- ISSUE 2/2010
- Copyright and Credits
- Guest Editorial
- Feature: Deadly Omissions
- Flight Operations
- Maintenance and Certification
- Accident Synopses
- Recently Released TSB Reports
- Regulations and You
- Debrief: Stick to the Basics: Stable Approach and Sterile Cockpit
- Take Five: Underwater Egress
- Full HTML Version
- PDF Version
- An Ounce of Prevention…There Are Many Types of Measurements
- Accessing Flight Information Services via the RCO System
- The SAC Column: A Review of Research into Avalanche Accidents and How it Might Relate to Pilot Decision Making
- Jet Blast Hazard
- The Introduction of Supplemental Briefing Cards and Other Technologies for Passengers Who Are Blind or Visually Impaired
by Cliff Marshall, Technical Program Manager, Technical Program Evaluation and Co-ordination, Standards, Civil Aviation, Transport Canada
There are many ways to measure performance: in school, exams are graded to establish academic abilities; in sports, time is clocked in split seconds to verify athletic prowess. Similarly, performance measurement can be used to determine how well a safety management system (SMS) is performing in an organization. SMS performance measurement is a tool that provides a method of measuring a company’s progression towards achieving its established safety goals and objectives. It is a process that helps answer the question “How are you doing?”
Performance measurement is an on-going activity in any effective SMS and must be applied during all phases of SMS development. It comprises three principal activities:
- Establishing what should be measured;
- Determining how it will be measured; and
- Monitoring it to ensure goals are being accomplished and the right thing is being measured.
An organization must constantly seek to identify hazards and understand the potential risks in order to focus on addressing the most critical organizational issues. This not only allows the organization to prioritize what it wants to address and measure, but it also provides a mechanism that allows the organization to demonstrate visible progress and continuous improvement to the SMS.
By using its unique hazard register and safety risk profile, the organization can adopt appropriate goals and objectives that address specific identified hazards and, at the same time, provide realistic and attainable goals. For example, if an organization were to set an objective of “zero controlled airspace violations,” it might be unrealistic to expect reaching this objective in a brief time period such as a year. It would be more reasonable to set yearly goals of reduction over a longer period. An organization could overburden its system by trying to complete too many objectives at once, or by attempting to overcome objectives that are too large in scope. Performance measurements are the tools that allow management to trace their progress with regard to these safety goals.
Performance measurement can also be applied to areas of weakness identified by the quality assurance (QA) program. When there are findings identified in an area, the organization can establish performance measurements to verify the effectiveness of the corrective action. Measurement of the safety goals should be a regular part of management function. Safety goals and objectives should be reviewed on a regular basis to ensure they are still relevant. The operational environment is dynamic, not static; the goals, objectives and measures should therefore be continually reviewed and revised as the organization changes.
A management review of the SMS relies on the information collected from performance measurements in order to determine if the SMS is performing as intended. A full management review should look at all aspects of the system—including performance measurement—and, where weaknesses are detected, changes should be made. This is an on-going process that allows the SMS to continually adapt and improve.
By using these processes, an organization will become proficient in identifying and addressing the type of performance measures it needs to align with the safety objectives. It’s useful to remember that before anything can be done, senior managers need to buy into the safety management philosophy and adopt performance-based management principles. There must be management endorsement at a company-wide level to ensure success. The focus should be on strategy and vision, not day-to-day operational controls. Managers should develop safety goals, ensure that each employee understands how their job fits into the strategy, and provide guidance so that departments can develop appropriate measures.
The accountability for accomplishing performance measures rests with the accountable executive. The responsibility for accomplishing goals and objectives, however, extends to all individuals in the organization. Everyone has a role to play.
by Rob Bishop, Service Analyst, Level of Service and Aeronautical Studies, NAV CANADA
In 2005, NAV CANADA announced a plan—highlighted in AIP Canada (ICAO) Aeronautical Information Circular (AIC) 23/05—to address longstanding problems with the remote communications outlet (RCO) system. The plan, known as the RCO Redesign, involves changes in many areas of the country that affect how pilots access flight information services from flight information centres (FIC) while en route. Changes include the use of new, dedicated flight information service en route (FISE) RCO frequencies as well as the addition of new RCOs in some areas and the decommissioning of others to address coverage gaps or overlaps.
One of the RCO Redesign’s key safety goals is to reduce the current congestion and interference problems resulting from the FIC’s provisions of FISE and other services on 126.7 MHz. By using alternate FISE frequencies, pilots are now able to use 126.7 MHz more effectively in its primary function—as an air-to-air frequency for pilots to broadcast their intentions and their aircraft’s position—thereby reducing the risk of conflict when conducting VFR and IFR flights in uncontrolled airspace.
Currently, five primary frequencies are used to provide FISE: 122.37(5) MHz, 123.27(5) MHz, 123.37(5) MHz, 123.47(5) MHz, and 123.55 MHz. Other frequencies are sometimes used in instances where the primary ones are not compatible with the site. In some areas where frequency congestion is not an issue, 126.7 MHz will continue to be used by the FIC for FISE, safety message broadcasts and communication searches in addition to fulfilling its primary role of air-to-air communication.
Our experience with introducing the new FISE frequencies indicates that many pilots believe their radios are not capable of using the FISE frequencies published with three digits after the decimal. This is not the case for 760-channel radios. If the second position after the decimal can be tuned to a 2 or 7, then the radio can access frequencies with 25 KHz spacing (e.g. 123.37 = 123.375 MHz). For more information, refer to section COM 5.3 of the Transport Canada Aeronautical Information Manual (TC AIM).
While FICs no longer use or monitor 126.7 MHz in most areas of the country, they are capable of selecting 126.7 MHz, when required, to provide aeronautical broadcast service (significant meteorological information [SIGMET] and urgent pilot weather reports [PIREP]) and to conduct communication searches for overdue aircraft. This feature is indicated in aeronautical publications as 126.7 (bcst).
As changes are made, it is important to know where to find the most up-to-date information. Since changes reflected in aeronautical publications that are on the 56-day revision cycle are no longer published by NOTAM, pilots must use the following sources to obtain the correct FISE frequencies:
- The current edition of the Canada Flight Supplement (CFS) under the following FIC entries: Halifax, Québec, London, Winnipeg, Edmonton, Pacific Radio (Kamloops FIC), Whitehorse, and Arctic Radio (North Bay FIC);
- Notices published 60 days in advance of a change. These can be found under Notice on NAV CANADA’s Web site (http://www.navcanada.ca/) or on NAV CANADA’s aviation weather Web site (http://www.flightplanning.navcanada.ca/) via the NOTICES link; and
- NAV CANADA’s Web site (click on Services, ANS Programs, then RCO Redesign). This site includes a brochure that describes the RCO Redesign project as well as current RCO maps for each FIC area. These maps are kept up to date as changes occur.
The redesign of the RCO system is reducing frequency congestion and allowing pilots to have better access to the services and information they need, while freeing up 126.7 MHz for its essential safety function. The project involves over 180 RCO sites and, to date, half of the sites have been completed. With changes occurring every two months, pilots must be vigilant to ensure they have the correct FISE frequencies for accessing the en route services and information they need to conduct their flight.
Have you checked NOTAMs?
The SAC Column: A Review of Research into Avalanche Accidents and How it Might Relate to Pilot Decision Making
by Ian Oldaker, Soaring Association of Canada (SAC)
Even though people are capable of making decisions in a thorough and methodical way, it appears that most of the time they do not. A growing body of research suggests that people unconsciously use simple rules of thumb, or heuristics, to navigate the routine complexities of modern life. Pilots have to make decisions quickly and often, and may be using heuristics more frequently than we think. Heuristics give quick results because they rely on only one or two key pieces of evidence, and though they are not always right, they work often enough to guide us through routine but complex tasks such as driving or shopping.1 Six heuristics are recognized as being widely used in our daily decision making: familiarity, consistency, acceptance, the expert halo, social facilitation, and scarcity.*
Ian McCammon reviewed 715 recreational avalanche accidents and found that there is good evidence that many avalanche victims fell prey to one or more of what are called heuristic traps.* He further explained that because these heuristics work so well and because we use them for everyday decisions, we are misled by these unconscious heuristics. He cautioned that it is not possible to establish conclusively the causes of these accidents by heuristic traps.* However, experimental results from other fields of human behaviour would support many of his findings.*
In his study, McCammon showed that many avalanche victims appeared to ignore obvious signs of danger. Almost two-thirds of the parties that were aware of the hazard still proceeded into the path of the hazard anyway.* Why? In many cases the people involved had received formal avalanche training, which included how to recognize the hazard and how to mitigate it. People at all four levels of training (none, awareness, basic and advanced) appeared equally susceptible to heuristic traps. McCammon’s study gives us the basis of looking at how heuristics would apply to pilots, and what we might be able to do about improving safety through the pilots’ actions.
Familiarity: Actions that do not require much thought are familiar, and we base our decision on what we did the last time we were in a similar situation. This works in most cases, but when something in the situation changes, this rule of thumb can become a trap. Pulling up sharply into a thermal works most of the time when no one else is around, and the habit is formed. However, when others are in the thermal, a different technique may be needed to avoid colliding with a glider above. Power pilots train for an engine out in the circuit and return to the field for landing. This makes it hard to resist the decision to do a 180° turn in a real engine failure on departure, despite not having enough height.
There is an apparent tendency among skiers who are highly trained (in avalanche hazards) to make riskier decisions in familiar terrain.* Remarkably, skiers with advanced training travelling in a group in familiar terrain exposed their parties to about the same hazards as parties with little or no such training.* This observation would suggest that familiarity negates the benefits of training! This also suggests that high-time or competitive glider pilots flying in familiar mountain and ridge terrain could make riskier decisions, even if they were trained in the hazards of such flying.
Consistency: In gliders on cross-country flights, deciding when to leave the last thermal for a final glide to return home, or any long glide for that matter, is usually a decision not taken lightly. However, once the decision has been made, the pilot would find it easier to stay on the glide, since it is easier to maintain consistency with the original decision. This heuristic saves time because we stick to our original assumptions.* Most of the time it is reliable, but it can become a trap when our desire to be consistent overrides critical new information about an impending hazard*, like getting low. Some pilots experience the effect of this heuristic trap when they push the weather to some poor outcome. In hindsight, it is often difficult to understand why a pilot stayed with a course of action despite worsening conditions.
Acceptance: This heuristic pushes us to do something or take part in an activity that we hope will get us accepted or liked by others. We are very vulnerable to this, even from an early age. Typically, in men it shows up as competitive, aggressive or risk-taking behaviour, and is more prevalent with younger men when women are involved. This would suggest that pilots at a club with mixed-gender flying activities would be more susceptible to this type of heuristic than non-mixed gender. Also, a pilot new to the group might be susceptible to this heuristic when trying to validate his acceptance by the others in the group.
The expert halo: This heuristic refers to the leader of a group—often an informal leader—who makes critical decisions for the group. Situations that can lead people into the expert halo trap could be based on local knowledge or experience, or simply on the person’s age or assertiveness. In the case of competitive gliding, it could be the assumed leader—the pilot who is followed by many because of his or her past successes or local knowledge. Another leader is the competitor who leaves first from the last thermal before the finish, whether or not he is an acknowledged expert.
Data in McCammon’s study suggests that the expert halo heuristic may have played a role leading to avalanche accidents, particularly in large groups.* Often, decisions made by the “leader” are followed by others despite there being information available that this might not be the best course of action.
Social facilitation: When a group is involved in a decision, an individual’s risk-taking will be enhanced or diminished, depending on the skills of the group as a whole. In the avalanche study, it was found that when a person had received formal avalanche training, he or she would tend to take substantially more risks after meeting others.* People with less training took fewer risks.
At a flying club, when the conditions might warrant an individual decision not to fly, a group discussion with other pilots may expose less experienced or more experienced pilots to accepting greater risk. We will normally expect less skilled pilots to take fewer risks than the more experienced in a group. In this context, by following the others (expert halo heuristic), will the less experienced take more risks than they can handle? Will this social facilitation heuristic, combined with the pilot’s desire for acceptance, mean that we will inevitably have even experienced pilots exposed to more risk than when they are flying outside a group dynamic? Like other heuristic traps, social facilitation lulls its victims into a sense of feeling safe, even when dangers are obvious.
Scarcity: The scarcity heuristic is the tendency to value opportunities in proportion to the chance that the person may lose them, especially to a competitor.* In skiing situations in avalanche territory, the scarcity heuristic works exactly contrary to personal safety—it appears to become a more tempting decision-making trap as the avalanche hazard rises.* This trap requires more analysis to determine how it could apply to competitive glider pilots, for example those who may be tempted to take a difficult route in the mountains on the chance that they will gain an advantage over their competitors. In commercial flying, this might apply to self-imposed pressures and increased risk-taking to prevent the loss of business.
Avalanche victims fall prey to heuristic traps because they are simple to use and they have proven themselves in other areas of daily life. The challenge for avalanche educators continues to be to develop and effectively teach simple, useful decision-making tools that are viable alternatives to the heuristic traps described here. What would be needed to apply these lessons to the training of pilots? McCammon’s work to analyze avalanche accidents suggests that we will not be able to influence individual pilots by training alone in the subject of heuristics. He states that effective risk management and decision-making tools need to be included in pilot training. For aviation activities, training such as pilot decision making (PDM) and single-pilot resource management (SRM) need to be used along with our knowledge of human factors.
For more information on heuristics in avalanche accidents and how they might apply to human factors in flying, go to ttp://avalancheinfo.net/Newsletters%20and%20Articles/
1 Gigerenzer, et al. Simple Heuristics That Make Us Smart, pp. 3–34. New York, USA: Oxford University Press, 1999.
* Ian McCammon, “Heuristic Traps in Recreational Avalanche Accidents: Evidence and Implications.” Avalanche News, No. 68, Spring 2004. The Canadian Avalanche Centre, Revelstoke, B.C.
The following is published as a result of an Aviation Safety Information letter from the Transportation Safety Board of Canada (TSB).
On June 25, 2006, a Boeing B737-600 was cleared for takeoff from the threshold of Runway 26L at the Vancouver, B.C., international airport. At the same time, a Cessna 182 was stopped at Taxiway C; once the B737 began to roll, the tower controller cleared the Cessna 182 to taxi to position on Runway 26L and wait. The Cessna 182 taxied onto the runway immediately, and as it began to turn left to line up, the left wing lifted as a result of encountering the jet blast from the departing B737. The Cessna 182 sustained damage to its right wing tip and propeller.
Recorded radar data showed that the B737 was approximately 1 200 ft down the runway when the Cessna 182 encountered the jet blast. The Transport Canada Aeronautical Information Manual (TC AIM) (TP 14371E), section AIR 1.7 “Jet and Propeller Blast Danger” provides guidance to pilots to help them avoid jet and propeller blasts from other aircraft. A diagram in this section identifies the potential danger areas behind three representative types of turbo-jet aircraft, namely “executive”, “medium”, and “jumbo” jets, based on three engine-thrust rating levels: 10 000, 25 000, and 55 000 lbs, respectively. The depicted distances show the danger zones behind the three classes with their engines at both idle and take-off power settings. For example, behind a medium jet with an engine thrust rating up to 25 000 lbs, at take-off thrust, the danger area is 150 ft wide and extends 1 200 ft behind the departing aircraft. For a jumbo jet at takeoff, the danger area is shown as 275 ft by 1 600 ft.
The performance of medium jet aircraft allows them to also operate from smaller Canadian airports, where the greater population of light airplanes and helicopters operate, providing a varied mix of aircraft operations, in both size and performance. Many of these general aviation pilots have little experience operating behind these larger jet aircraft. The information provided in the TC AIM is therefore a vital aid for these pilots.
A review of engine thrust ratings for modern generation aircraft such as the Boeing B737-800, the B747-400, and the Airbus A320 shows that engine thrust has risen considerably over the years. As a result, it is not uncommon for a modern medium jet engine to produce considerably more thrust than the 25 000 lbs referenced in the TC AIM and for the heavy jumbo jet to produce thrust levels reaching 90 000 lbs. This significant increase in thrust ratings increases the danger area behind a departing modern jet. Accordingly, basing their decision on the data in TC AIM AIR 1.7, pilots entering a runway behind a medium jet, for instance, may encounter jet blast far stronger, for a longer time period, and at greater distances than depicted in the TC AIM. Therefore, there is an increased risk that a light aircraft could be damaged or upset by jet blast even though the current guidelines in the TC AIM were being followed.
Action taken by TC
As a result of this letter, the TC AIM section AIR 1.7 was updated and the following text was added:
As newer aircraft are designed to handle more weight, larger engines are being used. Executive jets may have thrusts of up to 15 000 lbs; medium jets may have thrusts of up to 35 000 lbs; and some jumbo jets now have thrusts in excess of 100 000 lbs. Therefore, caution should be used when interpreting the danger areas for ground idle and take-off thrust settings, as some of the distances shown may need to be increased significantly.
In addition, although the danger areas depicted in the diagram have not changed, the thrust figures have been updated to reflect the revised figures above.
The Introduction of Supplemental Briefing Cards and Other Technologies for Passengers Who Are Blind or Visually Impaired
by Erin Johnson, Civil Aviation Safety Inspector, Cabin Safety Standards, Standards, Civil Aviation, Transport Canada
Navigating an airport and travelling on board an aircraft can be very stressful experiences for many, and they are even more so for passengers with a disability. Close your eyes and imagine navigating today’s chaotic world of travel without the use of your sight. Passengers who are blind or visually impaired (i.e. with partial vision) face numerous challenges when travelling by air. Not only do they have to find their way around the airport, but they must also manoeuvre in the tightly enclosed space of an aircraft cabin.
There are a number of new and innovative technologies to help these passengers overcome travel difficulties. The types of technology that help mitigate obstacles for people who are blind or visually impaired vary. Information can be disseminated to these passengers in a non-visual format via use of audible signage, audible information products, and tactile-based information, such as Braille. Types of technology that facilitate this include personal electronic travel/navigation aids (e.g. sonic devices) and GPS-based systems. These aids provide mobility assistance to persons who are blind or visually impaired. More information on this technology is available in the following Transport Canada publication on technologies for travellers with sensory or cognitive disabilities: http://www.tc.gc.ca/innovation/tdc/summary/13200/13247e.htm.
The Canadian Aviation Regulations (CARs) require that air operators provide an individual safety briefing when the contents of the standard safety briefing are insufficient due to a passenger’s sensory, physical or comprehension limitations, seat orientation or responsibility for another person on board the aircraft. Because of this requirement, a crew member must provide a detailed oral briefing to passengers who are blind or visually impaired. This briefing includes facilitating a tactile familiarization with the equipment that passengers may be required to use; advising them of where to stow their cane, if applicable; advising passengers of the number of seat rows between their seat and the closest exit and also of their alternate exit; providing an explanation of the features and operation of the exits; and, if requested, providing a tactile familiarization of the exit.
Braille supplemental briefing cards
Air operators must also provide each passenger at each passenger seat with a safety features card containing, in pictographic form, the information required by the Commercial Air Service Standards (CASS). However, until now, the regulations did not stipulate a requirement to provide passengers who are blind or visually impaired with a card to meet their needs. Recent amendments to Subpart 705 of the CARs and the accompanying Standards introduced a provision for supplemental briefing cards in Braille and large print.
Section 705.44 of the CARs introduces supplemental briefing cards along with the requirements for their visual display of information in Braille and large print. It requires that air operators provide on board every aircraft two copies of the supplemental briefing card in four formats, which may all be displayed on one or more supplemental briefing cards.
With this initiative, passengers who are blind or visually impaired are now provided the same safety information as all other passengers on board.
In addition to travelling with a personal attendant, passengers who are blind or visually impaired may also choose to travel with a service animal. A service animal is sometimes referred to as an “assistance animal”. The majority of service animals are dogs. In some cases, however, other animals—such as monkeys—have been trained to provide services for persons with a disability.
Air operators are required to permit service animals in the passenger cabin of aircraft with 30 or more passenger seats. However, the carriage of a service animal is subject to certain conditions. Firstly, the individual must require the animal for assistance. Secondly, the animal must be certified, in writing, by a professional service animal institution as having been trained to assist a person. Finally, the animal must be properly harnessed in accordance with standards established by a professional service animal institution.
For more information on the carriage of service animals, please consult Advisory Circular (AC) 700-014 at: http://www.tc.gc.ca/eng/civilaviation/opssvs/managementservices-referencecentre-acs-700-700-014-502.htm.
Things to keep in mind…
It is important to remember that good communication between passengers who are blind or visually impaired and crew members/airline personnel is essential. Good communication addresses the concerns, service, and safety needs of passengers.
It is also important to be aware that the supplemental briefing cards do not replace the requirement for the individual safety briefing. Rather, they are an effective tool for crew members to assist passengers with disabilities. With the advent of supplemental briefing cards and the use of service animals and other innovative technologies for passengers with disabilities, air travel has been made safer, easier and much more enjoyable for persons who are blind or visually impaired.
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