First Edition 2013

Experiences at the European Test Pilots’Loss-of-Control-Inflight Workshop

Part 91 -A strong focus going forward

Loss of control

Pilots who fly glass,shouldn’t throw stones

Human Factorsin aviation maintenance

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Message from the Acting Director

Dear Readers

Welcome back to the New Year and all that it brings! Nowthat we have commenced with 2013, and the joys of theholiday are fast fading away, let’s set our minds on makingaviation safety one of our personal goals for 2013.

Aviation safety and security is at the core of the CAA’smission and is our primary focus. At the CAA, we haveresolved, together with the Department of Transport andthe Board, to provide a professional and effective serviceto you, our clients, in this year.

Aviation is a vital part of the economy and a refreshingrecreation for ‘weekend warriors’. Keeping the skies safeis an integral part of both aspects of aviation, as weremember the costly effect of incidents and accidents onthe economy and on personal lives. Aviation security,similarly, enables the industry to function more effectivelyand gives greater peace of mind to passengers. Yet itremains true that in this industry, we all have a role to playin keeping the skies as safe as possible for everyone.

ICAO compliance is the foundation of every State’s aviationlaw and regulations and safety oversight activities and ofthe SACAA’s mandate. This means that all the SACAAstaff members are involved with ICAO compliance, be itdirectly as in the case of the technical departments orindirectly as in the case of the corporate support functions.The ICAO Coordinated Validation Mission (ICVM)

scheduled for 2013 has been confirmed by ICAO for 24 to30 July 2013. The ICAO CMA Project, proactively launchedin 2012, to ensure the SACAA’s and RSA’s ICAO complianceto international requirements, has gained momentum andstature and is currently being driven through the ICVM TaskForce.

The involvement of all stakeholders regarding safety inaviation also includes the partnership of the aviationindustry with the SACAA in reducing accidents andincreasing compliance. This includes forums such as theIndustry Liaison Forum and the General Aviation SafetyInitiative and other initiatives such as the Safety FirstCampaign.

In this edition we continue to deliberate on some of theconsequences of automation on human factors relatingto pilots, a significant change in the regulations pertainingto Part 91, (general aviation), and the ever-importantsubject of Loss of Control. I hope that you find these articlesinformative and helpful.

Wishing you a fruitful 2013; until the next edition, fly safelyand let’s make pre-flight checks one of our new year’sgoals!

Poppy KhozaActing Director of Civil Aviation

In this editionP4

Pilots who fly glass, shouldn’t throw stones

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Part 91 - A strong focus going forward

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Loss of control

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Experiences at the European Test Pilots’

Loss of Control Inflight Workshop

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Human factors in aviation maintenance

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In 1903, after re-establishing the lift formula from Otto Lilienthal,the Wrights famously took to the controls of their magnificentWright ‘Flyer’ and became airborne for a distanceapproximately the length of a Boeing 747. However, thewooden and canvas flyer had initially stalled during the Wrightbrothers’ first attempt at flight, and this was arguably the firstever human-machine aviation-related accident, as describedin this paragraph in which Wilbur lamented after the incident:‘…the power is ample, and but for a trifling error due to lackof experience with this machine and this method of starting,the machine would undoubtedly have flown beautifully’. Theaircraft flown on that important day in history was also theimpetus for understanding and utilising technology toautomate parts of the machine in order to maintain control.

There is a vast difference in design between the aircraft beingbuilt today and the wooden device flown by the Wrightbrothers over a century ago. At present, the advanced flightdeck incorporates flight data information on cathode raytubes (CRTs) and liquid crystal displays (LCDs) – the mainreason that manyobservers refer to thesesystems as ‘g lasscockpits’. In fact, thecomplete digitisedfl ight deck systemconsists of electronicat t i tude d i recto rindicators (EADIs);electronic horizontalsituation indicators( E H S I s ) ; d a t amanagement systems(FMS) and symbolgenerators to drive theelectronic indicators;navigation systemcontrol and displayu n i t s ( N D ) ; a n dcomputerised air datasystems. Various crewalerting systems (inBoeing the EICAS, and in Airbus the ECAM) are incorporatedon the modern flight deck to support pilots in operating theiraircraft more safely in today’s congested airspace. Thisincludes, for example, a Traffic Collision and AvoidanceSystem (TCAS) and Controlled Flight into Terrain (CFIT)avoidance equipment, such as the Enhanced GroundProximity Warning System (EGPWS) technology. Computershave also resulted in fuel saving by means of advancednavigation and electronic fuel management. The Airbus’swide-body fleet has a clever method of changing its centreof gravity by moving fuel around automatically.

The modern jet airliner has evolved from that first flightimagined by Leonardo Da Vinci and is the culmination ofthat dream, integrating in its complex technology almost allof humankind’s scientific thought to date. Only computertechnology has paralleled aviation in its rapid evolutionaryadvance; and the modern jet airliner is the proud heir of bothfields of human endeavour, combining aviation and computer

technology in an elegant fusion.

Although flight deck automation has been well received bythe aviation industry and pilots, observers are raising importanthuman factor issues. Research suggests that the increasedpresence of computers (such as flight managementcomputers, FMCs) on board these flight decks has resultedin some pilots spending an increasing amount of ‘heads-down’ time during critical phases of flight, a key contributionto unnecessary distractions. Traditionally, the operation ofanalogue-type aircraft meant that pilots were often makingan exceedingly large number of minute mistakes. The modernadvanced flight deck incorporates highly sophisticatedcomputers, which now take care of the mundane or routineaircraft operations. Any mistakes committed by the humanoperator on these aircraft are more likely to result in acatastrophic disaster. For example, the use of reduced thrusttakeoffs has become an everyday method of reducing wearand tear on jet engines. However, a mistake in the input ofthe correct temperature into the flight management

computer may resultin disaster if theai rcraf t fa i l s toaccelerate duringthe takeoff phase(when the assumedtemperature is farh i g h e r t h a n i sactually required).This highlights thefallibility of the basiccomputer-humandyadic. Experts inthe field refer toGIGO or ‘garbage-in-garbage-out’. Inother words, thisdyadic is only ass t r o n g a s t h eweakest link, thehuman being. Theevidence supports

the theory that human error is a significant root cause ofmany of the more advanced aircraft accidents and incidents.

Analyses of the variables implicated in aircraft incidents andaccidents indicated that the rise in the number of aircraftaccidents in the early to mid-1990s has emerged as a symptomof the increasing adoption of new aircraft technology; forexample, an Airbus A300-600 operated by China Airlines thatcrashed at Nagoya in 1994; a Boeing 757 operated byAmerican Airlines that crashed near Cali, Columbia in1995;and more recently an Air France A330, and a Boeing 737-800 operated by Turkish Airlines that went down in a muddyfield less than a mile short of the runway at Amsterdam'sSchiphol airport shortly before it was due to land on 25February 2009.

Advancements in technology create a myriad of bothadvantages and disadvantages. Thankfully however, themajority of changes have resulted in a far safer and pilot-

Pilots who fly glass, shouldn’t throw stonesBy Dr. Preven Naidoo

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friendly environment. Accidents will continue to occur, nomatter how ‘fail-safe’ the system is designed to be. At thecoal-face of operations and always directly affected orinvolved in an aircraft accident, are the pilots, more specificallyhowever, the heart and mind of the pilot. Latent flaws willalways persist within the aviation system and the question ofhow pilots mitigate adverse systemic weaknesses in the worldof glass, should be elucidated.

The ever-increasing complexity of the environment requiresvigilance from the human operator by maintaining situationalawareness (cognitive control). Ecological error is a term relatedto the cognitive control (the mind of the pilot) that a humanbeing has with regards to a specific situation. Error on the flightdeck, flawed decisions and a breakdown in CRM skills areviewed as symptomatic of a loss in this cognitive control. Howdoes this theory impact on the operation of the glass-cockpitpilot? Flying an aircraft requires the integration of situationalawareness components as a whole. In older generation oranalogue type cockpits or flight decks, this means that thehuman operator must interpret a steady stream of incomingcues to maintain situational awareness. The difficulty in thismethod is that the pilot must use abstract information tovisualize the three-dimensional position (vertically, laterally,speed/energy) of the aircraft, in other words, ‘where am I inspace?’ In the glass cockpit, however, the pilot’s need tocontinuously interrogate reality in order to maintain perfectsituational awareness, is drastically reduced by being given‘reality on a plate’. Advancements in display technology suchas CRTs and LCD screens have resulted in powerful equipmentsuch as navigational displays to provide the picture. Althoughthe pilot’s ability to then place the aircraft accurately in three-dimensional space is made easier, loss of cognitive controlmay transpire from the complacency provided by the moderncockpit set-up.

A recent study on advanced flight deck automation foundthat pilots are so confident in the ability of the ‘computers’that they are now becoming increasingly reactive rather thanproactive in responding to a dynamic environment. It istheorised that the majority of human-factor related errorcommitted on the flight deck is based on the failure to preventerror. In one particular study conducted to determinenavigational errors, it was found that crews of analogue-typeaircraft were twice as likely to detect an error before it led to

an actual deviation, whereas glass-cockpit pilots were thentwice as likely to detect the error only after the deviation hadtaken place (see: Savage, J. 2000. Situational awareness inglass cockpits. Proceedings of the Joint International MeetingFSF, IFA, IATA, Nov., Rio, Brazil). Glass-cockpit pilots must thereforebe aware of these types of psychologically-related weaknesseswhen operating highly advanced aircraft. The realism andcomprehensiveness of displays must be complemented by anactive and positive attitude of crew and in case of doubt, byreference to airmanship and common sense.

The design of the technologically advanced flight controlsystem in the Airbus (as an example) means that the aircraftcan never be stalled (in normal law, i.e., at least 60% of thecomputers functioning normally). Features such as these mayresult in pilots perceiving the automation system of these aircraftmore favourably than others, thus strengthening thecomplacency dimension. By over-relying on advancedautomation systems (which in the majority of cases are very,very reliable) the pilot can severely underestimate the awesomeforces of the environment and specifically the power of adversemeteorological conditions. The glass-cockpit pilot who is vigilant(in cognitive control) is the one who is acutely aware of thetechnologically advanced systems, its advantages,disadvantages and limitations; this is the heart of the advancedautomated aircraft pilot.

We are first and foremost pilots; however we should also beeffective flight deck managers. On the automated flight deckwe must manage the various levels of automation availableto us. Clearly, increasing levels of automation will reduce theworkload in most scenarios. However, we must change themindset that drives us to operate at the highest levels at alltimes. Automation lacks the flexibility required to makeunanticipated changes to flight path requirements. So, in thesecircumstances, a lower level of automation should lowerworkload, and thereby preclude us from becoming task-saturated and losing situational awareness.

Acronyms:

FMS - Flight Management SystemND - Navigation DisplayEICAS - Engine Indicating and Crew Alerting SystemECAM - Electronic Centralised Aircraft MonitoringCRT - Cathode Ray TubeLCD - Liquid Crystal Display

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In today’s world we are seeing the most incredible aircrafttraversing the skies.

Most of us have already enjoyed the opportunity of flying onairliners such as the Airbus A380, and now aircraft as new asthe Boeing 787 Dreamliner. Air travel is a way of life for many.

Add to this the increasing number of private aircraft ownerswho are purchasing and flying their own aircraft, either forrecreational purposes or for business use. Not only are thesefolk investing in your traditional light aircraft, from the Cessnaand Piper families, but now also large jet-types, includingBoeing in the form of the BBJ, as well as an array of very lightbusiness jets (VLJ) that are in many ways affordable, and apleasure to own and fly. This is to mention but only a few.

Lately this has presented the international aviation industrywith a challenge regarding the governance and regulationof these activities within an already crowded commercialindustry.

To respond to the myriad of developments, ICAO has beenactively engaging authorities the world over to align theirPart 91 (more commonly known as “General Aviation”)regulations to ensure consistency and fair legislativerepresentation .

What is Part 91?

For the purpose of ensuring a common understanding, I willsummarize. Part 91 regulations and technical standards coverthe flight rules and regulations pertaining to non-commercialflight operations. The Part also contains general operatingand flight rules which are applicable to everyone who takesto the sky.

The section is very broad in scope, however it provides generalguidance in the areas of general flight rules, visual flight rules(VFR), instrument flight rules (IFR), aircraft maintenance, andpreventative maintenance and alterations, amongst manyothers.

Locally, the Part 91 sector has been largely overlooked interms of oversight. It comes as no surprise that the SACAAand industry jointly acknowledge that operations in this sectorhave not been complying with regulations and standardrequirements. This non-compliance has opened up room forillegal and dangerous operations which often take placeunder this Part.

The revision of the Part 91 CATs and CARs has been a two-year process involving members of the industry, with ICAOas the driving force in aligning the regulations with internationalstandards. As a result, you will now notice a significant change

in the regulations pertaining to Part 91. Please consult therelevant CATs and CARs for full details about these changes,or one of the inspectorates mentioned in this article forassistance in this regard.

Statistically speaking

The graph below indicates the number of accidents per flyingactivity in the last 12-month period.

From this table, we can clearly see where the problems lie.The large number of accidents within the private sector inSouth Africa is, short of a better word, unacceptable.

Globally, it would be adequate to compare our statistics witheither New Zealand or Australia; Australia being the first choiceas they have an almost equal number of registered aircraftas SA, and activity within general aviation is also similar.

General aviation operations in Australia continue to have anaccident rate higher than for commercial air transportoperations: in 2011, about four times higher for accidents,and nine times higher for fatal accidents than in 2002.

For general aviation aircraft, accidents and serious incidentsoften involved terrain collisions, aircraft separation issues, oraircraft control problems. Where general aviation aircraftwere involved in an incident, airspace incursions, failure tocomply with air traffic control, and wildlife strikes werecommon.

In an ongoing attempt to reduce the number of accidentsand incidents within the private and GA sector, as well as toensure that legislation and technical standards are alignedwith ICAO and international best practice, the SACAA hasappointed additional inspectors. These inspectors will focusspecifically on operations under this part, and will beincreasingly visible and active within this focus area to mitigatethe risks posed.

Part 91 - A strong focus going forwardBy Mark Swarts

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The team

The newly appointed Part 91 team comprises three individualswho bring with them much aviation expertise, and who arealso still active aviators within their respective sectors. Theteam functions under the leadership of Ms Yolinda Mooloo.

Mark Swarts - Mark is the holder of a BCom Managementdegree from the University of Johannesburg. His aviation careerincludes six years of working within the air traffic managementbusiness at ATNS, followed by his tenure as a four-year, full-time commercial pilot and marketing representative for BateleurAir Charter flying Beechcraft King Air, 1900 and Cessna Citationaircraft. Mark is currently completing his Flight Instructor’s rating,and has also been actively involved with aviation EnglishLanguage Proficiency. He may be contacted atswartsm@caa.co.za.

Shakil Sayed - Shakil has been in the aviation industry for morethan 10 years, having been actively involved in GeneralAviation. Shakil hails from an instructional background, andremains involved in instruction. Contact Shakil atsayeds@caa.co.za.

Tshepo Sello - Tshepo worked for SAA for a period of 10 yearsbefore flying for Naturelink as a charter pilot for two years.Before joining the CAA earlier this year, Tshepo also flew forSA Express for two years, flying the Canadair Regional Jetrange. Tshepo can be contacted at sellot@caa.co.za.

A consolidated plan

The Part 91 team has already commenced work to get a fullunderstanding of the state of the GA sector. The overridingpriority for the team is to offer a helping hand to the industryto ensure compliance with new regulations and standards,thereby keeping everyone safe in enjoying what they lovemost… flying. As part of its mandate, the team members willeach be specialising in an array of activities to help bring thelocal industry to par with international best practice.

1) Increased presence on airfields across the country.

All three team members have prepared a mastersurveillance plan which will take them across the countryto large and small airfields alike to meet with local GA pilotsand institutions, and to conduct ad-hoc ramp inspectionsto gauge the state of legislative compliance within thissector.

2) Education is of vital importance.Strengthened relationships with institutions, including thelikes of the Recreation Aviation Administration SA (RAASA)and the Aero Club of South Africa, will present theopportunity for direct support to these organisations, suchas being accompanied on visits and roadshows aroundthe country to educate industry, and help them withcompliance concerns and issues.

3) Strengthened ties with the GA sector.As pilots themselves, the team understands the passion forflight. With this in mind, the team extends an offer of supportto everyone within the GA sector. Legislation is, however,fundamental, and as such the team will have to ensureenforcement of legislation where activities are illegal anddangerous.

4) Flight operations support for airshows.Mark has dedicated his time to provide flight operationssupport at all local airshows to ensure that the necessarysupport can be provided in this wonderful service to thegeneral public.

Our aim

The overriding priority for the team with the support of theircolleagues at the SACAA as well as the industry, is to reducethe number of aviation accidents and incidents; to educatethose enjoying the privileges of their flying licences in terms ofregulations and standards; and to enjoy the growth of thisvital economic sector within our country, namely aviation.

We encourage you to get in touch with us. Our passion foraviation is the same as yours – our priorities are too.

International Committee for Airspace Standards and Calibration

The International Committee for Airspace Standardsand Calibration (ICASC) was created following the8th International Flight Inspection Symposium andexists to supplement the biennial formal symposiumsby promoting continuity in the exchange of regulatory,technical, operational and commercial informationin flight inspection. In March 2009 the InternationalCivil Aviation Organisation included ICASC in the listof international organisations that may be invited toattend suitable ICAO meetings.

The picture was taken during the symposium held inCape Town on 23, 24 and 25 October 2012.

From left to right:Herve Renouf, France; Albert Morudi, SACAA; OnorioRocca, Canada; Joe Doubleday, USA

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At some point in a pilot’s career, he/she has been subjectedto the loss of control of an aircraft during flight or groundoperation. Whilst some have been lucky or experiencedrecovery from life-threatening situations, others have suffereda fatal result. Loss of control is a broad subject that may beattributed to many factors.

What is loss of control and the causes?

Loss of control includes significant, unintended departure ofthe aircraft from controlled flight, the operational flight envelope,or usual flight attitudes, including ground events. A deviationfrom controlled flight may lead to an accident or incident. Lossof control occurs due to aircraft design, aircraft malfunction,human performance and so forth.Below are scenarios of accidents that have resulted due to aloss of control and the factors that led to the event.

Scenario 1

On 3 March 2009, the pilot, accompanied by a passenger,intended to depart from Kimberley aerodrome to Ladysmithaerodrome as per the flight plan submitted to Kimberley ATC.The aircraft experienced a loss of engine power during takeoff.The pilot failed to maintain control of the aircraft and crashed.Both pilot and passenger were fatally injured. The investigationrevealed no technical defects that could have caused theaircraft to crash. The aeroplane was destroyed during theaccident sequence and minor damage was caused to theairport perimeter fence and surrounding vegetation.

What caused the accident?

The investigation revealed that the pilot did not maintain thecorrect flying speed after the engine failure, as the result of anover-rich mixture setting. Contributory to the cause of theaccident was the fact that the auxiliary power switch hadbeen inadvertently switched off, as it was presumably mistakenfor a landing gear switch.

Scenario 2

The pilot took off from Swellendam aerodrome on a privateflight to complete a circuit with the intention of landing at thesame aerodrome. The pilot encountered fog after takeoff anddecided to return to the aerodrome. He subsequently lost

control of the aircraft and crashed on the threshold of therunway. The pilot sustained serious injuries and was taken to ahospital. The aircraft was destroyed.

What caused the accident?

The pilot lost control of the aircraft when he became spatiallydisorientated in dense fog after takeoff during an attempt toreturn to the airport. In addition to that, the pilot did not obtaina weather report before the flight.

Scenario 3

The pilot stated that he was to perform a crop spraying detail.During the takeoff roll he lost directional control and the aircraft’sleft wing clipped a tree next to the runway, which caused theaircraft to ground loop through 180 degrees, leaving the aircraftentangled in trees next to the runway.

The pilot sustained minor injuries to his hand. The aircraft sufferedsubstantial damage to the wings, airframe, engine and propeller.

What caused the accident?

The pilot lost directional control of the aircraft during the takeoffroll and hit trees next to the runway.

Number of fatalities in South Africa resulting from a loss ofcontrol

Loss of controlBy Bongi Mtlokwa and Renisha Naidoo

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A total of 64 Loss of Control (LOC) accidents were reported inthe period under review (2009 – 2011). Four of these were fatalaccidents with a total of six fatalities. Eleven people sustainedserious injuries in these accidents. In addition, a total of 104people were exposed to the LOC accidents. It goes withoutsaying that LOC accidents can result in serious injuries andfatalities in addition to damage of property. Are LOC accidentsavoidable? To answer the question, we must first understandthe causes of LOC accidents.

What causes LOC Accidents?

Loss of control is caused by various factors, including lack ofadequate training in handling the aircraft in adverse weatherconditions, deep landings, runway surface conditions, poormaintenance of the aircraft, etc. Loss of control can happenduring takeoff, in flight and during landing.

LOC Accidents according to phase of flight

Fifty-five percent of LOC accidents occur in the landing phase,followed by 24 % during the takeoff phase. In the landing phase,reports have showed that aircraft veer off the runway just aftertouchdown. In some instances the approach is not stable,which may lead to deep landings which are followed by veeringoff the runway or runway overruns, in some instances.Reports have indicated that the recurring cause of loss ofdirectional control during the landing phase is the weather,more specifically wind shear, crosswinds and gusty conditions.

LOC Accidents per type of operations and prevention

The above graph indicates that 61% of LOC accidents occurduring private operations, followed by training operations with34%. Few pilots in the private sector are able to stay currentand practise their emergency procedures on a regular basis.When faced with adverse weather conditions or an emergencysituation, they lack the coordination to regain control of theaircraft expediently and safely. Many pilots develop adependence on automated systems and rarely exercise theirmanual flying skills. By developing guidelines for frequency ofmanual flight time for normal and abnormal operations, pilotscan maintain their flying proficiency. During flight training, thestudent has the security of a more experienced pilot (instructor)on board. However, sometimes the instructor may becomecomplacent and that places both occupants in a dangeroussituation. Students have fairly limited decision-making abilities,

however this usually improves with more experience and training.When placed in a situation outside of the norm, students mayact on impulse rather than a logical sequence. By providingenhanced training programmes that aid students inunderstanding the behaviour of an aircraft near or outside thelimits of normal flight regimes, for example completing a circuittraining session in crosswind conditions, pilots are better equippedto handle these conditions. This also applies to the introductionof better warning systems that display incorrect configurationduring critical phases of flight for aircraft operating in closeproximity to the ground, for example game capture (helicopters).

Geographical presentation of LOC Accidents

This is the geographical presentation of LOC accidents. Gautengis the highest; this could be attributed to the fact that theprovince has high aviation activity.

Conclusion

Experience makes us wiser and by educating fellow aviators,we prevent future occurrences. By improving training standardsthat assist aviators to mitigate risks during abnormal proceduresand instilling a safety culture amongst pilots, we can preventfuture LOC fatalities. So the next time you hear a pilot bragabout his close encounter with death, take a moment to remindhim of the family he almost left behind. Fly safely and remember,when in doubt, have a cup of coffee.

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It was my privilege to have been invited to deliver a key-notelecture at the 1st International Loss-of-Control-Inflight (LOC-I) Conference/Workshop ("How to tackle Aviation’s numberone killer?") for the Institute for Flight Safety (Institut fuerFlugsicherheit) in Salzburg, Austria last November. I washumbled by the amazing gathering of expertise at thisconference, from test pilots developing the latest technologyat Lockheed-Martin, Airbus and Boeing, to German, Americanand British human factor specialists. It was also a specialexperience to have had the opportunity to chat to the TurkishAirlines safety manager who investigated their B737-800 crashin Schiphol. He presented a thought-provoking presentationon the event, with many lessons learned.

According to Dr. Deiter Reisinger, the coordinator of theevent, LOC-I has killed more than 5 000 people in commercialaviation over the last decade. General aviation is equallyaffected, with the number of stall and spin accidentscontinuing to be high. Despite the proliferation of advancedtechnology, such as fly-by-wire and soft or hard envelopeprotection, these types of accidents continue to haunt oursafety critical environment. What is wrong with pilots? Is thisa training issue? Do we have to do more research on humanmotion perception and motion cueing? Are simulators usedin today’s training good enough? These were the questionsposed by the organisers, and after two intense days of debate,I’m still unsure of the most cost-effective way forward intackling the issues related to LOC-I. The goal of thisconference/workshop was to bring together researchers, testpilots, certification staff, regulatory bodies and pilots to helpshape the future. There may be solutions to the issue –however, all industry members, from airlines to regulators,must agree on certain steps and implement change. Thequestion with which I left, and which is still hanging over mewas, “Are we ready for the change?”

Loss of control is defined in literature as an unintendeddeviation by the pilot or crew of an aircraft from the intendedflight path. This deviation or loss of control from the intendedflight path manifests itself within three basic realms of flight,such as a stall, spin, or overbanked flight. According to NASAresearch, numerous human factors are at the root cause ofLOC-I, including improper training and gaps in training,automation confusion, distraction and loss of awareness.Environmentally, it includes weather, wake vortices, foreignobject damage, and at a systems-induced level, issues includesuch elements as poor design, failed components, loss ofcontrol power, propulsion problems, and so on.

There was an agreement amongst the delegates that thecurrent global regulatory requirements for recovery fromLOC-I are inadequate and do not stress sufficiently therecurrent basic flying skills necessary to prevent such loss ofcontrol.

Although the conference was packed with interesting andthought-provoking discussions, I will mention only a few ofthem here.

Somatographic illusion

In trying to make the go-around a safer manoeuvre, researchwarns of the somatographic illusion. During the go-around

a pilot may become distracted by the speed of the aircraftas it begins to approach VFE (an IAS increasing quicklytowards the barber’s pole has a powerful attracting effect,moving eyes away from a proper scan), and the sensationof climb from the accelerating inner ear fluid, can result ina dangerous, unintentional descent. Such was the case inthe Gulf Air A320 accident and the Afriqiyah A330 crash,where a fly-by-wire system had also played a contributoryeffect. Additionally, it was discussed that pilots’ aggressivenesswith the flight controls can result in adverse PIO (pilot inducedoscillation). Be aware of the go-around very close to theground, and avoid that tail-scrape. The safety effort thereforerelies on finesse, together with the maintenance of a robustand disciplined pilot scan during phases of flight with highworkloads. Training should thus identify where the breakdownin the scan occurs, and set prevention strategies from theseconclusions.

Automation-related LOC

In another case study, a go-around below 200’ in an AirbusA330 had resulted in a tail scrape. Basically what happenedwas that on a short final approach, with the autopilotengaged, the thrust had transitioned into an idle state. Thepilot flying elected to continue with a go-around manoeuvre,however the pilot had failed to take the levers completelyinto the TOGA detent, bringing it back into the CLB detent,whereby the auto-thrust system remained at IDLE, resultingin a few red faces. This highlights the importance of knowingthe automation system of the complex aircraft thoroughly,and comprehending the various FMA indications in order toavoid a loss of control situation.

High-altitude LOC

Captain Hiromitsu of ANA gave us a step-by-step accountof the B737 in-flight incident of 2011. In this case, Reason’sholes in the Swiss cheese had lined up in such a way that theaircraft was no longer under control and plummeted from41000’, only to be recovered at 34000’. The aircraft had rolledleft and briefly reached an angle of 131.7 degrees, with apitch of 35 degrees nose down. It was found that the veryjunior co-pilot had transitioned between two B737 types, witha fundamental ergonomic anomaly. The trim switch on thefirst aircraft was in the same position as the door mechanismswitch of the second aircraft type he’d been operating. AddATC distraction to this mix, and you have a recipe for potentialdisaster. What became clear from this was the fact thatinappropriate management of distraction can easily lead toa loss of control scenario.

LOC defence methods

There was a lively debate on the utilisation and necessity ofan AOA indication for pilots on large to medium size transportclass aircraft. To summarise from commercial licence theory;the angle of attack ( ) is the angle between the chord lineof an aerofoil and the vector representing the relative motionbetween the body and the fluid through which it is moving.The AOA vane, with which we’re familiar on our aircraft, givesimportant information to the air data computers and flightmanagement systems in terms of flaps/slats requirements,etcetera. However, would the actual indication on the flight

Experiences at the European Test Pilots’ Loss-Of-Control-Inflight (LOC-I)Workshop in Salzburg, Austria.

By Dr Preven Naidoo

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deck be of benefit? The speaker on the topic agreed that itwould, and could eliminate many errors during takeoff orlanding. However, the accuracy of the instrument itself wouldbe of paramount importance. However, we do have subtlecues of AOA currently in our aircraft. By being cognisant of thedifference between actual air speed and stalling speed, pitchangle and FPA, and of course the pitch limit indicator, we areprovided with the situational awareness necessary to avoidexcess AOAs leading to aerodynamic stall situations andresultant loss of control (Figure 1). The jury is still out on thepossibility of an actual indication for normal operations (we dohave the emergency BUSS setup, or back-up speed system,on the A330, with loss of ADRs). Nonetheless, the balancebetween cost and benefit will be the ultimate referee in thissituation.

Figure 1

By transitioning from the dial-type display to the ribbon concept,the modern flight deck has lost some of the basic peripheralcues we could utilise for situational awareness. However, thebasic mantra echoed at this safety conference was that theaerofoil flies on pitch and thrust, in other words, at a particularangle of attack. Pilots flying modern, advanced aircraft shouldremember the basics, which make the difference; i.e., scan,detect deviations, and change ATTITUDE (both the aircraft’sand the pilot’s). Capability does not mean expertise. With anincrease in aircraft technology, there comes an increase incapability (improved safety), however, there is also a subtlereduction in expertise (that is, actual flying skill). It is up to eachindividual advanced aircraft pilot to maintain his or her ownskill/expertise. I believe that the most appropriate place toaccomplish this is in a flight simulator. Practice (proficiency),makes…permanent.

The standard level D simulator has a limited aerodynamicenvelope, and therefore will not simulate accurate stallingbeyond CLMax; it can be said then that the basic airlinesimulator is somewhat limited (Figure 3) for loss-of-control training,in that it may encourage inappropriate control inputs andcreate surprises onboard the actual aircraft. Nonetheless, Ibelieve that there is potential use in providing an avenue togain confidence. At present some amazing developments inthe flight simulator industry are taking place in Europe at AMST(Austria Metall System Technik GmbH). We were introduced tothe SUPRA project (simulation of upset and stall behaviour oftransport category aircraft) and Desdemona (Figure 2), theresearch tool combining flight simulation, disorientation trainingand a human centrifuge. Named after Shakespeare'sDesdemona, the Venetian beauty who enraged her fatherwhen she eloped with Othello, Desdemona the flight simulatoris capable of sustaining as much as 7Gs. She is a truly uniquesimulation tool, due to the special characteristics of herremarkable and innovative motion platform. The aim of such

training is to provide the pilot with the right tool in an emergencyloss-of-control event. Practice to proficiency, makes permanent.This may be the next training step for the airline transport pilot.

Figure 2: AMST’s Desdemona

Figure 3: Typical Airbus flight simulator envelope

Conclusion

Loss-of-control training for large transport category aircraft ispossibly the next big challenge for airlines. We as pilots arethe last line of defence in a highly complex environment, andmaintaining high levels of expertise is the least we can do forthe privilege of being at the cutting edge of humankind’s mostimpressive achievements to date.

Fly safely.

Acronyms:

NASA - National Aeronautics and Space AdministrationVFE - Maximum indicated airspeed with flaps.IAS - Indicated Air SpeedTOGA - Take Off/Go AroundCLB - ClimbFMA - Flight Mode AnnunciatorAOA - Angle of AttackFPA - Flight Path AngleADRs - Air Data Reference

Without the intervention of maintenance personnel,equipment used in complex technological systems such asaviation, rail and marine transport would drift towards a levelof unreliability that would rapidly threaten efficiency andsafety. Despite the essential contribution of maintenance tosystem reliability, inadequate maintenance is, however, alsoa major cause of system failure. Understanding the humanfactors in maintenance is more necessary than ever, if weare to improve safety and reliabil ity in aviation.

Since the end of World War II, human factors researchershave studied pilots and the tasks they perform, as well as airtraffic control and cabin safety issues. However, until recently,maintenance personnel were overlooked by the humanfactors profession. Yet, maintenance is one of the largestcosts incurred by airlines. It has been estimated that for everyhour of flight, 12 man-hours of maintenance occur. Mostsignificantly, maintenance errors can have grave implicationsfor flight safety.

Maintenance personnel are confronted with a set of humanfactors unique within aviation. Maintenance technicians workin an environment that is more hazardous than most otherjobs. Furthermore, dealing with documentation is a keyactivity, and maintenance engineers typically spend nearlyas much time wielding a pen as they do holding a screwdriver.

Maintenance personnel thus face unique sources of stress.When maintenance personnel leave work at the end of theirshift, they know that the work they performed will be reliedon by crew and passengers for months or years into the future.It is also true that the emotional burden on maintenancepersonnel whose work has been involved in accidents islargely unrecognised outside the maintenance fraternity.

In order to understand how and why maintenance errorsoccur, we first need to understand the organisational contextin which they occur. Figure 1, below, shows the main causalelements involved in accidents and incidents:

Organisational inf luences on maintenance error

Factors such as training and qualification systems, theallocation of resources, and the cultural or value systemscould all contribute to maintenance errors. One of the mostcommon reasons given for maintenance violations is timepressure, and this in turn may be symptomatic of organisationalconditions such as planning, staffing levels, or work scheduling.

Local conditions

The individual actions that lead to maintenance incidentsoften reflect local conditions present in the workplace at thetime of the action. Accurately identifying the nature of anerror and the local conditions that prompted it, is a critical

step towards identifying how the system can be improvedto prevent the problem from occurring again. Some of theconditions in maintenance which produce errors and violationsmore frequently are:

- Time pressure- Maintenance procedures and documentation- Teamwork- Shift handover- Group norms- Fatigue- Lack of system knowledge- Equipment deficiencies- Design for maintainability

Individual actions

It has been estimated that human error is involved in 70percent of aircraft accidents. The use of the term ‘humanerror’ should not imply that we have a problem with people.In many cases, maintenance errors are symptoms ofunderlying problems within the organisation. Although theyare unwanted events, errors are valuable opportunities toidentify improvements. There are two main approaches todescribing errors: physical descriptions and psychologicaldescriptions.

Physical descriptions of errors

A simple approach to the categorisation of human errors isto describe them in terms of the observable actions of theerror-maker. Errors are frequently divided into acts of omission,commission, or timing and precision. Physical descriptionscan be useful and, in most cases, are relatively easy to apply.Unfortunately, they give very little insight into why the erroroccurred, or what it reveals about the wider system.

Psychological descriptions of errors

Psychological error models require us to categorise errors

Human factors in aviation maintenanceAn extract from a report produced by the Australian Transport Safety Bureau

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according to the person’s intentions at the time of his/her action. An advantage of psychological descriptions is that they enableus to place the error in its organisational context, and thendevelop countermeasures tailored to the root causes of theproblem. In the report the following six psychological error typesrelevant to maintenance are considered:

- Perception errors- Memory lapses- Slips- Wrong assumptions- Technical misunderstandings- Procedure violations

Risk controls

Risk controls are features put in place to manage hazards inthe workplace. There are two main types of risk controls relatedto maintenance error – preventative controls and recovery riskcontrols.

Preventative risk controls are intended to reduce the chanceof unwanted events such as human error. Examples ofpreventative risk controls are components designed to preventincorrect installation, or streamers on rigging pins that reducethe chance that the pin will be inadvertently left in place. Inother cases, preventative risk controls take the form of training,qualifications, or procedures such as the use of shadow boardsor other methods to keep tools under control.

Recovery risk controls are designed to detect and recover froma dangerous situation once it has started to develop. Functionalchecks and duplicate inspections are examples of proceduresdesigned to detect maintenance errors.

Managing the risk of maintenance errors

Error management systems - In airline maintenance, there is anincreasing emphasis on error management as an integral partof an organisation’s safety management system (SMS).According to the International Civil Aviation Organisation (ICAO),an effective SMS requires strong management commitmentand attention to concerns, ranging from corporate culture toevent invest igat ion and human factors t ra in ing.

Incident reporting programmes in maintenance - Progress isslowly being made towards error reporting systems that enable

maintenance engineers to disclose genuine mistakes withoutfear of punishment. While all involved in aviation safety mustbe prepared to take responsibility for their actions, a punitiveresponse to genuine errors is ultimately counterproductive.

Human Factors Training - Until relatively recently, human factorstraining was rarely provided to maintenance personnel. In the1990s, an initial wave of maintenance human factors trainingcourses began in the US, modelled on successful cockpit resourcemanagement training. This early training was typically referredto as maintenance resource management (MRM). A secondwave of maintenance human factors training has beengenerated by new requirements from ICAO, EASA, and TransportCanada that call for maintenance staff to have knowledge ofhuman factors principles.

Learning from incidents - In most cases, the immediatecircumstances of a mishap are symptoms of deeper,fundamental problems. Treating the symptoms of a problemwill rarely lead to adequate solutions, and may even makethings worse. To make lasting improvements we need to identifyand treat the underlying fundamental origins, or root causes,of mishaps.

Incident Investigation Systems - Incident reports provide valuableraw material from which safety lessons can be extracted. Inrecent years, several investigation techniques have beendeveloped speci f ical ly for a i r l ine maintenance.

Conclusion

The aviation industry could not function without the contributionof maintenance personnel, yet maintenance error is a significantand continuing threat to aviation safety. While maintenancetechnicians must still take responsibility for their actions, managingthe threat of maintenance error requires a system-level response.The organisational response to maintenance error involves twopaths. Firstly, the probability of maintenance error can beminimised by identifying and counteracting error-producingconditions in the organisation. Secondly, it must beacknowledged that maintenance error is a threat that can bereduced, but never entirely eliminated. Organisational resiliencein the face of human error can be maximised by ensuring thatappropriate risk controls are in place to identify and correcterrors, and minimise the consequences of those errors thatremain undetected, despite the best efforts of the organisation.

- Read the full report on the SACAA website.

Source: US Air Force Website

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