investigating the management factors in an airline accident · ment from u.s. investigative and...

F L I G HT SAFE TY FOUN D A TI O N • F L I G H T S A F E T Y D I G E S T • MAY 1991 1

possible directions to pursue in accident in-quiries.2 Since that time, accident preventionmanagement has received significant endorse-ment from U.S. investigative and regulatorybodies. For example:

“Highest on my personal list [of airline safetyefforts] is a corporate commitment to aviationsafety in the form of a vigorous, viable andvisible proactive flight safety program. … Inaddition to providing an organizational homefor flight safety, management must also con-duct other safety related activities… .” Dr. JohnLauber, member, U.S. National TransportationSafety Board (NTSB).3

“I want to encourage executives of airline com-panies to monitor personally the safety of theiroperations as closely as they monitor their bottomline. … It means providing continuous review

The management factor in aircraft accidentinvestigation has emerged as a relatively re-cent phenomenon, at least in civil aviation.The absence of a specific investigative proto-col is only part of the reason. General lack ofunderstanding of what constitutes safety/ac-cident prevention management is prevalentthroughout many parts of the aviation com-munity.

This discussion essentially is a follow-up totwo papers on accidents and management pub-lished previously. The first (1984) was a chal-lenge to managements, airline or otherwise, tobecome more attentive to accident preventionmanagement for reasons of potential personalliability of executives, as separate from corpo-rate liability in the event of accidents.1 Thesecond (1988) was a discussion of manage-ment factors in aviation safety with a hint of

Investigating the Management FactorsIn an Airline Accident

The significance of management’s role in the sequenceof events ending in accidents is examined and suggestions

are advanced that the influence of management beincluded in accident investigations.

byC.O. Miller, Ph.D.System Safety Inc.

F L I G HT SAFE TY FOUN D A TI O N • F L I G H T S A F E T Y D I G E S T • MAY 19912

and oversight of policies, practices, proceduresand systems to maximize safety. This mayinvolve designating a safety auditor or settingup separate department reporting directly tothe CEO (chief executive officer).” James Busey,administrator, U.S. Federal Aviation Adminis-tration (FAA).4

Some organizations have been proponents ofimproved safety management in recent years.The fact remains, however, that theinvestigation of accidents in civilaviation does not have a proce-dure or protocol that will encour-age examination of managementfailures in a causal sense. For ex-ample, whereas the NTSB has neverbeen bashful about criticizing theFAA, the airlines or manufactur-ers (the three principal managingagencies), its approach seems tobe more oriented towards a spe-cific shortcoming identified withindividuals or a given organiza-tional segment (e.g., pilots, opera-tions, maintenance, design). Themanagement system leading to the deficiencyoften goes unchallenged. That is another wayof saying that examination of the agency orcompany’s accident prevention efforts, or lackthereof, seems to take a back seat to establish-ing after-the-fact causation.

A recent exception to this situation came fromthe NTSB in its examination of “Delta DFW-2.” The occurrence of “Delta DFW-1” was theL-1011 windshear approach accident on Au-gust 2, 1985 at the Dallas/Ft. Worth airport,whereas number 2 was an attempted takeoffof a Boeing 727 with retracted flaps on August31, 1988. In the earlier accident, the board didnot examine the airline’s safety managementstructure (it was examined in subsequent liti-gation).

In Delta DFW-2, the Board recommended thatthe FAA “initiate a joint airline industry taskforce to develop a directed approach to thestructure, functions and responsibilities of airlineflight safety programs with the view towardadvisory and regulatory provisions for suchprograms at all Part 121 (relatively large, sched-

uled) airlines.”5 The FAA responded to theboard’s recommendation on April 12, 1990,when the administrator cited FAA’s urging ofthe airlines to have an internal evaluation (au-dit) program and the FAA’s strengthening ofits own enforcement actions as a response infull to the board’s recommendation.6

Review of the FAA’s proposed evaluation ad-visory circular (AC)7 reveals the FAA is really

calling for an extension of its owninspection authority, not unlike, inprinciple, the “delegated optionauthority” applied to design certi-fication at some manufacturers.Calling this initiative an audit pro-gram fails to address the safetymeaning of the term.

Further indication that managementfactors investigation is an ad hocprocedure at best throughout theworld rests in the absence of anymanagement factor sections in ex-isting civil aviation accident inves-tigation manuals or in regulations

such as International Civil Aviation Organiza-tion (ICAO) Annex 13.8

Accordingly, this discussion examines the sig-nificance of management’s role in accident se-quences of events, recognizing it has a role inall accidents. Suggestions are offered for somespecific steps that could be accomplished toreadily improve the situation.

Background to Management Fac-tors

In Mishap Occurrence or Preven-tion

Effective accident prevention can be linkedinalterably to effective management. This preceptwill be found in the earliest safety textbooksthat were developed in the industrial safetyfield. It also can be found in the attitudes andpractices of some airlines as early as the late1930s. W.A. Patterson, ultimately United’s boardchairman, was frequently cited for putting par-ticular emphasis on safety to his senior man-

Some organi-zations havebeen propo-nents of im-

proved safetymanagement inrecent years … .


agement staff.9 Some of the airline accidentinvestigations in the 1930s identified so manyair navigation problems and questions of in-vestigation objectivity, that the Air Safety Boardwas formed in the United States along withthe Civil Aeronautics Administration (CAA),the predecessors to today’s NTSB and FAA.These were governmental management cor-rective efforts.

The earliest teachings in accident investiga-tion at U.S.C. in the 1950s concentrated uponman, machine and environmental factors, andbegan to discuss safety programs.

The next decade saw the initial developmentof “Advanced Safety Management” and “Com-mand” courses, first from the U.S. Air Force,then U.S. Navy, and later adopted by all U.S.military services. The classes were significantbecause they were comprised of higher rank-ing officers than the safety officers who imple-mented safety programs at the working level(including the investigation specialists). Theseranking officers then had access to very seniorcommanding officers, something which wouldbe somewhat difficult for the lieutenants.

These new safety programs weresignificant also because they forcedthose of us who were teaching thecourses to approach accident pre-vention more from management’spoint of view than we had donepreviously. Appendix I, startingwith what has been sometimescalled the “5-M diagram,” is anexample of this. It portrays sym-bolically the overview role thatmanagement must play in accidentprevention or, conversely, wherecausation may lie in the event ofan accident. The Man-Machine-Medium (Environment) fundamentals were re-tained from the past to which another factor,Mission, was added. This was to emphasizethat in a military or civil endeavor, admittedto or not, one does not practice safety profes-sionally just to prevent injuries or death. Themission, be it delivering ordnance or provid-ing a viable air transportation system, is animportant piece of the safety package.

Appendix I also shows the interrelationshipsof these various factors to stress and illus-trates that one should not, for example, exam-ine man or machine factors independently —the man-machine interface depicted by the over-lapped areas between the two variables mustbe studied, too. Similarly, when one asks thequestion what most influences the combinedMan-Machine-Medium-Mission, the answermost logically is Management; hence its topposition.

What Is Real World Safety andAccident Prevention Management?

The foregoing description of management’srole in accident prevention or investigationnotwithstanding, why do we not see more for-mal recognition of safety/accident preventionmanagement in civil airline activity? It hasbeen suggested that perhaps not enough air-line executives have had the benefit of com-mand or advanced safety management train-ing — only about 50 percent of U.S. airlinesnow have identifiable safety departments.10

Nevertheless, the airline safetyrecord of most developed countriesis nothing to be ashamed of, albeitnot all carriers try to improve al-ways and in all ways. Also, at leastindependent investigating organi-zations such as the NTSB gener-ally have had little difficulty iden-tifying inadequacies of the regu-lating organizations, such as theFAA in the United States, becausethe board’s charter from the U.S.Congress is quite specific in de-manding oversight of the adequacyof Federal Aviation Regulations

(FARs). The board has begun only recently toconsider other agency or company manage-ment factors in accidents. The reasons forthese seemingly ambivalent perceptions of airlinesafety are certainly not simple and probablyhave many explanations. One explanation,however, is confusion about what really con-stitutes safety/accident prevention manage-ment. Two theories are advanced, the classic(sometimes thought of as “traditional”) and

Effectiveaccident pre-

vention can belinked inalter-ably to effec-tive manage-

ment.


the safety program approaches.

The classic management approach argues thatapplying classic functions of basic manage-ment will inherently provide optimized safety.These functions include effective planning, staff-ing, organizing, directing, coordinating, con-trolling, evaluating, decision-making, motivat-ing, communication, standardization, leader-ship, etc. Take any classic management textand certain of these terms will be found andemphasized as a function of when the bookwas written. Not too facetiously, the theorygoes that these principles apply as well torunning the local drug store or a major gov-ernment agency, airline or manufacturing com-pany. Translated to the subject under discus-sion here, it can be argued, and often has been,that adequate safety levels are reached by eachperson or organizational segment (e.g., pilotsor operations departments) simply doing theirthing; that is, managing professionally. Safetyis everybody’s responsibility. Thesafety program approach has noquarrel with traditional fundamen-tals of management, but suggestsone should not stop there, giventhe complex technical and socio-logical nature of aviation today.

A relatively recent publication isavailable that addresses the realworld of aviation accident preven-tion and management (The Practiceof Aviation Safety: Observations fromFlight Safety Foundation Audits).11

This report summarizes the impres-sions of three qualified aviationprofessionals while conducting pri-vate audits of airline and corpo-rate operators during a 10-year pe-riod. Audits here equate to safetysurveys; that is, information gained from non-attributive interviews and observations reportedin such a way that accident prevention, notretribution, is the objective. The role of man-agement is stressed in this report with con-comitant safety shortcomings being identifiedat one time or another at all levels and in alldepartments. Interestingly enough, the au-thors found it was rare that managers wereaware of such problems as were identified un-

til brought to their attention by these outsideobservers.

A safety program involves specialized acci-dent prevention efforts in addition to safetybeing part of everyone’s job. Thus, a descrip-tive title might well be “Accident PreventionProgram.” It is based upon proven accidentprevention tasks, accomplished by appropri-ately qualified personnel. Each of us in thebusiness any length of time has developed sucha task list, formally or otherwise.

Considering the DifferenceBetween Task and Function

A fine-line differentiation between task andfunction is necessary here. In simple terms, atask is work assigned to a person, somethingmanagement normally does under the doc-trine known as “division of work.” Function,

on the other hand, is generally abroader term, being a normal orcharacteristic action.12 The taskphraseology is usually in a formthat managers better understand.It is something for which they au-thorize the expenditure of fundsand that they understand.

The IATA safety program is alsotask-oriented, albeit the programelements are called “functions” asshown in Appendix III.13 They areclassified into four major areas;organization of accident preven-tion programs, collection/analy-sis/communication of safety infor-mation; technical and training safetycoordination; and corporate emer-gency response procedures. Fur-

ther explanation of this material can be foundin a paper presented by United Airlines’ Capt.David Simmon Jr. who was also the chairmanof the IATA Safety Advisory Committee, thegroup from which the policy developed.14

A recent study, “Airline Accident PreventionManagement Factors” by Capt. Homer Mouden(reference 10), similarly established tasks andareas of greatest accident prevention impor-

A safety pro-gram involves

specializedaccident pre-

vention effortsin addition tosafety being

part ofeveryone’s job.


tance based upon interviews with 53 personsrepresenting 13 airlines of varying sizes andseven relevant aviation organizations. Majorcategories of effective accident prevention ac-tion included communication, training (includingcockpit/crew resource management), standard-ization and flight data analysis. Many of thoseinterviewed were chief executiveofficers.

Many of the pronouncements aboutsafety programs through the yearstend to equate the term “safety pro-gram” with “safety officer” or“safety organization.” This maycome to pass with many, if not most,agencies or companies. However,as stated earlier, the important mat-ter is that appropriate tasks be per-formed by appropriate people.Depending upon the size of theorganization, its cultural and busi-ness mores, a formal safety organization aspictured on an organizational chart might notbe the best or most practical solution. It isimportant in an organizational theory sense tobe certain all dimensions of an effective orga-nization, safety or otherwise, are in place; namely,the line or decision dimension, the staff oradvisory dimension, the informal dimensionand the interdepartmental dimension. Mouden’sreport deals with this area effectively; the studyshould be mandatory reading for all seniorairline, regulatory and aircraft manufacturingofficials.

Short-range Possibilities forAccident Prevention Management— Investigation After the Mishap

Given the options of the “classic/traditional”and “program” approaches to managementfactors investigation, the latter approach shouldbe used, at least as the investigation commu-nity begins to undertake such effort formally.This view is taken on the belief that it is rela-tively easy to provide task descriptions as stan-dards compared to some of the broader basedterminology associated with old-line manage-ment theory. For example, one could easily

cite a task for an airfield inspection program,using any number of existing publications asa description of what should be done specifi-cally. Conversely, given something like “coor-dination,” the scope thereof would be quitedifficult to establish standards for but it couldbe evaluated post-accident.

The current safety literature willreadily show a commonality of tasksthat could be synthesized into acommon format in some form ofinvestigation manual. The listsshould include key reference docu-ments much the way that aerospacerecommended practices are writ-ten by the Society of AutomotiveEngineers (SAE). Another approachwould be that of an FAA AdvisoryCircular; however, this may not beas promising, because ACs relateto specific regulations. The detail

required for safety/accident prevention man-agement tasks would not be amenable to de-tail regulations — far too much variation amongairlines exists. To even imply that such tasksshould be universally mandatory through regu-lations would be a mistake. In any case, what-ever guideline documents are decided uponwould have to be prepared by a cross-sectionof experts from within the affected fields ei-ther through research funding or a committeeof some professional society like the Interna-tional Society of Air Safety Investigators (ISASI).In the interim, however, Appendixes II and IIIplus references 12 and 13, when combined withlocal knowledge, could be used as the proto-col for near-term forthcoming investigations.

Of course, one thing is to know what to do —the tasks; it is another matter how they shouldbe approached procedurally and with whatkind of personnel. A parallel would seem tobe present within aviation accident investiga-tion methodology that applies here. It wasnot too many years ago that human factorsinvestigation was comprised only of crash in-jury survival and rescue factors plus sometoxicology data. This human factors conceptwas expended to include “human performance,”so much so that some investigating bodieslike the NTSB have isolated the survival and

… the impor-tant matter isthat appropri-

ate tasks beperformed byappropriate

people.


performance factors investigators organization-ally. To some, the human performance func-tion was opposed on the basis it was steppingon the turf of the operations personnel — andsometimes it did. What eventually stabilizedthe separation of the two was the realizationthat human performance was of sufficient im-portance in itself that it demanded separate,identifiable attention and it required the in-troduction of otherwise absent technologies;e.g., behavioral specialists.

And so it is expected to be with safety/acci-dent prevention management investigation. Aseparate group structure would be expectedto be created as part of the investigating body’steam in most airline accidents, coordinatingwith the operations, witness, records groupsand others. Hopefully, the investigating agencypersonnel and the members of the manage-ment factors group would have the necessaryprofessional safety experience and training todo the job right, and that means understand-ing what a safety program is all about. Itwould seem this type of groupwould be the logical investigationassignment for the participatingairline’s safety director (if one ex-ists) and not let his or her talentsbe wasted just effecting coordina-tion with the investigating authorityas is frequently done now.

Are the necessary skills availabletoday? The answer is yes if in-vestigation-experienced people areinvolved in safety activities. Theanswer is no if someone thinksthat just because he or she is anexperienced pilot, engineer or what-ever, he is sufficiently knowledge-able about safety/accident prevention man-agement to do a highly credible job on theinvestigation.

Again, taking a lesson from mistakes made inthe introduction of human performance in-vestigations, if management factors groups areformed, specific training is essential for pro-spective group members. This is what theNTSB finally did for its investigators.

One alternative, for investigating agencies orparticipating parties to the investigation, is tolocate persons in their organizations who havehad military safety officer training. The chancesare good that they can speak the safety pro-gram language because their training has prob-ably included it under the general heading ofaccident prevention.

As to training curricula, again the selectedtask list becomes paramount. Take safety policyfor example. Policy is usually referenced inthe early part of all plans. Personnel whohave taught accident/incident prevention, in-cluding investigation, can describe what con-stitutes an effective safety policy — hence, aneffective plan — with examples to illustratespecific principles. For instance, a company’ssafety policy which simply states “safety isour total priority” is not facing reality. It maydo so with a shock when the hard facts ofcompromises come to light in an investigation— compromises deemed necessary during day-to-day operations.

Another policy shortcoming fre-quently seen is the chief executiveofficer saying that he or she is thechief safety officer, without acknowl-edging delegation of accident pre-vention tasks which must surelybe done to some degree. The CEOmust create additional accountabil-ity with the intended result thatall people in the organization re-alize their role in safety is not justto themselves but to others as well.

What about the distinctions betweeninspections, audits and surveys —do personnel people understand

the differences? The “black hat” (bad guy)check of rigid adherence to established rules(inspections) becomes confused with the “whitehat” (good guy) non-retribution inquiry (sur-vey) or vice versa … with audits falling some-times in-between but mostly closer to, if notequivalent to, surveys. If and when such con-fusion does occur, the task will not be as effec-tive as it could be.

One of the IATA safety program tasks is “par-

… a company’ssafety policywhich simply

states “safety isour total

priority” is notfacing reality.


ticipation in industry safety activities.” How-ever, do managers, especially CEOs, know whythis is important? An informal poll was takenof the audience at a recent International Soci-ety of Air Safety Investigators (ISASI) semi-nar. They were asked if they knewof an accident that occurred 18months earlier.

The accident involved the reluc-tance of two flight attendants whowere advised by two well-informedpassengers of a serious pretakeoffsnow/icing hazard. The flight at-tendants failed to notify the cock-pit crew because of prior negativeexperiences with cockpit cabin com-munication. The aircraft crashedwith a loss of 24 lives, includingthose of both pilots and one of theflight attendants.15 No more than one-third ofthe attendees had heard of the accident andfewer had heard of the lesson that was avail-able.

“Learn from the mistakes of others; you’ll neverlive long enough to make them all yourself.”The original source of this statement is un-known, but it was brought to the aviation safetycommunity’s attention by Jerry Lederer, presidentemeritus of FSF. Lederer also commented morethan once, in keeping with the basic thrust ofthis article, that ”the first person called to tes-tify at every major accident investigation hearingshould be the airline CEO.”

Interviews on management factors during aninvestigation might find their way to the verytop of a given organization. Investigators mustbe professional and be able to communicatewith top management. Some persons havealso suggested that as the interviews proceedup the corporate ladder, the interviewer shouldbecome one of the higher-ranked personnelon the investigating team. Officers and CEOsof airlines and other organizations may tendto prefer discussing things with people of es-sentially equivalent rank. This is one way toprevent bypassing of the field investigatorsby corporate officials in favor of contactingthe review and decision-makers directly.

Two top level procedural or regulatory changesalso are recommended. The first is to modifyAnnex 138 to account for the role of a manage-ment factors group in the international pro-cess of investigating accidents. Similarly, an

appropriate chapter in the ICAOManual of Accident Investigation16

should reflect the same thinking.These thoughts are not revolution-ary when one recognizes that theICAO Accident Prevention Manual17

a l ready has a d i scuss ion o fmanagement’s importance to safety,and the ICAO Accident/Incident Re-porting Manual already has a goodstart on management factors.18 Ac-tion on these items rests with theNTSB in the United States and withits counterparts in other countries.

The second action should be a regulation re-quiring written definition of a safety/accidentprevention program by each airline. Each pro-gram would be modified as necessary by theairline and periodic reports would be submit-ted to regulating authorities at discrete inter-vals (every year or two). Their purpose wouldbe to assure the attention of top company offi-cials to their safety programs. Companies withexisting programs would adapt them to therequired format.

The Longer Range Challenge

The safety debate accompanying deregulationin the United States provides a case history ofwhat investigators face when trying to evalu-ate shortcomings in traditional managementfactors following an accident. In accidentssuch as the Air Florida accident in Washing-ton, D.C., in 198219 and the Continental DC-9takeoff accident in Denver in 198720, issues ofcrew capability were paramount. Deficienciesand related factors were attributed by manyobservers to deregulation’s effects on staffing.Lack of appropriate windshear training sur-faced in the Delta DFW-1 accident, during aperiod of rapid growth in operations. Thesubject of maintenance shortcuts and poor, ifnot fraudulent, record-keeping arose in sev-eral accidents in the 1980s, especially among

“ … the firstperson called totestify at everymajor accidentinvestigation

hearing shouldbe the airline

CEO.”


some smaller carriers.

Fundamental questions like these became re-lated to the financial viability ofthe carrier in a period of intensecompetition. Who could tell forsure why corporate decisions weremade (e.g., elimination of safety andengineering departments)? Werecommunications inadequate becauseof poor leadership? Was coordina-tion bypassed in the name of expe-diency? These are difficult, if notimpossible, questions to answer ina cause-effect sense. Time and fundsavailable to conduct most investi-gations are limited.

Furthermore, to examine classic managementfunctions post-accident would require addi-tional and markedly different types of skillsthan are found usually among accident inves-tigators. Such disciplines as accounting, per-sonnel selection, labor relations and law (cor-porate and contract) would have to be included.For these reasons, investigations using the classicmanagement factors approach appear to beimpractical, at least for the immediate future.

An Art and a Science

Accident investigation is an art, with certainareas having become highly scientific throughexperience gained over the years. But art, as

well as science changes, especially if initia-tives are taken based upon lessons from thepast including lessons from sources other than

the particular business one is in.

The aviation community has seenremarkable changes in attentionto human performance problemsin civil aviation from points of viewboth before and after the accidentfact. Some authorities in the fieldwill say the time delay from hu-man performance knowledgegained to knowledge applied toaccident prevention should bemeasured in decades, not just afew years. The same can be saidabout safety/accident prevention

management.

If we look back on the 1980s as a period dur-ing which the civil aviation community awoketo human performance as a specific challenge,perhaps it is not too much to ask that a similarchallenge should be recognized for the 1990sregarding safety/accident prevention manage-ment.

More specifically, if a given airline has a de-fined safety/accident prevention program, itshould make sure it is effective by referencingthe kinds of tasks cited in this paper and imple-menting those tasks with qualified personnel.If the airline does not believe it can developsuch a program, it should look to trade asso-ciations like IATA, Air Transport Association(ATA) and the Regional Airline Association(RAA). Assistance in program developmentmay also be sought from consultants.

Government authorities should take steps tointroduce safety/accident prevention manage-ment investigation into the accident inquiryand require broadly stated safety programs(although not all the same kind) for all carri-ers. ♦

Accidentinvestigation is

an art, withcertain areas

having becomehighly

scientific.


tors and their subset relationship to manage-ment.

The mission factor had been discussed at mili-tary oriented U.S.C. courses, but was not in-troduced into the diagram until 1976 at thesuggestion of E.A. Jerome, consultant, writerand former staff member with Flight SafetyFoundation. A sixth M, money, was suggestedat about the same time, perhaps not too face-tiously, by John J. Carroll, formerly chief ofthe accident prevention branch of the NTSBand later managing director of the Flight SafetyFoundation.

The 5-M diagram is a classic example of safetyideas being perceived, reviewed, modified, am-plified and hopefully, improved, but in any

event, communicated.

Experience has demonstrated that Man-Ma-chine-Medium-Management-Mission factors rep-resent a valuable model for examining eitheraccident causation or accident prevention (5-M diagram). That is, when one seeks causalfactors or preventive/remedial action, the dia-gram of the intertwined circles becomes a mean-ingful checklist for fact-finding and analysisto ensure that all factors are considered.

The five factors are closely interrelated, al-though it can be argued that management playsthe predominant role. Mission is located asthe target or objective to emphasize that effec-tive mission accomplishment is implicit in pro-fessional system safety work.

This concept evolved when T.P. Wright of CornellUniversity first introduced the man-machine-environment (medium) triadinto the aviation safety language dur-ing the late 1940s; he was influen-tial in the development of the Cornell-Guggenheim Aviation Safety Divi-sion of the University College, Uni-versity of Southern California (U.S.C.).Follow-on instructors used the 3-M(man — machine — medium) termi-nology.

The author first provided an illus-tration of the fourth M, management,circa 1965, at U.S.C., when develop-ing and teaching the school’s initialadvanced safety management andsystem safety courses. This appearedin his 1966 text, The Role of SystemSafety in Aerospace Management. In1972, Vernon L. Grose, who subse-quently taught the system safetycourse at U.S.C. and later for theU.S. National Aeronautics and SpaceAdministration (NASA), introducedthe diagram approach (right). Thatemphasized the interrelationships be-tween the man-machine-medium fac-

Appendix ISystem Safety Factors

™ System Safety Inc.

The 5-M Diagram

MAN

MEDIUMMACHINE

MISSION

M

AN

A G E ME

N

T


1. Develop and coordinate implementation ofsafety plans.

2. Assist in establishment of specific accidentprevention requirements.

3. Conduct or participate in hazard analyses,including the resolution control process re-lated thereto.

4. Determine and/or review emergency pro-cedures.

5. Participate in program reviews and simi-lar milestone events during system devel-opment and use.

6. Maintain an accident/safety known-prece-dent center.

7. Effect liaison with other safety organiza-tions.

8. Provide recommendations for and conductsafety research, study and testing.

9. Implement safety education, training, in-doctrination and motivation programs.

10. Conduct or otherwise coordinate safety sur-veys, audits and inspections.

11. Participate in group safety efforts such ascouncils and standardization boards.

12. Direct or otherwise participate in accident/incident investigations.

13. Develop and follow-up recommendationsresulting from investigations.

14. Provide objective response to safety inquiryas a staff advisor, in confidence when ap-propriate.

Notes Concerning System SafetyTasks in Aviation

1. Safety Plans

A top-level secret of safety/accident preven-tion management is planning. Several kindsof formalized safety plans are found in today’scomplex aviation system. They include pro-gram accident prevention, system safety engi-neering, accident/incident investigation, di-saster control and security plans. One wouldexpect to find in all these plans a clear state-ment of management’s safety policy to protectpeople and conserve other resources.

2. Requirements

U.S. Federal Aviation Regulations (FARs) arebut one type of safety requirement and theyare minimum requirements, at that. Other typesinclude, but are not limited to, in-house stan-dard operating procedures or even self-im-posed operational criteria. Accident preven-tion requirements come mainly from the bitterlessons of the past, but they must be com-bined with understanding of the people in-volved, their capabilities and limitations. Re-quirements are also more effective when peoplewho must observe them participate in theirdevelopment.

3. Hazard Analyses

History has provided volumes of known pre-cedent concerning accident causation. Appli-cation of precedents with new knowledge isthe hazard analysis process. Literally dozensof analysis techniques have been documentedand can become as sophisticated as the bud-get allows. Unfortunately, analysis of the peoplepart of the equation leaves much to be desiredand awaits closer coordination between hu-man behavioral and safety professionals.

Appendix IISystem Safety Tasks


4. Emergency Procedures

Normal emergency procedures are those whichbest judgment and sometimes a fixed trainingrequirement suggest will occur under a givenset of circumstances (e.g., engine failure ontakeoff). However, operations and trainingmust consider the abnormal — the unplanned,unique combination of events, the less-than-perfect individual pilot or other crew mem-ber. Safety knowledgeable people can andshould become involved personally in emer-gency procedure determination, because theirexperience will usually include an apprecia-tion for the full scope of human reaction tocomplex, hazardous situations.

5. Program Reviews

Modern safety/accident prevention manage-ment includes periodic pauses to reflect progress— what lessons have been learned, what haz-ards exist and what is the best way to proceed.These are sometimes combined with othermanagement reviews. In any event, the safetyspecialist can usually provide a relatively in-dependent view on issues compared to line(decision-making) personnel. These reviewsshould occur over the entire life cycle of thesystem in question.

6. Known Precedent Center

Essential to every accident prevention programis a comprehensive safety database, or pre-planned access to one. It must also be effec-tive time-wise. The database could be large orsmall, a safety library or a simple list of whoshould be called for answers to certain ques-tions. Without simplified and rapid access tothe mistakes of the past (known precedent) noone would be able to “learn from the mistakesof others … .”

7. Liaison

This is closely allied to the known precedenttask immediately above. However, nothingsubstitutes for personal communication in safetymatters. The subject of safety can be sensi-tive, as well as complex. Thus, it is wise tobecome acquainted with knowledgeable per-

sonnel in the field who are cooperative andparticipative. Seminars such as those providedby the Flight Safety Foundation and the Inter-national Society of Air Safety Investigators fostersuch liaisons.

8. Safety Research, Study and Testing

Chief engineers, flight inspectors and chief pi-lots usually think they are right — and mostof the time they are. Unfortunately, life isfilled with assumptions that precede everydecision or action. If those assumptions areincorrect or incomplete about hazards, it fol-lows that some safety research, study or test-ing should be conducted to validate assump-tions bearing upon those hazards and/or ex-plore other solutions. A key corollary to thisitem is to realize there is a difference betweentesting safety and testing safely.

9. Safety Education, Training, IndoctrinationAnd Motivation

These four activities, influencing human be-havior, are different from one another. Educa-tion is teaching people to think. Training isdeveloping skills so that one can perform cer-tain tasks. Indoctrination is the application ofeducation and training to the new situation.Motivation is an attitude development pro-cess, often most successful when it leads theperson being influenced to think it was his orher own idea. Unless these processes are per-formed at the right time and with minimumconfusion between them, they might even havea negative learning effect. Also, the place tostart is with oneself.

10. Surveys, Audits and Inspections

An occasional “outside” look is traditional inthe practice of management. This is particu-larly vital in safety if objectivity is the targetof the examination, because emotions and sen-sitivities often run high when the stakes in-clude the physical well-being of people or theirlivelihoods. Surveys and inspections repre-sent opposite ends of a spectrum of outsidereviews. Surveys are relatively informal andnon-retributive (white hat) while inspectionsspecifically check against stated requirements


with potential penalties for non-conformance(black hat). Audits may fall somewhere be-tween depending upon how they are defined.Both extremes are usually necessary, but foroptimum effectiveness they should not becomeconfused either by the evaluatees or the evalu-ators.

11. Group Safety Effort

Another well-known principle of managementis that group dynamics can produce more ef-fective output than that represented by a math-ematical sum of the number of participants.In air safety work, group effort becomes moresignificant because hazard alleviation is rarelythe province of a single discipline or part ofthe aviation community. Safety councils, com-mittees, panels, etc., when properly conductedwith safety professionals present, contributeto accident prevention in ways not otherwiseachieved.

12. Accident/Incident Investigations

Were man’s requirements, decisions and op-erations perfect, no air safety problems wouldexist. When something does go wrong, themeaningfulness of the remedial action is de-pendent upon the accuracy and timeliness ofthe investigation of the unwanted event. Socio-legal reasons for accident investigations existas well. Consequently, aviation needs a meansnot only to answer immediate post-mishapquestions, but also a method to enhance knownprecedent as described above. Incidents, of

course, are simply accidents minus definedlevels and methods of injury to people or damageto property (where more investigations shouldbe accomplished than are taking place today).

13. Recommendations

Knowing what has happened to cause an acci-dent/incident is one thing; developing practi-cal remedial actions is quite another matter.The mettle of management is tested here be-cause of the classic performance-cost-sched-ule tradeoffs that become involved. Further-more, it is necessary to have some specificfollow-up system to track recommendationsaccepted in good faith but which tend to fallthrough bureaucratic cracks when the com-motion and emotion settles down.

14. Staff Advisor

Everyone needs an expert to turn to for an-swers that exceed his or her personal knowl-edge. For aviation safety, and depending uponthe size of an organization, that person mightbe a qualified safety specialist on the staff oran employee of the FAA, a friend or consult-ant. Besides safety expertise per se, however,a requirement also exists for someone whocan be approached confidentially and withoutfear of recrimination. Unintentional mistakesare often incompatible with company or gov-ernment rules; hence, if future prevention benefitis to be derived therefrom, an unofficial com-munications channel must be encouraged.Sometimes this is called the “chaplain” func-tion in safety/accident prevention management.


Collection/Analysis/Communication of SafetyInformation

Maintaining a flight safety data base torecord and preserve operational safety in-cident information.

Participation in industry safety activities.

Internal analysis of incident trends andperiodic reviews with senior management,including the CEO.

Communication to crew members of ap-propriate safety information, including thepublication of a safety magazine, incidentsummaries, safety bulletins, technical let-ters and safety articles.

Operation of a confidential crew memberincident reporting system.

Organization of Accident Prevention Programs

Independent internal investigation of inci-dents and accidents with provision of ap-propriate safety recommendations to man-agement.

An overview function comprising appro-priate safety assurance and quality assur-ance programs.

An airfield inspection program.

Comprehensive safety training programsfocused on specific safety objectives.

A flight data recorder exceedance program.

Developing management objectives to re-verse undesirable safety trends.

Appendix IIIFlight Safety Functions

Per IATA Technical Policy ManualOPS Amendment No. 37, 1 July 1989


1. Miller, C.O., “Safety Management: A NewCause of Legal Action?” presented at theProfessional Development Conference ofthe National Safety Management Society,Washington, D.C., U.S., April 26, 1984.

2. Miller, C.O., “Management Factors FollowingCivil Aviation Mishaps,” International So-ciety of Aviation Safety Investigators ISASIForum, September 1988.

3. Lauber, Dr. John, member, U.S. NationalTransportation Safety Board (NTSB), in aspeech before the Aero Club of Washing-ton, Washington, D.C., U.S., March 28, 1989.

4. Busey, James, Administrator, U.S. FederalAviation Administration (FAA), in a speechbefore the Aero Club of Washington, Wash-ington, D.C., U.S., March 27, 1990.

5. NTSB Recommendation A-89-130, resultingfrom the Board’s investigation of the DeltaAir Lines Boeing 727-232 Accident, August31, 1988, 1988, Dallas/Ft. Worth Airport,Texas, U.S.

6. Busey, James, FAA Administrator, letter toJames L. Kolstad, Chairman, NTSB, April12, 1990

7. FAA, “Air Carrier Internal Evaluation Pro-grams,” Draft Advisory Circular 120-X, ini-tiated by AFS-200. (comments were dueDecember 30, 1990.)

8. International Civil Aviation Organization(ICAO), International Standards and Recom-mended Practices for Aircraft Accident Inves-tigations, 7th Ed., revised to May 1988 (An-nex 13 to the Chicago Convention on Inter-national Aviation in 1944).

9. Numerous personal communications withJerome Lederer.

10. Mouden, Capt. L. Homer, Airline AccidentPrevention Management Factors, a study funded

by the Aviation Research and EducationFoundation of Herndon, Va., U.S. (In finalediting and printing process, January 1991.)

11. Arbon, Capt. E.R., Mouden, Capt. L. Homerand Feeler, R.A., The Practice of AviationSafety: Observations from Flight Safety Foun-dation Audits, Flight Safety Foundation, Ar-lington, Va., U.S., June 1990.

12. Webster ’s New World Dictionary, Third Col-lege Edition, 1988.

13. IATA, Technical Policy Manual OPS-20,Amendment No. 37, 1 July 1989.

14. Simmon Jr., Capt. David A., “Model Air-line Safety Program,” presented at the FlightSafety Foundation (FSF) 41st InternationalAir Safety Seminar, Sydney, Australia, De-cember 1988.

15. Air Ontario F-28 Accident, Dryden, Ontario,Canada, March 10, 1989.

16. ICAO, Manual of Accident Investigation, Doc.6920-AN855/4, 1979 as revised.

17. ICAO, Accident Prevention Manual, Doc. 9422-AN/923, 1984. (See Sect. 3.3.)

18. ICAO, Accident/Incident Reporting Manual,2nd Edition, Doc. 9156-AN/900, 1978. (Fromthe section “Explanatory Factors”)

19. NTSB, Report of the Air Florida B-737 Ac-cident, Washington, D.C., U.S., January 12,1982.

20. NTSB, Report of the Continental AirlinesDC-9 Accident in Denver, Colo., U.S., No-vember 15, 1987.

About the Author

C.O. Miller, Ph.D, is president of System SafetyInc., and consults on various safety issues. He has

References


been involved as a safety professional for morethan 36 years — in industry, research, university,government and private consulting environments.As a consultant, he has performed safety engineeringand management studies including contracts withthe U.S. Department of Defense, the U.S. Departmentof Transportation, the U.S. National Aeronauticsand Space Administration and the U.S. NuclearRegulatory Commission.

Miller was director, Bureau of Aviation Safety,U.S. National Transportation Safety Board from

1968 to 1974. He was a pilot in the U.S. MarineCorps in World War II and later an industry testpilot for three years.

Miller holds a Bachelor of Science degree inaeronautical engineering from the MassachusettsInstitute of Technology, a Master of Science degreein systems management from the University ofSouth California and a Juris Doctorate from thePotomac School of Law. He has been accorded“Fellow” rankings by the American Institute ofAeronautics and Astronautics, the Human FactorsSociety and the System Safety Society.

In 1990, worldwide airlines operating large jettransport aircraft (excluding those jet trans-ports built by the U.S.S.R.) recorded 11 fatalaccidents and seven hull losses accounting for357 fatalities. The preliminary information on

the fatal accidents and hull losses was pub-lished in the February 1991 issue of Flight SafetyDigest. The following seven tables and a graphprovide updated information on the world-wide airline annual, monthly and daily air-

An Annual Update of Worldwide Jet TransportAircraft Fatal Accident and Hull Losses

Calendar Year 1990by

Shung C. HuangStatistical Consultant

Aviation Statistics


craft utilization, and delineate the associatedsafety records.

Table 1 is a comparison of jet transport aircraftflight hours by U.S. airlines and all non-U.S.airlines. The data for U.S. airlines are basedon the monthly U.S. “Air Carrier Aircraft Uti-lization and Propulsion Reliability Report,”which is compiled and published by the U.S.Federal Aviation Administration (FAA) fromdata furnished by individual air carriers. Theinformation for those jet transport aircraft fleetsand hours flown for non-U.S. airlines was pro-vided by aircraft manufacturers, news mediaand other sources. Overall, worldwide air-lines flew a total of 20.163 million hours in1990, a decrease of about one percent as com-pared with data for 1989.

Actually, worldwide jet transport operationsin 1990 had a good start. In the first sevenmonths of the year, the monthly hours flownand aircraft utilization showed a steady in-crease. Airline traffic began slowing downonly after the Iraqi invasion of Kuwait in Au-gust. When the military confrontation in thePersian Gulf appeared unavoidable, terroristsworldwide, who supported the Iraqi invasion,increased their threats against individuals andinstitutions who were against the Iraqi plans.Consequently, airport security and flight safetybecame a worldwide issue. As a precaution,many air travelers and corporations either post-poned or cancelled their travel plans.

Table 2 shows the monthly changes of U.S. jettransport aircraft in use and the hours flown

Table 2

U.S. Airline Jet Transport AircraftIn Service and Hours Flown by Month

Calendar Year 1989 and 1990

Aircraft in Service Hours Flown(000) ChangesMonth 1989 1990 1989 1990 Aircraft HoursJanuary 3,807 3,859 858,657 887,621 + 52 + 28,964February 3,714 3,910 760,048 813,201 + 196 + 53,153March 3,392 3,910 726,417 910,365 + 518 +183,948April 3,677 3,951 870,576 873,050 + 274 + 2,474May 3,622 3,832 821,910 877,455 + 210 + 55,545June 3,697 3,971 835,066 891,583 + 274 + 56,517July 3,502 3,962 809,599 920,216 + 460 +110,617August 3,825 3,661 898,497 861,473 - 164 - 31,024September 3,710 3,669 823,686 810,773 - 41 - 12,913October 3,745 3,671 841,399 845,468 - 74 + 4,069November 3,848 2,734 828,748 560,189 -1,114 -268,559December 3,864 2,472 874,018 523,571 -1,392 -350,447

Source: U.S. Air Carrier Aircraft Utilization and Propulsion Reliability Reports

Table 1

Worldwide Airlines Jet Transport Aircraft Hours FlownCalendar Year 1989-1990

1989 1990 ChangesWorldwide Airline Total 20,349,000 20,163,000 - 186,000 (0.9%)U.S. Airlines 9,885,000 9,774,000 - 111,000 (1.1%)Non-U.S. Airlines 10,464,000 10,389,000 - 75,000 (0.7%)


for calendar year 1989 and 1990. Note that themonthly flight hours for the first seven monthsin 1990 were higher than those in the sameperiod of 1989. Since August 1990, the num-ber of U.S. jet transport aircraft in use wasreduced from 3,962 aircraft in July to 3,661 inAugust and 2,472 in December, a decrease of45 percent; the flying hours also dropped from920,216 hours in July to 523,571 in December,a drop of 43 percent. Although worldwidedata is not available at this time, the Gulf Warand terrorist threats brought worldwide air

travel to a near standstill for months.

Table 3 presents the average number of air-craft in service and flight hours at the end of1990, and the accumulative hours flown since1959. To reduce operational cost, more fuelefficient, twin-engine jet transport aircraft havejoined the worldwide airline fleet. As of theend of 1990, more efficient, twin-engine, andtwo-crew jet transports account for more than20 percent of the fleet and 25 percent of totaljet flight time.

Table 3

Worldwide Airline Jet TransportAircraft Hours Flown in Thousands

By Number of Jet Engines1959-1989-1990

No. of Aircraft Annual Aircraft Accumulative Totalin Service Dec. Hours Flown Hours Flown

Aircraft Type 1990 1989 CY 1990 1959-1990

Two-engine 5,055 4,734 12,520,000 129,891,000Three-engine 2,285 2,283 4,475,000 103,605,000Four-engine 1,334 1,365 3,168,000 105,364,000 Total 8,674 8,382 20,163,000 338,860,000

Two-engine 58.3% 56.5% 62.1% 38.3%Three-engine 26.3% 27.2% 22.2% 30.6%Four-engine 15.4% 16.3% 15.7% 31.1% Total 100.0 100.0 100.0 100.0

1st generation 480 590 531,000 81,689,0002nd generation 4,732 4,620 9,652,000 169,869,000 1

Widebody 1,645 1,603 5,083,000 62,327,000 1

Efficient 1,817 1,569 4,897,000 24,975,000 2

Total 8,674 8,382 20,163,000 338,860,000

1st generation 5.5% 7.1% 2.6% 24.1%2nd generation 54.6% 55.1% 47.9% 50.1%Widebody 19.0% 19.1% 25.2% 18.4%Efficient 20.9% 18.7% 24.3% 7.4% Total 100.0 100.0 100.0 100.0

Two-crew 5,219 4,874 12,798,000 131,415,000Three-crew 3,455 3,508 7,365,000 207,445,000 Total 8,674 8,382 20,163,000 338,860,000

Two-crew 60.2% 58.2% 63.5% 38.8%Three-crew 39.8% 41.8% 36.5% 61.2% Total 100.0 100.0 100.0 100.01 Readjusted since 1987.2 Efficient jet includes B-757, B767, MD-80, MD-81, A-310, A320, F-100.


Table 4 shows the average daily utilization inhours by aircraft type. In 1990, the averagedaily utilization in hours is shown by aircrafttype. In 1990, the average daily utilization ofthree-engine jets was 5.7 hours which was thelowest in the past four years. This is becausedaily utilization of the Boeing 727, as reportedby the FAA and the Boeing Commercial Air-craft Group, were substantially lower than in1989. There are still a few hundred first gen-eration jets in service, but their daily utiliza-tion averaged less than two hours a day. It isexpected that the first generation jet will bephased out in the next three or four years.The daily utilization of widebody jets aver-aged nine hours worldwide, and that of new,

efficient jets was about eight hours a day. How-ever, some Boeing 747, 767, Airbus A-310 andLockheed L-1011 aircraft were used by U.S.airlines at utilization rates as high as 14 hoursper day.

Table 5 shows the distribution of worldwideairline fatal accidents and hull losses by phaseof operation. Overall, 30 percent of the fatalaccidents occurred during takeoff, approximately50 percent during approach and landing, and18 percent in cruise and two percent duringground operation.

Table 6 presents the distribution of fatal acci-dents, hull losses and rates by aircraft make

Table 4

Daily Utilization of Jet Transport Aircraft by Aircraft TypeCalendar Year 1987-1990

Aircraft Type Daily Utilization (Hours)1987 1988 1989 1990

Two-engine 6.9 6.7 6.7 6.7Three-engine 6.8 6.6 6.3 5.3Four-engine 6.9 6.8 6.7 6.61st Generation 3.2 2.9 1.6 1.82nd Generation 6.6 6.4 6.2 5.6Widebody 8.9 8.0 8.7 8.5Efficient 7.9 7.4 7.2 7.4Two-crew 7.0 6.8 6.7 6.7Three-crew 6.8 6.8 6.5 5.9

Table 5Fatal Accidents and Hull Losses

By Phase of Operation1959-1990

In Number of Accidents (percentage)

Takeoff/ Approach/ Approach/ Takeoff/Climb Cruise Landing Ground Year Ground Landing Cruise Climb14(43.8) 3(9.3) 15(46.9) 0(0.0) 59-64 1(2.4) 22(53.7) 4(9.8) 14(34.1)14(25.5) 7(12.7) 34(61.8) 0(0.0) 65-69 6(8.1) 41(55.4) 7(9.5) 20(27.0)18(24.0) 16(21.3) 41(54.7) 0(0.0) 70-74 11(11.0) 52(52.0) 12(12.0) 25(25.0)16(28.0) 12(21.4) 27(48.2) 1(1.8) 75-79 6(5.7) 43(51.2) 11(13.1) 24(28.6)15(27.2) 13(23.6) 25(45.5) 2(3.7) 80-84 7(10.3) 37(54.4) 8(11.8) 16(23.5)23(36.5) 12(19.0) 27(42.9) 1(1.6) 85-89 3(4.8) 29(46.0) 9(14.3) 22(34.9)

2(18.2) 1(9.1) 5(45.5) 3(27.2) 1990 2(28.6) 4(57.1) 0( 0) 1(14.3)

102(29.4) 64(18.4) 174(50.2) 7(2.0) 59-90 36(8.2) 228(52.2) 51(11.7) 122(27.9)


and model in terms of first generation, secondgeneral generation, widebody and new effi-cient jet. Table 7 presents the fatal accidents

and hull-loss rates by number of aircraft en-gines and number of flight crew members. Theoverall fatal accident rate for 1990 is .054 acci-

Table 6

Worldwide Airline Jet Transport, Fatal Accidents, Hull Losses and Rates1959-1990

Number of Fatal Accidents and Hull Losses*1st Generation 2nd Generation Widebody EfficientFatal Hull Fatal Hull Fatal Hull Fatal Hull

1959-1964 32 41 — — — — — —1965-1969 34 47 21 27 — — — —1970-1974 41 51(54) 30 37(41) 4(5) 3(5) — —1975-1979 23 35(36) 26 36(37) 7 11 — —1980-1984 12 18 32 40 11 9(10) — —1985-1989 12 11 34 36 11(3) 11(2) 4 3

1990 2 2 8 4 0 0 1 1

1959-1990 156 205 151 180 33 34 5 4

Accidents per 100,000 Flying hours1959-1965 .342 .438 — — — —1965-1969 .115 .159 .197 .252 — —1970-1974 .179 .236 .109 .135 .111 .0821975-1979 .133 .203 .075 .104 .062 .0981980-1984 .157 .235 .072 .090 .051 .0501985-1989 .366 .305 .066 .070 .042 .042 .039 .0291990 .376 .376 .082 .041 — — .020 .020

1959-1990 .188 .251 .089 .105 .052 .054 .020 .016

*Aircraft destroyed by force are excluded from computation of rates.

Table 7

Worldwide Airline Jet Transport Fatal Accidents, Hull Losses and Rates1959-1990

Jet Transport AircraftTwo- Three- Four- Two- Three- All

(Hours in thousands) engine engine engine crew crew AircraftFatal CY 1990 6 3 2 6 5 11Accidents Accumulative

as of 1990 123 71 151 112 233 345

Hours(000) CY 1990 2,083 1,491 1,584 2,133 1,473 1,833per Fatal AccumulativeAccident as of 1990 1,055 1,459 697 2,173 890 982

Hull CY 1990 5 0 2 2 5 7Losses Accumulative

as of 1990 158 77 188 136 287 423

Hours(000) CY 1990 2,500 * 1,584 6,399 1,473 2,880per AccumulativeHull Loss as of 1990 1,345 1,459 560 966 722 801

* No rate is computed because of no fatal accidents.


Figure 1 — Worldwide Jet Transport Aircraft Fatal Accident Rate and TrendCalendar Year 1959-1990

’60 ’62 ’74’64 ’66 ’72’68 ’70 ’76 ’78 ’80 ’82 ’84 ’86 ’88 ’90

1.20

1.00

0.80

0.60

0.40

0.20

0.15

0.13

0.11

0.09

0.07

0.05

0.03

0.01

0.00

Year

Fat

al A

ccid

ents

per

100

,000

Air

craf

t H

ou

rs F

low

n

*

dents per 100,000 flight hours and the hull-loss rate is .034 aircraft per 100,000 flight hours,as compared with .083 fatal accident and .073hull-loss rates in 1989. Since worldwide air-lines logged a total of over 20 million hours in1990, these rates produced an average of 1.83million flight hours per one fatal accident.Considering that the air distance between NewYork City and Paris is 3,144 nautical miles and

the round trip flight time averages 16 hoursby current subsonic jet transport, a person couldtake a round trip by a widebody jet transportaircraft from New York to Paris every day formore than 320 years before being involved ina fatal accident if the current airline safetyrate prevails. Figure 1 shows the fatal acci-dent rates and the trend for the 30-year pe-riod. ♦

* The scale changes above the 0.15 accident rate.


Reports Received at FSFJerry Lederer Aviation Safety Library

Reference

Advisory Circular 61-107, 01/23/91, Operationsof Aircraft at Altitudes Above 25,000 Feet MSLand/or Mach Numbers (Mno) Greater than.75. — Washington, D.C. : United States. Fed-eral Aviation Administration, 1991, January 23.vi, 29 p.

AC 91-8B, dated April 7, 1982, is cancelled.

Key Words1. AirPilots — Training.2. Private Flying.3. Jet Transport — Piloting.4. Airplanes — Turbojet Engines.

Contents: Recommendations High-altitudeAltitude Training — Purpose — Outline —Ground Training — Weather — Flight Plan-ning and Navigation — Physiological Train-ing — Additional Physiological Training —High-Altitude Systems and Equipment —Aerodynamics and Performance Factors —Emergencies and Irregularities at High Alti-tudes — Flight Training. Mach Flight atHigh Altitudes — Purpose — Critical As-pects of Mach Flight — Aircraft Aerodynam-ics and Performance.

Summary: This advisory circular is issued toalert pilots transitioning to complex, high-per-formance aircraft which are capable of operat-ing at high altitudes and high airspeeds of theneed to be knowledgeable of the special physi-ological and aerodynamic considerations in-volved within this realm of operation. On Sep-tember 17, 1982, the National TransportationSafety Board (NTSB) issued a series of safetyrecommendations which included, among otherthings, that a minimum training curriculumbe established for use at pilot schools cover-ing pilots’ initial transition into general avia-tion turbojet airplanes. Aerodynamics and physi-ological aspects of high-performance aircraft

operating at high altitudes were among thesubjects recommended for inclusion in this train-ing curriculum. These recommendations werethe result of an NTSB review of a series offatal accidents which were believed to involvea lack of flightcrew knowledge and proficiencyin general aviation turbojet airplanes capableof operating in a high-altitude environment.[Purpose/Background]

Advisory Circular 61-65C, 2/11/91, Certification:Pilots and Flight Instructors. — Washington,D.C. : United States. Federal Aviation Admin-istration 1991, February 11. 18 p.

AC 61-65B, dated August 6, 1984, is cancelled.

Key Words1. Flight Training — United States.2. Air Pilots — Certification — United States.3. Air Pilots — Training — United States.

Summary: This advisory circular providesguidance for pilots and flight instructors onthe certification standards, written test proce-dures, and other requirements contained inFederal Aviation Regulations (FAR) Part 61.

Code of Aviation Law (Greece): Greek OriginalText and English Translation (Supplied by theGreek CAA). — Athens : Greece. Parliament,1988, November 11. 105 p.

Key Words1. Aeronautics — Law and Legislation —

Greece.2. Aeronautics, Commercial — Law and Leg-

islation — Greece.3. Airplanes — Law and Legislation — Greece.4. Transport, Planes— Law and Legislation

— Greece.

Notes:

1. Spiral-bound; photocopy of Greek text; typesetEnglish translation.


2. Government Gazette of the Hellenic Re-public, Athens, November 11, 1988, First Sec-tion, Issue No 250, Law No 1815, Ratificationof the Code of Aviation Law.

3. This Law was drawn up by the SpecialCommittee for drawing up the Code of Avia-tion Law, which was formed by virtue of Law1400/1983 (Government Gazette No 156) andby virtue of decision No 2117/18.12.1983 ofthe Communication Minister.

4. “True translation from Greek of the at-tached original Government Gazette.” Athens20-2-1988, G.D. Goulanaris, translator.

Contents: Scope of the Code — AircraftTraffic — Airports — Compulsory Acquisi-tions-Restrictions of Ownership — AviationSchools-Diplomas and Licenses — AircraftRegister and Books-Nationality — AircraftAirworthiness — Aircraft’s Pilot — Aircraft’sOwnership — Aircraft Mortgage — AircraftLiens — Aircraft Hiring — Aircraft’s Char-tering — Transport of Persons, Baggage andArticles — Liability Stemming from the Op-eration of the Aircraft — General Average,Assistance and Salvage — Aircraft Insurance— Administrative Control with Respect to anAircraft Accident — Administrative Sanctions— Limitations — Criminal Provisions — Gen-eral and Transitory Provisions

Reports

Accident Facts, 1990 Edition / National SafetyCouncil [Statistics Department]. — 70th ed.— Chicago : National Safety Council, 1990.108 p. : ill., charts, tables, maps. ISBN: 0-87912-149-1.

Key Words1. Accidents — Statistics — United States.2. Industrial — Statistics — United States.3. Violent Deaths — Statistics — United States.

Contents: All Accidents — Work Accidents— Occupational Health — Motor-VehicleAccidents — Public Accidents [includes trans-portation] — Home Accidents — Farm Resi-dent Accidents — Environmental Health —

Other Sources — Glossary — Index.

Summary: A statistical review through 1989(mostly United States) covering accident factsin several major categories. Includes histori-cal data.

The FAA Altitude Chamber Training Flight Pro-file: A Survey of Altitude Reactions - 1965-1989 /Charles D. Valdez, M.P.H. (Civil AeromedicalInstitute). — Washington, D.C. : United States.Federal Aviation Administration, Office of Avia-tion Medicine; Springfield, Virginia : Avail-able through NTIS*, 1990, September. ReportDOT/FAA/AM-90-12. iii/iv, 8 p.

Key Words1. Altitude, Influence of.2. Atmospheric Pressure — Physiological

Effect.3. Air Pilots.

Includes bibliographical references.

Summary: Reactions from 1,161 trainees outof 12,759 trainees subjected to the FAA alti-tude chamber training flights from 1965-1989are annotated in this survey. Although therewere some mild and expected reactions (in-cluding aerotitis media, aerosinusitis, aerodon-talgia, hyperventilation, abdominal distress,claustrophobia, decompression sickness, ap-prehension, tingling, unconsciousness), thesetraining profiles appear to provide a safe learningenvironment without compromising thestudent’s health and safety. Inside chamberinstructors did not fare as well, perhaps dueto age and cumulative number of exposures,and recommendations are suggested for im-proved safeguards.

An Engineer’s Perspective on the Air Transporta-tion Industry: The Last Forty Years / Joseph F.Sutter (Boeing Commercial Airplane Company)and David C. Knowlen (Boeing Co.). —Warrendale, Pennsylvania : Society of Auto-motive Engineers, 400 Commonwealth Drive,Warrendale, Pennsylvania, U.S.. 15096-0001 U.S.;1990. Report SAE SP-90/845. Report SAE902012. 16p. ISBN: 1-56091-089-5.

Key Words


1. Boeing Airplanes — History.2. Transport Planes — History.3. Aeronautics, Commercial — History.4. Aeronautical Engineers.

Seventeenth William Littlewood Memorial Lec-ture. Presented at the Aerospace TechnologyConference and Exposition, Long Beach, Cali-fornia, October 1-4, 1990.

Summary: From his 40 years experience, asthe industry made the transition from piston-driven to jet-powered airplanes, the authordraws lessons on airplane design, businessphilosophy, and the role of the engineer. Fewtechnical advances in aircraft design have beenrevolutionary. Most have been evolutionaryand are the result of continuing to learn andapply lessons from previous designs. Sutteralso cites examples where the success of anairplane could be traced to the willingness toapproach a design from a fresh perspective.Another strength of Boeing products is long-term flexibility. Designs that can be length-ened or shortened or fitted with new powerplantsmake it possible to adapt models to changingmarket for more range or more payload longafter the model has been introduced. Engi-neers should commit themselves to a broaderrole. The challenge of the future requires tech-nically astute engineers with marketing andfinancial skills, who can work directly withcustomers, if they are to regain their positionas leaders in the transportation industry.

Aircraft Accident Report: Markair, Inc., Boeing737-2X6C, N670MA, Controlled Flight into Ter-rain, Unalakleet, Alaska, June 2, 1990. — Wash-ington, D.C. : United States. National Trans-portation Safety Board; Springfield, Virginia,U.S. : Available through NTIS, 1991, January23. Report NTSB/AAR-91/02; NTIS PB 91-910402. 85 p. : charts, graphs, maps.

Key Words1. Markair, Inc.—Accidents — 1990.2. Aeronautics — Accidents — 1990.3. Aeronautics — Accidents — Approach.4. Aeronautics — Accidents — Instrument Ap-

proach Charts.

5. Aeronautics — Accidents — Pilot Train-ing.

6. Cockpit Resource Management.

Summary: On June 2, 1990, during a mid-morning positioning flight with only four crewmembers on board (two pilots and two flightattendants), MarkAir Boeing 737-200 descendedprematurely during a localizer DME (distancemeasuring equipment) approach to runway 14at Unalakleet, Alaska, U.S., and struck the groundabout 7.5 miles short of the runway at 0937hours local time. Instrument meteorologicalconditions existed at the time, and the flightwas on an IFR flight plan. The flight wasoperated under FAR Part 121. The aircraftwas destroyed but there was no fire. A flightattendant seated in the rear jumpseat receivedserious pelvic injuries. At the completion ofthe teardrop procedure turn, the crew seemedto mentally jump one stepdown ahead of thepublished approach procedures. Seconds be-fore impact, the captain sighted the groundand initiated a sharp pull-up sufficient to alignthe aircraft with the rising terrain, spreadingimpact loads sufficiently to prevent the airplane’scomplete destruction at the point of initial groundcontact. The report contains the cockpit voicerecorder transcript.

The NTSB determines that the probable causeof this accident reflected deficiencies in flightcrewcoordination, their failure to adequately pre-pare for and properly execute the nonprecisionapproach and their subsequent premature de-scent. The safety issues discussed in this re-port include cockpit resource management andapproach chart symbology. The Safety Boardissued a safety recommendation on approachchart standardization to the Federal AviationAdministration (A-91-15). Safety recommen-dations were also issued to MarkAir, Inc., onthe subjects of cockpit resource management(A-91-16 through 17) and checklist usage (A-91-18). [Executive Summary]

*U.S. Department of CommerceNational Technical Information Service (NTIS)Springfield, VA 22161 U.S.Telephone: (703) 487-4780


Accident/Incident Briefs

The aircraft ran off the end of the runway andcollided with a building. The aircraft wasdestroyed and one person on the ground waskilled; one of the crew members sustained mi-nor injuries. There were no passengers.

The pilot was cited for not checking maxi-mum takeoff weight, forgetting the pilot’s brief-ing, being careless about crew supervision andfor uncoordinated decisions. The flight engi-neer was cited for not coordinating the abortedtakeoff with the pilot, for other uncoordinatedactions and for violating procedures. Recom-mendations were made relating to personnelactions, including that crew members shouldfollow aircraft flight manual procedures andbe trained periodically in theory as well aspractical procedures.

Jet Blast, Unbraked CartResult in Dented Aircraft

Boeing 737: Minor damage. No injuries.

Boeing 747: No damage. No injuries.

The Boeing 737 was parked at the terminalgate ready to depart. Passengers were aboardand final documentation was being processed.

A Boeing 747 had pushed back from a nearbygate and was beginning to taxi to the runway.As it passed the parked 737, the larger aircraftwas required to make a 90-degree left turnfrom the parking apron to the taxiway; somepower was added to number three and fourengines to assist in the turn.

The resulting jet blast blew a number of con-tainers and other loose equipment about theramp area. A heavy baggage cart that hadbeen left with the brakes off was blown acrossthe ramp at a speed estimated to be more than30 mph — it struck the engine nacelle of theBoeing 737 that had been ready to depart the

This information is intended to provide an aware-ness of problem areas through which such occur-rences may be prevented in the future. Accident/incident briefs are based upon preliminary infor-mation from government agencies, aviation orga-nizations, press information and other sources.This information may not be accurate.

Air CarrierAir Carrier

Heavy AirplaneBalks at Flight

Antonov An-24: Aircraft destroyed. Fatal inju-ries to one person on ground, minor injuries to onein aircraft.

The pilot did not follow flight manual proce-dures that call for limiting the weight of theaircraft according to the available runway lengthand environmental conditions. He also failedto accomplish a preflight briefing with the flightengineer prior to takeoff. The aircraft wasprepared to take off at 1500 hours in daylightconditions from an airfield in Laos.

During the takeoff run, the twin-engine turbo-prop aircraft reached V1 speed but did not liftoff as expected. Without an order from thepilot, the flight engineer aborted the takeoff.


gate which was then delayed until a deeplydented section of the nacelle assembly wasreplaced.

Buggy AirspeedsBring Bumpy Landing

BAe 146-200: Moderate damage. No injuries.

Distractions began before the aircraft startedits descent. A high volume of radio trafficcaused a delay in contacting the carrier ’s han-dling agent at the airport. After the descentwas initiated, the descent checklist was inter-rupted at the landing data item by a call fromthe handling agent which was answered bythe captain, who was flying the aircraft. Thelanding data checklist item interrupted was acheck of the landing speeds and that the posi-tions of the airspeed bugs had been properlyreset from the takeoff values to the landingspeeds. The captain indicated to the first offi-cer that he would return to the checklist aftercompleting the call.

However, the captain’s attention then becamefocused on air traffic control instructions andon flying the aircraft. He stated later that hemay have repositioned the yellow outer bugfrom the takeoff setting but did not recall re-setting the other bugs from their takeoff set-tings. The first officer stated that he lookedacross at the captain’s airspeed indicator andthought the bugs were set correctly, althoughone of them was not visible from the normalright-hand seating position.

The aircraft was cleared for a visual approach;the runway had a short cliff on the approachend. After the aircraft was established on fi-

nal approach with flaps set at 33 degrees aminute before touchdown, the first officer no-ticed that the airspeed was about 112 knotsinstead of the proper bug speed of 118 knots.He called “speed” to the captain who responded“on bug” to indicate that he was properly fol-lowing his orange inner bug; however, thiswas still set at the takeoff setting of 111 knotsinstead of the 118-knot landing value whichwas properly set on the copilot’s airspeed in-dicator bug. Airbrakes were then selected andthe aircraft encountered a slight sink as it crossedover the cliff on short final leg. The captainallowed the airspeed to reduce further in or-der to cross the runway threshold at about 106knots, the speed he had set on his next bug,which should have been 113 knots.

The captain estimated that the aircraft wasslightly low coming across the threshold, butexpected that the landing flare would lead toa normal touchdown about 600 feet along therunway. He closed the throttles and began thelanding flare; however, there was no decreasein the aircraft’s rate of descent and it landedhard on the paved undershoot area just priorto the runway. The pilot was able to taxi theaircraft to the parking ramp and the passen-gers were deplaned without further incident.

Inspection of the aircraft revealed extensivedamage to the underside of the fuselage in thetail area that included a minor perforation ofthe pressure vessel. Marks on the overrunarea prior to the runway were consistent witha moderately heavy landing in an excessivelynose-high aircraft attitude. A check of theairspeed indicators revealed that the captain’sinstrument read high by two to three knots inthe range between 80 and 120 knots. Thiscould have further lowered the aircraft’s ac-tual airspeed from recommended values inaddition to the incorrect setting of his bugspeed.

Fuel ShortageShortens Trip

Cessna Citation: Aircraft destroyed. Serious inju-ries to six.

Air Taxi/CommuterAir TaxiCommuter


The aircraft was completing a flight in thedarkness of early evening on a November dayin Finland. There were two crew membersand four passengers aboard.

As the aircraft was being flown on an ILS ap-proach to the destination airport at approxi-mately 1825 hours, both engines failed at analtitude of 2,000 feet. The flight crew wasunable to restart either engine and the aircraftmade an emergency landing in a small field.The aircraft landed hard and skidded approxi-mately 300 feet before it stopped. The aircraftwas destroyed by the hard landing and all sixoccupants received serious injuries.

Investigators noted that the engines had faileddue to fuel exhaustion. It was found that thetanks had contained 60 percent of the requiredminimum fuel for the flight prior to depar-ture.

The pilot was cited for numerous instances ofpoor decisions, improper operation, wrong at-titude, low experience in aircraft type and forselecting an unsuitable area for the unsuccess-ful forced landing. The copilot also was citedfor poor decisions.

Demonstration FlightGot Carried Away

Gates Learjet Model 31: Substantial damage. Noinjuries.

The aircraft was being used for a demonstra-tion flight and the demonstration pilot had

allowed the other pilot, a non-Learjet ratedpilot with limited jet experience in a CessnaCitation, to do the flying.

A landing was being made under the follow-ing marginal conditions: the landing distancerequired was 2,750 feet and the distance avail-able was 2,674 feet; the required approach pathangle was four degrees because of obstacles inthe approach sector; there was both an up-slope and a down-slope to the runway; thedemonstration pilot was preoccupied with thenon-familiar approach and landing conditions;and there was little crew coordination.

The aircraft touched down with a high sinkrate at idle thrust. The hard landing causedthe supporting structure for the right engineto fail, causing substantial damage. There wereno injuries to the four occupants aboard.

Contributing factors to the hard landing acci-dent included faulty preflight planning andpreparation by the demonstration pilot, faultypreflight planning by the aircraft manufacturerconducting the demonstration flight; poor land-ing judgment and execution; and lack of coor-dination between the two pilots.

Be Prepared forClear Air Turbulence

Rockwell Turbo Commander 690: Substantial damage.No injuries.

The turboprop twin was cruising at 20,000 feetin visual meteorological conditions in the latemid-January afternoon over Argentina. Theonly occupants were two crew members.

The aircraft encountered severe clear air tur-bulence, pitched nose up, banked to the rightand rolled inverted. It descended verticallyand accelerated to a speed beyond the recom-mended never-exceed airspeed. The two crewmembers joined forces to recover and stabilizethe aircraft at 13,000 feet.

After it was landed with no further difficulty,the aircraft was inspected for signs of struc-tural damage. Both wings and ailerons had

Corporate ExecutiveCorporateExecutive


suffered substantial damage during the effortto recover the aircraft from the steep dive.

The Final Cause:Continued VFR Flight into…

Piper PA-32R-300 Lance: Aircraft destroyed. Fa-tal injuries to five.

The plan was to take three passengers fromone Canadian airport to another airport for anice fishing trip. Departure of the single-engineaircraft was scheduled for 1700 hours early inFebruary. The pilot planned to drop off threeof four original passengers and return to hishome base with the remaining passenger.

There is no record that the pilot obtained aweather briefing and no flight plan was filed.Reported weather at 1600 hours for the air-port included 2,500 feet broken, 7,000 feet over-cast and visibility 15 miles with temperatureand dew point of -9 and -13 degrees C. Thearea forecast included generally overcast weatherwith ceilings at 3,000 feet, three-to-five milesvisibility in light snow with patchy light freezingdrizzle and local ceilings down to 700 feet agl.Moderate clear icing in freezing drizzle wasforecast for below 4,000 feet.

The aircraft was not equipped with anti-icingor de-icing equipment other than a heated pitot-static tube. The 400-hour pilot had a privatelicense, authorized for day VFR flight. Althoughhe had approximately 26 hours of instrumentflight instruction, five hours of night instruc-tion and 20 hours of solo night flight time, hewas not endorsed for night flying and had noinstrument rating. Log book entries indicatedhe had carried passengers at night previously.

The aircraft took off in darkness at 1740 hoursand reported to the control tower when hedeparted the control zone to the north, butgave no indication of his intended altitude.Radar tracking showed that the aircraft madea 180-degree turn 29 nautical miles northeastof the airport. Shortly afterwards, 20 milesfrom the airport, the aircraft stuck a steel hy-droelectric transmission tower and crashed inan open field. The aircraft was destroyed andall five occupants were fatally injured.

At the time of the accident, it was dark withlow overcast skies and freezing precipitation.A lightplane pilot reported an hour earlier fromthe accident area that cloud bases were 2,800feet agl with freezing precipitation. Clear icehad formed on his windshield which had to-tally frosted over.

The Canadian Aviation Safety Board determinedthat the pilot attempted a night VFR flight inunsuitable weather conditions. The board ispreparing recommendations to reduce the num-ber of accidents involving VFR flights into ad-verse weather conditions.

Ground Checked OKFlight Check NG

Cessna 310: Substantial damage. No injuries.

There were an instructor pilot, a student pilotand one other occupant aboard the light twin-engine aircraft during a single-engine train-ing session. While the student pilot was fly-ing the aircraft, the left propeller began anuncommanded return to flat pitch, producingheavy drag that caused the aircraft to yaw tothe left. The instructor took control of theaircraft and made a precautionary landing ina field.

The instructor made a visual inspection of thepropeller, performed an extensive run-up anddetermined that the propeller was function-ing properly. He then taxied the aircraft to adirt road and took off. When the aircraft reacheda height of 20 feet, it yawed left and the pilothad to put it back on the ground. It landedhard and was substantially damaged. All of

Other GeneralAviation

OtherGeneralAviation


the landing gear legs were sheared off, bothwings were damaged and the fuselage wastwisted. There were no injuries to the threeoccupants.

A Case for theVisual Fuel Check

Enstrom F-28A: Moderate damage. No injuries.

The student pilot with almost 30 hours of ro-torcraft flight time noted that the fuel gaugeread 90 pounds and, with an instructor pilotaboard, took off in mid-morning for a duallesson on quick stops that lasted about 20 min-utes. After the final landing, the instructorconfirmed with the pilot that there was enoughfuel left for the student’s intended 30-minutesolo flight and left the aircraft.

During the following solo flight during whichhe practiced quick stops, the student moni-tored the fuel gauge to ensure that enoughwas available. After approximately 20 min-utes of flight, while flying straight and levelat a height of 40 feet and an airspeed of 60mph, the rotor and engine rpm indicator needles

split. The pilot applied full throttle but therpm readings remained erratic so he closedthe throttle and entered autorotation for a forcedlanding.

The pilot carried out a run-on landing duringwhich the tail rotor struck the ground at ap-proximately the same time he leveled the skids.The pilot was not injured and was able to shuteverything down before leaving the aircraft.

The fuel gauge read 60 pounds. However, sub-sequent examination of the tanks revealed thatthey were empty. Due to poor communica-tion, neither the student pilot nor the instruc-tor had visually checked the fuel quantity priorto the flight.

Too Slow, Too Low

Bell UH-1B: Aircraft destroyed. Serious injuriesto one.

The helicopter was being used for fire fight-ing. An external water drop bucket was beingcarried.

The aircraft was not properly aligned with thewater drop site and the pilot was trying tomaneuver it into the wind to make anotherattempt at a water drop. However, the heli-copter was too low and slow and, according towitnesses, appeared to settle toward the groundwith power on. It entered trees and descendednose down and to the right until it impactedthe ground. The aircraft was destroyed andthe pilot, the only occupant, received seriousinjuries. ♦

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