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A U G U S T 2 0 1 5

FOCUSI S S U E 8 4

Korean Air Cargo Flight 8509

Munitions Safety in Training & Operations

Safety in Training

Air Canada Flight 143

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IN THIS ISSUE

R E P U B L I C O F S I N G A P O R E A I R F O R C E

S A F E T Y M A G A Z I N E

TRAINING SAFETY

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CONTENTS

EDITORIAL BOARD

Chairman

COL Philip Chionh

MembersLTC Danny Koh Keng SengLTC Ong Choon HuiME6 Lim Choon PengMAJ Freddie TeoMAJ Khoo Pak SynMAJ Marcus WooMAJ (DR) Jason LowMS Audrey Siah Yushu

FOCUS is published by Air Force Inspectorate, HQ, RSAF, for accident prevention purposes. Use of information contained herein for purposes other than accident prevention, requires prior authorisation from AFI. The content of FOCUS is of an informative nature and should not be considered as directive or regulatory unless so stated. The opinions and views in this magazine are those expressed by the writers and do not reflect the official views of RSAF. The contents should not be discussed with the press or anyone outside the armed services establishment.

FOCUS magazine is available on these sites:Internet: http://www.mindef.gov.sg/rsafIntranet: http://webhosting.intranet.defence.gov.sg/web/AirForce/AFI/index.htm

EditorME5 Kenny Tan

Assistant EditorsME3 Philippe Ashley LimCPL Lee Xun’An

Design byJAB Design Pte Ltd

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FOREWORD COL Philip Chionh Head Air Force Inspectorate

Cert No: 2007-2-1606SS ISO 9001:2008

Cert No: OHS. 2007-0179BS OHSAS 18001:2007

Munitions Safety in Training & Operations165 Squadron

Safety in Training815 Squadron

Case Study: Air Canada Flight 143

Case Study: Korean Air Cargo Flight 8509

Safety ActivitiesSafety Awards4 Pics 1 WordQuotesCrossword Puzzle

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T raining constitutes the main bulk of our daily activities and we do so as realistically as possible, providing

sufficient safety margins and safeguards to help ensure our airmen are not endangered or injured in the process. Our airmen hone their competencies and skills and are imbued with strong fundamentals from the very start of their training in Air Force Training Command. Today, this incorporates virtual training in an effective and safe environment. In the operational squadrons, our airmen also regularly participate in exercises and competitions with our international friends all over the world.

As we continue to train as we fight, we need to guard against being carried away. We should be mindful of the ‘pendulum swing’, which is the delicate balance between pushing our operational boundaries too

hard and being overly safe such that we do not achieve our objectives. There is also the insidious tendency during relatively routine operations to allow complacency to set in and safety considerations to wane. Adequate supervision coupled with active knowledge of safe operating limits have to be exercised and kept in tempo with all our operations.

A good safety record is an indication of our operational readiness. We have come a long way since the Singapore Air Defence Command was established in 1968 to evolve into the RSAF of today. Our safety track record has steadily improved over the years and achieved 14 years of accident-free operations. Let’s endeavour to continue training safely so that we go home to our loved ones every day! I wish one and all the very best as we celebrate our Nation's Golden Jubilee this year – Happy 50th National Day!

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MUNITIONS SAFETY IN

GBAD TRAINING & OPERATIONS

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I NTRODUCTION“Our missiles are still on site!” I shouted at the silhouette of the person on his mobile phone

standing in the partial darkness. While the Ground Based Air Defence (GBAD) operation had officially ended, the live missiles were still on site, awaiting the missile transport team’s arrival. After speaking to the errant serviceman, it was apparent that he knew about the clear set of orders prohibiting the use of mobile phones when live missiles are on site and he had adhered to it throughout the operation. However, he confessed that he had assumed that the end of the operation also meant the cessation of the mobile phone restrictions.

An operation like the one above encompassed multiple aspects of coordination and areas to look out for, as well as the involvement of many different personnel. Amidst the flurry of things, a simple yet important safety order on mobile phone usage may be interpreted as an administrative order if the rationale is not being understood and appreciated. A successful operation like the one above could be blemished or turn into a failure if safety is not observed, resulting in an incident. Especially in a training environment which constitutes most of our hands-on activity, such folly will set us back unnecessarily, inadvertently crippling our operational readiness. As my Commanding

Officer often said, “the operation is not over until our equipment are parked, office keys returned and personnel safely at home.”

IMPORTANCE OF MUNITION SAFETY In GBAD operations, munitions to the weapon system are akin to the rounds for a small arm. Without them, the weapon system is no more than a conglomeration of machinery – without the ability to deliver an effect or impact. On the other hand, the presence of munitions necessitates the protection of our people from the inherent risks posed by munitions or any form of explosives. Handling of high capability munitions is a hazardous job and the consequences of an incident can be severe or even fatal. This article will focus on some aspects of how munition safety is important at the different levels.

SAFETY FEATURES IN MUNITIONS – THE MANUFACTURERDuring a live firing exercise conducted by 23rd Bn, Singapore Artillery, a 155mm artillery round exploded in the barrel of a FH2000 gun howitzer on 9 Mar 1997 in Wairou, New Zealand. The incident resulted in the death of two servicemen from the SAF. Another 12 servicemen were also injured in the incident1. The Committee of Inquiry convened by MINDEF found that there was no human error or breach of safety regulations. It was subsequently concluded that the most probable cause of the incident was a defective fuse attached to the incident 155mm shell.

In this incident, the batch of fuses which contained the defective fuse had undergone sampled testing and was certified for conformance to the required military specifications. Based on these certificates which fulfilled the protocol then, MINDEF accepted the fuses. However, a post-incident 100% inspection of the batch found that 1.3% of the certified fuses were defective. Investigations also revealed that the contracted company did not check if the factory manufacturing the fuses was able to fulfil the required military specifications.

To avoid a recurrence, the fuses have since been provided by a different manufacturer and 100% inspections were performed on these fuses henceforth.

SAFETY IN MUNITIONS HANDLING – THE COMMANDERS Training ManagementOn 18 Mar 2013, seven US Marines were killed and eight others were injured when a 60mm mortar round exploded in the firing barrel during a live firing exercise. A suspension on the use of all 60mm mortars was immediately issued following the incident2. Investigations found that the accident had occurred when one of the Marines “double-loaded” mortar rounds into the firing barrel. While human error was identified as the main causal factor, training deficits in terms of the firing commands and firing procedures, as well as the lack of supervision over the incident mortar section were identified as contributory factors in the investigation3.

It was further reported that the Marines were used to the 81mm mortar system, which has an “automatic” firing mechanism4. Investigations also revealed that there was a “perceived sense of urgency” during the exercise. Based on the above, it was postulated that the incident 60mm mortar was set on the “trigger mode5” during the firing, thereby creating the unfortunate gap of chance for “double-loading”. Whilst human error at the individual level had been identified as the main causal factor of the

1 The 155mm Gun Howitzer Chamber Explosion on 9 Mar 97 in New Zealand. http://www.mindef.gov.sg/imindef/press_room/official_releases/nr/1997/jun/28jun97_nr.print.img.html

2 Pentagon bans 60mm mortar round after Marine deaths. http://www.cbsnews.com/news/pentagon-bans-60mm-mortar-round-after-marine-deaths/

3 Investigation: Mortar explosion that killed 7 Marines result of double-loaded round. http://archive.marinecorptimes.com/article/20140121/NEWS/301210019/

4 In an 81mm mortar, the firing mechanism is set by engaging the firing pin at the bottom of the barrel as a protrusion. A mortar round is loaded into the barrel from the top by allowing it to slide down to the bottom of the barrel through gravity. This action causes the primer of mortar round to impact the protruded firing pin at the bottom of the barrel, undergoing ignition “automatically” without a need to trigger.

5 In a 60mm mortar, there are two modes of firing. The first mode is similar to the 81mm mortar as seen in footnote 4. The second mode requires the gunner to activate a trigger manually after the round has been loaded, in order for the mortar round in the barrel to be fired off.

MAJ Kong Ting Wai

incident, it is worthwhile to evaluate the latent loopholes prior. The operation of two weapons of similar design operations may have seemed efficient on the surface. However, there were key differences between the two mortar variants. The 81mm variant required only loading, but the 60mm variant could be operated in two different modes.

In this situation, it was likely that the room for error was small, hinging on the communication or coordination between the loader and the firer. On hindsight, could the management of the Marines have been more deliberate in the deployment of the two variants? Was the possibility of confusion between the two variants identified as a hazard?

Were there clear orders on whether the firing is to be performed in the “automatic” mode or “trigger” mode?

Electromagnetic (EM) InterferenceDuring a strike on Libya in 1986, numerous US electronically-guided weapons went astray during the attack and hit non-intended targets6. One of the helicopter platforms also reported complaints of partial loss of control caused by EM interference. The far-reaching effects of EM interference experienced meant that protection against it cannot be ignored. As the amount of equipment that operates in the EM spectrum proliferates, there is a need to ensure that conflicting weapons or platforms are kept far apart, either physically or in the EM spectrum, to prevent interference.

While shielding against radio frequency radiation (RFR) by design or the use of EM filtering devices in munitions is addressed at the manufacturer’s end, the procedural measures and controls like hazard identification and mitigation against EM interference arising from RFR is an integral part of our safety management. These issues are addressed by the programme management team, and would undergo commanders’ acceptance before platform employment at the unit level. Enforcement of application especially in training

scenarios then prepares us to operate safely even in real operations. It imbues continuous awareness in everyone, citing the individual who used the mobile phone mentioned earlier.

SAFETY IN MUNITIONS HANDLING - THE OPERATOR/INDIVIDUAL During Operation Enduring Freedom in 2010, a U.S. soldier in Afghanistan suffered permanent disabilities to his hand after performing improper procedures for the operation of the M2 machine gun7. The soldier had initially tried to use a rock to force a locking pin of the machine gun mount into place. When that did not work, he used a .50 calibre round to knock in the locking pin. After several hits, the primer of the .50 calibre round was activated and set off in the soldier’s hand. The soldier suffered permanent and serious injuries to his right hand.

In this incident, it was a clear case of the operator failing to adhere to designed usage. Tampering with, or using any munition in a way it is not designed for is an accident waiting to happen.

6 Thompson M. (1989, Jan 22). Mixed Signals May Have Misguided U.S. Weapons. http://www.cheniere.org/misc/mixedsignals.htm

7 Weapons Safety Message 10-02, US Department of Defense. www.everydaynodaysoff.com/wp-content/uploads/2010/06/m2-50-caliber-machine-gun-rock-hand-explosion-meo.jpg

M U N I T I O N S S A F E T Y I N G B A D T R A I N I N G & O P E R A T I O N S F O C U S M A G A Z I N E — A U G 2 0 1 5 — I S S U E 8 4

“Tampering with, or using any munition

in a way it is not designed for is an accident waiting

to happen.”

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SAFETYIN

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I NTRODUCTIONTechnology in military aviation is changing at an unprecedented pace. The increased

system capability and complexity has resulted in corresponding increase in hazards associated with maintenance and operation. In particular, ground maintenance crew have to contend with hazards such as toxic chemicals, loud noises and working in areas with restricted access, to name a few. While additional layers of safety have been incorporated into the system design or maintenance procedures to mitigate this, these are not foolproof. Indeed, they can have the unfortunate potential to lull personnel into a false sense of security: less attention is required as there will always be adequate warning of all potential hazards. Ultimately, the men and women working on these systems are still our last line of defence in ensuring that the risk of performing a task is minimised through taking active precautions, completing the tasks in accordance with the manuals while looking out for, assessing and mitigating ad-hoc risks in the process. To do these proficiently in operations, they must be properly equipped with the necessary safety mindset and knowledge right from the beginning – during training. In this article, we will look at what has been done in the RSAF to develop strong safety mindsets and skills during ab-initio training of junior Air Force Engineers (AFEs).

WHAT IS SAFETY IN TRAINING? Safety in training encompasses two separate but closely related areas. Firstly, safety in training entails that training is conducted under a safe yet realistic environment. In this way, training effectiveness can be maximised while minimising the risks to trainees. One example is the simulation of contingency scenarios which can be encountered during real operations, such as engine fires due to oil leak, rather than actually exercising this high risk scenario.

Secondly, through the training, the trainees must develop a strong knowledge of the necessary safety watch areas and precautionary practices, and internalise the importance of safety in the trainees. The desired end state is transformational: trainees who want and are able to apply safety during operations after training is completed.

These two areas of safety in training, though distinct, are closely related, and mutually reinforcing. Conducting training in a safe environment will lower the risk of accidents in training. This reinforces the importance of safety and having the appropriate safety knowledge. Having the knowledge of the important things to look out for in safety will lead to trainees being more vigilant and taking informed precautions against potential safety hazards, reducing the

In GBAD, munition safety at the operator/individual level is being controlled by strict procedural controls from storage, transportation, loading and firing. These control measures ensure that there is no room for unnecessary deviation or unauthorised improvisation. Not only does an inadvertent activation of a munition cause personnel injury or death, it would also result in the damage or loss of equipment and other munitions due to collateral damage. Any incident would also undermine the confidence in the unit’s ability to handle the munition or weapon system.

MUNITIONS SAFETY IN GBAD TRAINING/OPERATIONSThe weapon systems and munitions that we operate in GBAD undergo thorough and detailed safety assessments. This includes identification of hazard areas and detailed analysis of these hazards in every phase of the system employment from maintenance, deployment and operation, up to the point of firing. Operator level safety regulations and actions are written to cover every known contingency, especially those pertaining to munitions. Stringent adherence to these regulations in training provides a safety layer, facilitating a process for continuous improvement. CONCLUSIONThe nature of our business is to fulfil our mission in protecting our skies. While we fulfil this

obligation, we must also ensure that we achieve and provide the best for our men in munition safety. As the munition industry continues to progress, it is not only the responsibility of the manufacturer to ensure the production of safe munitions, but also the responsibility of the commanders and management who ensure the rigorous evaluation of safety measures, resource management and enforcement of safety regulations. Most importantly, the operator and the last man on the ground must be fully aware of the safety regulations, understand and appreciate the rationale behind these regulations so that we can achieve “Mission Success, Safety Always” both in training and operations.

MAJ Kong Ting Wai is an Air Warfare Officer (GBAD) from 165 SQN. He is currently the Unit Safety Officer/S2. He graduated from the National University of Singapore with a degree in Chemistry in 2007.

ABOUT THE AUTHOR

M U N I T I O N S S A F E T Y I N G B A D T R A I N I N G & O P E R A T I O N S

Ms Karen Tang Lifen

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likelihood of accidents during training. To achieve these outcomes, training must be targeted to build both a strong safety mindset, as well as imbue the trainees with the necessary safety knowledge and practices.

BUILDING A STRONG FOUNDATION OF SAFETY MINDSETFirst ImpressionsThe individual’s perspective of the importance accorded to safety will be first and foremost rooted to the initial impressions he receives in the organisation. The signals sent out during training then becomes of high priority, as this is where new staff will begin their career in the organisation. In many aviation maintenance organisations, the safety induction program is the first critical step towards inculcating new staff with a strong sense of safety mindset and awareness.

Amongst other things, the induction program should outline the safety system in the organisation, and how this contributes to its mission. By introducing new trainees to the organisation’s safety policy, programme and management system right from the get go, the emphasis on safety can be firmly imprinted on them. In the RSAF, a safety induction program is mandatory whenever a person joins a new unit. This includes Air Engineering Training Institute (AETI), which is the de facto starting point of professional training for all AFEs in the RSAF. Reinforcement of SafetyInstilling the importance of safety during induction is but the first step to mould the safety mindset in our junior AFEs. This will have to be constantly reinforced as they step through the various stages of training before they are eventually qualified to work on the aircraft. At the lowest level, adherence to SOP is drilled into the trainees through performing of mandatory tasks such as always performing a safety brief before the start of any practical training. The mandatory maintenance of the On-Job-Training Booklet ensures that each trainee

clocks the preset number of tasks required to be considered proficient. Another way to reinforce the importance of safety during training is through stimulating trainees’ higher level thought processes to be more attuned towards safety. This can be through Human Factors case study discussions. By working through the safety deficiencies and possible mitigations in the case study, the trainee will subconsciously pay closer attention to similar areas subsequently during practical training and later on, when they perform their tasks as a qualified junior AFE.

BUILDING A STRONG FOUNDATION OF SAFETY KNOWLEDGE AND PRACTICESGeneral and Aircraft-Specific SafetyIf we liken a strong safety mindset to taking aim at the goal in football, having a solid grounding

in safety knowledge and practices is analogous to the actual technique used to strike the ball to send it true into the net. Imparting the correct safety knowhow is therefore as important as inculcating the “Safety Always” mantra in order to achieve the RSAF safety goal of developing operational capabilities with zero accidents.

Safety in military aviation logistics can be broadly divided into general safety around aircraft and activity-specific safety. General safety is concerned with hazards associated with operating around aircraft or performing general/common maintenance tasks such as depanelling, wirelocking, aircraft towing and jacking. Associated hazards include “aircraft bites”i, working at heights and hearing damage. Activity-specific safety is concerned with specific logistics tasks that have hazards that are more unique. For example, munitions loading on a fighter aircraft carry the risk of fire and explosion while aircraft launching exposes the launch crew to jet blast and sharp moving control surfaces just to name a few.

Thus, imparting the necessary knowledge for both general and activity-specific safety to

logistics personnel during training will not only minimise incidents/accidents, but more importantly, prepare the personnel to be able to operate independently and safely post-training.

Imparting Safety Skills in the RSAFIn the RSAF, the importance of actively building safety into training is established and well-recognized. During ab-initio training in AETI, this is achieved through classroom lectures on aircraft safety, as well as practical lessons on general maintenance tasks in the workshops and on the aircraft to provide first-hand experience of some safety watch areas. Soft skills, such as knowledge of safety theories like the 5M4Lii

safety analysis model used in the RSAF also train the personnel to have a keen sense of the general safety watch areas and hone their instincts for potential hazards for unfamiliar activities. While this is largely adequate to instill general aircraft safety, the scope of activities trainees are exposed to in AETI is but a fraction of the total number of maintenance and rectification activities they will need to perform after their training completion. Moreover, there will be type-specific hazards that will demand the attention of trainees streamed towards those aircraft after

i Aircraft Bites refer to injuries or cuts sustained by personnel due to contact with aircraft sharp edges.

ii The 5M4L model adopted by RSAF is to guide the user in analysing and identifying the root cause of the incident/accident. It focuses on the individual factors contributing to the error, then systematically moves through the various levels of the organisation, starting with the team factors, unit management factors and finally the RSAF management factors. In accordance with Reason's (1990) Swiss Cheese model, it looks beyond the active failures into the latent causes.

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Associated hazards include aircraft bites, working at heights and hearing damage.

Depanelling – a fundamental skill that can cause injury if mishandled.

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AETI. Examples of these hazards include cockpit safety and hydrazine exposure (F-16).

This is where OJT helps to bridge the gap. During the OJT phase, trainees undergo a type course to understand, amongst other things, unique hazards that the particular aircraft type is exposed to. They also perform trade-specific activities on actual aircraft under close supervision. This allows the trainees to build their confidence in performing aircraft maintenance in a safe environment. But even OJT will not be able to expose trainees to the full scope of their tasks or all the possible contingency scenarios. Moreover, new procedures and inspections will always be introduced during the life of an aircraft. Hence,

good aviation maintenance practices must also be ingrained during training so that they will be able to apply the same fundamental safety principles for an unfamiliar task. One example of good aviation maintenance practice is to always check against and comply with technical orders when performing their tasks.

TRAINING SAFELY – THE NEXT BOUNDSome aspects of aircraft ground logistics carry inherent risk, in particular, contingency measures such as responding to brakes fire or hydrazine activation. Training for these contingencies can be technically challenging, operationally costly (as an aircraft has to be made available on ground), and potentially dangerous. Today, we are now able to leverage on improvement in simulation technology to more readily conduct these training scenarios in a safer environment. This has already been implemented in AETI where trainees perform activities such as aircraft

S A F E T Y I N T R A I N I N G

marshalling and hot brakes inspection through controlling the actions of an on-screen character in first-person. While this sort of simulation is limited – the trainees do not practise the actual motions that will be performed – it does hone their knowledge of the procedures to be followed and the cues to pay attention to during such activities. It also allows a greater variety of malfunction scenarios to be incorporated into training. Technology is now available to take this one step further; RSAF has incorporated Virtual Reality (VR) technology into Flight Line Crew (FLC) training for launch and recovery of aircraft, where the VR maintenance simulator simulates the F-16 and the working environment

of the FLC. The trainees are thus able to develop their critical thinking skills when encountered with a simulated major defect and practise the emergency procedures safely in a virtual environment which they have no opportunity to do so on an actual aircraft.

While simulation technology opens up new possibilities for conducting aircraft logistics and maintenance training safely, this may be prohibitive due to the potentially higher cost of developing and maintaining the more sophisticated equipment necessary to support this training when compared to traditional methods. However, it can be expected that this barrier will be slowly overcome as technology matures and the cost of developing such systems decreases.

Fitment of a fuel tank pylon – a delicate jacking procedure requiring strict safety observance.

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Ms Karen Tang Lifen is currently the Unit Safety Officer of 815 SQN. She graduated from the Aircraft Accident Investigation Course in 2015, the RSAF Safety Officers' Course in 2014 and holds a Bachelor of Engineering Degree in Mechanical Engineering from the Nanyang Technological University.

ABOUT THE AUTHOR

CONCLUSIONThe ability to train safely in a realistic environment forms the cornerstone for our logistics personnel to perform their tasks safely during actual operations. This requires developing the correct safety mindset as well as imparting the necessary safety knowledge and practices. While we have focused specifically

on entry-level training in this article (i.e. from a Non-Qualified Person to a Qualified Senior Technician), it should be emphasised that attaining technical qualification does not herald the end of safety training. Safety training must be viewed as a continuous process in order that safety will not just remain undiluted, but indeed, be constantly improved during operations.

References: • AFLO 006 (Safety Management System)• AFLO 401 (Training Policy)• AFLO 401.00.026 (AELO Staff Induction

Programme)• AFLO 401.15.013 (Management of On-The-

Job Trainees to Q-Tech and Q-SNR Tech Status)

• RSAF-O-06-2, RSMM (Part I: Safety Policy, Chapter 1: RSAF Safety Philosophy)

• RSAF-O-06-2, RSMM (Part II: Safety Promotion, Chapter 4: Safety Training Programme)

• RSAF-O-06-2, RSMM (Part V: Accident/Incident Management, Chapter 5: Human Factors Analysis Model (HFAM)

• AETISO 4.1.2 – Safety Policy• AETISO 4.1.4 – Safety Programme• 1041-3-M3/6-8 dated 30 Jul 14, “Governance

Framework for the AELO Training Transformation (Learning Technology)”

Harnessing Virtual Reality to train FLCs in a low risk environment.

Accident Prevention

Branch (APB), AFI

23 July 1983

CASE

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AIR CANADA FLIGHT 143

OCCURRENCE SUMMARYOn 23 Jul 1983, Air Canada Flight 143, a

new Boeing B767, prepared to take-off under the command of Captain Robert Pearson and Copilot Maurice Quintal. Flight 143 was planned to travel from Montreal to Edmonton at 41,000ft. At that time, the Boeing B767 was a very new, advanced model aircraft to Air Canada air and ground crews. They were still in the process of inducting the aircraft and getting used to the aircraft’s systems. As the aircraft cruised at 41,000 feet over Red Lake, Ontario, the cockpit warning system sounded, drawing the crew’s attention to a fuel pressure problem on the aircraft's left fuel tank. Assuming the fuel pump had simply failed, the pilots turned it off. The aircraft's cockpit digital fuel gauges were inoperative as a result of an electronic fault which was clearly marked out on the instrument panel and documented in the airplane logbook. The flight management computer indicated that there was still sufficient fuel for the flight. A few moments later, a second fuel pressure alarm sounded indicating a fuel pressure problem on the right fuel tank. This prompted Captain Pearson to divert to Winnipeg. Seconds after the right fuel tank warning, the left engine ran out of fuel and failed. Air Canada Flight 143 declared a “Mayday” emergency and began hurriedly preparing for an emergency single-engine landing at Winnipeg. Less than a minute after the left engine failed, the right engine also stopped. With both engines dead and still flying at 35,000ft, Flight 143 lost all electrical and hydraulic power. The Boeing B767 was one of the first airliners to employ an Electronic Flight Instrument System whose displays relied on the electricity generated by the engines.

Without the engines, the system went dead and all of the multifunction instrument panels in the cockpit went blank. Only a few basic mechanical emergency flight instruments remained. The emergency ram air turbine system, a hydraulic pump and a small generator powered by a small windmill turbine driven by the slipstream of air under the aircraft, automatically deployed to provide basic hydraulic aircraft control systems. Soon, the pilots realized that they wouldn’t be able to reach Winnipeg and decided their only option was to divert to the former RCAF Station Gimli, a closed air force base with a single long runway and no emergency support equipment. Without the necessary power to operate the landing gear, the pilots attempted to lower the aircraft's landing gear via a gravity drop. The heavy main landing gear lowered and locked into position, but the lighter nose wheel did not. As the runway came into view, the pilots realized that the aircraft was coming in too high and too fast, posing the danger of running off the end of runway before stopping. The pilots briefly considered a complete 360-degree turn to reduce speed and altitude, but quickly

S A F E T Y I N T R A I N I N G

Source: mentalfloss.com

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decided that they did not have enough altitude to complete the manoeuvre successfully. Captain Pearson then decided to execute the forward slip manoeuvre, a technique commonly used by gliders and light aircraft to descend quickly without increasing airspeed but increasing drag instead, to lose altitude safely. As Flight 143 approached the runway at Gimli, the pilots found out that the airstrip had been converted into a race track complex with a guardrail installed down the centerline of the runway. Without any other options, Captain Pearson was forced to continue. As soon as the wheels touched down on the runway, Captain Pearson braked hard, blowing out two of the aircraft's tires immediately. The nose wheel gear collapsed, causing the aircraft's nose to slam into the ground and scrape along the runway. The nose grazed the centerline guardrail, helping to slow the airplane further. In the ensuing ground evacuation, none of the 61 passengers onboard were seriously hurt. Minor injuries to some of the passengers resulted when the passengers exited the aircraft via the rear slides which were not long enough to accommodate the increased height due to the nose down, elevated tail attitude of the aircraft. The friction of the nose grinding along the centerline guardrail caused a

minor fire in the aircraft’s nose area which was quickly extinguished by racers and track-side workers with fire extinguishers.

INVESTIGATION FINDINGSThe investigation found that on the day of the incident, the aircraft had flown from Edmonton to Montreal and was scheduled to return to Edmonton under a different crew. Before departure from Montreal, the ground engineer informed Captain Pearson of a problem with the digital fuel gauges and confirmed that the fuel tanks would be verified with a dip-check. Captain Pearson misunderstood the information to mean that the aircraft had been flown with the fault from Toronto the previous afternoon.

As such, he believed undertaking the flight to be still within legal limits. On entering the cockpit, Captain Pearson consulted the aircraft's Minimum Equipment List (MEL), which told him that the aircraft could not be flown in this condition. However, the Boeing 767 was still a very new aircraft, and there were ongoing-extensive changes to the MEL. In fact, some pages of reference handbook were still blank pending development of procedures. Due to the incompleteness of the reference handbook, it had become an unofficial procedure for flights to be authorized by maintenance personnel. The investigation also revealed that at the time of the incident, Canada was converting from imperial to the metric system. Air Canada’s new Boeing 767 fleet was the first aircraft-type to be calibrated in metric units amongst all the other aircraft-types. Pilots needed to know the weight of the fuel onboard their aircraft while ground refueling crew calculated the amount of fuel being pumped into the aircraft by volume. In order for the pilots and the ground refueling crew to communicate, a conversion factor was used to convert between mass and volume. With the digital fuel gauges out of service, a manual dipstick check was performed which indicated 7,682 liters already in the tanks. For the trip to Edmonton, the fuel requirement was calculated to be 22,300 kilogrammes. To calculate how much more fuel had to be added, the refueling ground crew converted the quantity in the tanks to kilogrammes, subtracted that figure from 22,300 kilogrammes and converted the result

back into a volume. This volume was the quantity that they pumped into the aircraft. In older aircraft, this task would have been completed by the flight engineer. However the Boeing 767 was the first of a new generation of airliners with so many systems computerized and automated that it required only a pilot and co-pilot. However, the ground refueling crew incorrectly used an initial conversion factor of 1.77 which converted the weight of a liter of fuel into pounds and a subsequent conversion factor of 0.8 which converted pounds to kilogrammes. This resulted in a conversion factor error which resulted in the aircraft carrying 22,300 pounds of fuel instead of the 23,300 kilogrammes needed. As a pound is roughly half a kilogramme, Captain Pearson received only half the amount of fuel required for the trip to Edmonton. Mindful that the digital fuel gauges were unserviceable, Captain Pearson double checked the ground refueling

The Boeing 767 cockpit Fuel Control Panel.

A typical fuel conversion chartSource: http://www.streamline-ops.com

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A I R C A N A D A F L I G H T 1 4 3

Source: en.wikipedia.org

Source: nwaonline.com

Source: damninteresting.com

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crews’ math. However, he used the same wrong conversion factors and arrived at the same wrong result. The investigation report blamed Air Canada for lack of adequate and timely training of all the crews involved. The Aviation Safety Board of Canada found Air Canada management guilty of corporate and equipment deficiencies while praising the pilots and cabin crew for their exceptional professionalism and skill. The safety board recommended that Air Canada and all operators of the Boeing 767 keep more spare parts, especially replacements for the defective fuel quantity indicator in its maintenance inventory. Also highlighted was the need for better and more adequate training on the metric system to Canadian pilots and ground refuelling crew. However, the internal Air Canada investigation concluded that the pilots and ground crews were at fault but their resulting suspensions were overturned on successful appeal. The aircraft was temporarily repaired at Gimli and flown out to be fully repaired at a main maintenance base two days later.

WHAT IT MEANS TO USNo doubt automation and new technologies lighten our workload over current or 'legacy' designs but we have to keep our eyes open for seemingly benign failures which could cascade and affect safe operations. On the other hand, we cannot afford to be too cautious either, with an undesirable result of multi-layered checklists which could unwittingly stifle advancement. A delicate balance must be struck between safety and operational effectiveness. When technology fails us, we have to be ever ready to revert to basics as Captain Pearson did to safely put the distressed airplane back on ground. We just cannot afford to be complacent in our daily work.

Complacency on the part of the Captain Pearson resulted in his failure to clarify the significance of the faulty digital fuel gauges. His assumption that the aircraft was flown the previous day with failed fuel gauges, gave him a false sense of security. Had he checked the airplane form and clarified with the ground engineer, it would

have heightened his senses in verification. Complacency led him to loosely use the same wrong conversion factor as well. The lack of approved procedures implemented also opened the doors to error. Our manuals and books today have safety supplements and interim orders to keep constantly abreast with systems changes and upgrades on our airplanes. Through the years, we’ve had the privilege in learning from both the British and American systems, piecing together a robust system of our own in documentation and processes. It is our duty as individuals to surface ambiguities in the system when we see them so that amendments can be timely made. The lag in B767’s MEL update was more likely a normal occurrence those days. A carefully-formulated interim supplement would have alleviated the latent failure. Such supplements and measures are today deliberated on by subject matter experts before implementation and we abide strictly by them until rescinded by an amended document.

This accident was sourced from the internet version of “Air Crash Investigation”. APB's FOCUS editorial team relates the accident facts and findings as presented on the video. Insights are then shared, drawing parallels as to the how factors leading to the accident relate to us in the RSAF context.

Management had failed to facilitate a safe documentation transition and Man eventually short-changed himself on fuel requirements.

CONCLUSIONBoth the aircrew and ground crew lacked the training and exposure to the metric system. Especially with new systems, understanding has to be solicited in the form of quizzes and examinations in the training process. It is important that we put pride and shame aside and ask for clarification or perhaps revision training when we are unsure of our processes and procedures. Complacency stems from a sense of Invulnerability; that it only happens to others. Knowledge gained from training ultimately empowers us to mitigate our natural human weaknesses which we must first acknowledge. Fortunately, the same Man factor that caused the emergency also saved the day with excellent decision making in diverting early and subsequently in superior handling of the aircraft. Ultimately, their actions resulted in the saving of precious lives and brought the emergency to a happy ending.

A I R C A N A D A F L I G H T 1 4 3

Source: hawaii.hawaii.edu

Source: cbc.ca

Source: samcollends.blogspot.com

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KOREAN AIR CARGO FLIGHT

8509

CASE

STU

DY

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OCCURRENCE SUMMARYOn 22 December 1999, Korean Air Cargo Flight 8509 took-off at night from London,

England heading for Milan, Italy with Captain Park Duk-Kyu, First Officer (FO) Yoon Ki-Sik, and Flight Engineer (FE) Park Hoon-Kyu at the controls. Captain Park was an experienced pilot with almost 13,500 flight hours while FO Yoon was relatively inexperienced with just under 200 flight hours.

On the day of the incident, it was a dark moonless night when Flight 8509 departed. After take-off, the Captain banked the aircraft for their planned left turn. However, his Attitude Director Indicator (ADI) or Artificial Horizon showed the aircraft was not banking and the comparator alarm sounded repeatedly.

Accident Prevention

Branch (APB), AFI

22 December 1999

Source: aircargonews.net

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Confused, Captain Park banked the aircraft more steeply in an effort to get it to turn left. Although the flight engineer called out, “Bank! Bank!” repeatedly, the FO said nothing and the Captain continued to bank the aircraft to the left.

Less than a minute after take-off, Flight 8509's left wing scraped the ground, the aircraft immediately rolled over and plunged into the ground at a speed of 250-300 knots with a 40° pitch down and 90° left bank attitude. The aircraft exploded on impact with none of the crew surviving the crash.

INVESTIGATION FINDINGSAccident investigators found that on the previous flight, one of the plane’s inertial navigation units (INUs) had partially failed, providing erroneous information to the captain's ADI. As the FO's ADI and the backup artificial horizon were taking correct information from another INU, a comparator alarm sounded to warn the pilots of the discrepancy. As the previous flight was conducted in daylight, the faulty ADI indication was easily identified.

The previous flight crew had simply switched the captain's ADI input selector to the other INU and the correct information returned. At London, the fault was reported but unfortunately the ground engineers who attempted the repair did not have the correct troubleshooting documentations available.

The ground engineers did not think of replacing the reported INU as one of them had identified and repaired a damaged connector plug on the artificial horizon unit. When the repaired ADI responded correctly to its “Test” button, they believed the fault had been corrected. Without the troubleshooting manuals, they did not know that this “Test” button only tested the individual ADI and not the connected INUs.

The reported fault was never actually repaired and the plane was signed back into service for the flight later that night. Accident investigators also found that prior to take-off, Captain Park was in a bad mood due to the multiple delays on ground.

As Korean culture encouraged respect for seniors and strongly discouraged any form of contradictory actions from juniors, FO Yoon failed to speak up or take over the controls when he realised that Captain Park was carrying out the wrong actions and had exceeded the aircraft’s safety limits. The investigation highlighted the need for Korean Airlines to provide better training to their aircrew with regards to cockpit communication and assertiveness.

WHAT IT MEANS TO USThe sound of an alarm must garner attention from the crew as it is designed so. Loss of Situational Awareness on the part of Captain Park had deteriorated to a point where he could not react to nor decipher the Flight Engineer’s verbal cautions as he fixated on his frozen ADI.

Good airmanship includes being inquisitive to all alarms and ambiguous transmissions. It has to trigger a need to clarify why or what it was for. Had this cross-check been done, the pilot would have confirmed the discrepancy in displays and taken corrective action either by switching to standby source on his display or handing over controls to the co-pilot for corrective actions.

Cockpit Gradient sadly, is prevalent in certain cultures to this day. Cockpit Gradient is the fear to speak up against superiority in rank or status. Safe-training environments are instantly created when there is no fear to communicate. As humans, we are prone to make mistakes thus, nobody is perfect. This psychological barrier of a junior pilot telling an experienced pilot that he is wrong is hard to break. This barrier to speak up is common in young and junior personnel. It takes time and courage to break through it. Experienced, senior operators have to encourage a speak-up culture by means of praise and encouragement when junior crew effectively callout a timely caution. Nobody should ever be chided for a “stupid” caution

“Cockpit Gradient sadly, is prevalent in

certain cultures to this day.”

Source: blogs.tribune.com.pk

Source: sg.beritasatu.com

Source: airdisaster.com

Source: commons.wikimedia.org

It is heartening that the advent and evolution of CRM more than ten years ago, has prevented potential incidents. In addition, both air and ground operators must endeavor to acquire in-depth knowledge of their professional areas. Be curious, be inquisitive and speak up if things do not look right.

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call as it shakes confidence in training. It takes humility on the part of experienced crew to admit they missed seeing something that was spotted by someone junior. In a multi-crew cockpit, professional crew positions take precedence regardless of seniority. This has to apply to inter and intra-cockpit platforms.

Lack of Assertiveness on the part of the FE also contributed to the crash. The FE had the best overview of both the Pilot’s and FO’s instrument panels. The FE would have been the first to notice the difference in displays and should have called out a more precise call than “Bank! Bank!”. Was it an instruction to bank even more? The ambiguity of the vocalisation in such a crucial time left no room for error; and error happened! A more assertive call would be “Pilot, reduce bank!” or “Pilot, right bank now!” could have provided some recovery action. The relatively new FO also could and should have done the same in assertiveness nonetheless.

Complacency played a part in the accident as well. The cultural norm of perceived infallible superiority caused Captain Park to become self-reliant over time. The action of taking-off and landing a multi-crew airplane had probably developed into a solo and routine act.

The existence of the copilot’s instruments had become irrelevant as he had his own which were all that he needed. After all, they have always been reliable, haven’t they? We have to guard against routines that lull us into patterns such that we stop using aids that are readily available such as checklists and secondary instruments and most importantly, other crew members.

On the maintenance side, Lack of Professionalism was prevalent on the Ground Engineers’ part. It was not elaborated why or what proper documentation of the INU defect on the previous flight was not available. Nevertheless, the troubleshooting sequences were carried out apparently “off-the-head” with no reference to maintenance manuals which would have provided step-by-step troubleshooting and rectification procedures. Lack of Resources as such was also a contributing factor. General knowledge of aircraft systems was also apparently lacking in that the press-to-test function on the ADI only tested the instrument and not the upstream INU data feed. The faulty ADI connector plug was only an assumption. We have to adhere to maintenance procedures and SOPs. They were written over time “in blood”. Knowledge empowers us. It gives us an edge over uncertainty.

CONCLUSIONThe RSAF has imbued a strong safety culture and fundamentals from the training schools. The emphasis on safe training is constantly drilled into individuals by embedding safe-thinking mentality in mission planning and executions, while ensuring mission success.

This accident was sourced from the internet version of “Air Crash Investigation”. APB's FOCUS editorial team relates the accident facts and findings as presented on the video. Insights are then shared, drawing parallels as to the how factors leading to the accident relate to us in the RSAF context.

F O C U S M A G A Z I N E — A U G 2 0 1 5 — I S S U E 8 4K O R E A N A I R C A R G O F L I G H T 8 5 0 9

Source: slideshare.net Source: airdisaster.comSource: youtube.com

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Ministry of Home Affairs Safety Study Visit Air Force Inspectorate

3 JUN 15AFI hosted a delegation of 19 senior commanders and directors from the various departments of the Ministry of Home Affairs (MHA) on 3 Jun 15 during which RSAF's safety management system, incident reporting, audit framework and human factor management was shared. The delegation leader was Mr Goh Liang Kwang, Chief Inspectorate & Review Division of HQ MHA.

Helicopter Group AFI Safety Workshop Sembawang Officers’ Mess

10 JUL 15

SAFETY ACTIVITIES

UAV Group AFI Safety Workshop Tengah Officers' Mess

13 MAY 15

Ministry of Manpower Safety Study Visit Air Force Inspectorate

16 APR 15

AFI hosted a visit by the Occupational Safety and Health (OSH) Inspectorate from the Ministry of Manpower (MOM) on 16 Apr 15. The MOM delegation led by Mr Chan Yew Kwong, Director OSH Inspectorate Department, was briefed on the RSAF’s Safety Management System and accident and incident investigation processes. Their objective was to learn RSAF’s safety practices and programmes for possible implementation at MOM.

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CPT JONATHAN LAU, 123 SQN, PC

On 24 March 2015, CPT Jonathan Lau was assigned for an Anti-Submarine Warfare (ASW) flight. During the pre-flight checks on the Pitch Trim Assembly of the Pilot Assist Servo module, he noticed that the Mixer Pitch Input Link bolt was marginally shorter than that seen on the other trim servos in the aircraft. On investigation, specialist trade Air Force Engineers rejected the aircraft for flight. The initial assessment was that a shorter-than-normal bolt was installed on this component. Subsequent investigation however revealed that it was an acceptable alternate part used. CPT Lau had recently displayed similar tenacity upon discovery of wrongly-oriented wire-locks culminating in a Letter of Commendation. For his consistency, exceptional diligence, and professionalism in going beyond his checklist requirements, CPT Jonathan Lau received the Outstanding Safety Award.

LTA KENNETH CHEONG, 143 SQN, ACC

On 23rd Feb 2015, LTA Kenneth Cheong was the Aircraft Captain of an F-16 on a day General Handling sortie. Whilst raising the landing gear after take-off, he observed that the gear handle warning light remained on with the 3 greens extinguished. He continued with departure while keeping

within the landing gear speed limit. Expeditiously requesting a hold in the designated area, a visual inspection revealed the nose landing gear was partially retracted with both main landing gears up and locked. Subsequently, the gears were lowered in accordance with the checklist. With landing gear positively down and locked, he adjusted for fuel and recovered to land. Severe vibrations were however felt when the nose landing gear was lowered and brakes applied. He maintained directional control and stopped the aircraft with 1500ft of runway remaining before shutting down on the runway. For his vigilance, sound thinking, decision making and professional handling of the emergency, LTA Kenneth Cheong was presented the Outstanding Safety Award.

LTA SOLOMON PETERSON TEO, 201 SQN, PC

On 10th Feb 2015, ALTaCC was planned to control one SP and two CH in SAFTI LFA 500ft and below. Four UAVs were operating 7000ft and above. One of the UAVs, Scorpion 3, was cleared by the Tengah Air Base (TAB) Tower Controller to descend from 9000ft to 2000ft for recovery but his clearance would have breached the minimum safety separation of 2000ft between UAVs and the adjacent RSAF aircraft. LTA Solomon, the incident Mission Commander, immediately informed the Tower Controller about ongoing helicopter operations below and recommended an alternate recovery route, averting an incident. During the mission he had monitored TAB Tower frequency, heightening his awareness when Tower experienced comms issues. Knowing that the controller was preoccupied, he closely monitored R/T exchanges enabling his detection of the confliction. For his vigilance and actions, LTA Solomon Teo received the Outstanding Safety Award.

OUTSTANDINGSAFETY AWARDS

4 PICS 1 WORD

A F E R G I

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F W S G O Y

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1: “USS Essex Sailors participate in command physical training” by Official U.S. Navy Page #

2: “Working dog training” by soldiersmediacenter #

3: “Swiss Aviation Training Airbus A330/340 Full Flight Simulator” by swiss_a320 #

4: “Motorcycle training at Fort Bragg” by Eve Meinhardt #

Authorisation granted by LOTUM GmbH to publish 4 Pics 1 Word in FOCUS.

5: “Safety first” by LouisvilleUSACE #

6: “Audi R8 V10 Safety Car” by T-low Photography #

7: “Little boy without training wheels with helmet and sandals” by azmil77 #

8: “Safety first!” by emmy.anne # # Image was cropped from original

The images used on this page are licensed under CC by 2.0, and links can be accessed via the digital version of this issue.

What word can you derive from the 4 pics?

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F O C U S M A G A Z I N E — A U G 2 0 1 5 — I S S U E 8 4

Email your answers with your Rank/Name, NRIC, Unit and Contact details to AFI (ME3 P Ashley Lim) before 25 Sept 2015. All correct entries will be balloted and 3 winners will receive S$30 worth of NTUC Fairprice vouchers each.

The crossword puzzle is open to all RSAF personnel except personnel from AFI and the FOCUS Editorial Board.

TALK TO USWe welcome your feedback, contributions of safety-related stories, cartoons, suggestions, experiences or concepts you could share. Email us at apb_pub@defence.gov.sg with your full name, NRIC, and contact number.

CROSSWORDPUZZLE

FOCUS #83WINNERS

LTA Surindran Nair, ATD

ME2 Vijayandren S/O Suppiah, ACC Hub

DX4 Patrick Phua Jia Liang, HQ AFMS

AcrossTechnology in military __________ is changing at an unprecedented pace

having a solid grounding in safety knowledge and __________ is analogous to the actual technique used to strike the ball to send it true into the net

The reported __________ was never actually repaired and the plane was signed back into service

The __________ program should outline the safety system in the organisation

These control measures ensure that there is no room for unnecessary __________ or unauthorised improvisation

Captain Pearson __________ the information to mean that the aircraft had been flown with the fault from Toronto the previous afternoon

It was likely that the room for __________ was small

During a __________ firing exercise conducted by 23rd Bn, Singapore Artillery

We cannot afford to be too __________ either

2.

3.

5.

8.

9.

11.

13.

14.

15.

DownThe trainees must develop a strong __________ of the necessary safety watch areas and precautionary practices

Without the engines, the __________ went dead and all of the multifunction instrument panels in the cockpit went blank

Tampering with, or using any munition in a way it is not designed for is an __________ waiting to happen

Amidst the __________ of things

Less than a minute after the left ________ failed, the right engine also stopped

The ability to train __________ to perform their tasks safely during actual operations

1.

4.

6.

7.

10.

12.

WIN!S$30 NTUC

Fairprice vouchers

QUOTES

The night environment will continue to be an

insidious threat to aircrews.

COL Kevin Teohthen-HAFI (ASC 2007)

Shortcuts cut life short.

The best safety device is a careful worker, get the

safety habit.

St. Olaf Safety Committee

The real challenge tosafety that the RSAF facesis not a lack of experience,

but the need to ensurethat high standards are

achieved with or withouthigh levels of experience.

BG Ng Chee Khernthen-CAF (ASC 2007)

Ans

wer

s to

Pag

e 28

: “TR

AIN

ING

” an

d “

SA

FE

LY”