Dash 8 Tail Strike: Weakness in Stabilised Approach Procedures
Dash 8 Tail Strike: Weakness in Stabilised Approach Procedures The Canadian Transportation Safety Board (TSB) has released their final report on a heavy landing and tail strike that occurred to Porter Airlines Bombardier Dash 8 Q400 C-GLQO landing at Sault Ste. Marie Airport on 26 May 2013. The aircraft landed hard and the tail of the aircraft contacted the runway resulting in significant damage but no injuries. Their report highlights a weakness in the operators stabilised approach procedures. The Commander was Pilot Monitoring (PM). The First Officer was Pilot Flying (PF). The FO had 134 hours on type and during line training, training captains had identified: …several areas requiring improvement amongst them pitch/power management during approaches and “the elimination of large power changes to chase speed in descent”. The TSB describe how: The aircraft descended through 500 feet AGL at 127 KIAS (Vref+6) on the extended center line of the runway, the captain made the “stabilized” call which was acknowledged by the first officer. Shortly afterwards the aircraft began to drift above the glidepath, the first officer applied pitch down inputs and the airspeed increased, however, the aircraft continued to drift above the glidepath nearing the 3.5 degrees angle. The first officer reduced engine power from 13% to 5% (flight idle) and pitched the nose down slightly, the airspeed began to decay rapidly and the rate of descent increased. The captain focused on the visual did not notice the power change, the accelerating rate of descent and decreasing airspeed. Descending through 90 feet AGL the airspeed dropped below Vref, descending through 40 feet AGL over the runway threshold the airspeed had decayed to 116 KIAS (Vref-5) and the aircraft had descended below the 2.5 degrees approach angle. The captain noticed that the aircraft was too low and the rate of descent had increased to 900 fpm and called for power. The first officer increased the pitch angle, then applied power just as the aircraft touched down at a recorded 7.3 degrees nose up (the TSB made the annotation that due to the sampling interval the actual attitude might have peaked at a higher angle) and +3.05G. 7.3 degrees nose up with gear fully or near fully compressed is consistent with a tail strike. The TSB report that: As the aircraft passed through approximately 90 feet HAT, the airspeed dropped below VREF and continued to decrease. At the same time, the vertical speed was increasing above -800 fpm and the aircraft was drifting below the ideal 3° PAPI glide path. The PM did not notice the increased rate of descent, most likely because he was monitoring the visual approach out the window at this point and not the aircraft instruments. As a result, no call-out for a go-around, as required by the company SOP, was made by the PM when the airspeed dropped below VREF. Continuing the approach when an aircraft does not meet the criteria for a stabilized approach is cited by the Flight Safety Foundation as being a contributing factor in 66% of approach and landing accidents and serious incidents. Neither crew member identified that the airspeed had dropped below VREF; the flight no longer met the requirements of a stabilized approach, and an overshoot was required. The TSB concluded that the “stabilized” call at 500 feet was justified as all stabilized approach criteria laid out in the...
read moreRadar for Wave Height Measurement
Radar for Wave Height Measurement The EnRoute Wave Height Measurement Problem In 2011 Canadian Transportation Safety Board (TSB) issued their investigation into a S-92A accident offshore Canada in 2009, in which 17 people died and one passenger, Robert Decker, survived. Additionally this accident was subject to a public inquiry. The Hon Robert Wells QC’s Offshore Helicopter Safety Inquiry (OSHSI) focused more on some of the survivability and wider safety issues. In advance of Transport Canada rulemaking as recommended by TSB, Canadian industry voluntarily stopped flying to installations with wave heights measuring in excess of six meters (equivalent to the certified ditching capability of an S-92A with a five bag floatation system). This action was several years in advance of the UK Civil Aviation Authority (CAA), who announced their intent in their February 2014 CAP1145 report (‘Safety review of offshore public transport helicopter operations in support of the exploitation of oil and gas’). Off Newfoundland, wave height is determined by wave-rider buoys off St Johns and close to the offshore installations. The wave height in between is not however measured. Aerossurance has previously reported on challenges of wave height monitoring in the UK. The HF Radar Research As early as 1955 peaks in high frequency radio wave echoes had been identified as due to ocean waves. Studies in the 1970s showed that surface currents, surface winds and surface waves could be derived from radar data. The Canada-Newfoundland and Labrador Offshore Petroleum Board (C-NLOPB), the local offshore industry regulator, contracted research organisation C-CORE, formerly the Centre for Cold Ocean Resource Engineering, to examine if HF radar could be used to determine en-route wave height, and give near real-time knowledge of the sea state all the way from St John’s to the offshore installations. The C-NLOPB briefed the UK Helicopter Safety Research Management Committee (HSRMC) in May 2013 (view the 3.5Mb presentation here). However, in March 2014 it was reported at a meeting of the local Helicopter Operations Safety Committee (HOSC) that: The C-CORE HF Radar Technology Report was presented to Operators [i.e. oil companies] in November 2013; it was decided by Operators to pursue other technology at this time. The alternatives were not articulated at that time. It however remained a controversial matter locally: CBC: Monitoring of waves needs to improve, offshore workers say. Aerossurance is an Aberdeen based aviation consultancy. For expert advice on offshore helicopter design, operations, survivability and safety, contact us at enquiries@aerossurance.com Follow us on LinkedIn for our latest updates. ...
read moreWait to Weight & Balance – Lessons from a Loss of Control
Wait to Weight & Balance – Lessons from a PC-12 Loss of Control On take off, pitch control of a Pilatus PC-12 was lost resulting in a series of pitch oscillations and stall warnings. Fortuitously the pilot was able to abort the take off with only damage to one main wheel. The incident could have been avoided if a more rigorous approach had been taken to aircraft loading. The US National Transportation Safety Board (NTSB) recently reported on this incident. It involved PC-12 N617BG, operated on a Part 135 commercial on-demand passenger flight by operated as a commercial on-demand passenger flight by FlighTime Business Jets, LLC from Austin-Bergstrom International Airport (AUS), Texas with 9 persons on board on 12 September 2013. The pilot stated: At rotation speed I smoothly and steadily rotated to establish a positive rate of climb to Vx (120 knots). As the aircraft accelerated to 95 knots the airspeed stagnated and a positive rate of climb was not possible. Simultaneously, at 95 knots, the aural STALL WARNING activated accompanied by the STICK SHAKER. This was immediately followed by the STICK PUSHER violently pitching the nose down at the runway. I was able to override the STICK PUSHER to avoid a nose wheel impact on the runway. When I leveled the aircraft at about 20-30 feet AGL, the unaccelerated airspeed was still in the 95 knot range and again the aural STALL WARNING and STICK SHAKER activated. This again was followed by an immediate and violent nose pitch down caused by the STICK PUSHER. I repeated a recovery to level flight and avoided runway contact. The scenario repeated itself once again and the airspeed continued to appear to be stagnant. Again at about 95 knots the aural STALL WARNING and STICK SHAKER activated which was immediately followed by a STICK PUSHER violent downward pitch. Again I recovered from the unusual attitude and avoided runway contact. After this recovery I was able to establish wings level and aborted the takeoff. The company’s FAA Operations Specifications stated that ‘only actual weights’ be used when determining the aircraft weight and balance. Irrespective of regulation, the use of actual weights for smaller aircraft is good practice recognised in industry standards: The International Association of Oil & Gas Producers (IOGP), formerly better known as OGP, recommends the use of actual weights for aeroplanes below 5,700kg and helicopters in para 9.4.1 of their Aviation Management Guidelines (Publication 390). The Flight Safety Foundation’s award winning Basic Aviation Risk Standard (BARS) for contracted air operations requires the use of actual weights for aircraft of less than 30 passengers (Control 6.1). The NTSB explain that: The pilot’s weight and center of gravity graphical plot for the incident flight did not take into account carry-on items/baggage [and] showed a CG of about 239 inches and a weight of 10,369 lbs. However, the FAA reported to the NTSB that: …about 490 lbs of carry-on items were not included in the weight and balance for the incident flight. The items consisted of a small ice chest and food that weighed about 60 lbs and four ice chests and boxes of food that weighed about 430 lbs. The actual passenger weights obtained for the flight was 2,031 lbs, which was obtained from passenger interviews. A weight and center of gravity plot showed that the incident flight was about...
read moreAerossurance Joins HeliOffshore
Aerossurance Joins HeliOffshore HeliOffshore is a global safety-focused organisation formed by major offshore helicopter operators. They state: We enable helicopter operators to develop, share and apply best practices, create and use advanced technology, and advocate for harmonised flight standards. HeliOffshore is dedicated to achieving the highest levels of safety, in the air and on the ground. Its activities will benefit the millions of oil and gas workers who depend upon the industry to get them to work and back home safely, as well as the crews who fly the helicopters and the teams who maintain them. Aerossurance first covered the plan to evolve the former European Helicopter Operators’ Committee (EHOC) into HeliOffshore last June. In October the five founding members Avincis (now Babcock), Bristow Group, CHC Helicopter, Era and PHI Inc launched HeliOffshore in London (which we covered here). The CEO of HeliOffshore is Gretchen Haskins, the former Group Director Safety Regulation of the UK Civil Aviation Authority (CAA) and Group Director of Safety at NATS. Bill Chiles, the former CEO of Bristow, who was awarded the Flight Safety Foundation‘s Laura Taber Barbour Air Safety Award last year, is the first chairman of HeliOffshore’s board. As a result of the UK Joint Operators Review started in 2013 by Avincis, Bristow and CHC, plus reviews of the data, and consultation with stakeholders, these areas formed the initial focus for the HeliOffshore (all areas that Aerossurance has published past articles): Automation Pilot monitoring Stabilised approaches Accident survivability Application of health and usage monitoring systems (HUMS) Information exchange Aerossurance is an Aberdeen based aviation consultancy, with extensive experience of offshore helicopter operations. Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates....
read moreInadvertent Fire Bottle Discharge During Maintenance
Inadvertent Fire Bottle Discharge During Maintenance The CHIRP Charitable Trust, who run the UK’s Confidential Human Factors Incident Reporting Programme, has reported on an inadvertent fire bottle discharge incident during maintenance in their Air Transport FEEDBACK Issue 113. The Aircraft was on a heavy maintenance input and several teams were busy working in the flight deck area. Three tasks were being worked simultaneously. Two engineers were assigned to the task of checking the APU [Auxiliary Power Unit] fire bottle squib circuit test. Engineer A, who was in the flight deck, believed that engineer B had disconnected the squib and was set-up to perform the check. Engineer A pulled the fire handle and fired the APU fire bottle which discharged. Engineer B indicated that he did not have the task sheet available as Engineer A had them, despite the fact that one was working in the flight deck the other was at the tail area. There were six people on the intercom system and the flight deck was very busy with a number of activities taking place simultaneously, this resulted in avoidable distractions and poor communication. CHIRP provide the following analysis: Distractions – The engineer lost his train of thought at important stages of the work due to numerous people on the intercom system. Organisational Factors – The company identified that the method of operation (when performing function checks at the end of the check) was not an isolated one and that there was some degree of this being the accepted norm. CHIRP go on to comment: This event highlights some routine HF [Human Factors] related problems. As well as looking at the individual HF errors, the organisation involved has taken steps to ensure there is a more co-ordinated approach to carrying out checks and functions. This applies particularly at busy times – typically towards the end of the maintenance input. While this is an easy mistake to make, it can serve as a lesson to ensure we have put processes and communications in place when carrying out function checks. Safety Resources Aerossurance has previously written about Professor James Reason’s 12 Principles of Error Management. UPDATE 8 April 2020: NTSB Confirms United Airlines Maintenance Error After 12 Years The UK CAA has issued this infographic on distractions: For support on maintenance human factors, preventing maintenance errors and improving maintenance performance you can trust, contact aviation consultancy Aerossurance: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates. ...
read moreSea State Forecasting – CHIRP
Sea State Forecasting – CHIRP The CHIRP Charitable Trust, who run the UK’s Confidential Human Factors Incident Reporting Programme, today published Air Transport FEEDBACK Issue 113. This included discussion of a report on sea state forecasting in the North Sea. The original report submitted to CHIRP was: Post CAP 1145 [Safety Review Of Offshore Public Transport Helicopter Operations], a sea state limit has been placed stopping CAT [Commercial Air Transport] operations overseas greater than sea state 6, or 6 metres. We reported for duty one hour before flight as requested. There were no managers present despite the knowledge that the weather (sea state) was due to deteriorate during the afternoon. The Met Office website 12:00Z forecast for the sea off the Aberdeen coast showed a maximum wave height of 4.5 metres, the 18:00Z forecast for the sea off the Aberdeen coast showed a maximum wave height of 6.5 metres over the majority of the UK North Sea as far as The Shetland Isles. One of us contacted the Met Office for clarification of the forecast wave height and was told the sea off the coast of Aberdeen would have waves in excess of 6 metres between 14:00Z and 15:00Z. There was a request made for the hourly forecast charts to be faxed to us so we would have the evidence at hand if management challenged us on our decision to stop flying, but they were not willing to send us the information, only give a verbal brief. Crews elected not to depart on flights that would require a return overseas greater than 6 meters. Management accepted crew’s decision when briefed later. Lessons Learned: Crews should not have to rely on verbal conversations with forecasters and hourly forecast should be made available on the Met Office website. It is noticeable, and very encouraging, that while the reporter was concerned that they would need strong evidence to back any decision not to fly, that the management did accept that decision without the hourly data they had requested. CHIRP commented: The Met Office provides forecasts of Significant Wave Height on a briefing system used by offshore helicopter operators called OHWeb. Operators are required to base their planning and operating decisions on the Wave Height forecasts on OHWeb. Since the report to CHIRP was received, the time steps for the forecasts on OHWeb have been increased from 6-hourly to 3-hourly to improve the fidelity and availability of the forecasts. Although the Met Office generate the product in hourly time steps, it was decided that the provision of hourly reports would not be appropriate because they could represent a potential source of pressure on pilots. With hourly forecasts, it could be that some pilots would feel compelled to ‘design’ the flight route around areas of high sea state using successive short term sea state forecasts. Moreover, with high sea states some pilots could have a tendency to await the next forecast with the mission on hold instead of cancelling it, taking a ‘rest’ break, and replanning it thoroughly. Despite the introduction of 3–hourly forecasts there remains the potential for actual sea states to be higher than those forecast; when this occurs the N Sea operators confer over the source, number and reliability of the reports before making a collective decision to operate, postpone or cancel flights....
read moreNTSB Report on 2013 S-76A++ Tail Rotor Blade Loss
NTSB Report on 2013 S-76A++ Tail Rotor Blade Loss The US National Transportation Safety Board (NTSB) has reported on a fatal Sikorsky S-76A++ accident to a Gulf Of Mexico offshore helicopter during a post-maintenance check flight of avionics systems. The accident occurred on 15 March 2013 to N574EH, operated by Era Helicopters LLC. The pilot and two mechanics died. After testing the avionics, the pilot allowed the mechanic to fly the helicopter at 1,000 feet above ground level. The mechanic maneuvered the helicopter for about 1 minute and then stated that he was transferring control of the helicopter back to the pilot. Two seconds later, the cockpit voice recorder (CVR) cut off. About 1 minute after the CVR cut off, the pilot made a routine radio call to the tower controller that he was returning to land. Two minutes after this call, the pilot radioed the tower controller and his company’s dispatcher, stating that he had a problem and would be landing off-airport immediately. Several ground witnesses noticed the helicopter as it flew toward the accident site, and it was making an unusual noise, described as grinding, screeching, or whistling. The helicopter impacted with a high vertical descent rate and a postcrash fire ensued. Examination of the helicopter revealed that the main rotor and tail rotor systems had low rotational energy at the time of ground impact. Two of the tail rotor blades (yellow and red) were fractured adjacent to the tail rotor hub. The fracture signatures on the red/yellow tail rotor spar assembly were consistent with the red tail rotor blade spar initially fracturing and the red tail rotor blade departing from the tail rotor. The NTSB say that: The resultant imbalance of the tail rotor fractured the tail gearbox (TGB) output housing studs and most likely tripped the CVR g-switch, which cut off the CVR. UPDATE 17 March 2019: Our diligent readers have correctly highlighted that this NTSB statement about the g-switch is erroneous as it isn’t compatible with the CVR transcript and the earlier discussion of subsequent radio calls to air traffic. The NTSB continue: The yellow tail rotor blade spar fractured due to high centrifugal forces as a result of the imbalance, and the yellow blade departed from the tail rotor; the tail rotor was then rebalanced. The two remaining tail rotor blades continued to provide partial tail rotor anti-torque, and tail rotor drive remained continuous through the TGB. The entirety of the red and yellow blade separation event likely occurred very quickly, with only a momentary bump or vibration at the time of blade separation. As the TGB output housing began to separate from the center housing, the gears likely began going out of mesh, allowing the output bevel gear to eventually contact the TGB center housing. This condition likely resulted in the loud, unusual noise reported by witnesses, as well as a drag force on the tail rotor drive system. As the pilot attempted to land, he likely shut the engines down in conjunction with an autorotative landing. Because the tail rotor drive system and main transmission remained mechanically linked, when the engines were shut down, it is likely that main rotor speed (Nr) degraded due to the compromised TGB. As a result, the helicopter developed a high vertical descent rate until ground impact. The red blade spar fracture...
read moreCessna 208B Caravan Ditching Video, Molokai, Hawaii, 2013
Cessna 208B Caravan Ditching Video, Molokai, Hawaii, 2013 We have previously covered the graphic ditching of Sikorsky S-76C 9M-STE (MSN 760398) of MHS Aviation in the South China Sea on 12 December 2013, and a passenger video of the ditching and rescue. Coincidentally, the day before (but in practice a couple of hours later due to the time difference), another ditching occurred, this time of a Cessna 208B Caravan off Hawaii, filmed by a passenger (Ferdinand Puentes). Sadly one person died in this accident (State Health Director Loretta Fuddy) and three people were seriously injured. The NTSB report that: On December 11, 2013, at 1522 Hawaiian standard time, a Cessna 208B, N687MA, sustained substantial damage following a loss of engine power and ditching into the Pacific Ocean near Kalaupapa, Hawaii. The airline transport pilot and two passengers were seriously injured, one passenger was fatally injured, and five passengers received minor injuries. Makani Kai Air was operating the flight under the provisions of 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed for the cross-country flight, which had originated about 2 minutes before the accident. A company flight plan had been filed. The flight departed from the Kalaupapa airport on the island of Molokai, and was en route to Honolulu International airport, on the island of Oahu. The pilot stated that shortly after takeoff, a loud bang was heard and there was a total loss of power. After a short glide, he performed an open ocean ditching. The airplane floated for approximately 25 minutes and then sank. All the passengers put on their life preservers and exited the airplane. US Coast Guard and Maui Fire and Rescue personnel recovered the passengers approximately 80 minutes later. Local press subsequently interviewed the pilot. UPDATE 23 May 2016: The NTSB final report includes: All the passengers and the pilot exited the airplane through the rear right door, and the airplane remained on the water surface for approximately 25 minutes before it sank. One passenger swam to shore, and United States Coast Guard and Maui Fire and Rescue helicopters recovered the pilot and 7 passengers from the water about 80 minutes after the ditching. Several passengers stated that the pilot did not provide a safety briefing before the flight. One passenger stated that the pilot asked how many of the passengers had flown over that morning and then said, “you know the procedures.” The passenger who died before the first responders arrived was found wearing a partially inflated infant life vest. The autopsy of the passenger did not reveal any significant traumatic injuries, and the autopsy report noted that her cause of death was “acute cardiac arrhythmia due to hyperventilation.” Another passenger reported that he also inadvertently used an infant life vest, which he said seemed “small or tight” but “worked fine.” If the pilot had provided a safety briefing, as required by Federal Aviation Administration regulations, to the passengers that included the ditching procedures and location and usage of floatation equipment, the passengers might have been able to find and use the correct size floatation device. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The loss of engine power due to the fracture of multiple blades on the compressor turbine wheel, which resulted in a ditching. The reason for the blade failures could not be determined due...
read moreUK CAA CAP1145: Update on North Sea Helicopter Safety (CAP1243)
UK CAA CAP1145: Update on North Sea Helicopter Safety (CAP1243) Not long after the fatal loss of Eurocopter AS332L2 G-WNSB 1.5 nm west of Sumburgh Airport, Shetland Islands on 23 August 2013 with 4 fatalities (AAIB Special Bulletin), the UK Civil Aviation Authority (CAA) launched an rapid review on offshore helicopter safety. CAP1145 This CAA Review resulted in the CAP1145 report (‘Safety review of offshore public transport helicopter operations in support of the exploitation of oil and gas’), issued in 20 February 2014. CAP 1243 The CAA have now issued CAP 1243, the Offshore Helicopter Review Progress Report, which provides an update on the 10 months to 31 Dec 2014. In their press release, the CAA highlighted 4 safety improvements introduced since CAP1145 was published: Stopping flights over the most extreme sea conditions (Aerossurance has previously covered the European Aviation Safety Agency (EASA) actions to introduce Airworthiness Directives to make the certified ditching capability clear). Ensuring every passenger on an offshore helicopter flight is equipped with new improved Emergency Breathing System (EBS) ahead of schedule (Aerossurance has previously covered the industry imitative to introduce a Compressed Air – Emergency Breathing System, a technology the CAA had considered and rejected in the 1995 CAP641 Review of Helicopter Offshore Safety & Survival). Standardisation of pilot training, particularly for the use of complex automated systems on helicopters and the associated operating procedures (Aerossurance has previously commented on the Joint Operators Review (JOR) review, the formation of HeliOffshore and on the issues of automation and monitoring). Establishing a new top level group to drive change, the Offshore Helicopter Safety Action Group (OHSAG) that includes unions, industry and the CAA (which Aerossurance has discussed too). House of Commons Transport Committee Additionally the House of Commons Transport Committee have released a more detailed statement by EASA on some of the actions underway. That committee called for a Public Inquiry in its Second Report of Session 2014–15 on Offshore Helicopter Safety (report HC 289), particularly into the effectiveness of the CAA, but its recommendation was dismissed by the Department for Transport (DfT). Aerossurance covered that report and the DfT response previously. SINTEF Helicopter Safety Studies Oddly, one reason for this rejection was that a large, industry funded, study had been conducted previously in Norway by the research institute SINTEF (Helicopter Safety Study 3, issued in 2010). The HSS-3 was the third Norwegian study published over two decades. HSS-1 covered 1966-1990 and HSS-2 1990-1998. The second Norwegian HSS report was issued following the last fatal air accident in Norway (apart from a fatal passenger incident in 2014 previously reported by Aerossurance). That accident, which followed a high speed shaft failure on Eurocopter AS332L1 LN-OPG on 8 Sept 1997 resulted in 12 fatalities. Since that time there have been four fatal accidents in the UK sector: Sikorsky S-76A+ G-BJVX in the Southern North Sea 2001 (Main Rotor Blade failure), with 11 fatalities Eurocopter AS365N G-BLUN in the Irish Sea in 2006 (Controlled Flight Into Terrain / Water at night), with 7 fatalities Eurocopter AS332L2 G-REDL in the Central North Sea in 2009 (MGB epicyclic failure), with 17 fatalities which was also subject to a Scottish Fatal Accident Inquiry Eurocopter AS332L2 G-WNSB on approach to Sumburgh in the Northern North Sea in 2013 (Controlled Flight Into Terrain / Water) with 4 fatalities (the AAIB report is awaited) It should be noted that there is approximately 50% more flying in the UK sector than Norway. CAP491 HARP Report...
read moreThe ‘Automation Problem’ – A Discussion
The ‘Automation Problem’ – A Discussion Automation, or perhaps more correctly the use of automated systems, has become a hot topic in the aviation industry, particularly since the issue of the accident report into the loss of AF447 (issued in July 2012). We review one analysis of the underlying cause and discuss a warning about an emerging threat. Automation Introduction Aerossurance has covered the outcome of investigations into fixed wing accidents such as the Asiana OZ214 B777 Accident at SFO 6 July 2013 and other serious incidents involving Boeing 737s, Embraer ERJ 170s and Airbus A320s. Aerossurance has also discussed a Royal Aeronautical Society Rotorcraft Group conference in July 2014 on the introduction of automation to offshore helicopters, provocatively titled Technology: Friend or Foe?. The use of helicopter automation is only likely to increase (see: Bell 525 Fly-By-Wire Update). We also covered the release of a series Crew Resource Management (CRM) videos from UK Civil Aviation Authority (CAA) including one that reconstructed of an actual incident where autopilot mode confusion during the glidescope capture results in loss of control a breakdown in collective situation awareness. The ‘Automation Problem’: by Captain Ed Pooley The 20th issue of Eurocontrol‘s Hindsight magazine focused on automation matters. Among the series of articles and case studies, we particularly recommend an article on The ‘Automation Problem’ by Ed Pooley. Pooley was Head of Safety for a large UK regional airline and is now a consultant and Chief Validation Adviser for SKYbrary. Pooley comments that high levels of automation has had two main effects: Pilots’ Knowledge of both their automated systems and the way they interact with how aircraft fly, however they are controlled, is often insufficient to cope with abnormal events unless these are resolved by straightforward checklist compliance. The extent and nature of the Decision Making which is required to operate a highly automated aeroplane today is quite different from that required to fly most similar-sized aeroplanes thirty years ago. Cockpit monitoring (a topic discussed by Aerossurance in August) and compliance with standard operating procedures are powerful controls that can mitigate risk of a range of accident types. Pooley however contends that these only treat the symptoms of the real automation problem, stating: The focus needs to be placed firmly on effective knowledge-based decision making. Pooley goes on to analyse the Air France AF447 A330 and Asiana OZ214 777 accidents. He also examines two more positive outcomes (the Qantas QF32 A380 and the less well know Cathay Pacific A330 serious incident were both engines started to malfunction after fuel contamination). He concludes, perhaps in places a little controversially: …whilst the way automation is delivered in aircraft design can always be improved, the root of the automation problem we are seeing today does not lie primarily – as many human factors experts will tell you – in system design. Rather, it lies in ensuring that people with the right aptitude and ability are trained as pilots in the first place. And that they are thereafter provided with type and recurrent training which is compatible with a job which now typically has very long periods of automated routine punctured only very rarely by the challenge of something completely) unexpected. Even with the very best selection processes, a successful outcome to any path through training is not a guaranteed one. There is a very heavy responsibility on all aircraft operators to ensure that they do not release pilots...
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