- Aviation Safety Letter - Issue 2/2014
- Guest Editorial
- Flight Operations
- Maintenance and Certification
- SMS - Working Together for the Safety of Everyone
- TSB Final Report Summaries
- Judgement - Your Decision (TP 5305E)
- Accident Synopses
- Take Five… Gear Down and Locked
- Everything Moves At An Airport. Be Alert! (TP 14010E)
How Safe Is DANGEROUS?
by Scott Tyrrell, International Helicopter Safety Team (IHST) member Article republished with the kind permission of the IHST.
In the 1979 courtroom drama film titled And Justice For All, an eccentric judge played by actor Jack Warden takes a lawyer played by Al Pacino for a hair-raising ride in his personal Bell 47 helicopter over the Baltimore harbour and Fort McHenry. The judge laughs as he tests how far they can possibly go without running out of fuel, while Pacino’s character, his terrified passenger, begs him to land the helicopter immediately. The judge is a veteran of the Korean War, is possibly suicidal, keeps a rifle in his chambers at the courthouse and a 1911 pistol in his shoulder holster, and eats his lunch on the ledge outside his window four stories up. There are many who believe that reality mirrors film and that some films mirror reality; but certainly this type of dangerous behavior doesn’t exist in the world of aviation where professionalism, rules, regulations and extensive training are required prior to entering the cockpit. The actual facts, however, may be surprising. The International Helicopter Safety Team (IHST) was formed in 2005 to lead a government and industry cooperative effort to address factors that were affecting an unacceptable helicopter accident rate. The group’s mission is to reduce the international civil helicopter accident rate by 80% by 2016.
Human factors and pilot decisions
An IHST subcommittee of helicopter experts, from government and industry, called the U.S. Joint Helicopter Safety Analysis Team worked from 2006 to 2011 to complete an in-depth analysis of three years (2000, 2001, 2006) of U.S. helicopter accident data. The analysis team used 15 different industry categories to categorize each of the 523 accidents.
In describing why each accident happened, the analysis team organized their findings from each accident into standard problem statements. The team arranged the standard problem statements according to a continuum of detail that ranged from high level (Level 1), to more detailed (Level 2) and to the most specific level of detail (Level 3). Pilot Judgment & Actions was noted as a Level 1 standard problem in 969 instances within the 523 accidents studied. This indicates that there were many cases where Pilot Judgment & Actions was cited multiple times in the same accident.
Within the area of Pilot Judgment Actions, the IHST analysis team also noted that the Level 2 standard problem of Human Factors—Pilot’s Decision occurred frequently across a high number of accidents. Finally, the Level 3 area associated with Human Factors—Pilot’s Decision resulted in the following table:
Standard Problem Statement
Level 3 for Human Factors—Pilot Decision
|Count||Percentage of ALL Occurrences|
|Disregarded cues that should have led to termination of current course of action or manoeuvre||92||8.6%|
|Willful disregard for rules and SOPs||32||6.1%|
|Failed to follow procedures||28||5.4%|
|Pilot misjudged own limitations/capabilities||25||4.8%|
|Willful disregard of aircraft limitations||11||2.1%|
|Disregard of rules and SOPs||11||2.1%|
|Management disregard of known safety risk||9||1.7%|
|Not in possession of valid airman/medical certificate||8||1.5%|
|Sense of urgency led to risk taking||6||1.1%|
|Failure to enforce company SOPs||4||0.8%|
|Pilot disabled warning system||2||0.4%|
|Human factors—Pilot’s decision—Other||1||0.2%|
If the pilots had chosen a different decision or operation to follow, this could have led to the elimination of a number of these accidents and would have certainly been a step in the right direction towards the IHST goal of an 80% reduction in the accident rate.
To describe how each accident could have been prevented, the team organized their analysis from each accident into intervention recommendations.
They are included in the following tables:
Level 1 Safety Management Systems
Level 2 Risk Assessment/Management
Level 3 Intervention Recommendations
|Count||Percentage of ALL Occurrences|
|Use Operational Risk Management Program (Pre-flight and In-flight)||62||11.8%|
|Personal Risk Management Program (IMSAFE)||53||10.1%|
|Mission-Specific Risk Management Program||41||0.7%|
|Establish/Improve Company Risk Management Program||5||0.1%|
Level 1 Training/Instructional
Level 2 Safety Training
Level 3 Intervention Recommendations
|Count||Percentage of ALL Occurrences|
|Training emphasis for maintaining awareness of cues critical to safe flight||47||8.9%|
|Risk assessment/management training||28||5.4%|
|Aeronautical decision-making training||26||5.0%|
|Flight training on common operational pilot errors||19||3.6%|
|Pilot judgment training risk assessment||15||2.9%|
|Crew resource management training||14||2.6%|
|Training emphasis on techniques for maintaining visual alertness||10||1.9%|
Recent National Transportation Safety Board (NTSB) accident reports have revealed that these types of accidents are still occurring in today’s environment of aviation professionals. Examples of helicopter pilots exceeding their presumed flying qualifications or level of expertise can be found in recent news headlines:
“Helicopter pilot killed trying to herd plastic-wrapped bull”
“Helicopter crashes while flying out of hangar”
Former pilot and internationally recognized expert in the field of aviation human error, Tony Kern, explains this issue succinctly:
“Failures of flight discipline can—in a single instant—overcome years of skill development, in-depth systems knowledge and thousands of hours of experience.”
The aviation community must demand accountability at all levels so that full adherence to the highest level of flight discipline will ensure the safest flying environment. At risk behaviour—a behaviour in which an individual is willing to assume unnecessary risks while performing a particular task in his or her everyday life—along with rogue management, operations, pilots, aircrew and maintainers have no place in the profession of aviation.
Ignoring the rules
A clear example of at risk behaviour occurred on October 15, 2002, when a chief flying instructor (CFI) was providing night VFR cross-country instruction to a student in a Schweizer 269C helicopter. They had discussed their low-fuel situation, but elected not to stop and refuel because neither had a credit card.
On the last leg of their flight, the low-fuel light illuminated, followed a few minutes later by complete loss of engine power. During the autorotation, the helicopter was substantially damaged when it struck trees and the tail boom separated from the airframe. Miraculously, neither pilot was injured.
This is not the first accident of this kind and, unfortunately, probably will not be the last. The IHST analysis team’s data revealed 12 occurrences of the standard problem unaware of low fuel status leading to fuel starvation/exhaustion, and this accounted for 2.3% of all accident occurrences. A quick FAA Rotorcraft Accident Database query of “fuel exhaustion”, during the five calendar years from 2007 to 2011, results in 14 accidents with six fatalities.
During that helicopter scene in the movie And Justice For All, after a low level flight under a bridge and in close proximity to other structures, the judge reaches the infamous halfway point for his fuel. After repeated requests from Pacino, the judge finally turns the helicopter and heads back to the heliport. Pacino is terrified that they will not make it back and the judge tells him to trust his instincts. Shortly thereafter, however, the engine experiences fuel exhaustion and quits. The judge enters into an autorotation manoeuvre and lands short in shallow water. He says, “almost right on the button. I told you that I had good instincts. Another 90 ft and we would have made it. Let’s swim to the shore.”
What’s the lesson to be learned? It’s simple. The “Rules of Aviation” may sometimes appear unintelligent, arbitrary or irritating. But only dumb luck will help you if you break them.
Scott Tyrrell, a former U.S. Air National Guard officer, is a Continued Operations Specialist and Accident Investigator in the FAA Rotorcraft Directorate. His previous experience includes over 20 years in aircraft maintenance, including extensive knowledge of C-130 aircraft maintenance, as Commander of an Aircraft Maintenance Squadron and Mission Support Group.
Floatplane Operators Association (FOA) Best Practices
by Tim Parker, Treasurer, Floatplane Operators Association and Operations Manager, Pat Bay Air Seaplanes
Commercial floatplane travel is an every day occurrence on the West Coast, but not all of that travel is the same. Some operators fly tree fallers into camp, others fly tourists to fishing lodges. Commuters and business travellers fly to and from Victoria and Vancouver.
For the Floatplane Operators Association (FOA), this varied market creates challenges when designing best practices—the FOA’s core mandate. Best practices need to be clear and concise because members need to understand the rationale behind each best practice. With this understanding, members can agree on what is required.
The FOA’s membership runs the gamut from large floatplane airlines that employ hundreds of people and operate in a very public sphere, to smaller companies that operate in remote locations, far away from the public. Float flying is also a segment of the industry that is often the entry point for new commercial pilots who may be influenced by the actions of their peers. Because of the variety in operator and pilot experience, it was felt necessary to implement a standard level of professionalism in an aviation segment that has sometimes been portrayed as having a cavalier attitude toward safety and rules.
The idea is that FOA member pilots will adhere not only to the Canadian Aviation Regulations (CARs) but also to FOA best practices. In many instances, these best practices go beyond the CARs or include concepts not yet addressed in regulations. A perfect example of a best practice not covered by regulation is the practice of not flying after sunset. It’s perfectly legal to fly until grounding time, but scheduling a flight between sunset and grounding time uses up any cushion for unexpected delays. Furthermore, when it comes to training and technology, regulations often just can’t keep up due to the complex process of creating and promulgating new regulations. FOA best practices include requiring pilots to have underwater egress training and floatplanes to be equipped with a satellite tracking device. These requirements are not in the CARs which means a FOA member adhering to the best practices is safer than an operator who just follows the CARs.
So how does the FOA create these best practices? We have a board that is truly representative of member operators—from single-plane outfits to the biggest floatplane operator in the land. The board can draw on a breadth of knowledge going back decades and spanning the country. At the board level, we share what each member does to increase safety and reliability for their organization. What in the past would have been considered proprietary information belonging to a particular company is now readily shared. This information can help us learn what flight following device works best for a company of a given size and how to go about creating a segmented weight system for an airline. It can also improve delivery of pilot decision making (PDM) and underwater egress training by including pilots from different companies in a single class. This is especially useful for smaller operators. This sharing of information makes it easy to write a fairly simple best practice that all members can follow.
But at its core, the idea of best practices requires the buy in of the membership. If they don’t see a benefit in being members or adhering to best practices, the whole exercise is futile. For our members the buy in is that the existence of the FOA enhances the credibility of floatplane travel as a safe, professional and efficient means of transportation in Canada. For more information about the FOA, visit www.floatplaneoperators.org.
Airport Paper Chase
by Michael Oxner. This article was previously published in the March-April 2013 issue of Canadian Aviator magazine and is republished with permission.
Recently, I rejoined the ranks of current pilots. After a while out of the cockpit, I knew I had more to do than just “kick the tires and light the fires.” Part of being a good pilot is being prepared, and part of being prepared is getting set up with charts.
Controllers talk to pilots who don’t have current publications—or fly with no publications at all—with unfortunate regularity. Sometimes, it’s a matter of an unscheduled stop in a region that the flight simply isn’t planned for. Other times, it’s a variety of other possibilities ranging from thinking we know all we need to know to just not thinking about that one aspect of the flight.
Something that struck me while taxiing on my flight was just how far my mind had come from the airport environment in those few years. Happily, I was flying at an airport that I knew fairly well, since I had flown there in the past and since I serve that airport in my regular air traffic control duties. In fact, most airports I have flown out of are either very simple (one runway and one taxiway, for example) or are places that I became familiar with for other reasons in the past before flying there. Because of this, a chart of the airport wasn’t high on the list of needs in my mind.
That said, runway incursions are a serious concern. It was identified that some pilots are unfamiliar with the airports they were operating out of, and that airport information had to be made available to pilots. There are well-designed airport charts in the Canada Air Pilot (CAP), which include all the standard instrument departures (SIDs), standard terminal arrivals (STARs) and instrument approach procedures. Not many VFR pilots would think of carrying such a chart collection since these are primarily targeted at IFR pilots. But those airport diagrams would be very useful indeed for VFR pilots.
NAV CANADA has made the airport diagrams from the CAP available to pilots free of charge on their Web site. A pilot with internet access can visit http://www.navcanada.ca and, from the menu options on the left-hand side, select “Aeronautical Information Publications” and then “Canadian Airport Charts” from the sub-menu that loads afterwardFootnote 1 . This link will allow you to download a PDF version of these charts that can be printed out and taken with you in the cockpit as a reference.
Just make sure you have the current charts before your flight. When you receive instructions from ATC while taxiing, you will have a reference map if you need one. Signs are posted around the airfield, for reference on the move. The charts can be used when ATC is issuing taxi instructions so you can visualize your assigned route, plan ahead and see where the “hot spots” are. These potentially tricky areas are highlighted on the charts to call a pilot’s attention to the areas identified at the airport where traffic conflicts can occur. ATC is also aware of these places and they tend to keep a close eye on them, but an alert pilot can help keep these hot spots cold.
If you don’t happen to have a copy of the airport chart handy and are unfamiliar with the aerodrome, letting ATC know that fact can be helpful. Controllers have a lot of things to do, both on and off the radio, and when a pilot acknowledges instructions, it is expected that the pilot will taxi as instructed. Sometimes, though, a pilot can take a wrong turn. If a wrong turn is made, make sure the ground controller knows—the sooner, the better.
An unfamiliar pilot can also request progressive taxi instructions“Canadian Airport Charts” from the sub-menu that loads afterwardFootnote 2. This takes a little extra effort from the ground controller, but usually ATC would rather make this effort than have you end up somewhere you shouldn’t be—especially if it’s an active runway. Progressive instructions would include “turn-by-turn guidance” as the global positioning system (GPS) designed for driving would call it these days and it can help if you forget your charts.
As useful as these airport charts are, they’re not a complete list of essentials for pilots. The Canada Flight Supplement should be carried as well, as it includes VFR Terminal Procedures Charts and the critical details of various airfields. Also, a current VFR navigation chart (VNC) has areas of interest plotted, like restricted areas and airspace boundaries related to ATC (such as control zones, terminal areas, etc.).
Again, a pilot may wind up in a situation unexpectedly and need information that isn’t being carried. In such a case, a call to ATC or FSS can yield the needed information since staff there have copies of the same publications. As long as you know who to call and how to get a hold of them, ATC and FSS personnel can help. It’s a good idea to sit down, peruse the charts to see where this information can be found and become familiar with the locations along your route of flight during the planning stage.
Sometimes it’s hard to break down and ask for help. After all, we’re trained as pilots to be cool and prepared, so admitting you’re not isn’t fun. But ATC is just a call away if this kind of help is needed. Flight safety is their job, and if they can help, they will.
- Footnote 1
The NAVCAN Web site was updated since the original publication of the article, and the Canadian Airports Charts are now in the Related Links section of the Aeronautical Information Products page.—Ed.
- Footnote 2
It should be pointed out that the “progressive taxi” procedure is not formally defined or used in MANOPS, nor in the TC AIM. It remains a discretionary service that ground controllers may or may not be able to offer.—Ed.
TC AIM Snapshot: Flight Operations in Sparsely Settled Areas of Canada
“Sparsely settled area” is no longer a defined area. As such, the pilot/operator must decide what survival equipment is to be carried on board the aircraft in accordance with the regulations.
CAR 602.61, “Survival Equipment—Flights Over Land”, regulates the survival equipment required for aircraft operations over land in Canada. The regulation requires a pilot to carry on board the aircraft survival equipment sufficient for the survival on the ground of each person on board, taking into consideration the geographical area, the season of the year, and anticipated seasonal climatic variations. The survival equipment must be sufficient to provide the means for starting a fire, providing shelter, providing or purifying water, and visually signalling distress. The AIR Annex contains a Table that is a useful guide in helping pilots and operators choose equipment to ensure that they are operating within the regulations.
Experience has shown that pilots who are not familiar with the problems associated with navigating as well as other potential dangers of operating aircraft in sparsely settled areas of Canada tend to underestimate the difficulties involved.
Some pilots assume that operating in this area is no different than operating in the more populated areas. This leads to a lack of proper planning and preparation that can result in pilots exposing themselves, their crew, passengers and aircraft to unnecessary risks. This in turn can lead to considerable strain being placed on very limited local resources at stop-over or destination aerodromes. It has resulted in lengthy and expensive searches that could have been avoided with careful planning and preparation. Also, it has resulted in unnecessary loss of life.
Sparsely settled areas of Canada require special considerations for aircraft operations. For further information, please refer to the Transport Canada Aeronautical Information Manual (TC AIM), Section AIR 2.14.
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