The article in Aviation Safety Letter (ASL) issue 3/2004, "When Night VFR and IFR Collide," was very informative. To me, it reinforces the need to prohibit turns before 1 500 ft AGL during all IFR and night VFR operations into all operators' SOPs. If these procedures were implemented, trained for and reinforced into everyday operations, this type of accident could be prevented. Turns should only be allowed under these circumstances: for terrain avoidance, a departure instruction/procedure, or collision avoidance. "Black hole" departures create the "somotogravic illusion," which causes the crew to believe they are in a climb when the aircraft may indeed be descending. Under these conditions, extra vigilance by both crew members must be exercised in regards to aircraft vertical speed, climb performance and airspeed. Too often, the "killer norm" is for the pilot flying to start turning immediately after takeoff, while the pilot not flying is transmitting on the radio, and writing on the flight log when the aircraft, if allowed to descend unnoticed, is seconds away from ground contact. Operators need to implement SOPs for their crews to train to climb straight ahead and closely monitor aircraft performance, while maintaining a "sterile" cockpit to at least a minimum of 1 500 ft AGL.
In a review of 35 non-fatal airline incidents attributed primarily to crew error, it was concluded that failure to monitor and/or challenge the pilot flying (PF) contributed to 31 out of the 35 occurrences. In the incidents studied, the pilot monitoring, or pilot not flying (PNF) reported that preoccupations with other duties prevented them from monitoring the PF closely enough to catch an error being made while taxiing or flying. In 31 of the 35 occurrences, the PNF was preoccupied with some form of head-down work, most commonly paperwork or programming the flight management system (FMS).
Recently, I was assisting in the evaluation of aircraft equipment on international routes. The captain had approximately 20 000 hr total time, and about 3 000 hr in command on the type. The first officer was newly hired, with a new type certificate on the airplane, and about 1 000 hr total time. About 1.5 hr after departure, in cruise at FL 350, we entered an area of heavy convective build-ups, with imbedded thunderstorms. I noticed that the first officer, who was the PNF at the time, started reprogramming the FMS (to circumnavigate the weather) without first advising the captain that he was going head-down. At that time, the aircraft was on autopilot. The PNF then experienced difficulties in entering waypoints, and requested assistance from the captain, who immediately helped him, abandoning the sight of the instrument panel and the weather radar display. The aircraft entered clouds and met severe turbulence. While still on auto-pilot and trying to maintain the selected flight level, the aircraft entered into a series of high-speed stalls. It took the crew about 30 s to stabilize the flight.
The lesson? In this case, the PNF did not advise the PF that he would reprogram the FMS after he became aware of the deteriorating weather. The PF then abandoned monitoring the radar at a critical moment and elected to attend to a less critical task. Somebody must always fly the airplane, even during automated flight. Periods of head-down activity, such as programming the FMS, are especially vulnerable because the PNF's eyes are diverted from other tasks. It is essential that the standard operating procedures (SOPs) specify when it is recommended or allowed to go head-down.
Captain Jan Jurek
International Civil Aviation Organization (ICAO)
Earlier this year I lifted off from the Beaver Lake Forestry pad, east of Lac La Biche, Alta. I made a call on the aerodrome traffic frequency (ATF), 123.2, that my intention was to fly to the Tanker Base at the Lac La Biche airport. A few minutes later, I called turning from right base to final for Runway 29 at 3 500 ft and 3 mi. At about 1 mi., a CL-215 pulled out onto the runway and began backtracking on Runway 29. At the same time, an Astar lifted off from its hangar in a southerly departure. Again, no contact on 123.2. After landing at the Tanker Base, I was informed that "their" frequency was 122.05! Exclusive use of an unpublished frequency is unprofessional and keeps other airport users "out of the loop". Should all ATFs be made into mandatory frequencies (MF)?
Name withheld upon request
Good reminder to all. Use of company discrete frequencies is allowed but not at the expense of the ATF, or even a MF for that matter. -Ed.