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AeroSafetyW O R L D
A330 CFIT IN TRIPOLI
CAUSAL FACTORS FROM LIBYAN CAA
THE JOURNAL OF FLIGHT SAFETY FOUNDATION
Smartphone distraction controversyHEMS AS350 FUEL STARVATION
Forecasts begin to convergeU.S. AIRLINE PILOT SHORTAGE
ETA for ICAO standards and manualsAIRPLANE UPSET PREVENTION
JULY 20
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fightsaety.org/IASS2013
@Flightsaety #IASS2013
66th annual International Air Safety Summit
IASS 2013
Omni Shoreham Hotel
Washington, DC, USA
october2931, 2013
IASS 2013 Te 66th Annual International Air Saety Summit (IASS) will be held October 29-31, 2013 at the Omni
Shoreham Hotel in Washington, DC, USA. Please visit website below or hotel details and urther details about the event
as they become available.
http://flightsafety.org/IASS2013http://flightsafety.org/IASS2013 -
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FLIGHTSAFETY.ORG| AEROSAFETY
WORLD|
JULY 2013
PRESIDENTSMESSAGE
Capt. Kevin L. Hiatt
President and CEO
Flight Safety Foundation
O
n May 15, during one of the
semi-annual meetings of our
Board of Governors, I reported
on the financial condition ofFlight Safety Foundation. The Founda-
tions financial report draws a lot of at-
tention because it speaks directly to the
organizations ability to meet its financial
obligations and to carry on with its vital
work of reducing risk in aviation.
Beginning in late 2011, as the 2012
budget was being constructed, we saw
signs that our primary funding source
membership revenue was beginning
to decrease because of a fall-off in exist-
ing member renewals and a slowdown
of new member sign-ups. Other factors
included a decrease in attendance at our
safety summits and an increase in oper-
ating costs tied to the development of a
major new safety program and to some
internal operating inefficiencies.
While the state of the world economy,
which has at least an indirect impact on
membership and conference attendance,
is beyond our control, we have taken a
number of steps to address our financial
and operational situation.
We studied where we could reduce
overhead without negatively impacting
our level of service, which essentially
meant taking a look at how efficiently
we meet the needs of our members and
the aviation community as a whole. What
resulted from that exercise was a reduc-
tion in full-time staff members from a to-
tal of 26 to 20 in our offices in Alexandria,
Virginia, U.S., and Melbourne, Australia.Technical project facilitation, executive
leadership and AeroSafety Worldproduc-
tion have been modified in order to re-
duce the overhead. Our ratio of operating
costs to total intake is 14 percent, which
is very good when compared with other
non-profit organizations.
We also are working to freshen up our
safety seminars. We want our summits
and seminars to be the most valuable
and engaging safety events you attend
each year. We recognize there are many
other conferences to choose from, so we
are working hard to make our summits
and seminars the industrys best.
I am working with our International
Air Safety Summit (IASS) and Business
Aviation Safety Summit (BASS) agenda
committees to make the Foundations
two premier events more real time,
featuring carefully vetted presentations
on more current safety and operational
topics. We will be adding interactive
technology so viewpoints and opinions
can be shared instantaneously. We also
are targeting venues that are interesting
and easy to travel to, all the while keeping
the cost as low as possible.
But what we really need is your
support. Whether you are currently a
member, or a person who is aware of us
and not a member, or someone who has
just picked up this magazine for the first
time, you need to support the Founda-tion. Our value to you and the industry
is multi-dimensional. We continually
facilitate reducing the risk in aviation
through research committees, public
and industry meeting appearances, our
magazine and website, summits, and
news media interviews. In addition,
everyone associated with aviation has a
responsibility to give back to the indus-
try that we personally gain from. We
must keep aviation as risk free as we can,
in order to continue to thrive and grow.
Without the Foundation to be that
international, independent and impar-
tial source to help facilitate the cause,
the aviation industry may not progress
as well as we have in the past. Please re-
new your membership, sign up as a new
member, attend a summit or just donate.
All these can be done on our website, and
we need you now to help us continue to
provide the service we all need!
THE FOUNDATIONNeeds Your Help
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I
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JULY 20132
|
18
AeroSafetyWORLD
12
23
features
12 CoverStory | Libyan CAA Accident Analysis
18 MaintenanceMatters | Mitigating Technician Fatigue
23 FlightDeck |Short Supply of U.S. Airline Pilots
27 FlightOps |ICAO Finalizes Upset Prevention Changes
33 FlightOps |Crackdown on Distraction
38 StrategicIssues|Constant-Angle, Nonprecision Approaches
departments1 PresidentsMessage | The Foundation Needs Your Help
5 FoundationFocus|Lederer Legacy
7 SaetyCalendar | Industry Events
9 InBrief| Safety News
contentsJuly 2013 Vol 8 Issue 6
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AeroSafetyWORLDtelephone: +1 703.739.6700
Capt. Kevin L. Hiatt, publisher,FSF president and [email protected]
Frank Jackman, editor-in-chief,FSF director of [email protected], ext. 116
Wayne Rosenkrans, senior [email protected], ex t. 115
Linda Werfelman, senior [email protected], ext. 122
Rick Darby, associate [email protected], ex t. 113
Jennifer Moore, art director
Susan D. Reed, production [email protected], ex t. 123
Editorial Advisory Board
David North, EAB chairman, consultant
Frank Jackman, EAB executive secretaryFlight Safety Foundation
Steven J. Brown, senior vice presidentoperation
National Business Aviation Association
Barry Eccleston, president and CEOAirbus North America
Don Phillips, freelancetransportationreporter
Russell B. Rayman, M.D., executive directorAerospace Medical Association, retired
.
|.
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sing
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whilean
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inopera
tion.|
:
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JULY 2013
43 DataLink |Business Aircraft Runway Excursions46 InfoScan | NextGen Midterm Challenges
50 OnRecord | Automation Surprise
We Encourage Reprints(For permissions, go to )
Share Your Knowledge
I you have an article proposal, manuscript or technical paper that you believe would make a useul contribution to the ongoing dialogue about aviation saety, we will be
glad to consider it. Send it to Director o Publications Frank Jackman, 801 N. Fairax St., Suite 400, Alexandria, VA 22314-1774 USA or [email protected].
The publications sta reserves the right to edit all submissions or publication. Copyright must be transerred to the Foundation or a contribution to be published, and
payment is made to the author upon publication.
Sales Contact
Emerald Media
Cheryl Goldsby, [email protected] +1 703.737.6753
Kelly Murphy, [email protected] +1 703.716.0503
Subscriptions: All members o Flight Saety Foundation automatically get a subscription toAeroSafety Worldmagazine. For more inormation, please contact the
membership department, Flight Saety Foundation, 801 N. Fairax St., Suite 400, Alexandria, VA 22314-1774 USA, +1 703.739.6700 or [email protected].
AeroSafety World Copyright 2013 by Flight Saety Foundation Inc. All rights reserved. ISSN 1934-4015 (print)/ ISSN 1937-0830 (digital). Published 11 times a year.
Suggestions and opinions expressed inAeroSafety Worldare not necessarily endorsed by Flight Saety Foundation.
Nothing in these pages is intended to supersede operatorsor manuacturerspolicies, practices or requirements, or to supersede government regulations.
About the Cover
The Libyan Civil Aviation Authority has
disseminated saety fndings based on
the crash o this Airbus A330-202.
Franois-Xavier Simon
27 33
38
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FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JULY 2013
FOUNDATIONFOCUS
Many of you are familiar with
the fact that the Flight SafetyFoundation has been around
for more than 65 years. You
also are aware of the work that the
Foundation does on a daily basis to
pursue its ever-important mission of
being the leading voice of aviation safety
around the world. You readAeroSafety
World, you see us in the media, you do
research on our website, use our tool
kits, etc. All of these items do not come
without a cost to the Foundation. Like
so many non-profit organizations, we
depend heavily on our membership dues
to fund our safety efforts. We value and
appreciate each member and the support
that each member gives to us. In spite of
that, membership dues are not always
enough to keep our projects and efforts
going, especially during the challenging
economic times we are facing today.
At a time of constrained resources,
increased regulation and unprec-
edented scrutiny, the aviation industrys
survival depends on safe operations.
Practices for safe operations are re-
searched, initiated and actively pub-
licized and distributed by the Flight
Safety Foundation. However, there is al-
ways more to be done. This job is never
complete. The Foundation will always
be needed in good economic times, but
even more so during the downturns.In turn, we will always need support in
order to do our work.
The Foundation is a 501(c)3 orga-
nization, which in the United States
simply means that we are recognized
as a charitable organization and we are
able to receive tax-deductible dona-
tions from companies and individuals
around the globe. It is not uncommon
for charities large and small to hold
fund-raising drives and events to help
sustain the organization, thereby keep-
ing the core activities going.
For this reason, we are kicking off
the FSF summer fund-raising drive,
highlighting the words and works of the
late Jerry Lederer, the founder of the
Foundation. Over the next few weeks,
you will be seeing interesting facts and
quotes from Jerry Lederer, as well as
projects and products that the Foun-
dation has had a hand in developing,
both past and present. Check out our
blog for our new feature Jerry Lederer
Says ... as our founder talks about
safety and the Flight Safety Founda-
tion. You will also see his comments on
Facebook, LinkedIn and Twitter.
We will be reaching out to mem-
bers and non-members alike. We will
always include a link to the dona-
tion page of the FSF website, so thatanyone who wants to is able to donate
to our cause.
The drive will culminate in the FSF
Inaugural Benefit dinner at the Nation-
al Press Club in August in Washington.
This dinner will be held to recognize
the accomplishments of the Founda-
tions past and honor Jerry Lederer, as
well as showcase the current and future
endeavors. We also hope to raise mo-
mentum to move into the future.
The Flight Safety Foundation has
recently had to adjust some of its
current practices from the way things
have been done in the past to the way
it does business now. It is essential
that we change with the times, so that
we can continue to be the impartial,
independent voice of aviation safety,
as we are known around the world. A
fund-raising drive is a new change, and
a necessary addition to our business
practice at this time. We want to create
a new path to keep the Foundations
legacy moving forward into the next 65
years and beyond. We hope that we can
count on your support.
Susan Lausch
Senior Director, Membership
and Business Development
LEDERERLegacy
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OFFICERS AND STAFF
ChairmanBoard o Governors David McMillan
President and CEO Capt. Kevin L. Hiatt
General Counseland Secretary Kenneth P. Quinn, Esq.
Treasurer David J. Barger
ADMINISTRATIVE
Manager oSupport Services and
Executive Assistant Stephanie Mack
FINANCIAL
Financial Operations
Manager Jaime Northington
MEMBERSHIP AND BUSINESS DEVELOPMENT
Senior Director oMembership and
Business Development Susan M. Lausch
Director o Eventsand Seminars Kelcey Mitchell
Seminar andExhibit Coordinator Namratha Apparao
MembershipServices Coordinator Ahlam Wahdan
Consultant, StudentChapters and Projects Caren Waddell
COMMUNICATIONS
Director oCommunications Emily McGee
GLOBAL PROGRAMS
Director oGlobal Programs Rudy Quevedo
Foundation Fellow James M. Burin
BASIC AVIATION RISK STANDARD
BARS Managing Director Greg Marshall
Past President William R. Voss
Founder Jerome Lederer19022004
MemberGuideFlight Saety Foundation801 N. Fairax St., Suite 400, Alexandria VA 22314-1774 USA
tel +1 703.739.6700 ax +1 703.739.6708 ightsaety.org
Member enrollment ext. 102Ahlam Wahdan, membership services coordinator [email protected]
Seminar registration ext. 101Namratha Apparao, seminar and exhibit coordinator [email protected]
Seminar sponsorships/Exhibitor opportunities ext. 105Kelcey Mitchell, director o events and seminars [email protected]
Donations/Endowments ext. 112Susan M. Lausch, senior director o membership and development [email protected]
FSF awards programs ext. 105
Kelcey Mitchell, director o events and seminars [email protected] product orders ext. 101Namratha Apparao, seminar and exhibit coordinator [email protected]
Seminar proceedings ext. 101Namratha Apparao, seminar and exhibit coordinator [email protected]
Website ext. 126Emily McGee, director o communications [email protected]
Basic Aviation Risk Standard
Greg Marshall, BARS managing director [email protected]
BARS Program Ofce: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia
tel +61 1300.557.162 ax +61 1300.557.182
acebook.com/lightsaetyoundation
@lightsaety
www.linkedin.com/groups?gid=1804478
S
ince 1947, Flight Saety Foundation has helped save lives around the world. The
Foundation is an international non-prot organization whose sole purpose is to
provide impartial, independent, expert saety guidance and resources or the
aviation and aerospace industry. The Foundation is in a unique position to identiy
global saety issues, set priorities and serve as a catalyst to address the issues through
data collection and inormation sharing, education, advocacy and communications. The
Foundations efectiveness in bridging cultural and political diferences in the common
cause o saety has earned worldwide respect. Today, membership includes more than
1,000 organizations and individuals in 150 countries.
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JULY 2013
Serving Aviation Saety Interestsor More Than 65 Years
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FLIGHTSAFETY.ORG|AEROSAFETY
WORLD|
JULY 2013
SAFETYCALENDAR
Aviation safety event coming up?
Tell industry leaders about it.
I you have a saety-related conerence,
seminar or meeting, well list it. Get the
inormation to us early. Send listings to Frank
Jackman at Flight Saety Foundation, 801 N.
Fairax St., Suite 400, Alexandria, VA 22314-
1774 USA, or .
Be sure to include a phone number and/
or an email address or readers to contact
you about the event.
JULY 819 Aircrat Accident Investigation.
Southern Caliornia Saety Institute. San Pedro,
Caliornia, U.S. Denise Davalloo, , , +1 310.940.0027, ext.104.
JULY 10 Hazardous Materials Air Shipper
Certifcation Public Workshop. Lion Technology.Dedham, Massachusetts, U.S. (Boston area). Chris
Trum, ,
, +1 973.383.0800.
JULY 1011 Airline Engineering and
Maintenance Saety. Flightglobal and Flight
Saety Foundation. London. Jill Raine, , , +44 (0) 20 8652 3887.
JULY 1519 AAB International Annual
Meeting. Aircrat Accreditation Board
International. Kansas City, Missouri, U.S.
, .
JULY 1524 SMS Theory and Application.
MITRE Aviation Institute. McLean, Virginia, U.S.
Mary Beth Wigger, ,
.
JULY 1718 59th ALPA Air Saety Forum.
Air Line Pilots Association, International.
Washington. Tina Long, ,
.
JULY 2324 Aviation Human Factors and
SMS Wings Seminar. Signal Charlie. Dallas.
Kent Lewis, , ,+1 850.449.4841.
JULY 2426 16th Swinburne Aviation
Industry Conerence. Hawthorn, Victoria,
Australia. Peter Bruce,
, +61 3 9214 8507.
JULY 29AUG. 2 Fire and Explosion
Investigation. Southern Caliornia Saety
Institute. San Pedro, Caliornia, U. S. Denise
Davalloo, ,
,
+1 310.940.0027, ext.104.
JULY 31AUG. 2 Airport Wildlie Hazard
Management Workshop. Embry-Riddle
Worldwide. Dallas. .
AUG. 1216 Aircrat Perormance
Investigation. Southern Caliornia Saety
Institute. San Pedro, Caliornia, U. S. Denise
Davalloo, ,
,
+1 310.940.0027, ext.104.
AUG. 1922 ISASI 2013: Preparing the
Next Generation o Investigators. International
Society o Air Saety Investigators. Vancouver,
British Columbia, Canada. Ann Schull, , ,
+1 703.430.9668.
AUG. 2930 International AviationSaety Management Inoshare. Flight Saety
Foundation. Singapore. Namratha Apparao,
,
+1 703.739.6700, ext. 101.
SEPT. 911 NextGen Ahead Air
Transportation Modernization Conerence.
Aviation Week. Washington. .
SEPT. 2327 Unmanned Aircrat Systems.
Southern Caliornia Saety Institute. San Pedro,
Caliornia, U.S. Denise Davalloo, , ,
+1 310.940.0027, ext.104.
SEPT. 2426 MRO Europe 2013.Aviation
Week. London. .
SEPT. 2527 ALTA Aviation Law
Americas. Latin American and Caribbean Air
Transport Association. Miami. ,
+1 786.388.0222.
SEPT. 29OCT. 1 SMS/QA Symposium. DTI
Training Consortium. Disney World, Florida, U.S.
, ,
+1 866.870.5490.
OCT. 10 ACAS Monitoring Dissemination
Workshop (SESAR Project 15.04.03). Eurocontrol.
Langen (Hessen), Germany. Stanislaw Drozdowski
.
OCT. 1416 SAFE Association Annual
Symposium. SAFE Association. Reno, Nevada,
U.S. Jeani Benton, , , +1 541.895.3012.
OCT. 1516 Icing Conditions: On-Ground
and In-Flight. European Aviation Saety Agency.
Cologne, Germany. Carmen Andres ,
+49 221.89990.2205.
OCT. 1517 Saeskies Australia 2013.
Canberra, Australian Capital Territory. Doug
Nancarrow,
,
+61 (0) 2 9213 8267.
OCT. 2224 SMS II. MITRE Aviation
Institute. McLean, Virginia, U.S. Mary Beth Wigger,
, ,
+1 703.983.5617.
OCT. 2224 2013 NBAA Business Aviation
Convention & Exhibition. National Business
Aviation Association. Las Vegas..
OCT. 2931 66th International Air Saety
Summit. Flight Saety Foundation. Washington,
D.C. Namratha Apparao, , ,
+1 703.739.6700, ext. 101.
NOV. 38 CANSO Global ATM Saety
Conerence. Civil Air Navigation Services
Organisation. Amman, Jordan. Anouk
Achterhuis, , +31 (0) 23 568 5390.
NOV. 1315 10th ALTA Airline Leaders
Forum. Latin American and Caribbean Air
Transport Association. Cancn, Mexico.
,
.
DEC. 2122 European Business Aviation
Saety Conerence. Aviation Screening. Munich,
Germany. Christian Beckert, ,
, +49 7158 913 44 20.
APRIL 13, 2014 World Aviation Training
Conerence and Tradeshow (WATS 2014).
Halldale Group. Orlando, Florida, U.S. ZeniaBharucha, , +1 407.322.5605.
APRIL 1617, 2014 59th annual Business
Aviation Saety Summit (BASS 2014). Flight
Saety Foundation and National Business Aviation
Association. San Diego. Namratha Apparao,
, , +1 703.739.6700, ext. 101.
mailto:[email protected]:[email protected]://www.scsi-inc.com/AAI.phphttp://www.scsi-inc.com/AAI.phpmailto:[email protected]://bitly/XNDWUvmailto:[email protected]://www.flightglobalevents.com/mro2013http://www.flightglobalevents.com/mro2013mailto:[email protected]://www.aabi.aero/mailto:[email protected]://mai.mitrecaasd.org/sms_course/mailto:[email protected]://safetyforum.alpa.org/mailto:[email protected]://www.signalcharlie.net/Seminar+2013http://www.signalcharlie.net/Seminar+2013mailto:[email protected]://swinburne.edu.au/engineering/aviation/events/conferencemailto:[email protected]://www.scsi-inc.com/FEI.phpmailto:[email protected]:[email protected]://www.scsi-inc.com/API.phpmailto:[email protected]://www.isasi.org/mailto:[email protected]://fliglhtsafety.org/meeting/infoshare2013http://aviationweek.com/mailto:[email protected]://www.scsi-inc.com/unmanned-aircraft-systems.phphttp://www.scsi-inc.com/unmanned-aircraft-systems.phphttp://www.alta.aero/aviationlaw/2013/home.phphttp://www.alta.aero/aviationlaw/2013/home.phpmailto:[email protected]://www.dtiatlanta.com/Symposium2013.htmlhttp://www.dtiatlanta.com/Symposium2013.htmlmailto:[email protected]://bit.ly/10ok2HEmailto:[email protected]://www.safeassociation.com/http://www.safeassociation.com/mailto:[email protected]:[email protected]://webshop.easa.europa.eu/icingmailto:[email protected]://www.safeskiesaustralia.org/mailto:[email protected]://bit.ly/YJofEAhttp://www.nbaa.org/eventsmailto:[email protected]:[email protected]://flightsafety.org/aviation-safety-seminars/international-air-safety-seminarmailto:[email protected]://www.canso.orgsafetyconference2013/http://www.canso.orgsafetyconference2013/mailto:[email protected]://www.alta.aero/mailto:[email protected]://www.ebascon.eu/mailto:[email protected]://halldale.com/wats#.Ub4RyhYTZCYmailto:[email protected]://flightsafety.org/basshttp://flightsafety.org/aviation-safety-seminars/international-air-safety-seminarhttp://bit.ly/YJofEAhttp://halldale.com/wats#.Ub4RyhYTZCYhttp://flightsafety.org/bassmailto:[email protected]://fliglhtsafety.org/meeting/infoshare2013http://aviationweek.com/http://bit.ly/10ok2HEhttp://webshop.easa.europa.eu/icinghttp://swinburne.edu.au/engineering/aviation/events/conferencehttp://mai.mitrecaasd.org/sms_course/http://safetyforum.alpa.org/http://bitly/XNDWUvhttp://www.safeskiesaustralia.org/mailto:[email protected]:[email protected]:[email protected]://www.safeassociation.com/http://www.safeassociation.com/mailto:[email protected]:[email protected]://www.dtiatlanta.com/Symposium2013.htmlhttp://www.dtiatlanta.com/Symposium2013.htmlmailto:[email protected]://www.alta.aero/aviationlaw/2013/home.phphttp://www.alta.aero/aviationlaw/2013/home.phphttp://www.scsi-inc.com/unmanned-aircraft-systems.phphttp://www.scsi-inc.com/unmanned-aircraft-systems.phpmailto:[email protected]:[email protected]://www.isasi.org/http://www.scsi-inc.com/API.phpmailto:[email protected]:[email protected]://www.scsi-inc.com/FEI.phpmailto:[email protected]:[email protected]://www.signalcharlie.net/Seminar+2013http://www.signalcharlie.net/Seminar+2013mailto:[email protected]:[email protected]:[email protected]://www.aabi.aero/mailto:[email protected]://www.flightglobalevents.com/mro2013http://www.flightglobalevents.com/mro2013mailto:[email protected]:[email protected]://www.scsi-inc.com/AAI.phphttp://www.scsi-inc.com/AAI.phpmailto:[email protected]:[email protected]:[email protected]:[email protected]://www.ebascon.eu/mailto:[email protected]://www.alta.aero/mailto:[email protected]://www.canso.orgsafetyconference2013/http://www.canso.orgsafetyconference2013/mailto:[email protected]:[email protected]:[email protected]://www.nbaa.org/eventsmailto:[email protected] -
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. .
Save the Date
International Aviation Safety Management
InfoShareAugust 2930, 2013
Singapore
Inaugural
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FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JULY 2013
INBRIEFINBRIEF
Weather-Tower Markings
T
he U.S. National Transportation Safety Board (NTSB),
citing three fatal accidents involving small airplanes that
collided with meteorological evaluation towers (METs), is
recommending that all such towers be registered, marked and,if possible, lighted.
The NTSB issued two safety recommendations to the U.S.
Federal Aviation Administration (FAA), calling on the agency
to require tower registration and marking and to establish a
database for the required registrations.
METs defined by the NTSB as temporary structures
that measure wind speed and direction during development of
wind energy conversion facilities often are erected quickly
and without notice to the aviation community. They typically
are just under 200 ft above ground level (AGL), which is the
threshold at which FAA notification is required, and they are
unmarked and unlighted.
Pilots have reported difficulty seeing METs from the air
which has led to accidents, the NTSB said. Without measures
to enhance their conspicuity, such as marking and lighting these
structures and maintaining a record of their locations, METs
pose a continuing threat to low-altitude aviation operations
such as those involving helicopter emergency medical services,
law enforcement, animal damage control, fish and wildlife sur-
veys, agricultural applications and aerial fire suppression.
The FAA approved recommended guidelines in June 2011
for a uniform and consistent scheme for voluntarily markingMETs of less than 200 ft AGL; the guidelines did not discuss
voluntary lighting, and the FAA said recommending lighting for
the METs would not be practical because many are in remote
locations without power sources.
Ten states have acted to require at least some METs to be
marked and/or registered, and the NTSB issued recommenda-
tions for states, territories and the District of Columbia to pass
similar legislation.
Other recommendations called on the American Wind
Energy Association to revise the Wind Energy Siting Handbook
to indicate the hazards that METs present to aviation operations
and encourage voluntarily marking them [in accordance with
FAA Advisory Circular 70/7460-1, Obstruction Marking andLighting] to increase their visibility.
New Round for IOSA
An International Air Transport Association (IATA) conference has endorsed development of
an enhanced version of the IATA Operational Safety Audit (IOSA).
Enhanced IOSA is expected to be implemented by September 2015.
IATA said that the current IOSA program has laid a solid foundation for improved opera-
tional safety and security, eliminating redundant industry audits. However, audit protocols have
changed very little since IOSAs establishment in 2003, and modifications are needed to enhance
operational safety and security practices, IATA said.
The association said Enhanced IOSA will include measures to ensure continuous confor-mity with IOSA standards and recommended practices through quality control processes and
self-auditing in between IOSAs two-year audit cycle.
IATAs Ops Conference endorsed Enhanced IOSA at a May meeting in Montreal.
During the same meeting, IATA said it was joining with other organizations, including the
Association of European Airlines, Eurocontrol, the Civil Air Navigation Services Organisation
and the International Federation of Air Traffic Controllers Associations, to develop an action
plan for the Single European Sky (SES). The action plan includes plans to reduce infrastructure
duplication within the SES area by centralizing services and streamlining computer technology.
Oleg_ivano.../Dreamstime
U.S. National Transportation Safety Board
Safety News
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|FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JULY 2013
INBRIEF
Pushing for SES
The European Commission (EC) has moved to update regu-
lations that it says will accelerate changes in the regions air
traffic control system as it implements the Single European
Sky (SES) and avert the capacity crunch that is expected to
accompany a 50 percent increase in air traffic over the next 10
to 20 years.
The European Transport Workers Federation (EFT) is
protesting the move, which it says is placing unacceptable
pressure on air traffic management (ATM) employees.
The ECs plan calls for organisational and budgetary sep-
aration of national supervisory authorities from the air traffic
control organisations [that] they oversee while at the same
time ensuring sufficient resources are given to the national
supervisory authorities to do their tasks. Some supervisory
authorities have not had adequate funding to perform their
jobs, the EC said, adding that plans call for airlines to have
a new role in signing off air traffic control organisationsinvestment plans to ensure they are better focused on meeting
customer needs.
Another proposal would allow for more flexible operation
of the functional airspace blocks (FABs) the regional units
designed to replace the current patchwork of 27 national air
traffic control units so that the FABs could create industrial
partnerships and increase performance. At the same time,
Eurocontrols role would be strengthened to allow it to operate
centralized services more efficiently, the EC said.
Other EC proposals call for strengthening the role of the
EC in setting performance targets for European ATM in safety,
cost efficiency, capacity and environment. The performance
review body will operate with increased independence andhave the authority to issue sanctions when targets are not met.
In addition, the EC proposed that support services including meteorology, aeronautical information, communica-
tions, navigation and surveillance be provided by private
companies.
European Union Transport Commissioner Siim Kallas
said the proposals would strengthen the nuts and bolts of the
system so it can withstand more pressure and deliver ambi-
tious reforms.
The EFT, however, objected that the plans are part of a
never-ending process of liberalisation, deregulation and cost
cutting in the ATM industry.
The organization said that, although it originally sup-
ported the SES concept, it opposes mounting pressure on
workers and will oppose new plans that do not address thesocial aspects of SES.
Runway Incursion Audit
AU.S. government watchdog agency has begun an audit of
the Federal Aviation Administrations (FAAs) efforts to
prevent runway incursions.
The Department of Transportations Office of Inspector
General (OIG) said the audit is needed because of an increase
in the number of serious runway incursions from six in fiscal
year 2010 to 18 in fiscal 2012 and a 21 percent increase in
total runway incursions from 954 in fiscal 2011 to 1,150 infiscal 2012.
The FAA has reorganized its Runway Safety Office and
changed its methods of reporting runway incursions since the
last program review in 2010. The OIG said the objectives of
the audit, which was begun in late May, are to evaluate FAAs
progress in implementing initiatives to prevent runway incur-
sions and effectiveness in reporting and evaluating runway
incursions. InSapphoWeTrust/Wikimedia Commons CC-SA-BY-2.0
Tomgriger/Dreamstime.com
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INBRIEF
In Other News
Regular public transport operators in Australia and the organizations that maintain their aircraft face a June 27 deadline for
completing the transition to key elements of newmaintenance regulations. Work is continuing to update maintenance regu-
lations for charter operations, aerial work and private operations. European leaders have reached agreement on plans to unite
the continents airports and other transportation infrastructure into a unified network. The plans call for establishment of acore
transport networkby 2030.
TSB Urges Lightweight Recorders
The Transportation Safety Board of Canada (TSB), citing the
2011 crash of a de Havilland Canada DHC-3 Otter in the
Yukon, says the countrys small aircraft operators should install
lightweight recorders in their aircraft to monitor flight data.
For decades, recorded flight data has been instrumental in
advancing safety for our larger operators, said TSB Chair Wendy
Tadros. We think flight data monitoring should be an important
tool for Canadas smaller carriers, too a tool to help them man-
age safety in their operations.She noted that 91 percent of commercial aircraft accidents in
Canada and 93 percent of commercial aviation fatalities in the past
10 years have involved operators of small aircraft, and said, We
need to look at new ways of bringing these numbers down.
Recorded information will help accident investigators de-
termine the causes of accidents and develop ways of preventing
similar accidents in the future, Tadros said.
The TSB was unable to determine the cause of the March 31,
2011, crash of the DHC-3, which broke up in flight and crashed,
killing the pilot, the sole occupant.
Complications for NextGen
Uncertain funding and the possibility of future
furloughs of U.S. Federal Aviation Adminis-
tration (FAA) employees are complicating the
agencys efforts to develop the Next Generation Air
Transportation System (NextGen), FAA Adminis-
trator Michael Huerta says.
In remarks to a meeting of RTCA (formerly
known as the Radio Technical Commission for
Aeronautics), Huerta said employee furloughs
and cuts in the FAAs budget may be necessary in
the fiscal year beginning Oct. 1, unless the U.S.
Congress approves a long-term plan for federal
spending.
In May, the Department of Transportation
determined that funds were sufficient to allow
the FAA to transfer money into accounts to end
furloughs of air traffic controllers and other FAAemployees and to prevent the planned closures of
149 FAA air traffic control towers for the rest of the
current fiscal year, which ends Aug. 31.
The law that requires across-the-board spend-
ing cuts at all government agencies makes continu-
ity of NextGen programs more challenging, Huerta
said. The NextGen budget has increased from $130
million in 2007 to $1 billion for the current fiscal
year, an expansion that represents the increasing
urgency to modernize our system, Huerta said.
Trevor MacInnis/Wikimedia Commons
U.S. Federal Aviation Administration
Compiled and edited by Linda Werfelman.
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COVERSTORY
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S
urprise and hesitation prevailed during the
final seconds of an Afriqiyah Airways Air-
bus A330-202s approach to Tripoli, Libya,
the morning of May 12, 2010. The Libyan
Civil Aviation Authority (CAA) has determinedthat the aircraft was well below the minimum
descent altitude for the nonprecision approach
when the copilot, the pilot flying (PF), asked the
captain if he should initiate a go-around.
Although neither pilot had the required visual
references to proceed with the approach, seconds
passed as the aircraft continued to descend.
Finally, an aural warning generated by the terrain
awareness and warning system (TAWS) prompt-ed the captain to command a go-around.
The copilot applied full power and initiated
a climb. According to the CAAs final report, the
sensory effects of the A330s acceleration likely
BY MARK LACAGNINA Fatal
Inadequate crew coordination, an unstabilized approach and spatial
disorientation during a delayed go-around led to an A330 crash off Tripoli.
HESITATION
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Aurlien Tranchet|Airliners.net
Louaf Larb|Reuters
COVERSTORY
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caused the copilot to falsely perceive that theaircraft had entered an excessive nose-up pitch
attitude. He moved his sidestick forward, and
the climb reversed into a steep descent.
The captain assumed control, but he, too,
likely had become spatially disoriented. Instead
of pulling out of the dive, he moved his sidestick
full forward. Too late, the pilots caught sight of
the ground.
The A330 struck terrain close to the runway
threshold. The impact and post-impact fire
caused complete destruction to the aircraft, the
report said. Only one of the 104 people aboard
the aircraft survived.
Familiar Trip
The accident occurred during a scheduled 8.5-
hour flight from Johannesburg, South Africa,
with 93 passengers, eight cabin crewmembers
and an augmented flight crew of three pilots.
Tripoli is the home base for Afriqiyah Airways,
which at the time operated three A330s and six
A320 series aircraft.
The accident aircraft was manufactured in
2009. The report said that all three pilots had 516
flight hours in type. They had flown together
often and were familiar with the Tripoli airport.
The captain, 57, had a total of 17,016 flight
hours. He had flown A320, Boeing 727 and Fok-
ker 28 series aircraft for Libyan Arab Airlines
and Nouvel Air before being hired by Afriqiyah
Airways as an A320 captain in 2007. He earned
an A330 type rating in May 2009.
The copilot, 42, had 4,216 flight hours. He
held type ratings in the de Havilland Twin Otter,
A320 and A330. The report provided no details
about his previous flight experience.The relief pilot, 37, had 1,866 flight hours
and held type ratings in the A320, A330 and 727.
The crew departed from Johannesburg at
2145 local time, with the copilot at the controls.
In general, it is common practice within Afriqi-
yah Airways to designate the copilot as PF when
weather conditions do not result in difficulty in
handling the aircraft, the report said.
Locator Approach
The cruise portion of the flight was conductedat Flight Level (FL) 400 (approximately 40,000
ft). The flight took place without any notable
events until the approach, the report said.
At about 0530, air traffic control cleared the
crew to descend to FL 90. The controller said
that the weather conditions at Tripoli included
calm winds, 6 km (4 mi) visibility, a clear sky
and a temperature/dew point of 19/17 degrees C
(66/63 degrees F).
The airport had one precision approach, an
instrument landing system (ILS) for Runway 27,
but it was out of service. The VOR/DME (VHF
omnidirectional range/distance-measuring equip-
ment) facility at the airport also was out of service,
and only locator approaches were available. The
locator approach to Runway 09 was in use.
The report said that the crew conducted a
short approach briefing that included some de-
tails about the locator approach and how it would
be flown. However, essential points, such as the
intended use of the autoflight systems during the
nonprecision approach, were not discussed.
The fact that the approach briefing was
incomplete indicates that the crew did not an-
ticipate any special difficulty in the conduct and
management of the approach, the report said.
The locator approach was based on three
compass locators (nondirectional radio bea-
cons) lined up on the extended centerline of
Runway 09. The first, identified as TW, was
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MHA2,000
HL(R)53
090090090
270
270
GHARARAH301
TWN 32 39.7E013 03.1
TW
TRIPOLI435
DN 32 39.8E013 07.1
d
TRIPOLI365
GN 32 38.8E013 10.7
G
TRIPOLIVOR/DME 114.5
TPIN 32 39.7E013 09.3
TPI
MSA4,000 25 NM
from TW
MSA4,000 25 NM
from TW
MSA2,000 25 NM
from TW
MSA2,000 25 NM
from TW
270
1 MIN2,000 ft
NM10 9 8 7 6 5 4 3 2 1 0
3.9
L
TW
L
D
2,000 ft
Elevation 262 ft
Runway 09
270
090
090
1,350 ft
3.3 0.6
M
MISSED APPROACH:
Climb straight ahead
after passing L G turn
RIGHT and proceed to
TW L climbing to 2,000
and hold.
Plan and profile views
of the Runway 09
Locator instrument
approach procedure
show the alignment
of three compass
locators and the
altitude to cross
the final approach
fix inbound.
SusanReed,adaptedfrom
InternationalCivilAviationOrganization
14 | FLIGHT SAFETY FOUNDATION|AEROSAFETY
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COVERSTORY
3.9 nm (7.2 km) from the runway threshold
and served as an initial approach fix as well as
the final approach fix. The other two beacons,
located near the approach and departure
thresholds, respectively, marked the missed
approach point and the turning point for themissed approach procedure.
Generally, in the Tripoli Terminal Control
Area, arrivals are carried out under radar vec-
toring until intercepting the extended centreline
of the final approach segment, the report said.
Investigators were unable to determine
whether the crew conducted the approach
checklist. The approach checklist seemed to
be performed, but without any formal callouts,
the report said. The only item called out by the
crew was the altimeter setting.
Early DescentThe crew established the A330 at 1,400 ft on
the final approach course, 090 degrees, about
10 nm (19 km) from the runway. The approach
chart the crew was using indicates that the air-
craft should have crossed the final approach fix,
the TW locator, at 1,350 ft before descending to
the minimum descent altitude (MDA) of 620 ft.
However, recorded flight data showed that the
A330 began an early descent about 1.1 nm (2.0
km) before reaching the f inal approach fix.
Investigators determined that the copilot
might have inadvertently entered the distance
from the TW locator to the VOR/DME (5.2
nm), rather than the distance from the locator tothe runway (3.9 nm), when he programmed the
point at which the flight management system
would begin a descent on a three-degree glide
path for the final approach.
The aircraft was descending through 1,200 ft
when the captain established radio communica-
tion with the Tripoli airport traffic controller.
The controller asked if the runway was in sight,
and the captain replied, Established inbound,
sir. The controller then told the captain to
report the field in sight.
Unexpected Fog
Shortly thereafter, the pilots heard a radio
transmission by the crew of a preceding aircraft
advising that they had encountered patches of
fog on short final before landing. This likely
surprised the A330 crew and led the captain
to focus his attention on the outside to acquire
visual reference points, rather than on coor-
dinating with the copilot and monitoring the
flight parameters, the report said. Overall,
the management of tasks during the approach
deteriorated very quickly.
Although the relief pilot was in the jump seat
during the approach, there was no evidence that
he said anything or interacted with the other
pilots in any way.
The aircraft was configured for landing
when the copilot called for the landing checklist.
However, this could not be applied at this mo-
ment in time due to exchanges between the PNF
[pilot not flying] and the tower controller, the
report said.
The aircraft crossed the TW locator at 1,020
ft 330 ft below the published crossing altitude
at 0600:01. Neither pilot apparently recog-
nized the discrepancy.
The captain was engaged in obtaining a land-
ing clearance. He asked the controller, Confirm
clear to land if we have the runway in sight? The
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It is likely that
the captain did
not expect to have
to abort the fnal
approach and the
TOO LOW TERRAIN
warning [had]
destabilized him.
Somatogravic Illusion
Perceived position of airplane
Actual position of airplane
Balance sensors
in inner ear (otoliths)As the airplane accelerates,inertia causes sensors in theinner ear to move as if the
body were tilted. This givesa false sensation of climb.
Acceleration
Without visual cues orfeedback from instruments,pilots may overcompensate
for these perceivedchanges in attitude.
S s a n R e e d a d a p t e d f r o m
U S N a C h i e f o f N a a l A i r T r a i n i n g
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COVERSTORY
controller replied, Affirmative.
Clear to land. Wind calm.
Continue
A few seconds later, the cock-
pit voice recorder captured anautomated callout of hundred
above, indicating that the air-
craft was 100 ft above the MDA.
The copilot asked in Arabic,
You see?
The captain replied,
Continue.
Company standard operat-
ing procedures (SOPs) define the
continue callout as indicat-
ing that the PNF has acquiredthe visual references required to complete the
approach and landing. However, it is almost
certain that the weather conditions (as indicated
by the previous crew), the lighting conditions
and the actual position of the aircraft in relation
to the runway threshold did not enable acqui-
sition of the external visual references required
to continue the approach below the MDA, the
report said. The captain probably hoped to
obtain visual references in the next few seconds.
Moreover, because the crew of the preced-
ing aircraft had been able to land despite the
developing fog, the A330 crew might have been
confident that they also would be able to land,
the report said.
Shortly after the copilot acknowledged the
captains instruction to continue the approach,
an automated callout advised that the aircraft
had reached the minimum, the MDA at 620
ft, or 358 ft above ground level (AGL).
Neither pilot said anything for several
seconds. The copilot likely looked up from the
instruments and, not seeing the runway, asked,
Ill go around, captain? There was no immedi-
ate reply. The report noted that the copilot did
not initiate a go-around on his own volition, as
required by SOPs.
The aircraft was descending through 490
ft 228 ft AGL when the TAWS generated
the TOO LOW TERRAIN warning.
Go around, the captain said. Go around.Go around. The copilot disengaged the autopi-
lot, applied takeoff/go-around power, pulled his
sidestick back and asked the captain to retract the
flaps and landing gear.
The captain, as PNF, did not make the ap-
propriate callouts, the report said. It is likely
that the captain did not expect to have to abort
the final approach and the TOO LOW TER-
RAIN warning [had] destabilized him, the
report said.
Somatogravic Illusion
Four seconds after disengaging the autopilot
and initiating a climb, the copilot began to apply
nose-down pitch inputs on his sidestick. The
aircraft, which had climbed to 670 ft, entered a
steep descent.
The report said that the copilot likely had
suffered spatial disorientation typical of a
somatogravic [perceptual] illusion occurring
in the absence of outside visual references.
This would have resulted from the aircraf ts
sudden acceleration affecting the balance
organs of his inner ear, creating a sensation
of being tilted backward and the fa lse percep-
tion that the pitch attitude was excessive
(although it wasnt).
His reactions likely responded to the il-
lusion, rather than to the flight instruments.
At no time was the go-around pitch attitude
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COVERSTORY
controlled, nor did the copilot fol-
low the instructions from the flight
director, the report said. Neither
crewmember seemed to be aware of the
flight path of the aircraft.
As the A330 descended, the TAWS
generated successive warnings of
DONT SINK, TOO LOW TER-
RAIN and PULL UP. Nevertheless,
seconds before impact, the captain
pressed the priority pushbutton on his
sidestick and applied a sharp nose-
down input, the report said.
The pitch attitude was 3.5 degrees
nose-down as the aircraft descended
through 500 ft. By this time, the
copilot apparently had become aware
of the aircrafts flight path and had
pulled his sidestick all the way back,
intending to recover from the dive
but not recognizing that the captain
had sidestick priority. The captain
had not announced that he was as-
suming flight control.
Shortly before impact, the cap-
tain apparently became aware of the
aircrafts proximity to the ground
and reversed his sidestick input. The
descent rate was 4,400 fpm when the
A330 clipped trees and a high-tension
power line, and struck the ground in a
nearly level attitude at 0601:14. The im-
pact occurred 1,200 m (3,937 ft) from
the runway and slightly to the right of
the extended centerline.
Postmortem examination of the
victims indicated that all fatalities re-
sulted from severe trauma, the report
said. Media accounts said that the
survivor was a 9-year-old Dutch boy.
He suffered serious injuries and was
hospitalized in Tripoli for 48 hours
before being transferred to a hospital
in the Netherlands.
Fatigue FactorInvestigators determined that fatigue
might have been a factor in the ac-
cident, though the evidence was not
conclusive. All three pilots had received
more than 15 hours of rest before
reporting for duty at Johannesburg.
Moreover, the captain had taken a rest
period during cruise flight, returning
to the cockpit at 0410, almost two
hours before the accident occurred.
The report said that the copilot and the
relief pilot likely took their rest periods
before the captain.
However, the pilots had flowntwo consecutive night flights. This
would impose a certain amount of
fatigue which might [have] degraded
the performance of the flight crew and
increased the effect of somatogravic
illusions, the report said.
The pilots performance was
likely impaired [by] fatigue, but the
extent of their impairment and the
degree to which it contributed to the
performance deficiencies that oc-curred during the f light cannot be
conclusively determined.
Lessons Not Learned
The report noted that a similar event
had occurred 14 days before the ac-
cident: The captain and the copilot had
conducted the same locator approach
in the same aircraft on April 28. The
approach was similar in having been
unstabilized and marked by a prema-
ture descent. However, it terminated
with a missed approach initiated slight-
ly above the MDA and was followed by
an uneventful go-around and landing
on Runway 27.
The crew did not report the
go-around, as required, to Afriqiyah
Airways. The investigation committee
confirmed that analysis of the April 28
flight was not performed and the
crew had not reviewed and fully under-
stood what had happened during the
April 28 flight, the report said.
Tis article is based on the Libyan Civil
Aviation Authoritys Final Report o Ariqiyah
Airways Aircraf Airbus A330-202, 5A-ONG,
Crash Occurred at ripoli (Libya) on
12/05/2010, February 2013. Te report is avail-
able at .
Airbus A330-200
The two-engine A330 and the our-engine A340 were developed simulta-
neously by Airbus and share many systems and structural eatures. The
base-model A330-300 entered service in January 1994, a ew months ater
the A340.
The A330-200 is an extended-range version o the -300 that was introduced
in 1998 with a shorter uselage and higher uel capacity. Both models have
General Electric CF6-80, Pratt & Whitney PW 4000 or Rolls-Royce Trent 700 series
turboan engines rated at about 70,000 lb (31,752 kg) thrust.
The A330-200 accommodates 253 passengers in a twin-aisle cabin and
has maximum weights o 230,000 kg (507,063 lb) or takeo and 180,000 kg
(396,832 lb) or landing. Typical operating speed is 0.82 Mach, and maximum
range with reserves is 6,650 nm (12,316 km).
In 2012, maximum takeo weight was increased to 240,000 kg (529,109 lb) to
accommodate extra uel capacity and increase range to 7,050 nm (13,057 km).
Currently, 484 A330-200s are in operation worldwide.Sources: Airbus,Janes All the Worlds Aircraft
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MAINTENANCEMATTERS
In April 2010, after a base maintenance check
at Exeter, England, a Bombardier DHC-8-
102 was flown uneventfully to East Midlands
Airport to be repainted. During the return
ferry flight to Exeter, the right engine developed
a significant oil leak and lost oil pressure, so the
flight crew shut the engine down. Subsequently,
the crew noticed the left engine also leaking oil,
with a fluctuating oil pressure, so they diverted
to Bristol, where they landed safely.
The oil leaks were traced to damaged O-
ring seals within the oil cooler fittings on both
engines. Both oil coolers had been removed and
refitted during the maintenance at Exeter. It was
probably during re-installation that the O-ring
seals were damaged.1
During the investigation carried out by
the U.K. Air Accidents Investigation Branch
(AAIB), it was found that over the 17-week
period leading up to the end of a C-check, one
of the maintenance technicians working on the
aircraft had worked an average of 57 hours per
week, which was nine hours per week more than
allowed by the European Working Time Direc-
tive (WTD). The investigation also found that
during the 10 days prior to the aircrafts arrival
at Exeter, the same technician had averaged 15.7
work hours per day, resulting in the 11-hour
UntiringEfforts
BY MARIO PIEROBON
Fatigue among maintenance technicians can be
mitigated by fatigue reporting, bio-mathematical
models and shift-change management.
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MAINTENANCEMATTERS
post-shift rest entitlement in the WTD being
significantly curtailed. The technician reported
that he did not consider himself fatigued during
this period. However, he also said that during
the leak checks on the incident aircraft he felt
tired and had a lot on his mind, trying to get theaircraft ready for its scheduled painting slot, al-
though it was not an unusual level of tiredness.2
The AAIB said that a technician tasked to
work a 10-day period, with just one day off in
the middle, averaging 15.7 hours per day, is a
safety concern, particularly if not monitored
by the approved maintenance organization
(AMO). The AAIB also noted that the AMO
involved in this occurrence had no policy on the
maximum hours for a technician to work in any
24-hour period and relied on every technicianand manager, after undergoing human factors/
performance training, to communicate to their
supervisors the risk of fatigue. The AAIB said
that individuals who have undergone this train-
ing probably will be very responsible and will
request time off when they feel that they need it.
However, for some individuals this may not be
the case, particularly when they have a strong
desire to complete the job they have started
and when there is a financial incentive to work
longer hours, the report said.3
According to the AAIB, there is also evi-
dence from fatigue research that people are not
very good at detecting their degradation in per-
formance as they become fatigued. Therefore,
the responsibility for managing fatigue should
belong to the AMO and not just the individual.
The AAIB, however, notes that in Europe Part
145 (Annex II to Commission Regulation [EC]
No 2042/2003) states that the AMO needs to
take human performance limitations into ac-
count when planning maintenance tasks and,
although not specifically stated, this should in-
clude maintenance technician fatigue. However,
the acceptable means of compliance (AMC) and
guidance material (GM) to Part 145 currently do
not explain how this should be accomplished.4
In response to a safety recommendation
issued by the AAIB following this serious inci-
dent, EASA in early 2013 published a Notice of
Proposed Amendment (NPA) to EU Regulation
2042/2003 on continuing airworthiness to add
AMC and GM in Part 145 on how approved
maintenance organizations should manage and
monitor the risk of maintenance technician fa-
tigue as part of their requirement to take humanperformance limitations into account.
Working Time Directive
Unlike aircraft crewmembers whose duty time
is regulated by ad hoc and specific regulation,
aircraft maintenance engineers duty time is
standardized and regulated by the generic and
rather vague Council Directive 2003/88/EC (the
WTD), which leaves the door open to many
interpretations and exceptions, says Marco
Giovannoli, an aircraft systems engineer at Eti-had Airways and a fatigue and safety specialist.
The directive contains many opportunities
for derogation, or exception, which mainte-
nance organizations can use to circumvent the
limits. The directive states that derogations may
be made from the rest periods in the case of
activities involving the need for continuity of
service or production, particularly in industries
where work cannot be interrupted on technical
grounds. Also, derogations may be made by col-
lective workforce agreements.
Even without the derogations, the WTD
has been interpreted by some to mean that the
minimum daily rest period of 11 hours means
providing 11 hours of rest aftera working
period that could be up to 24 hours. Therefore,
maintenance organizations need to have clear
fatigue management plans that monitor their
staff working hours and working patterns to
reduce the risk of fatigue-related maintenance
errors. The published NPA (2013-01) is actu-
ally attempting to standardize across Europe the
interpretation of the working time directives for
aircraft maintenance operations.
With NPA 2013-01, EASA is filling a regula-
tory gap compared with other aviation regulatory
environments such as Canada and the United
States. According to the AAIB, Transport Canada
has published two NPAs (2004-047 and 2004-
049) which propose requirements for an AMO to
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MAINTENANCEMATTERS
manage atigue-related risks through a
saety management system (SMS).
o support these proposed regula-
tions, ransport Canada has published
guidelines or a atigue risk manage-
ment system (FRMS) that provides amethod or quantiying atigue risk on
a numerical scale using knowledge o
working hours and rest periods. he
AAIB also ound that the U.S. Federal
Aviation Administration (FAA) has set
up a maintenance atigue working group
to review the need or regulatory limits
on working hours or maintenance
technicians.5
Fatigue Risk ManagementEASAs new requirements or atigue risk
management are part o a larger rule-
making eort related to SMS in main-
tenance and continuing airworthiness
management organizations. Approved
maintenance organizations are going to be
required by EASA to implement an FRMS.
An FRMS needs to be careully
planned. o some extent, maintenance
organizations can draw rom already
produced research in relation to light
crews atigue, including the FRMS
Implementation Guide or Operators
jointly released by the International
Air ransport Association, the Interna-tional Civil Aviation Organization and
the International Federation o Air Line
Pilots Associations in 2011.
However, there are inherent di-
erences between aircrat maintenance
technicians work, working environ-
ment and associated atigue issues and
those o light crews. It becomes neces-
sary or a maintenance organization
planning an FRMS to properly consider
the maintenance-speciic atigue issues.
Reporting Fatigue
Fatigue should be a joint concern o
technicians, organizations and national
aviation authorities (NAAs). Without
proper and eective oversight by avia-
tion authorities, maintenance organiza-
tions may not have a strong enough
incentive to monitor and mitigate
atigue issues. In this situation, the NPA
is going to play an important role, as it
requires a rule-enorcing eort rom
European NAAs or atigue manage-
ment. More important, however, is
going to be the actual cultural transor-mation within maintenance organiza-
tions themselves.
Aircrat maintenance engineers
should be encouraged to report to su-
pervisors their degraded perormance
caused by atigue, and they should not
ace veiled threats o repercussions
rom their managers, says Giovannoli.
Nowadays i a pilot reports atigue,
[the reporting] is considered proes-
sional, conversely an engineer callingin atigued may be demonized. For a-
tigue to be consistently reported, tech-
nicians need a better understanding o
their atigue perormance limitations.
here is a strong subjective compo-
nent concerning atigue, and thereore
it is important to clearly illustrate the
various indicators and symptoms o
atigue and the possible methods o
osetting it, such as caeine, which
normally is the common counteracting
method used by aircrat maintenance
engineers, says Giovannoli.
echnicians should be advised about
correct sleep practices and good health.
Recommended levels o physical activ-
ity should be regularly practiced and a
balanced way o lie should be ollowed.
Moreover, managers and supervisors
should be properly trained to perceive
atigue symptoms and be empowered
to take corrective actions, even i these
could be perceived as detrimental to
organizational productivity, he said.
Vigilance Issues
Vigilance decrement is a orm o
short-term atigue to which aircrat
maintenance technicians are highly sus-
ceptible, especially during inspection
Vigilance Decrement Over Time
90
80
70
60
50
40
30
20
10
0
10 20 30 40 60 70 90 100 110 120 130 140
Vigilanceeectiveness%
Time (min)
Source: Australian Transport Safety Bureau
Figure 1
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MAINTENANCEMATTERS
tasks. his orm o atigue should be
particularly monitored by AMOs.
Alan Hobbs, in a report issued by
the Australian ransport Saety Bureau,
discussed vigilance issues. During the
Second World War it was ound thatater about 20 minutes at their posts,
radar operators became much less likely
to detect obvious targets, he said. his
problem applies to many monitor-
ing tasks where the search targets are
relatively rare. Aircrat inspection, the
checking o medical X-rays and quality
control inspection in actories are areas
where vigilance decrements may oc-
cur6 (Figure 1, p. 20).
Vigilance decrement applies par-ticularly to detection tasks where the
person is required to passively monitor
a situation that is boring and monoto-
nous, such as inspecting large numbers
o turbine blades. he limiting actor
is the ability to keep attention on the
task. For example, during the visual
inspection o an aircrat, a maintenance
worker may look directly at a deect,
yet i their attention is occupied with
other demands, the deect may not be
recognised. In general, inspection tasks
that involve variety and regular breaks
are less likely to suer rom vigilance
decrement.7
Bio-Mathematical Fatigue Models
Several sotware models are available
rom vendors as practical tools or
estimating work-related atigue associ-
ated with shit workers duty schedules.
Some o the models can be used with
any duty schedule, in which hours o
work (i.e., start/end times o work peri-
ods) are the sole input.
he main advantage o bio-math-
ematical atigue models is that they
allow the generation o qualitative and
quantitative orecasts o human atigue
based on a set o equations.8
Giovannoli, however, recognizes
such models intrinsic limitations, as
they do not consider the workers
individual variables and the conditions
around him, such as task diiculties,
working conditions and perception oatigue, which may drastically increase
the individuals actual level o atigue.
It is recommended to integrate a
bio-mathematical model in a wider-
ranging FRMS, he said. However,
available models should be careully
considered and validated beore imple-
mentation. One example o guidance
or the selection o bio-mathematical
models suitable or atigue risk man-
agement in aviation maintenance hasbeen provided by the Australian Civil
Aviation Saety Authority (CASA).
In its publication, Bio-Mathematical
Fatigue Modelling in Civil Aviation
Fatigue Risk Management, CASA
identiies opportunities or integrat-
ing models into a holistic FRMS while
developing management systems and
a corporate culture that understand
the uses and limitations o qualitative/
quantitative model predictions, use
their outputs with caution and in the
context o other operational opportuni-
ties and constraints, and adopt comple-
mentary multi-layered strategies to
proactively identiy and manage atigue
risk.9
CASA also discusses key actors to
consider when selecting and apply-
ing a bio-mathematical atigue model.
hese include the type o data to be
used as inputs, the physiological actors
described by the model components,
types o output predictions and their
relevance to task risks or other out-
come variables, data used or validation
and their level o equivalence to the
operational environment and subject
population, and the interpretation o
predictions or use in decision making.
CASA states that all these actors must
be considered, relative to the speciic
operational environment or their
intended use.10
In the application guidance mate-
rial, CASA provides an overview o sixbio-mathematical models rom com-
mercial and academic organizations
together with their related products and
services. CASA also provides a eature
comparison table and a discussion o
eatures in the context o commercial
aviation applications.
A sotware model that has been de-
veloped explicitly or light crew atigue
monitoring should not be selected, as it
may not allow or proper collection andelaboration o relevant inormation in a
maintenance environment.
Shift Work and Maintenance Errors
According to a study by Dawson and
Reid, Recent research has shown that
moderate sleep deprivation o the
kind experienced by shit workers can
produce eects very similar to those
produced by alcohol. Ater 18 hours o
being awake, mental and physical per-
ormance on many tasks is aected as
though the person had a blood alcohol
concentration o 0.05 percent. Boring
tasks that require a person to detect
a rare problem, like some inspection
jobs, are most susceptible to atigue
eects.11
Studies have shown, Hobbs said,
that 24-hour circadian rhythms inlu-
ence human error, with many aspects o
human perormance at particularly low
levels in the early morning. Memory
and reaction time are at their worst at
around 0400, and the chance o error
is increased. here appears to be an
increased risk o maintenance errors on
night shits.12
Hobbs said, It has been ound
that when maintenance technicians
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MAINTENANCEMATTERS
are experiencing sleepiness, they are at
increased likelihood o errors involving
ailures to carry out intentions, such as
memory lapses and perceptual errors.12
Sleepiness, however, seems to be less
likely to lead to mistakes o thinking suchas procedural misunderstandings.13
Twelve-Hour Shifts
welve-hour maintenance shits are
becoming increasingly common,
Hobbs said. In some cases, a com-
panys move to 12-hour shits is driven
by employee preerence rather than
management pressure. When compared
with eight-hour shits, 12-hour shits
oer certain advantages, such as lesscommuting time over the course o a
week, more days o, and the oppor-
tunity to complete more work in each
shit, with ewer handovers o tasks
between shits. Although workers tend
to be more atigued at the end o a 12-
hour shit than at the end o an eight-
hour shit, they sometimes report ewer
health problems and better sleep on a
12-hour shit pattern than when on an
eight-hour pattern.14
At present, there is no conclusive
evidence to indicate that extending
the duration o shits rom eight to
12 hours will increase the probability
o accidents or injuries. Nevertheless,
12-hour shits may not be appropriate
in all cases. Whenever a change is being
made to 12-hour shits, it is essential
to evaluate the eects o the change on
worker well-being and work quality.
Quite possibly, the most signiicant
eects o 12-hour shits would show
themselves on the journey home rather
than at work.15
Rotating Shifts
Rotating-shit workers may never
entirely become accustomed to a work
schedule, because the timing o shits is
constantly changing, Giovannoli said.
Direction and speed o rotation can
aect the adaptation to rotating shits.
Direction o rotation means the or-
der o changes to shits. wo common
types o rotation are orward, whenrotation is day to evening to night; and
backward, when rotation is day to night
to evening. Speed o rotation means the
number o consecutive working days
beore a shit change.
he current atigue science litera-
ture reports that a rapid (two to ive
days) orward-rotating shit system re-
duces mental and physical perormance
degradation and enables aster recovery
o both sleep and social activities. Incontrast, the ast backward-rotating
shit system is linked with reduced
physical and psychological health and
higher atigue.16
Night shit should not last more
than 10 hours including overtime and
two consecutive night shit blocks in
a row should not be allowed; with not
more than eight night shits in every
month, says Giovannoli. Furthermore,
night shit should not be extended
beyond 0800 and ater a night shit
block, two days o should be granted,
to provide enough rest time beore the
next shit, which in the orward rota-
tion is a morning shit.
he ideal o a totally non-atigued
technician may not be achievable in the
actual workplace, yet avoiding adverse
outcomes o atigue on saety and pro-
ductivity should be the objective while
implementing an FRMS. Empowering
atigue reporting, using bio-mathemati-
cal atigue models and properly manag-
ing work shits are valuable strategies
or targeted atigue risk management in
maintenance organizations.
Mario Pierobon works in business development
and project support at Great Circle Services in
Lucerne, Switzerland.
Notes
1. U.K. Air Accidents Investigation Branch
(AAIB),AAIB Bulletin 6/2011.
2. AAIB.
3. AAIB.
4. AAIB.
5. AAIB.
6. Hobbs, Alan. An Overview o Human
Factors in Aviation Maintenance.
Australian Transport Safety Bureau, AR
2008 055. December 2008.
7. Hobbs.
8. Australian Civil Aviation Saety Authority
(CASA). Bio-Mathematical Fatigue
Modelling in Civil Aviation Fatigue RiskManagement Application Guidance.
2010.
9. CASA.
10. CASA.
11. Dawson, D.; Reid, K. (1997). Equating
the perormance impairment associated
with sustained wakeulness and alcohol
intoxication. Journal of the Centre for Sleep
Research, 2, 1-8. Cited in Hobbs (2008).
12. Hobbs, Alan. An Overview o Human
Factors in Aviation Maintenance. ASB
ransport Saety Report Aviation
Research and Analysis ReportAR 2008 055,
December 2008.
13. Hobbs, A.; Williamson, A. (2003).
Associations between errors and contribut-
ing actors in aircra maintenance. Human
Factors, 45, 186-201. Cited in Hobbs (2008).
14. Hobbs, Alan. An Overview o Human
Factors in Aviation Maintenance. ASB
ransport Saety Report Aviation
Research and Analysis ReportAR 2008 055,
December 2008.
15. Hobbs.
16. Vangelova, Katia. Te Efect o Shi Rotation
on Variations o Cortisol, Fatigue and Sleep
in Sound Engineers. Industrial Health, 46,
490493 (2008); cited in Giovannoli, Marco,
Fatigue Monitoring to Improve Productivity
and Saety in Aviation Maintenance. City
University London (2008).
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The oten-orecast shortage o U.S. airline
pilots may inally come to pass, ed by a
perect storm o increasing demand or
new pilots, mounting retirements by baby-
boomer pilots and declining interest among young
people in airline careers, industry experts say.
A recent study by researchers rom several
U.S. universities reinorced the conclusions
o Boeings 2012 projection that the next two
decades will bring an unprecedented demand
or new pilots. Filling those jobs may not be
easy, the university study said.
he study orecast the hiring o more
than 95,000 pilots in the United States over
the next 20 years as a result o the combined
eects o new aircrat growth, pilot retire-
ments and pilot attrition rom the industry
or reasons other than retirement, as well
as government regulations especially rest
and duty time requirements that will limit the
number o hours pilots may work that may
lead to an increase in the number o required
new pilots.1
he Boeing study had orecast a need or
460,000 new pilots worldwide by 2032, includ-
ing 69,000 in North America (Figure 1, p. 24).
he Asia Paciic region will account or about
40 percent o the total worldwide need; that
number will include 71,300 in China alone.
he study cautioned that, in many regions o
the world, a pilot shortage is already here and
noted that the Asia Paciic region, in particular,
is experiencing delays and operational inter-
ruptions due to pilot scheduling constraints.2
he university study, which was conducted
at the request o an aviation industry stakehold-
ers group, acknowledged the ailure o requent
past warnings o an impending pilot shortage
to come to ruition, as well as conusion about
exactly what constitutes a shortage.Spiritartist/iStockphoto
FLIGHTDECK
BY LINDA WERFELMAN
Despite frequent warnings, an
actual shortage of airline pilots
would be the first since the 1960s.
ShortSupply
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Forecast New Pilot Demand Through 2031
40%
22%
15%
9%
8%3% 3%
Asia Pacic 185, 600
Europe 100,900
North America 69,000
Latin America 42,000
Middle East 36,100
CIS 11,900
Africa 14,500
Total 460,000
Region Pilots
CIS = Commonwealth of Independent States
Source: The Boeing Company
Figure 1
24 |FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JULY 2013
Does pilot shortage reer to a situation where
the lack o available qualiied pilots results in op-
erational disruptions, such as changes in schedule
or reduction o lights? the studys authors asked.
Using this deinition, the last pilot shortage oc-
curred in the 1960s. In this era, it was noted thatthousands o hours o lights by major airlines
had to be canceled and operations adjusted due to
the unavailability o qualiied pilots to hire.
Or does a pilot shortage mean a lowering o
hiring requirements to dip into the next wave o
applicants who, o course, still meet FAA [U.S.
Federal Aviation Administration] requirements
but are not at the top o the light experience
hierarchy? here is evidence to support this
was the case at the regional carriers in the most
recent hiring wave o 2007 and 2008.ypically, U.S. airlines have ound enough
qualiied pilots by hiring retired military pilots
and others rom civilian sources.
What is dierent now? the study asked
beore outlining several new considerations:
Recentlimitedhiringatmajorairlines;
Anincreaseinretirementsfrommajor
airlines over the next ew years;
Expansionofairlines;
Asmallernumberofnewflightinstruc-
tors who say they want careers with the
airlines; and,
Alegislativerequirementforairlinepilots
to possess airline transport pilot (AP)
certiicates which typically require
1,500 light hours.
he hiring o pilots or major airlines stimulates
demand or pilots throughout the industry, the
study said, adding that the unanswered question
now is whether hiring over the next ew years
will provide enough o a stimulus to develop an
adequate, continuous supply o pilots.
About 45,000 pilots are expected to retire
rom major airlines in the next 20 years, and with
18,000 current regional pilots, the industry willace a shortall unless a signiicant number o
new pilots enter the work orce, the study said.
Current projections indicate there will
be disruptions in the pilot labor supply unless
industrymarket undamentals change, more
pilots can be enticed into an airline pilot career
or the regulatory environment changes, the re-
port said. A status quo projection indicates that
there will be a shortage o around 35,000 pilots
(Figure 2, p. 25).
CFI Survey
he university study included a survey o certi-
ied light instructors (CFIs), gauging their
interest in an airline career, Kent Lovelace,
chairman o the Department o Aviation at
the University o North Dakota and one o the
studys authors, said during a panel discussion
inMayattheRegionalAirlineAssociations
(RAAs)annualmeetinginMontreal.
Its not so much how many pilots are out
there, but how many want to pursue the career,
Lovelace said, noting that many CFIs trained in
the United States plan to return to their native
countries to continue their aviation careers.
he survey, administered to 1,636 CFIs,
ound that 54 percent are planning on an
airline career. Nine percent o those ques-
tioned said they had abandoned their interest
in a career with the airlines because o the
A status quo
projection indicates
that there will be a
shortage of around
35,000 pilots.
FLIGHTDECK
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Forecast Shortages of Pilots to Staff the U.S. Airline Fleet
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
Cumulativenumberofpilo
ts
Yearlynumberofpilots
Yearly shortage Cumulative shortage
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031
Source: Higgins, James; Lovelace, Kent; Bjerki, Elizabeth et al.An Investigation of the United States Airline Pilot Labor Supply. 2013.
Figure 2
FLIGHTSAFETY.ORG|AEROSAFETY
WORLD|
JULY 2013
requirement or irst oicers to possess an AP.
An additional 33 percent said the requirement
had prompted them to reconsider their plans to
ly or the airlines.
he requirement included in a 2010 law
let room or exceptions to the 1,500-light-
hour requirement or military pilots and or new
pilots who graduate rom our-year colleges with
aviation degrees (ASW, 12/12, p. 43). he speci-
ics o those exceptions will be clariied in a rule
expected to be issued later this year by the FAA.
he numbers o CFIs hoping or airline ca-
reers are dramatically lower than they have been
in the past, Lovelace said, noting that 10 or 15
years ago, 75 to 90 percent o those questioned
said that they wanted to ly or an airline and
they knew which airline and which equipment.
Today,LovelacetoldtheRAA,ifyoucon-
vince 100 percent o those [the 54 percent] to
pursue an airline career, you dont have a sup-
ply problem. Nevertheless, he added, airlines
must actively persuade