flight safety information journal q4_04

8/10/2019 Flight Safety Information Journal Q4_04

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Flight Safety InformationFOURTH QUARTER 2004

INSIDE THIS ISSUESafety Management Systems Threat Error Management Model

ISASI Seminar 2005

Major Accidents/Incidents


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2FSI

Safety Management Systems

(SMS)3

Threat Error ManagementModel

7

ISASI Seminar 20059

Major Accidents / Incidents10

To FSI Subscribers:

Welcome to the Flight Safet

Information Fourth QuarterJournal. The journal is pro-

duced in order to create saf

awareness, provide timely a

valuable safety information

and to ultimately prevent a

dents. I welcome contribu

ing input, articles, and pho

from the readers.

Curt L. Lewis P.E., C

Flight SafetyInformation Journa

Published bywww.fsinfo.org

Managing EditorCurt Lewis P.E., CSP

[email protected]

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Randy [email protected]

Flight Safety Information Quarterly Journal is a service of:Curt Lewis, P.E., CSP

Lewis Engineering & Associateswww.Curt-Lewis.com


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Safety has always be a main design concernin the Aviation industry. The need for Safety

Management is a legal requirement for Air

Navigation Service Providers, but it is also a

business necessity.

A Safety Management System (SMS) is an

integrated set of work prac-

tices, beliefs and procedures

for monitoring and improv-

ing safety. SMS can be de-fined as a formal framework

for integrating safety into day

to day operation and in-

cludes safety goals and per-

formance targets, risk assess-

ments, responsibilities and authorities, rules

and procedures, and monitoring and evalua-

tion processes. It recognizes the potential for

errors and establishes defenses to ensure that

errors do not result in incidents or accidents.

Effective SMS generally have five key ele-

Safety Management Systems

The foundation of SMS is the implementa-

tion of a safety policy with in a company, in

which it expresses its commitment to

achieve the highest levels of safety.

Safety Management Systems make eco-

nomic sense

Not only do SMSs guard against

mishaps, but they also provide

economic benefits in helping the

company: Market the safety standards

of your operation.

Guard against the direct and

indirect costs of incidents and

accidents.

Improve communication, morale and

productivity.

Meet your legal responsibilities to man-

age safety.

Costs associated with an accident/incidents

are direct, indirect and industry/social

costs.

Direct costs:

Are easily measured on-the-spot; mostly re-

lated to physical damage; employee injuries

and aircraft equipment damage as well as

property damage.

Indirect costs:Indirect costs are usually higher and less

obvious, causing delays.

Clear policies.

Effective organization.

Systematic planning.

Performance measurement.

Audit and review process.

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Fig 1 Safety Management Cycle


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Indirect costs include:

Loss of business and

damage to the reputation

of the organization

Legal and damages claims

Surplus spares, tools and

training: If you have a

spares inventory and peo-

ple trained for a one-of-a-

kind aircraft that is in-

volved in an accident, the

spares and training be-

come surplus overnight.In many cases, the sale

value of the spares is be-

low the purchase cost.

The requirement for a

Safety Management System

Every organization needs a

functioning management

system that has continuity

throughout the organizationand provides positive control

of the operation. The system

must have the accountability

to ensue the effectiveness

and integrity of the opera-

tional management and con-

trol system.

The organization needs to

identify and assign responsi-

bility within the management

system for ensuring compli-

ance with regulatory require-

ments and established inter-

nal standards.

Components of a Safety

Management System

For each component of an

SMS where specific proce-

dures and processes are nec-

essary, check lists or flow

charts need to be developed

to facilitate implementation.All components of an SMS

should be reviewed on a

regular basis to ensure that

they remain current and rele-

vant to the organization.

All policies must be comple-

mented with clearly defined

procedures and processes

detailing how the policy is to

be implement and managed.

The following components,

as a minimum, should be

included in an SMS:

Policy: A policy statement re-

garding the company safety

goals should:

Contain a senior manage-

ment commitment to

safety as a fundamental

priority throughout the

organization and be signed

by the accountable execu-

tive;

Contain a clear statement

of objectives indicating the

organization's safety re-quirements and the princi-

ples and measures neces-

sary to conform to state

and local safety regula-

tions;

Promote a safety culture

embracing a non-punitive

reporting procedure;

Be relevant to the organi-

zation's operations;

Identify clearly that thesafety principles outlined

in the SMS policy state-

ment applies to employ-

ees, agents and other con-

tracted parties; and

The SMS should cover

procedures for reporting

and coordinating events

and activities performed

by other organizations that

are subject to their own

safety management sys-

tems, between the relevant

systems.


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Accountabilities: Ultimate responsibility

for the SMS remains at all times with the

accountable executive; however, responsi-bility for the implementation of the SMS

may be delegated to an identified respon-

sible person. The safety responsibilities of

managers and employees at different lev-

els in the organization should be clearly

defined and documented. Effective depu-

tation of responsibilities should be estab-

lished for operationally critical areas of

the operation when principal office hold-

ers are absent.

Flight Safety Program: The Flight Safety

Program should have: A responsible manager having the appro-

priate qualifications, significant authority

and independence from operational and

line management responsibilities.

A flight safety management plan that

describes the philosophy, structure,

responsibilities, resources and proc-

esses in place to prevent accidentsand achieve safe operations.

A process for setting safety goals as a

means of establishing an indication of

flight safety performance.

Accident Prevention Program: The acci-

dent prevention program should include:

A process to ensure the capture and

analysis of information that can be

used to identify operational hazards.

A process for the investigation of air-craft accidents and serious incidents.

The process should include proce-

dures for an interface with relevant

government regulatory and investiga-

tive agencies, as well as other entities,

including original equipment manu-

facturers.

A process for identifying and investigat-

ing internal events, occurrences and ir-

regularities that might be precursors toan accident or serious incident.

A process to ensure the implementation

of action by appropriate operational

managers to correct and prevent non-

conformities that affect flight operations.

A process to ensure regular and periodic

management reviews of significant and

relevant safety issues arising from the ac-

cident prevention and flight safety pro-

gram. A safety reporting system that permits

feedback from personnel regarding haz-

ards and safety related concerns, and in-

cludes analysis and action by manage-

ment as appropriate to identify and ad-

dress safety deficiencies.

A process to ensure dissemination of

flight safety information to appropriate

operational and other personnel to pro-

mote continuing education and interest.

Risk Management Program: Risk manage-

ment is the cornerstone of an SMS, and com-

prises three essential elements: hazard identi-

fication, risk assessment and risk control.

Proactive processes to collect and analyze

data from routine monitoring processes,

incidents, inspections and audits to assist

in hazard identification are required.

Hazards identified from data analysis and

trending need further assessment to de-

termine any potentially adverse conse-

quences in terms of risk exposure.

Based on the risk assessment process,

risks may be categorized with a degree of

acceptability and control measures intro-

duced to deal with those deemed unde-

sirable or unacceptable.


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Emergency Response Program: An SMS

should include contingency plans to ensure

the proper response demanded of different

parts of an organization when an emer-gency arises. The emergency response plan

must be assigned to a responsible manager

and reviewed as part of an SMS periodic

review, and also following any change to

key safety personnel, or any change to the

organization's operation that may affect

safety. The organization must have proce-

dures in place to ensure the effective com-

munication of the emergency response plan

to all personnel, including sub-contractors

and visitors.

Audits and Inspections: The accountable

executive is responsible for periodic reviews

of the SMS to confirm that the system re-

mains effective. The reviews may be per-

formed by persons within the organization

or by external means. Persons whose role

and reporting relationships are independ-

ent of the tasks, functions or operations

being evaluated should, to the maximumextent possible, perform the reviews.

IATA Operational Safety Audit (IOSA):

Section 1 of the IOSA Standards Manual

(ISM) and the associated Guidance Notes

incorporates all of the requirements of an

airline management system, including both

Safety and Quality Management Systems. It

follows that compliance with the IOSA re-

quirements achieves the necessary stan-

dards in SMS.

* * * *

References

Civil Aviation Authority Australia (2002)

Safety management systems: What's

in it for you? Http://www.casa.gov.

au/avreg/business/sms/guidance.

htm

Transport Canada Civil Aviation (2004) Safety

management Systems for small

aviation operations- A practical guide to

implementation. http://www.tc.

gc.ca/civilaviation/general/

Flttrain/SMS/TP14135-1/ menu.htm

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Threat Error Management ModelIt is inevitable that error will occur within a

system no matter how strenuously it was engi-

neered out. Threat error management (TEM)

is a framework for understanding operational

performance in complex environments. It fo-

cuses simultaneously on the operating environ-

ment and the humans working in it. The TEM

model proposes that threats and errors are an

integral part of daily flight operations and that

they must be managed by the flight crews toensure the safe outcome of flights. Threats are

events that are external to the flight deck and

must be managed by flight crew during normal

everyday flights.

In the model of threat and error management,

external threats are defined as situations, events

or errors that originate outside of the cockpit,

i.e. high terrain, poor weather, aircraft system

malfunction, errors made by the crew or main-

tenance, and Air Traffic Controllers (ATCO).

Such events increase operational complexity

and pose a potential safety risk to the mission.

Threats are to be expected by the crew and

briefed in advance. They may also be unex-

pected, appearing without warning or possibil-

ity of briefing.

Some threats are minor (a slight discrep-ancy in dispatch papers) or major (an incor-

rect altitude assignment).

Threat management is the act of minimiz-

ing the potential for the threat to occur.Errors are actions or inactions by the crew

that lead to deviations from organizational

or flight crew intentions or expectations.Errors in the operational context tend to

reduce the margin of safety and posea potential risk to the flight.

Fig 2 ICAO November 2004

Threat & Error Management Model

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Errors may be minor (selecting the

wrong altitude into the mode con-

trol panel,

but catching it quickly) or major

(forgetting to do an essential check-

list). The TEM model provides a

quantifiable framework to collect

and categorize safety data.

To be effective in establishing a

safety culture in an organization, it

must be established based on data

regarding the organizations prac-

tices and the threats inherent in

the operational context.

Multiple sources are used, one of

which is the Line OperationsSafety Audit (LOSA) in which ex-

pert observers collect data in the

cockpit during

normal opera-

tions. InLOSA, trained

observers record

and code poten-

tial threats to

safety and how

the threats areaddressed during

the flight. They

also record and

code the errors

such threats generate, and how

flight crews manage these

errors. The TEM model has been

successfully incorporated into air-

line training programs and, in some

cases, has replaced crew resource

management (CRM) training.

To be effective in

establishing a safety

culture in an or-

ganization, it must

be established based

on data regarding

the organizations

practices and the

threats inherent in

the operational

context.

The Air Traffic Services (ATS)

equivalent of CRM training is called

team resource management (TRM)

training. The integration of the

TEM model in TRM training may

lay the foundations for future opera-

tions safety monitoring in ATS.

* * * *

References

Helmreich, R. L., Klinect, J. R., &

Wilhelm, J. A. (2004). Models

of threat, error, & CRM in flightoperations. The University of

Texas at Austin.

Http://homepage.psy.utexas.edu

/homepage/group/Hemrich

LAB/Publications/pubfiles/

Pub240.pdf

Helmreich, R. L., Klinect, J. R., &

Wilhelm, J.A. (2004). Threat

& Error Management: Data

from line operations safety audits.

The University of Texas at

Austin.

Threat & Error Management Model (Doc

9803). (2004).

www.eurocontrol.int/safety/galle

ry/ content/public/library/

TEM%20&%20NOSS

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Accident / Incident OverviewFourth Quarter 2004

DATE AIRCRAFT REGISTRATION OPERATOR FATALITIES LOCATION

Sept 23 Cessna 208 N7392B Eagle Air Cargo 0 USA

Sept 25 Ford Tri-Motor N750RW private 0 USA

Oct 3 Howard 250 N6371C American Air-power

0 USA

Oct 5 Antonov 12 ST-SAF? Sarit Airlines 4 Sudan

Substantially damaged during an in-flight collision with terrain

The Bushmaster, a Ford Tri-Motor replica plane, took part in an air showat Fullerton. As it was attempting to takeoff, it departed runway 24. Thepilot pulled up to avoid ramp personnel. It just missed the control towerand slammed onto a street, sideswiping a car. The plane broke apart onimpact and erupted in flames.

The Howard 250, a converted Lockheed L-18, was prepared for take-off from Midland following the conclusion of the Fina-CAF AirSho.The aircraft was cleared for a runway 34L departure with winds at140 deg. /9 kts. Shortly after starting the takeoff roll the airplane be-gan to swerve to the right. Using the rudder the captain was able tocorrect back to the centerline. The airplane then swerved to the leftand using full right rudder the captain reported that he could not ar-rest the left turn. By the time the airplane reached the left side of therunway, the airplane had not reached the V2 speed (minimum takeofsafety speed) of 110 knots. The airplane departed the left side of therunway, became airborne and shortly thereafter, the right wing

dipped and contacted the ground. The airplane then spun 180 de-grees, impacted the terrain, and slid backwards coming to rest in anupright position.

The Antonov, piloted by four Russian crew members, reportedlyleft El Obeid around 11:35 for a flight to Juba. Weather circum-stances forced the crew to divert to Higlig. The aircraft crashed,killing al aboard. The identity of the plane has not been confirmed.


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Oct 08 Fokker F-28 S2-ACH Biman Bangla-desh

0 Bangladesh

Oct 14 Boeing 747 9G-MKJ MK Airlines 7 Canada

Oct 14 Canadair Re-gional Jet

N8396A Pinnacle Airlines 2 USA

Oct 15 Douglas DC-3 HK-1503 Aerovanguardia 3 Columbia

Biman flight 601 touched down far down Sylhet's 9000-feet runway 11/29The airplane overran the wet runway by 150 feet and ended up in a 20 ftwide canal. The cockpit sustained serious damage. The crew memberswere rescued from the wreckage after several hours. It had not yet beenconfirmed that the plane is damaged beyond repair. Damage to the for-ward fuselage is serious.

At 00:03 local time MK Airlines flight 1602 departed Windsor Locks-Bradley International Airport for a flight to Zaragoza, Spain with a cargoof lawn tractors. Take-off clearance was then given at 03:52 and thecrew conducted rolling take-off from near the end of Runway 24. TheBoeing 747 accelerated down the runway, but was unable to pick upenough speed. The tail contacted the runway and at a speed of about130 kts, 30 kts below take-off speed, the aircraft overran the runway.The tail smashed against a berm, causing it to separate from the mainfuselage. The airplane skidded into a wooded area and began to breakup. The wings separated and a fire started, which consumed the fuse-

lage.

At 22:08, the flight crew stated that they had a double engine failure andthat they wanted a direct route to any airport. Kansas City ARTCC di-rected the flight to Jefferson City Airport. At about 22:13, the flight crewstated that they had the runway approach end in sight. The airplane didnot make it to the airport and crashed and broke up in a residentialarea. about two miles from the airport. A large fire erupted.

Douglas DC-3 HK-1503 departed Villavicencio at 06:30 in the morningfor a cargo flight to Medelln- Jos Mara Crdova Airport. At 07:35the air traffic controller radioed that weather conditions at the airportwere poor due to fog. The captain then decided to divert to Medillin-Enrique Olaya Herrera Airport. While descending, the airplane struckelectricity wires and crashed into wooded area.


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Oct 19 Jetstream 31 N875JX Corporate Air-lines

13 USA

Oct 24 Learjet 35 N30DK Med Flight AirAmbulance

5 USA

Nov 07 Boeing 747 TF-ARR Air Atlanta Cargo 0 U.A.E.

Nov 18 Jetstream 31 YV-1083C Venezolana 4 Venezuela

Crashed in a wooded area on approach to Kirksville. Eight people arereported dead, five people were missing and there were two known survivors. METAR around the time of the accident (ca 00:33Z):KIRK 192355Z AUTO 03007KT 6SM BR OVC007 09/09 A2995 RMK AO2CIG 004V009 SLP1486//// T00940089 53011 TSNO=KIRK 200019Z AUTO 04005KT 3SM BR OVC003 09/09 A2995 RMK AO2TSNO=

The flight departed Brown Field's runway 8 at 00:23 after dropping amedical patient off, and was returning to Albuquerque. It climbedstraight ahead and the SoCAL TRACON controller instructed the pilotsto turn to a heading of 020 degrees, maintain VFR (visual flight rules),and expect their IFR clearance above 5,000 feet. The aircraft then en-tered a broken-to-overcast layer of clouds and crashed into the OtayMountain at an altitude of 2300 feet. Crashed in an isolated, mountain-ous area approximately two minutes after takeoff.

The aircraft was substantially damaged after overrunning run-way 30/12 (4060 meters long). The aircraft had aborted thetakeoff and could not be brought to a halt on the runway. Re-portedly, some tires burst, the undercarriage collapsed andthe left wing as well as fuselage received substantial struc-tural damage.

While attempting to land on runway 09, the Jetstream collidedwith the fire station to the right of the runway. The METARaround the time of the accident read: SVMI 181700Z 29005KT9999 -DZ BKN013 26/26 Q1013= (wind 290 degrees at 5kts, visi-bility >10000m, light drizzle, 5-7 oktas cloud at 1300ft, tempera-ture 26C dewpoint 26C QNH 1013hPa). A heavy thunderstormwas approaching the airport containing 3-4 oktas cloud at1200ft.

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Nov 21 CanadairRegional Jet

B-3072 China Yunnan 53 China

Nov 22 Gulfstream N85VT Jet Place Inc. 3 USA

Nov 27 CASA 212 N960BW USAF 6 Afghanistan

Nov 28 CanadairChallenger

N873G Air Castle 3 USA

Crashed into a frozen lake in Nanhai Park just two kilometers past therunway. Reportedly the aircraft struck a park ticket office, killing a parkemployee, before it crashed into the water.

Crashed short of the runway in foggy conditions after one of the wingsclipped a light pole. The METAR around the time of the accident read:KHOU 221253Z 12005KT 1/8SM BR BKN001 BKN006 OVC050 22/22A3002 (wind 120 degrees at 5kts, visibility 1/8nm/230 m, mist 5-7 oktascloud at 100ft, 5-7 oktas cloud at 600ft, 8 oktas overcast cloud at 5000ft,temperature 22C, dewpoint 22C, QNH 30.02in)

The CASA 212 was contracted by the US Air Force to supply Ameri-can forces deployed in remote areas of Afghanistan. En route toShindbad the airplane struck the top of Baba Mountain, in the heart of

the Hindu Kush mountains, at an altitude of 16,600 feet. Probably theaircraft had been caught in a narrow valley and crashed as the pilottried to make a steep turn.

The aircraft crashed on takeoff. It reportedly skidded sideways offthe runway, went though a fence and brush before hitting a road-way that ripped the cockpit from the fuselage. The aircraft at-

tempted to depart from Montrose's 7500 feet long runway 31. Theairport reported light snow and mist at the time of the accident.

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Nov 30 MD-80 PK-LMN Lion Airlines 26 Indonesia

Nov 30 HFB-320Hansa Jet

N604GA Grand AireExpress

2 USA

Dec 04 Convair CV-340 N41626 Miami Air Lease 0 USA

Dec 06 Cessna 208 N25SA Salmon Air 2 USA

The MD-82 skidded off the rain-slicked runway on landing. Solo has asingle 8530ft / 2600m runway (08/26).

The aircraft, carrying Grand Aire's president and chief executive,crashed shortly after takeoff from Saint Louis. METAR at the time of theaccident read: KSUS 301354Z 03003KT 3SM -RA BR OVC005 05/04

A3006 RMK AO2 SFC VIS 5 SLP183 P0001 T00500044=

The plane departed Opa-Locka at 08:39 carrying a load consisting ofelectronics, toys and furniture. About four miles offshore, the pilotfelt the plane vibrating and he saw smoke coming from the nr.1 en-gine. The crew were unable to feather the nr.1 propeller and theplane began to lose altitude. The pilot then turned and ditched theplane in the Maule Lake Marina in Miami.

Crashed while on an RNAV approach to runway 31

Dec 10 Antonov 28 GN-97121 Venezuela ANG 16 Venezuela

The M-28 departed Puerto Ayacucho at 09:12 for a flight to LaCarlota. It crashed in mountainous terrain at an altitude ofFL115.

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Dec 11 Embraer 110 PT-WAK NHR Taxi-Aereo 3 Brazil

The Bandeirante departed So Paulo on an early morning mail flighton behalf of TOTAL Linhas Areas. It crashed onto a house in the RuaUirapuru, killing one person inside.

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W H O WE R E Lewis Engineering & Associates is a multidiscipline engineering

and scientific consulting firm. Our personnel are qualified in the fields of:Residential/Light Commercial Engineering, Forensic Engineering,

Product Safety, System Safety, ISO 9001 Certification,

Accident Investigation/Reconstruction, Automotive Crash Worthiness,

Railroad Crossing Collisions

All work is accomplished by or under supervision of a registered Professional En-

gineer (PE) and Certified Safety Professional (CSP).

Curt Lewis P.E., C.S.P.

Lewis Engineering & Associates

Forensic Engineering Structural Safety

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I N D U S T R Y ST N D R D S

We are highly familiar with the industry

standards used to regulate industry

practices and procedures along with

those used to protect your employees

and customers from harm. We canthoroughly examine your business prac-

tices to ensure standards, laws and

codes are being followed appropriately.

Some of the more common standards

include:

ANSI OPEI

UL NIST

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Office:817-303-9096

Cell: 817-845-3983

E-mail: [email protected]

Web: Curt-Lewis.com

Lewis-Engineering.com

P.O. Box 120243

Arlington, TX 76012

USA


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Curt Lewis P.E., CSP

Lewis Engineering & Associates

Office: 817-303-9096 Cell: 817-845-3983 E-mail: [email protected]

Web: Curt-Lewis.com or Lewis-Engineering.com P.O. Box: 120243

Arlington, TX 76012 USA

Aviation Safety Engineering& Accident Investigation

Aviation Safety ProgramLewis Engineering & Associates can assist your company in

developing an effective aviation safety program tailored

Internal Reporting Sys-tem

Safety Information Dis-

tribution

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tee

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spections

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Investigation

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Aviation Safety Engineering goes beyond looking at aircraft and mak-

ing sure they are well maintained. Aviation safety engineering looks at

the big picture. It takes into account every aspect of your business

plus those that might impose risk to your employees or customers.

These areas include:

Airport Facilities and Airfields

Airport and Aircraft Security

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17/19

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