Flight Safety Pty Ltd
November 2009
Safety Alert
News from Flight Safety Pty Ltd
In This Issue
Audit Finding Analyses - ALAR/CFIT
Flight Safety Foundation Shaken
S-92 Emergency AD
New Heldeck Lighting Scheme
Pilot Fatigue
Helicopter Accident Analysis
ASRS Weather Incidents
Surgeons learn from pilots
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Dear Colleague,

This issue we begin our series of Audit Finding Analyses, a discussion of safety related, repetitive audit Findings, beginning with  ALAR/CFIT (Approach and Landing Accident Reduction/Controlled Flight into Terrain) awareness.

We also continue to highlight current affairs in Flight Safety from around the world, along the way alerting you to useful online resources to add to your collection; from FAA Airworthiness Directives, to NASA's Aviation Safety Resource Database to the Flight Safety Foundation.


Sincerely,

Colin Weir

Colin Weir, Managing Director
Flight Safety Pty Ltd
Audit Finding Analyses - ALAR/CFIT

Finding 1 - ALAR/CFIT (Approach and Landing Accident Reduction/Controlled Flight into Terrain)

Lockhart River illustrationCurrent deficiencies that compromise safety, as identified during routine external audit processes relating to ALAR/CFIT awareness training, could be compounded by curtailment of Flight Safety Foundation's operations - see article by the Flight Safety Foundation's president and chief executive Bill Voss below.

It would be a tragedy if they closed due to financial constraints as the Flight Safety Foundation is well known for their contribution to accident prevention through ALAR/CFIT awareness training strategies.

Alarmingly, the external audit process has shown that at least 90% of rotary and fixed wing operators do not have ALAR/CFIT awareness training programs.  High profile CFIT accidents such as Lockhart River, the Royal Flying Doctor - Mount Gambier and the Bond Helicopters, North Sea accident bear sad testimony to the fact that there are failures in the system.

The solution is clear-cut and achievable by even the smallest Operators.  It requires a proactive add-on to the traditional reactive Safety Management System in the form of an Accident Prevention module that includes ALAR/CFIT as a primary focus.  Coupled into this is a need to encompass the Flight Safety Foundation's teaching material and strategies. 

Find out more about Flight Safety Foundation's ALAR Tool Kit >>
Flight Safety Foundation shaken
 
Flight Safety FoundationThe Flight Safety Foundation's president and chief executive Bill Voss says  the aviation industry is going to have to decide whether it wants an organisation like the FSF for the future.

Voss says bad times do not only hit for-profit organisations, explaining:

"This year nearly 100 members went out of business and their support is sorely missed. It is also understandable that companies have to make cost cutbacks where possible. We certainly do the same. But when companies cut back on attendance to safety seminars, or exhibits at a show, the little adjustments of 1,000 great companies add up to a pretty challenging situation."

Read on at Flight Global >>

In a related editorial, the Flight Global magazine says:

"After 62 years of support for the entire aviation industry, it would be pity to see the Flight Safety Foundation go down because of lack of support from the businesses it served for so long."

... "It is [its] independence that makes the FSF so valuable. If it were not there, the industry would have to invent it, or see safety management return to the bad old days of making advances only through reactivity, and see standards revert to minimum legal levels."

Read comment at Flight Global >>
FAA Emergency Airworthiness Alert on S-92A helicopters
issued 29 October 2009

S92The US Federal Aviation Administration has warned of cracks in the main gearbox assembly (MGB) that may be present in some models of Sikorsky helicopters. If undedected, this could lead to loss of an MGB and subsequent loss of control of the helicopter.

Applicability:  Model S-92A helicopters, with MGB assembly, part number (P/N) 92351-15000-042 or -043, with MGB housing, P/N 92351-15110-042, -043, -044, or -045, installed, certificated in any category.

Read the full Airworthiness Directive AD# 2009-23-51 >>

Full list of other ADs >>
New Helideck Lighting Scheme - Interim Report

New helideck lighting scheme schematicFollowing on from our article in last month's newsletter, the CAA UK has released a draft interim report covers the development and testing of the new helideck lighting scheme (incorporating the 'H' and touchdown/positioning marking circle lighting).

The report will be updated and published formally as a CAA Paper once they have completed the further in-service trials taking place during the winter 2009/10 night flying season. The specification itself is presented in Appendix A (and represents an improvement on the provisional 'stage 2' specifications published in CAP 437, 6th Edition, Appendix E).
Pilot Fatigue in the spotlight

Auto PilotIn the US on Wednesday the 21 October 2009,  Northwest Airlines Flight 188, an Airbus A-320, overshot its destination by 150 miles before the pilots re-established contact with air traffic controllers, turned the plane around, and landed in Minneapolis.

The incident is still under investigation by the NTSB, however the issue of pilot fatigue has already become a hot topic. Were the pilots both asleep, or just distracted by using their laptops? What are the lessons to be learned?

One aspect is the pressure on commercial pilots to work longer for less; another relates to long periods of time spent on autopilot.

Aviation safety experts say the incident and ensuing uproar sheds light on the "don't ask, don't tell" policy about pilots occasionally breaking the rules to combat fatigue and boredom.

"Is it reasonable to expect two very bright professionals to stare straight ahead with their hands folded for six hours at a time?"

asked Bill Voss, president of the Flight Safety Foundation.

Pilots and airline safety advocates have been pushing the FAA to allow pilots to take controlled naps on flights to try to cope with sometimes grueling schedules. Some airlines in Europe and Asia already allow that, and the FAA is expected to propose new rules that may include a plan for controlled napping by pilots by the end of the year.

"As airlines cut corners, will pilot fatigue run the industry into the ground?"

"At 35,000 feet, pilots' main job is fighting fatigue" >>
EHSAT Helicopter Accident Analysis

EHSATThe European Helicopter Safety Analysis Team (EHSAT) has released its preliminary analysis report on helicopter accident analyses in EASA Members States between 2000 and 2005.

The report presents the results of 186 accidents where a final investigation report from the Accident Investigation Board has been issued. This represents some 58% of the entire set for this timeframe. The accident analysis aims at identifying all factors, causal or contributory, that played a role in the accidents.

EHSAT falls under the European Strategic Safety Initiative (ESSI) - a 10-year programme to enhance aviation safety for European citizens. It is a partnership between the European Aviation Safety Agency (EASA), other European national aviation authorities, manufacturers, operators, professional unions, research organisations, military operators and the general aviation community.

More than 150 organisations have participated to date. The basic principle is to improve aviation safety by complementing regulatory action by voluntarily commitment to cost-effective safety enhancements. Analysis of occurrence data, coordination with other safety initiatives and implementation of cost-effective action plans are carried out to achieve fixed safety goals.

Download the Preliminary Report >>
NASA's Aviation Safety Resource Database (ASRS) bulletin looks at weather incidents
 
ASRSIn a memorable October newsletter, the ASRS highlights a number of informative weather-related incidents by linking them to weather-related pop song titles, including:
  • Terminal Frost
  • Blame It on the Rain
  • The Wind Beneath My Wings
  • Ceiling Unlimited
  • Crying Lightning
  • Butterflies and Hurricanes
  • Snowbird
Read full Callback October edition >>
Surgeons learn lessons from pilots
 
PreflightBefore take-off, every pilot needs to brief their crew about what to expect.
At the end of each flight, they talk briefly about what went right, what went wrong and what could be done better.
Pilots say this brief and debrief system has reduced errors and made flying safer, and a growing number of NHS medics think this system should be adapted - to make surgery safer.

Two articles from the BBC website describe successful trails of the brief and debrief system in hospitals in the UK.

Whether it is hitting a tropical storm at 36,000 feet or negotiating an expected emergency in the middle of open-heart surgery, advance planning and a calm and ordered environment can make all the difference. It is a message NHS chiefs are keen to disseminate across the health service, and they have made a start with a new scheme called 'Productive Theatre'.

A report by researchers at the University of York claims that accidents, errors and mishaps in hospital affect as many as one in 10 in-patients - but that up to half of these were preventable.

One doctor who has trialled the brief and debrief system in two units at his hospital says incidents were reduced by between 30-50% over the period they used it.

"The lessons pilots can teach surgeons" (BBC) >>

"Making operations smoother and safer" (BBC) >>