AeroSafety World February 2011

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Entire Issue
 

AeroSafety World February 2011
68 pages. [PDF 4.8M]

It was a “VIP flight.” The Tupolev 154M was carrying the Polish president, government officials and parliament members from Warsaw to Smolensk, Russia, for a solemn ceremony. But weather conditions had deteriorated below minimums by the time the aircraft arrived in the vicinity of Smolensk.

“The crew did not take the correct decision to go to an alternate airport,” said the accident investigation report. The approach included numerous errors, including a lack of descent rate monitoring and of required callouts, and a mis-set altimeter.

“The expectation of punishment in case of proceeding to an alternate airdrome formed the dominant idea of landing by any means and drove them to take unjustified risks,” the report said. All 96 people aboard were killed in a CFIT. Mark Lacagnina details the findings of the Russian Interstate Aviation Committee investigation.

Features
 

Softening Level-Offs (Text only)

An altitude-capture software enhancement has been developed to eliminate the predominant cause of resolution advisories from traffic-alerting and collision avoidance systems. It works by automatically adjustingthe trajectory of at least one airplane converging with another during specific climb/descent scenarios. [Download PDF 3 pages. 221K]

Leveling Off (Text only)

The accident rate for commercial jets in 2010 was 0.54 major accidents per million departures. That was almost identical to the average rate of 0.55 for the previous five years and slightly better than the 0.57 rate for the previous decade. [Download PDF 4 pages. 273K]

‘Clash of Motives’ (Text only)

The flight crew’s failure to proceed to an alternate airport after being told repeatedly that the weather conditions at Smolensk (Russia) Severny Airdrome were significantly lower than the nonprecision approach minimums was the “immediate cause” of the controlled flight into terrain accident that killed all 96 people aboard a Tupolev 154M the morning of April 10, 2010. [Download PDF 5 pages. 281K]

SMS Swiss Style (Text only)

Attention to preferred languages, local culture and persuasive modeling has helped Switzerland move to the forefront in national implementation of safety management systems (SMSs), says Peter Müller, safety analyst technical, Safety Risk Management, Swiss Federal Office of Civil Aviation (FOCA). [Download PDF 2 pages. 142K]

Do the Right Thing (Text only)

The reason for a procedural deviation may stem from time pressure, working conditions or a lack of resources. This example is not only a classic maintenance human factors error, but also speaks to the issue of professionalism and integrity conflicting with efficiency. [Download PDF 3 pages. 148K]

Weighty Issues (Text only)

The owner’s “intentional understatement” of a helicopter’s empty weight was partly to blame for the Aug. 5, 2008, crash of a Sikorsky S-61N that killed seven firefighters and two crewmembers during a forest fire near Weaverville, California, U.S., the U.S. National Transportation Safety Board says. [Download PDF 5 pages. 350K]

Wildfires Make Their Own Weather (Text only)

Wildfires pose unique problems for the aviation community. There is the obvious physical danger of the fire itself to aviation facilities and aircraft on the ground. Visibility effects strongly depend on wind direction. Simply put, any wind direction that puts the fire upwind of you causes problems. [Download PDF 3 pages. 205K]

Dangerous Approaches (Text only)

Why didn’t the flight crew follow standard operating procedures? Why didn’t they fly their instruments? Why didn’t they hear and respond to the ground-proximity warning system (GPWS)? Poor decision making in many cases was caused by stress overload that resulted in the narrowing of crew focus to the point that warnings were not heard, recognized or acted upon. [Download PDF 6 pages. 647K]

Changing the Rules (Text Only)

Proposed changes in regulations governing helicopter emergency medical services operations — including a plan to institute stricter limits for weather minimums and flight crew rest requirements — are crucial to improving safety, the U.S. National Transportation Safety Board says. [Download PDF 4 pages. 126K]

By All Means (Text Only)

Airport and air traffic control specialists in Italy expect to manage runway incursion risk as a high priority for the foreseeable future as projections call for increased European air traffic with few runway additions, says Massimo Garbini, director general of Ente Nazionale di Assistenza al Volo (ENAV), the Italian company for air navigation services. [Download PDF 2 pages. 258K]

Departments
 

Executive’s Message | The System Works (Text only)

During a recent trip to Africa and the Middle East, I found myself in some situations that reminded me how important it is for each airline, and this industry, to really hold itself accountable for its safety performance. [Download PDF 1 page. 80K]

Editorial Page | A Grain of Salt (Text only)

When accidents are so rare and random that they become statistically irrelevant, which is where we’ve been for quite a while, a larger dataset must be used. [Download PDF 1 page. 66K]

Safety Calendar | Industry Events (Text only)

A listing of aviation safety-related conferences, seminars and meetings. [Download PDF 1 page. 65K]

In Brief | Safety News (Text only)

The airport air traffic controller on duty during the fatal crash of a Comair Bombardier CRJ100ER at Blue Grass Airport in Lexington, Kentucky, U.S., was “substantially fatigued when he failed to detect that the plane was on the wrong runway and cleared it for takeoff,” a team of sleep researchers say. [Download PDF 3 pages. 162K]

Data Link | Re-examining the Rudder (Text only)

Transport airplane pilots have used, or expected to use, the rudder “in ways not always trained and in ways not recommended by the manufacturer,” according to a survey conducted for the U.S. Federal Aviation Administration. The survey also found that “erroneous and accidental [rudder] inputs occur” and that some pilots had to compensate for overcontrolled or wrong-direction rudder commands. [Download PDF 3 pages. 91K]

Info Scan | When Worlds Collide (Text only)

Two worlds are colliding. The first is traditional, technical accident investigation, which is best served by full disclosure of all relevant facts by everyone involved, in addition to physical evidence. The goal is to determine causal factors and offer recommendations for reducing the likelihood of accidents with similar causal factors. [Download PDF 4 pages. 98K]

On Record | Fire Erupts During Maintenance Test (Text only)

The following information provides an awareness of problems in the hope that they can be avoided in the future. The information is based on final reports by official investigative authorities on aircraft accidents and incidents. [Download PDF 8 pages. 262K]

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