5. addressing business aviations most frequent and
TRANSCRIPT
2018NBAARegionalForum|SanJose,CA|September6,2018
AddressingBusinessAviation’sMostFrequentandExpensiveAccidents&Incidents
MarkE.Larsen,CAM,NBAADanRamirez,XOJETHardyS.Bullock,C.M.,Truckee-Tahoe
AirportDistrict
Welcome
• Runway Excursions
• Ground Handling Events
• Resources
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What we’ll discuss today:
2018NBAARegionalForum|SanJose,CA|September6,2018
RunwayExcursions
DanRamirez,XOJET
UnstableApproach
Background
– Jets:§ Major248§ Substantial361
– Turboprops:§ Major528§ Substantial243
TotalAccidents1,380
AccidentData2002-2014(FlightSafetyFoundationandAirclaimsDatabase)
Type ofEvent Number PercentageTotals%
Incursion 10 0.07%
Confusion 4 0.03%
Excursion 417 30%
RunwayAccidents
AircraftTypes
• Jets:36%
• Turboprop:24%
AccidentData2002-2014(FlightSafetyFoundationandAirclaimsDatabase)
AccidentFactors2004-2014
35%
26%
18%
18% 16%
14%
14%
13% 12%
12% Go-aroundnotconducted
Touchdown:Long
Landinggearmalf
Ineffectivebraking:rwycontam'n
ApproachFast
Touchdown:Fast
Touchdown:Hard
FlightCrew:CRM
Pilotdirectionalcontrol
Non-complianceSOP
DataSource:FlightSafetyFoundation2018
Corp/BizAircraftvs.121Fleet
0%
10%
20%
30%
40%
50%
60%
Corp/Biz
FullFleet
DataSource:FlightSafetyFoundation2018
Observations
• Continuinganunstabilized approachisacausalfactorin60% ofallapproach-and-landingaccidents.
• In75% oftheoff-runwaytouchdown,tailstrikeorrunwayexcursion/overrunaccidents,arearesultofunstableapproach.
CommonFactorsDuringUnstableApproaches
• Fatigue(e.g.,duetodisruptedsleepcycle,personalstress)
• Pressureofflightschedule(i.e.,makingupfortakeoffdelay,lastlegoftheday)
• AcceptingrequestsfromATCforflyinghigherand/orfasterthandesiredresultinflyingtoohighand/ortoofastduringtheinitialorfinalapproach(e.g.,requestformaintaininghighspeeddowntoGScapture)
• Excessivealtitudeand/orexcessiveairspeed(i.e.,inadequateenergymanagement)
• Laterunwaychange(i.e.,lackofATCawarenessofthetimerequiredtoreconfiguretheaircraftsystemsforanewapproach)
• Non-standardtask-sharingresultinginexcessivehead-downwork(e.g.,FMSreprogramming)
• Shortoutboundlegorshortdown-windleg(e.g.,incaseofunidentifiedtrafficinthearea)
• Inadequateuseofautomation:Latetakeoverfromautomation(e.g.,incaseofAPfailingtocapturetheGS,usuallyduetocrewfailuretoarmtheapproachmode)
• PrematureorlatedescentduetoabsenceofpositiveFAFidentification
• Insufficientawarenessofwindconditions(tailwindcomponent,lowaltitudewindshear;localwindgradientandturbulence)
CommonFactorsDuringUnstableApproaches
• Incorrectanticipationofaircraftdecelerationcharacteristicsinlevelflightorona3-degreeglideslope
• Failuretorecognizedeviationsortoremembertheexcessive-parameter-deviationcriteria
• ExcessiveconfidencebythePilotMonitoringthatthePilotFlyingwillachieveatimelystabilization;
• PF/PNFoverrelianceoneachothertocallexcessivedeviationsortocallforago-around;
• Visualillusionsduringthevisualsegmentorcontinuedapproachwithoutacquisitionofadequatevisualreferences
CommonFactorsDuringUnstableApproaches
UnstableApproach
MitigationStrategies
• SOPsarenumberonemitigationactiontopreventunstableapproaches
• SOPsenhanceflightcrewdecisionmakingprocessduringtimesofheavyworkload
• Operator’smanagementandaircrewsshouldmutuallydevelopandreviewSOPsforeffectives(LOSA,FOQA,Etc.)
MitigationStrategies
Throughouttheflight,gatesshouldbedefinedtostayaheadoftheaircraftatalltimes.
• Gateidentificationshouldbedefinedby:
• Aircraftposition• Aircraftaltitude• Aircraftconfiguration• Speed• Verticalprofile• Powersetting
TypicalGatePointsDataSource:FlightSafetyFoundation/
EmbraerALAR
MitigationStrategies
• TheFinalApproachFix(OuterMarkeroranequivalentfix)shouldbethelastgatetoconfirmthereadinesstoproceed:
• VisibilityorRVR(andceiling,asappropriate)shouldbebetterthanorequaltoapplicableminimums
• Aircraftposition,altitude,configurationandenergyshouldbeunderthestableguidelines
• Allbriefsshouldbecompletedandagreementonapproachconditions
TypicalGatePointsDataSource:FlightSafetyFoundation/
EmbraerALAR
MitigationStrategies
1. Identifyhighriskareas(withoperationaldata,FOQA,SMS,LOSA)
2. Developinterventionstoolstoreducetheriskinthehighestriskareas(SOPs,LOFT,AQP,ScenarioBasedTraining)
3. Non-precisionapproachhas5timestheriskasaPrecisionApproach,thereforeadjustSOPsandcompanypolicyfortheseoperations.
CriticalItemsforDevelopment
• Whenassessingthedaytodayrisktheproperrunwayenvironmentcanmitigatetheeffectsanunstableapproach
• Someoftheitemstolookatwhenlookingatanairportare:
• Safetyarea(RESA)orappropriatesubstitute(e.g.,EMAS)
• Aircraftrescueandfirefighting(ARFF)availableatalltimesduringflightoperations
MitigationStrategies
0% 50% 100% 150% 200% 250% 300% 350% 400%
DRY
WET
CONTAMINATED
ICE
Runwayrequired[%]
CriticalItemsforDevelopment
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110% 120% 130%
-10
-5
0
5
10
15
20
25
30
Repo
rted
windspeed[KTS]
Runwayrequired[%]
OPERATIONALPROCEDURESANDLANDINGDISTANCESCriticalItemsforDevelopment
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110% 120% 130% 140% 150%
50
60
70
80
90
100
Thresholdaltitud
ecrossing
[feet]
Runwayrequired[%]
CriticalItemsforDevelopment
Unstable Approach
Summary
Theperceptionoftherunwayandoutsideenvironmentshouldbekeptconstantbymaintaining:
• Driftcorrection
– Continuetrackingtherunwaycenterline,resistingthetendencytoprematurelyaligntheaircraftwiththerunwaycenterline;
• Aimingpoint(i.e.,thetouchdownzone)
– Remainonthecorrectflightpathuntilflareheight,resistingthetendencytomovetheaimingpointcloserand,thus,descendbelowthedesiredglidepath(i.e.,“duck-under”)
• Finalapproachspeedandgroundspeed
– Tomaintaintheenergylevel.
Summary
FAA(2007)AVR-20OfficePublication8133-8149
Hackworth,H.,Holcomb,K.,Dennis,M.,Goldman,S.,Bates,C.,Schroeder,D.,Johnson,W.(2007).AnInternationalSurveyofMaintenanceHumanFactorsPrograms(ReportNo.07/25).OklahomaCity,OK:FAACivilAerospaceMedicalInstitute.
Hall,S.,Johnson,W.B.andWatson,J.(2001).EvaluationofAviationMaintenanceWorkingEnvironments,Fatigue,andHumanPerformance:PhaseIII.Washington,DC:FederalAviationAdministrationOfficeofAviationMedicine.http://hfskyway.faa.gov
ICAO– Annex6– OperationsofAircraft,PartI– InternationalCommercialAirtransport– Aeroplanes,Appendix2,2.1.25
ICAO– ProceduresforAirnavigationservices– AircraftOperations(PANS-OPS,Doc8168),VolumeI–FlightProcedures(particularly,PartIX- Chapter1- StabilizedApproach– Parameters,ElementsofaStabilizedApproachandGo-aroundPolicy)
U.S.NationalTransportationSafetyBoard(NTSB)– ReportNTSB-AAS-76-5–SpecialStudy:FlightCrewCoordinationProcedureinAirCarrierInstrumentLandingSystemApproachAccidents
References
2018NBAARegionalForum|SanJose,CA|September6,2018
GroundHandlingEvents
HardyS.Bullock,C.M.,Truckee-TahoeAirportDistrict
Business Aviation Ground Handling Events are 3,800 times more likely than a fatal accident
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Source: The VanAllen Group, Inc. 2017
27PhotoCreditsTerryYeomans,IS-BAH,ProgramDirector
PhotoCreditsTerryYeomans,IS-BAH,ProgramDirector28
• Removes the aircraft from service
• Unplanned & significant expenses
• Distracts from the core business
• Damages your brand
• Affects your livelihood
• Injury and death
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Why spend valuable time working on this ground handling issue?
For Aviation Claims Over $1,000,000.00 ground handling was the cause 18% of the time, 15% of total cost.Source: Allianz Global Corporate & Specialty Global Claims Review 2014. Data based on accident years 2009-2013
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Losses & Data
Ground Handling Reporting Requirements… U.S. None, EASA mandates for EASA airports
Ground Handling Accident Database… Limited
Ground Handling Insurance/Loss Data… Unavailable
Operators are the responsible the link – Share Info – Prevent Losses
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50%
33%
10% 7%
Sources of Aircraft Ground Ops Damage
HangarRash TowingAccident GroundVehicleCollision Taxiing
The VanAllen Group 2016 & NBAA Survey Responses, 2016
“A total of 48 percent of respondents reported having one to three ground-handling incidents or close calls in
the last three years, while 8 percent reported having four to nine incidents or close calls.”
The National Business Aviation Association (NBAA) Safety Committee Survey 2016
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The Threat
FBO staffing, training & supervision issues
FBO equipment limitations
FBO financial pressures
Activity peak stresses
Inadequate ramp access control
Inadequate operator standards & practices
FBO: “That’s why I have insurance.” Crew: “The FBO did it.”
Behaviors that help reduce loss
• Selection of a facilities
• Communication with the FBO and the Airport (Some airports handle aircraft)
• Understanding of the ramp area, parking, peak period handling and field tempo
• Stand by your Plane. Duty Out vs. supervising service, movement and fueling.
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Behaviors that help reduce loss
• Communication with S&D
• Micro Risk Assessment: Ask questions, have you tugged this?, fueled this?, etc.
• How is the fuel truck parked?• Chocks?• Cones?• Personnel?• Tow equipment?
• Let others work for you! Go where the industry standards are being used.
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2018NBAARegionalForum|SanJose,CA|September6,2018
ResourcestoMitigateHazards
MarkE.Larsen,CAM,NBAA
NBAA Reducing Business Aviation Runway Excursions
Download at www.nbaa.org/ops/safety/in-flight-safety/runway/runway-excursions/
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Aviation Safety Information Analysis & Sharing
www.asias.aero
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NBAA Airport Audit Tool
Download at www.nbaa.org/ops/safety/airport-audit-tool/
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International Standard for Business Aircraft Handling (IS-BAH)
www.nbaa.org/admin/sms/is-bah
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NBAA Top Safety Focus Areas
Learn more at www.nbaa.org/top-safety-focus-areas/
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Questions?
• DanRamirezDirectorofSafetyXOJET,Inc.5022BaileyLoopMcClellanPark,[email protected]
• MarkE.Larsen,CAMSeniorManager,Safety&FlightOperationsNationalBusinessAviationAssociation1200GStreet,NW,Suite1100Washington,DC20005(202)[email protected]
• HardyS.Bullock,C.M.DirectorofAviation&CommunityServicesTruckeeTahoeAirportDistrict(KTRK)10356TruckeeAirportRd.Truckee,[email protected]
2018NBAARegionalForum|SanJose,CA|September6,2018