Tag: 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.

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:

Unsafe aircraft not welcome in Europe

Eurocontrol and the European Aviation Safety Agency (EASA) have brought live an automated system which alerts air traffic controllers when unsafe aircraft enter European airspace.

How does it work?

Network Management Director at Eurocontrol Joe Sultana, explained that “We have added another parameter to our system, and this is now checking if an aircraft coming from outside of Europe is coming from a state where the regulatory environment is accepted by the European Aviation Safety Agency”.

So in short: The system will now take an automatic look at the Third Country Operator Authorisation and alert ATC if there is a flight being operated from a aircraft on the banned list.

The regulation that a plane coming from a non EU country must have a Third Country Operator Authorisation has been in place since 2014, but controllers have had no way to implement it across the 30,000 flights it receives into Europe each day, until this new component was entered into their systems.

As a reminder, Eurocontrol receives the flight plans of all aircraft entering into European air space, while the EASA holds the Third Country Operator Authorisations information which confirms that planes are from countries with recognised safe regulatory practices.

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:

Hong Kong near-misses on the rise

According to recent figures released by the Civil Aviation Department (CAD) of Hong Kong, 2017 saw an increase in ‘loss of separation’ incidents within it’s airspace.

Twelve times, two aircraft came within 1000 feet and less than 5 nautical miles of each other last year. This is the highest in six years.

Local law makers are now calling for a new ATC system to be implemented. A local pilot operating regularly through VHHH/Hong Kong International Airport (HKIA) commented to FSB recently that the Air Traffic Services have been in “constant decline” over the past seven to ten years.

CAD insisted that alerts were issued “in a timely manner as per system design”. It said “losses of separation” were due to a number of factors such as adverse weather, operating procedures and human factors and they did occasionally occur due to the old air traffic system and other systems around the world. “CAD would investigate every individual incident according to established procedures and make necessary improvement,” the department added.

Hong Kong airspace is congested at the best of times. With four major airports within 150 kilometres and many overflights to and from mainland China, the 2016 introduction of a new Air Traffic System known as “Autotrac3” was set to assist in solving some of the complexity whilst increasing safety. The transition to the new system was challenging with various system issues.

The TMA is also complicated by significant terrain and regular adverse weather. Recent statistics show that air traffic is up over 3.5% already in 2018 with 36,000 movements occurring monthly (6.4 million passengers).

The continued massive year-on-year growth has seen the start of work to construct a third runway, expected to be operational in 2023-24 to facilitate the expected 100 million passengers using HKIA by that time.

This will no doubt just put further strain on an already complicated airspace situation.

The new third runway at HKIA- coming 2023-24.

Have you operated through the Hong Kong area lately? Can you provide an update?

Extra Reading:

Making a Ramp Check painless (with checklist)

Hello, we’re from the government and we’re here to help“.

The SAFA Program (Safety Assessment  of Foreign Aircraft) is not exclusive to the EU. Your aircraft can be inspected under the program in 47 different countries.

Here are the key points:

  • Ramp checks are possible in every country in the world – but follow a more regulated and common structure in SAFA Countries – totalling 47 – see the map and list below.
  • There is a standard checklist that is used by Inspectors in all SAFA countries, which you should be familiar with – see further down.
  • Three categories of findings have been defined. A “Category 1” finding is called a minor finding; “Category 2” is a significant finding and “Category 3” a major finding. The terms “minor”, “significant” and “major” relate to the level of influence on safety.
  • If there is a “corrective actions before flight authorised” finding – then the inspector is concerned and a repair must be made before the aircraft is released to fly.
SAFA

Unless your aircraft looks like this, you have little to worry about.

Here’s how a ramp check normally goes down:

  • The flight selected will either be your last of 6 legs for the day, or after a gruelling 12 hour jetlag-inducer, or at 3am when you were thinking about a quick nap during the turnaround. This much is guaranteed.
  • As you pull on to the stand, you will notice more yellow vests than normal hanging around.
  • Two of these will be your friendly ramp inspection team (to be fair, they almost always are)
  • A short time later, those yellow vests will be in the cockpit, and the first request will be for a look at your license, medical, aircraft documents (like Insurance, Airworthiness), and flight paperwork. Make sure you’ve done your fuel checks and there are a few marks on the flight plan.
  • If you get a good cop, bad cop scenario, one will disappear down the back (this will be the nice guy) and check the cabin, while the first will stay and ask you tough questions about the TCAS system.
  • Some time later, you’ll get a list of findings. The average check is probably about 30 minutes.
  • You can be guaranteed they will always have at least one finding – which will probably be obscure.
  • Sign off the checklist, and you’re on your way.

 

Some interesting points:

  • The Inspectors can ask you for manuals, documents, or guidance – but they are not supposed to test your knowledge of procedures, regulations, or technical matters. This doesn’t always happen in practice – so if you get a tough question – just say “I don’t know” – and let them note it if they want to. This isn’t a classroom test.
  • This guidance is given to Inspectors: Delaying an operator for a non-safety related issue is not only frustrating to the operator, it also could result in unwanted human factor issues with possible negative effects on the flight preparation. They can (should) only delay your flight for a safety related issue.
  • Some recent favourites: TCAS 7.1 – show me it and how it works (they just want to see that you have the current version), extra pair of eye glasses if noted on medical certificate, show me working personal flashlights, show me the aircraft manuals, and how you know they are up to date, show me your duty time rules.
  • Remember, it’s not you that’s being inspected. It’s your aircraft. If you’re uncomfortable with the questions, get them noted and allow your operator to discuss later.
  • Every inspector is a little different. Work with them and you’ll find that 90% of your ramp checks will be over in 20 minutes with little issue.
  • That guy that says he’s flown for 30 years and never had a ramp check probably isn’t lying. There aren’t that many of them, and you might go a long time without them.
  • Private Operators – especially in GA (even more so under the 5700kg mark) – are far less likely to get ramp checked. EASA guidelines do apply to General Aviation, but they are far more interested in Commercial Operators.

 


The Countries

SAFA

47 Participating States – those not in the EU are in bold below, and green/orange above.

Albania, Armenia, Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Canada, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Latvia, Lithuania, Luxembourg, Malta, Republic of Moldova, Monaco, Montenegro, Morocco, Netherlands, Norway, Poland, Portugal, Romania, Serbia, Singapore, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Macedonia, Turkey, Ukraine, United Arab Emirates and the United Kingdom.

 

The Checklist

 

Download by clicking above, or here: FSB SAFA RampChecklist

 

The Stats

These are interesting as background to the Program – although they are from 2012, which is the date of the most recent report from EASA on the SAFA program (thanks International Flight Resources for the summary)

 

– 2012 had just over 11,000 inspections performed, over twice as many as 2005.
– Most frequent private operator’s country of registration inspected was USA, Isle of Man, Germany
– Frequency of inspections is almost evenly split between EU and Non-EU countries. Largest number of SAFA locations were France (71), Italy (34), UK (31) and Germany (30)
– On average, 40 of the 54 possible items were inspected each time with 46% of the findings labeled “Significant”
– “Significant” findings are reported to the operator and the registered CAA. These will also require “Corrective action” prior to flight
– Latin American/Carib operators had the most number of findings
– USA and African operators were tied for second place
– Largest percentage of operators inspected: Germany (7.0%), Russian Federation and UK (6.8%), Turkey (4.9%) and USA (4.5%). France was 2.2%.

 

Resources:

 

How did your recent ramp check go down? Comment below …

Rules revised: SAFA Ramp Checks for ‘Suspect Aircraft’

01JUN: EASA have published new guidelines for inspectors to assess which aircraft should be prioritised for SAFA ramp checks in Europe and SAFA compliant states. ARO.RAMP.100(b) in the Part-ARO contains the updated list of aircraft that will be selected for priority checking:

(a) (when EASA receive) information regarding poor maintenance of, or obvious damage or defects to an aircraft;

(b) reports that an aircraft has performed abnormal manoeuvres that give rise to serious safety concerns in the airspace of a Member State;

(c) a previous ramp inspection that has revealed deficiencies indicating that the aircraft does not comply with the applicable requirements and where the competent authority suspects that these deficiencies have not been corrected;

(d) previous lists, referred to in ARO.RAMP.105, indicating that the operator or the State of the operator has been suspected of non-compliance;

(e) evidence that the State in which an aircraft is registered is not exercising proper safety oversight; or

(f) concerns about the operator of the aircraft that have arisen from occurrence reporting information and non-compliance recorded in a ramp inspection report on any other aircraft used by that operator;

(g) information received from EASA Third-Country Operator (TCO) monitoring activities;

(h) any relevant information collected pursuant to ARO.RAMP.110. (“whistleblowers”)

 

The revised Part-ARO, issued in May 2016, contains a large number of revisions and operators should take a close look at the changes.

For a general guide to SAFA Ramp Checks, have a look at our other article: Avoiding the Pain of a Ramp Check.

References:

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