Category: Safety

Check your checklist! Lessons from fatal King Air accident in Melbourne

The pilot at the controls of a Beechcraft B200 Super King Air that crashed shortly after take off had the aircrafts rudder trim in the full left position for take off, the Australian Transport Safety Bureau (ATSB) has found.

The ATSB final report said the aircraft’s track began diverging to the left of the runway centre line before rotation and the divergence increased as the flight progressed.

It then entered a shallow climb followed by a “substantial left sideslip with minimal roll” before beginning to descend. At this point the pilot issued a mayday call seven times in rapid succession.

Approximately 10 seconds after the aircraft became airborne, and two seconds after the transmission was completed, the aircraft collided with the roof of a building.

What Happened?

The investigation found that the pilot did not detect that the aircraft’s rudder trim was in the full nose-left position prior to takeoff.

“Prior to takeoff, there were several opportunities in the pre-flight inspection and before takeoff checklists for the pilot to set and confirm the position of the rudder trim,” the ATSB final report said.

A King Air flight simulator was used to recreate the event as part of the ATSB investigation.

The pilot who performed the flight simulator test commented that:

The yaw on take-off was manageable but at the limit of any normal control input. Should have rejected the take-off. After take-off the aircraft was manageable but challenging up to about 140 knots at which time because of aerodynamic flow around the rudder it became uncontrollable. Your leg will give out and then you will lose control. It would take an exceptional human to fly the aircraft for any length of time in this condition. The exercise was repeated 3 times with the same result each time. Bear in mind I had knowledge of the event before performing the take-offs.

The pilot also stated that it could be possible for a pilot to misinterpret the yaw as being caused by an engine power loss rather than from a mis-set rudder trim.

Safety message

Cockpit checklists are an essential tool for overcoming limitations with pilot memory, and ensuring that action items are completed in sequence and without omission. The improper or non-use of checklists has been cited as a factor in some aircraft accidents. Research has shown that this may occur for varying reasons and that experienced pilots are not immune to checklist errors.

This accident highlights the critical importance of appropriately actioning and completing checklists.

Checklist discipline

In previous correspondence between the accident pilot and the ATSB when discussing checklists, the pilot stated that:

“You don’t get complacent as a pilot but you get into a routine. The same as your pre-take-off checks, you get a routine and you don’t need to use a checklist because you are doing it every day, you are flying it every day… I take-off with one stage of flap because it gets me of the ground quicker. And I never change my routine…”

Wait what!??? It is stating the obvious but it’s a timely reminder that checklists are an essential defense against pilot errors. 

Sadly, it could have been a life-saver in this instance.

The ATSB video to supplement the report.

ATC Strike over, but nine Ethiopian Air Traffic Controllers remain in jail

5th September, update:

As of this morning, most controllers have returned to work. Some concessions made by ECAA. Addis ACC and TWR are again staffed with qualified controllers, so the safety situation, for now, is restored. However, 9 remain in jail. Returning controllers were forced to sign an ‘admission’ of illegal strike action in return for amnesty. IATA In Flight Broadcast Procedure requirement for Addis FIR remains in place, meaning you must broadcast on 126.9 as in other areas of concern in Africa. Further as we get it.

 

4th September:

Last week we were one of the first to expose the attempted ATC Strike cover up by the Ethiopian Civil Aviation Authority.

As a reminder, untrained and uncertified foreign controllers, retired and local non-operational ATC personnel are being used to control air traffic over Ethiopia. 

It is a catastrophic misjudgement, creating a safety risk in the Addis FIR and at Ethiopian Airports for pilots and passengers alike.

Here are some more updates since our last article:

  • On August 29, The International Federation of Air Traffic Controllers Association (IFATCA) penned a letter to the Prime Minister of Ethiopia. You can read it here.
  • The neighbouring controllers in Kenya warned that flights in and out of Addis Ababa are not safe. You can view their letter here – specifically they warned that the ‘possibility of air misses’ is real.
  • The ECAA over the weekend rejected concerns regarding the safety of Ethiopian airspace, specifically calling the claims from Kenya as “outright lies.”  The ECAA has said that ATC are operating “in accordance with ICAO Annex 1 provisions.” They did not deny however that foreign and retired ATC are being used.
  • The ECAA also outlined that the national carrier, Ethiopian Airlines, has “awarded” veteran Air Traffic Controllers,  who are performing their national obligation.
  • However on Monday, the local state affiliated broadcaster, Fana BC, reported that the Federal Police Commission had detained nine individuals on suspicion of attempting to disrupt international flights and coordinating a strike that began last week. This has been quickly condemned on social media, as many locals called on the government to resolve the issues raised by the ATCs rather than resorting to intimidation.

The ECAA claims that “some” of the striking controllers have returned to work.

Major airlines and uninformed passengers continue to fly into and over Ethiopia and this continues to be a major safety risk.

Do you have more to add this story?  Please, let us know!

Runway? Who needs one when you have a taxiway!

It’s happened again.

Around midnight on a perfectly clear night last week in Riyadh, a Jet Airways 737 tried to take off on a taxiway. The crew mistaking a new taxiway for a runway!

The crew, with thousands of hours experience, took off on a surface that didn’t have runway markings or runway lights. Thankfully no one was seriously hurt.  It’s too early to exactly say why this happened, but it’s clear that some sort of “expectation bias” was a factor. Expecting to make the first left turn onto the runway. One has to ask – was ATC monitoring the take off?

After the tragic Singapore 747 accident in Taipei, technology was developed to audibly notify crew if they were about to depart “ON TAXIWAY”. This is known as the Runway Awareness and Advisory System (RAAS).

Sadly the Riyadh incident is not isolated. There have been a plethora of near misses in the past few years (more details in Extra Reading below).

There have also been more than a few “incidents” of aircraft from C17’s to 747s landing at the wrong airports! The most notable near miss recently was that of an Air Canada A320 nearly landing on a taxiway full of aircraft at KSFO/San Francisco. But it’s happened to Delta and Alaskan Air recently too.

It is an even bigger issue at a General Aviation level (and not just because Harrison Ford did it!). The FAA safety team recently noted;

The FAA Air Traffic Organization (ATO) has advised of an increase in, “Wrong Surface Landing Incidents” in the National Airspace System (NAS).

Incidents include:

  • Landing on a runway other than the one specified in the ATC clearance (frequently after the pilot provides a correct read back)
  • Landing on a Taxiway
  • Lining up with the wrong runway or with a taxiway during approach
  • Landing at the wrong airport

The FAA published some shocking statistics:

  • 557wrong surface landing/approach events” between 2016-2018. That’s one every other day!
  • 89% occurred during daylight hours
  • 91% occurred with a visibility of 3 statue miles or greater


So what to do?

There are numerous ‘best operating practices’ pilots can use to help avoid such incidents.

  • Be prepared! Preflight planning should include familiarization with destination and alternate airports to include airport location, runway layout, NOTAMs, weather conditions (to include anticipated landing runway)
  • Reduce cockpit distractions during approach and landing phase of flight.
  • Use visual cues such as verifying right versus left runways; runway magnetic orientation; known landmarks versus the location of the airport or runway
  • Be on the lookout for “Expectation Bias” If approaching a familiar airport, ATC might clear you for a different approach or landing runway.  Be careful not to fall back on your past experiences.  Verify!
  • Always include the assigned landing runway and your call sign in the read back to a landing clearance
  • Utilize navigation equipment such as Localizer/GPS (if available) to verify proper runway alignment

It’s worth spending a few minutes watching this.

Extra Reading

 

The risks posed to civil aircraft by surface-to-air missiles

In Short: Worldwide the SAM threat is deemed to be “low” by ICAO with the caveat that this can change quickly when flying over or near conflict zones. The best risk mitigation is centred around which airspace you are operating over and what information you have access to. As we have explained before: There is no safe altitude from a large SAM.

What are surface-to-air missiles, and who has them?

Surface-to-air missiles (SAMs) are large, complex units, with the capability of reaching aircraft at cruising levels well above 25,000 ft, and they are designed to be operated by trained military personnel.

They are distinct from Man Portable Air Defence Systems (MANPADS), which are the smaller, shoulder-launched systems, the most dangerous of which being the FIM-92 Stinger which has an operational ceiling of 26,000 ft.

SAM systems vary but they are all designed to track and destroy military targets in flight. Due to the size and predictable flight paths, civil aircraft represent easy and highly vulnerable targets.

Many SAMs are mobile and can be moved quickly between locations. Many are located on warships. It is estimated that more than 70 States around the world have acquired SAMs as part of their military capability. A small number of non-State actors (i.e. militant groups) have also reportedly acquired SAMs, but as they require a radar system as part of the mechanism, they may not have the technical capability to use them. To date, SAMs have never been used by terrorists.

What has happened in the past?

There have been three documented occurrences where aircraft destruction has occurred due to SAM attacks.

The risk of intentional attack

To date, no documented case of intentional SAM attack on a civilian aircraft has been identified. In the case of MH17 and Iran Air, both occurred during periods of military conflict or high tension, whilst Siberia flight 1812 was shot down during a military training exercise.

ICAO say that “with regard to the States and non-State actors that currently do have access to SAMs, there is no reason to believe that the intent currently exists to target civil aviation deliberately.” And with regards to terrorist groups (as opposed to militarized forces), they say that “even where intent may exist there is currently no evidence of capability (in terms of hardware and trained personnel).”

Overall, the current risk to aviation from intentional SAM attack is therefore currently assessed to be low, the key caveat being to avoid overflying airspace over territory where terrorist groups tend to operate – normally areas of conflict where there is a breakdown of State control.

The risk of unintentional attack

Past events show us that the higher risk to civil aviation is from unintended and unintentional attacks when flying over or near conflict zones – missiles fired at military aircraft which miss their target, missiles fired at civil aircraft which have been misidentified as military aircraft, and missiles fired by State defence systems intended to shoot down other missiles.

Areas where there are armed conflicts going on clearly present an increased risk of an unintentional attack. But when assessing the risk of overflying a particular conflict zone, here are some more specific questions to consider:

Are there increased levels of military aircraft flying around in the region?

This could be anything from fighter jets being operated in a combat role, or for hostile reconnaissance; remotely piloted aircraft; or military aircraft used to transport troops or equipment. If military aircraft are one of the most likely targets for intentional attacks, then the chances of civil aircraft being mistakenly targeted increases in those areas where there are lots of military aircraft zipping around.

Are there likely to be a bunch of poorly trained or inexperienced personnel operating SAMs in the region?

This may be difficult to evaluate, but the risk is likely to be highest where SAMs may have been acquired by non-State actors. The risk is also likely to be higher in places where there is less of a robust command and control procedure for launching missiles, thus increasing the risk of misidentification of civil aircraft.

Is the territory below the airspace fully controlled by the State?

If not, and there are some areas controlled by militant or terrorist groups, the information on the presence and type of weaponry in such areas, as well as the information on who controls them, may not be readily available. In such regions, the information promulgated by the State about the risks to airspace safety may therefore not be 100% reliable.

Does the route pass over or near anywhere of particular importance in the context of the conflict?

These could be areas or locations that may be of strategic importance or sensitivity in the conflict, such as key infrastructure or military sites, which might be considered potential targets for air attack and would therefore be more likely to be guarded by SAMs.


Ultimately, risk mitigation is centred around which airspace you are operating over and what information you have access to. But as has been reported in the past, history has shown us that badly-written information published by the State often does little to highlight the real dangers posed by overflying conflict zones.

There is some evidence to suggest that more States are starting to provide better guidance and information to assist operators in making appropriate routing decisions, but we think this still has some way to go.

That is why we have been running our safe airspace map to provide guidance to assist operators in determining whether to avoid specific airspaces around the world.

 

Extra Reading:

Eruption possible: Öræfajökull volcano, Iceland

The Department of Civil and Emergency Management in Iceland have issued a new status for Öræfajökull volcano saying that it shows clear signs of unrest. They added that the volcano is in typical preparation stage before an eruption.

For more than 250 years Öræfajökull has been lying dormant. The volcano is covered with an ice cap which forms the southernmost part of Vatnajökull glacier. The cauldron formed last winter in the ice cap of the volcano’s crater.

The mountain stands at 2,110 m (6,921 ft) above sea-level.

If it does erupt – it has the potential to cause significant impact to aviation across the Atlantic. We all still remember Eyjafjallajökull !

You can keep updated by keeping an eye on

EU SAFA ramp checks NOT on the rise – but are you ready for one?

In Short: SAFA ramp checks are continuing at the normal pace. Avoid the common mistakes of Fuel/Calc and Flight Routing (with SID/STAR), PRNAV/RNAV-1, incorrect flight plans and TCAS 7.1. If you do get a finding, expect to get a follow up ramp check the next few times you visit, to ensure compliance.

There have been more reports in Airport Spy recently which suggest there may be an increase in SAFA (Safety Assessment of Foreign Aircraft) ramp checks in Europe. So we reached out to a dozen SAFA offices around Europe to check if it was true.

Here’s what they told us:

  1. No, they’re not conducting significantly more ramp checks at the moment.
  2. No, they’re not looking more closely at certain items.
  3. Rather, the items checked during the SAFA/SACA inspections are based on a risk based approach and can differ from operator to operator (for example depending on findings raised during previous inspections). Meaning that operators who get ramp checked with findings will most likely get ramp checked again, to see if they’ve sorted out the problems!

Common Findings

But what are some common findings and the things to make sure you are doing right so you don’t get caught out?

  1. Fuel Calculation and Flight Routing: Alternates must be planned with a SID/STAR routing.

In many parts of the world it is common to plan DCT but not in many European countries. Non-compliance during a ramp inspection could lead to either a Cat 2 finding when sufficient fuel was taken into account such that the required fuel is above the minimum, or a Cat 3 finding when this was not the case.

  1. PRNAV/RNAV-1 capability.

Non-compliance constitutes a Cat 3 finding when landing at airports (such as EHAM/Amsterdam) that require it. The finding will also be reported to the aeronautical oversight department who can give fines for such violations.

  1. Filing incorrect flight plans – specifically saying you are 8.33 MHz equipped and PRNAV/RNAV-1 capable.

Again, this could lead to findings and fines beyond the SAFA programme. An easy one to miss.

  1. TCAS 7.1

The TCAS 7.1 requirement became mandatory in EU Airspace from 1st of December 2015 and became a worldwide standard under ICAO from 1st of January 2017.  One to also watch out for if operating to EU overseas territories in the Caribbean where this requirement has also been implemented and during ramp inspections is enforced the same way.

How to prepare for one?

We wrote a 2017 article all about how to make a ramp check painless.

We have also updated the FSB SAFA Ramp Checklist. Download it here.

Keep a copy with you and run through it before you head towards the EU.

Back in 2016, EASA published new guidelines for inspectors to assess which aircraft should be prioritised for SAFA ramp checks in Europe and SAFA compliant states. For an overview of those guidelines, check out our article.

Have you been ramp checked recently? Let us know, by joining OpsFox! This is a community system, where every Pilot, Air Traffic Controller, Dispatcher, Handler, and CAA can add categorized reports, based on what they see and know at their home base or visited airport. Opsfox blurs the white noise and keeps only the relevant and current information at your fingertips, before you fly.

Extra Reading:

Bad NOTAMS = Runway overruns in Hamburg

If you’re headed to Hamburg, watch out. The runway is shortened, and the Notams are vague.

Poorly written NOTAMs struck again this week in Hamburg, Germany, when an A320 and a B737 both overran Runway 05 on landing – the first by SAS on May 11  and the second by Ryanair on May 15.

Runway 05 in EDDH/Hamburg has been undergoing works and a litany of related NOTAMs and AIP SUP were issued to explain.

A1608/18 – RWY 05 LDA 2370M. 12 APR 04:00 2018 UNTIL 23 MAY 21:00 2018. CREATED: 05 APR 09:50 2018

A1605/18 – SHORTENED DECLARED DISTANCES FOR RWY 05/23. AIP SUP IFR 09/18 REFERS. 12 APR 04:00 2018 UNTIL 23 MAY 21:00 2018. CREATED: 05 APR 09:42 2018

A2223/18 – TWY A1, A3, A4, A5 CLOSED. 02 MAY 10:26 2018 UNTIL 01 JUL 04:00 2018. CREATED: 02 MAY 10:27 2018

A2044/18 – ILS RWY 05 NOT AVBL. AIP SUP IFR 09/18 REFERS. 23 APR 09:17 2018 UNTIL 23 MAY 21:00 2018. CREATED: 23 APR 09:17 2018

A1725/18 – CONSTRUCTION EQUIPMENT IN DEP SECTOR ALL IFR DEPARTURES RWY 05. PSN WITHIN AN AREA 533810N 0095948E AND 533805N 0100023E. MAX ELEV 89 FT. NOT MARKED AND LIGHTED. SUP 09 2018, CONSTRUCTION WORK EDDH REFER. 12 APR 04:00 2018 UNTIL 23 MAY 20:00 2018. CREATED: 09 APR 13:10 2018

A1609/18 – RWY 23 CLOSED FOR ARR. 12 APR 04:00 2018 UNTIL 23 MAY 21:00 2018. CREATED: 05 APR 09:52 2018

Despite this, both were unable to stop before the last open exit (A6) and vacated further down the runway. Thankfully both resulted in no injury because all construction equipment was kept clear of, and beyond, taxiway E6.

A better NOTAM may have been:

RWY 05 IS SHORTER THAN USUAL DUE TO CONSTRUCTION WORK AT 23 END. REDUCED LANDING DISTANCE IS 2370M. LAST TAXIWAY OPEN FOR EXIT IS A6. CONSTRUCTION EQUIPMENT ON RUNWAY BEYOND TAXIWAY A6. 

You get the idea. Concise and plain language in one NOTAM to make it clear what the issue is and the consequences of going beyond 2370m of runway.

They did, to their credit, try and tidy it up since the incidents:

A2563/18 – RWY 05 CLSD EAST OF TWY A6. RWY 05 LDA 2370M. RWY 05 NON STANDARD TDZ AND AIMING POINT MARKINGS AT 400M FM THR ISO 300M. ADJUST LDG PERF ACCORDINGLY. 17 MAY 16:30 2018 UNTIL 23 MAY 21:00 2018. CREATED: 17 MAY 16:31 2018

In another serious incident associated with these runway works, a Vueling A320 (another foreign operator) nearly landed at the wrong airport on May 11. Thankfully ATC intervened on that one.

All incidents are now the subject of investigation.

Naturally it’s imperative for crew and disptachers to check and read all NOTAMS thoroughly. But with over 40 current just for EDDH/Hamburg right now, it’s easy to understand why things get missed.

Until then “adjust landing performance accordingly”.

Extra Viewing:

The only airport in the world with a mandatory wind limit

A slightly skeewiff statue of Cristiano Ronaldo is the most notable thing about LPMA/Funchal Airport which, since last year, has been known as Cristiano Ronaldo International Airport.

Before that, however, the airport on Madeira’s east coast was better known for hosting one of the world’s most challenging approaches and landings.

The airport’s runway is often buffeted by Atlantic winds, while its proximity to the mountains and ocean present yet more difficulties. Pilots scheduled to arrive here must undergo additional training, studying the approach in detail. Airlines wishing to fly into Funchal – sorry, Ronaldo – require special approval from the Portuguese aviation authority.

Earlier this year the Association of Portuguese Airline Pilots (APPLA) said it was vital that the airport closes when winds exceed the maximum limits (depending on wind direction). In a statement it said that “there are limits to anything in aviation. These limits generally exist for several reasons, including safety issues”. APPLA was concerned there had been some 20 commercial landings in the first half of 2017 when the wind had been exceeding limits.

What are these limits?

The Portuguese AIP warns that:

The Airport is located on a plateau on the east coast of Madeira Island. Except for the seaside, ground raises rapidly very closed to it. This fact generates, very often, wind variation and turbulence. Also severe low altitude wind shear conditions and / or micro burst are likely to be encountered.

Wind Limitations

When landing

Maximum of two minutes mean Wind Speed Values indicated by the Touchdown anemometer:

  • In the sector 300° to 010° MAG (clockwise) – 15KT, with the maximum Wind Gust of 25KT
  • In the sector 020° to 040° MAG (clockwise) – 20KT, with the maximum Wind Gust of 30KT
  • In the sector 120° to 190° MAG (clockwise), and if Runway in use is 05 – 20KT with a maximum Wind Gust of 30KT, and if Runway in use is 23 – 15KT, subject also to maximum Wind Gust of 25KT as indicated by MID Anemometer.

Maximum of two minutes mean Wind Speed Values, including Gust indicated by the MID or ROSÁRIO Anemometers

  • In the Sector 200º to 230º MAG (clockwise) – 25KT.

When Taking-off

Maximum of two minutes mean Wind Speed Values indicated by the MID anemometer:

  • In the sector 300° to 010° MAG (clockwise) – 20KT with no Gust limitations
  • In the sector 020° to 040° MAG (clockwise) – 25KT with no Gust limitations
  • In the sector 120° to 190° MAG (clockwise) and if Runway in use is 05 – 25KT with no Gust limitations, and if Runway in use is 23 – 20KT, also with no Gust limitations

NOTE: The limitations above do not supersede any Operators or Aircraft Operations Manual (AOM) limitations if these are more restrictive

Turbulence

  • Attention should be paid to the WIND DIRECTION INDICATORS located on the south side of the runway, near each touchdown area. They will reflect unexpected wind changes. Occasionally they will indicate wind from opposite directions;
  • When landing on RWY 05 wind differences greater than 5 KT, between Rosário and MID anemometers, may indicate turbulence on final;
  • When landing on RWY 23 with winds from South and Westerly Sectors, one may experience severe turbulence at low altitude over the RWY Threshold;
  • Headwind or nearly so, up to 15 KT will cause “WEAK” turbulence on final;
  • Wind of 15 KT from sector 020° to 050° MAG (clockwise) may cause “MODERATE” turbulence;
  • Wind of 15 KT or even less from sector 300° to 020° MAG (clockwise) may cause “SEVERE” turbulence;
  • Down drafts or up drafts are to be expected near the threshold of runways 05 and 23.

NOTE: Pilots are strongly requested to report to the Control Tower as soon as possible any turbulence and/or windshear that may affect operational conditions.

There have been recent attempts of political intervention by the Vice President of the Regional Government, Pedro Calado. He met recently with aviation officials in Lisbon but to no avail. He expressed to his amazement at the fact that the limits set for Madeira Airport have not been changed since 1964.

Calado says that “what is happening at Madeira Airport is unusual, it is the only airport in the world that has mandatory limits, meaning that even if the commanders consider having safety conditions to land, if the wind limits are above stipulated, can not do so under penalty of ANAC suspending its license to fly. ”

He is right about that. Air Traffic Control won’t stop you from making an approach and landing if the wind limits are exceeded but they will promptly report all flights having done so to the authorities back on the mainland. There have been threats of license and airline operational approval suspensions in the past.

Looks pretty fun though!

Have you flown into the airport recently and can update our opsgroup members? Drop us a line: bulletin@fsbureau.org

Extra Information:

  • The airport’s runway, supported by columns that lift it 70 metres above the ocean, extends out over what was once a beach. The construction of it began in 1983 after a Boeing 727 operated by TAP Portugal overshot the original runway in 1977 in windy and rain conditions, landing past the threshold before aquaplaning and sliding off the runway and plunging off a steep bank. The aircraft crashed into a bridge, split into two and burst into flames, killing 131 of the 164 on board. The accident remains TAP Portugal’s only fatal accident and the second deadliest in Portugal.
  • Portugal AIP
  • Pilot’s Briefing Room – Funchal 
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