here, since it encompasses the aspects of a safe culture. Briefly, a just culture is one in which the people involved share leadership and responsibility for the safety and stability of the work environment. Moreover, a clear line of accountability is drawn to support those times when a judgment of wrongdoing and appropriate justice is required.
A model to implement the qualities of a just culture is found within the expectations of an SMS. One fundamental expectation is that all members of the SMS will assume a role of leadership in reporting faulty or weak technology and human elements. Yet, as often happens, how the system is to be lived out is not well understood.
For example, the expectation for self-reporting of incidents or near misses (defined broader than just near miss aircraft accidents) assumes the ability of people to overcome their discomfort, if not outright fear, of facing conflict in an open and transparent manner.
Self-reporting incidents and near-miss accidents are wisely identified as important components of a system that is meant to be proactive and preventative in nature. Nevertheless, what is lacking are instructions on how to bridge the gap between the individual’s experience of being at fault, or identifying fault and not assuming blame. The experience, personally or within the existing corporate culture, likely includes negative consequences of being the bearer of bad news. There is clearly a gap between the ideal and reality.
To address this gap it is essential to understand how we deal with conflict. Generally, people have a repertoire of reactions when faced with a problem where they may not feel powerful enough to orient the situation to their advantage (or protection, if you will).
In North America, the consequences of conflict have been associated with loss. We are all born in a state of less power. Subsequently, we may have been in conflict with what we wanted or needed, and what our caregivers wanted or needed. Most of us have had varying degrees of experience with someone bigger than us yelling or hitting (intimidation), or using silence (rejection) to control us when we wanted attention for something. Children, with their limited understanding, relate these actions to a loss of affection, or a serious loss in their sense of value. These situations result in a social script that defines what conflict means to us and which skills to employ under different circumstances. As a result we, as adults, may fear the same loss when we are faced with a situation that threatens our status with those who have power over us.
In the workplace, very little is different. Those in power often direct the way and content of the conflict resolution process. When a problem arises, senior officials may often take responsibility, but it is the subordinate who bears the consequences. To assume that, as adults, we can simply self-report failings in our workplace that implicate us or our co-workers, and ignore that this self-exposure is a huge social leap in expectations, is naïve at best. Self reporting is possible, and it is important, but it is not an easy or natural act.
In order for self-reporting to be a viable option within an SMS, we must relearn what we believe about conflict. We must set up infrastructures that make the challenge worth the risk. We must collectively support each other in trying out these methods in our day-to-day activities. We need to experience respectful and mutual benefits as a result of these attempts.
Nevertheless, a just culture is not the figment of someone’s imagination. The ability to deal with conflict without blame, unless someone has stepped over the line of accountability, is happening now. We need to identify the occurrences that are successful, and hold these as examples of how sharing the responsibility for a just work environment occurs. Until there is a critical mass of people who are competent at facing conflict, our corporate and regulatory systems will be struggling to identify potential and real risks through a fog of self-defence.
With drug and alcohol testing expected to be introduced for safety-sensitive personnel sometime in 2007, over consumption of alcohol by passengers is likely to come under increased scrutiny.
Intoxicated passengers are more than just annoying to passengers and staff. They also pose a risk to their own safety and the safety of others because they may not be in a fit state to follow instructions in an emergency. Alcohol impairs almost all forms of mental activity, including decision making, memory, vigilance, and reasoning. It also adversely affects physical co-ordination.
In the past, service of alcohol was glamorized. Now, cabin crew are expected to serve alcohol responsibly.
Drunken passengers are a real safety risk, especially if there is an emergency. They may be unable to adequately comprehend instructions, and their physical ability to follow emergency commands may be impaired.
Some passengers may drink too much because of their fear of flying, some because they are celebrating the start of a holiday or an important occasion, and some because in normal life they are heavy drinkers.
Apart from the safety risk in an emergency, intoxicated passengers present a problem for maintaining order on the aircraft. Alcohol consumption has been reported as a factor contributing to 45 percent of on-board incidents according to U.S. research. In Australia, there is plenty of anecdotal evidence that drunken passengers are a problem.
Sometimes a passenger will board your aircraft looking fine, but two drinks later, they are slurring their words and carrying on. What happened? This kind of “drunk-in-aninstant” passenger has usually had a few at the departure lounge or a nearby bar, and it only takes a drink or two to tip him or her over the edge. It’s hard to detect how much alcohol someone has already had, but it soon becomes apparent when they start misbehaving.
Airline operators in Australia have provided cabin crew with training that helps them manage passengers who are behaving badly. The key is to communicate with the passenger in a way that avoids confrontation. You should be sensitive to the passenger’s background, adjusting your style to match the passenger’s gender, age, status and whether they are in a group or alone. For example, you would approach a drunken executive in first class in a more formal style, appealing to their sense of decorum. If that doesn’t work, you could slow the service right down, and hope that they fall asleep.
When all else fails, you have to say no (see box). You should never apologize for refusing someone a drink–you have a responsibility for safety. Follow your company procedures and refer to the laws about responsible service of alcohol. Obviously, you are not allowed to serve alcohol to anyone under age, and if you suspect someone is too young to drink, you should ask for proof of age.
Execs and dinnerware: The male executive was in his early 50s, very tall and heavy set. He was quiet and there were no signs of aggression. However, within the first two hours of the flight, he had consumed eight miniatures of vodka, equivalent to around 16 standard drinks. He got away with it because he kept ordering from different flight attendants. In the end there was no more vodka left on the B737.
The flight attendant approached him quietly, sat in the empty seat next to him and introduced herself, saying, “Mr. X, we have a bit of a dilemma; it has come to my attention that you have consumed a large amount of vodka. I will need your co-operation, as we must follow the responsible service of alcohol legislation.” He seemed a bit shocked, but he said he understood, and the flight attendant thanked him for his co-operation. He was quiet for the rest of the flight. That’s the ideal situation. But things can go wrong, especially in a group situation where sometimes people encourage each other to behave badly.
How to say no
- Be polite, yet firm.
- Say that you are concerned for their safety in the flight environment.
- Ask for their help to ensure that safety and order are preserved.
- Remind them that you have an obligation under responsible service of alcohol.
- Offer a non-alcoholic drink and food as an alternative.
- If the situation is getting out of control, inform the captain and consider closing bar service.
We’ve all heard about problems with intoxicated footballers flying home after a game, or to a holiday destination at the end of the season. On one flight to Honolulu some years ago, a team on their end-of-season “jolly” became a bit more than just rowdy: they were vomiting, urinating in the aisles, throwing food, shouting, and pulling seats apart. They were already well on their way to intoxication when they boarded, and that is where they should have been stopped. But they got through.
What do you do when things go horribly wrong like this? Your first step is to inform the captain of the situation, as there may need to be law enforcement arranged upon arrival. Rowdy and offensive behaviour is against the law. [Australian] Civil Aviation Regulation (CAR) 256AA says, “a person in an aircraft must not behave in an offensive and disorderly manner.” You may need to protect the other passengers by moving them away from the area, if possible. Try to identify who the leaders of the group are, and appeal to their leadership to help you to calm the situation down.
Rise in risky drinking-women catch up:
The latest published information shows that there has been a rise in the number of people drinking at risky or high-risk levels since 1995. The increase has been greater for women, with the proportion of “problem drinkers” rising from 6.2 percent in 1995 to 11.7 percent in 2004–05 . Over the same period, the proportion of men drinking alcohol at levels that might adversely affect their health rose from 10.3 percent to 15.2 percent.
Men are not necessarily more aggressive than women. A few years ago, 120 Australian and New Zealand dinnerware sales representatives were on board an airliner on their way to their annual conference. They were in high spirits, ordering a lot of drinks. It soon became clear that some had had a few before they got on. They did not turn nasty, but they were making an awful lot of noise. The flight attendants got together and decided on a strategy: they would slow the drinks down to a trickle. On this occasion it worked, and with some friendly persuasion the women settled down.
Airlines can take pre-emptive action if they are alert to the risks. That’s exactly what one responsible company did before they carried athletes to a certain series of world title matches. Anticipating trouble, the airline sent out letters to the clubs reminding them of their responsibilities to maintain good order on the flights. There were not to be any incidents of drunkenness or bad behaviour, or they would be refused carriage for the return trip. It worked. There was no trouble because each club had “read the riot act” to their players and supporters before the flights.
- One in five Australians drink at high-risk levels at least once a month.
- Australians aged 20–29 are the most likely of all age groups to drink at high levels.
- Intoxication usually refers to a blood alcohol concentration above 0.05 or 0.08 percent, but this is not universally agreed.To stay below this level, men should have no more than two standard drinks in the first hour, and one per hour after that. Women should have no more than one standard drink per hour.
- Intoxicated persons cannot function within their normal range of physical and cognitive abilities.
Not on: You should try to spot trouble before it starts. Refuse entry to anyone you suspect is intoxicated before they enter the aircraft. If someone looks and smells like they are drunk, they probably are. You could invoke the law, as [Australian] Civil Aviation Regulation (CAR) 256, paragraph 1 states, “a person shall not, while in a state of intoxication, enter any aircraft.” So what are the signs? They might be any or all of the following:
- talking loudly, quickly or with slurred speech;
- red faced;
All operators carrying passengers should have policies and procedures in place to guide pilots, flight attendants and ground staff on the management of alcohol consumption.
If you suspect someone is intoxicated, you should follow company procedures. Do not directly accuse them of being drunk. What you should say is something along the lines of, “excuse me, would you mind just stepping aside for a moment; someone will be with you shortly.” Then you should contact ground staff who should follow company procedures to prevent an intoxicated person entering the aircraft.
If you are in doubt about any aspect of alcohol service, ask your manager.
Sue Rice is a cabin safety inspector for the Australian Government Civil Aviation Safety Authority (CASA).
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