AU

TU

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ISSUE 80

The official publication of the United Kingdom Flight Safety Committee ISSN 1355-1523

O N C O M M E R C I A L AV I AT I O N S A F E T Y

The Cultural Approach to

delivering a dynamic and productive

SMS into the heart of your business

The Second European Safety Management Symposium

SMS - Safety Performance through People

w w w . b a i n e s s i m m o n s . c o m

28 & 29 September 2010 RAF Museum London UK

Hosted by the UK Flight Safety Committee and Baines Simmons, the Second European Safety Management Symposium provides a clear picture and practical strategies for SMS - what it is, how to make it happen and how to see a real, cost-effective return on investment in your business.

With key speakers from Military, Civil and Regulatory organisations, the 2010 Symposium focuses on how to enable and engage the people in your organisation to make a maximum contribution to integrating and facilitating your SMS.

A Practical Approach Have you read all the regulations and books and want:

a clear view of what good looks like

to know how to make SMS work for your business

to benchmark your organisation’s SMS status

an opportunity to meet and network with others looking for the same answers

an approach to Safety Management that you can understand, do and communicate

to deliver a practical Just Culture to your organisation

If you feel confident that all the components are largely in place in your organisation, but still seem to be missing the vital links to bring everything together, this Symposium will explain what you need to do for an integrated approach to make SMS work for your business.

The First FAiR® Users’ Workshop The event includes a free opportunity to discover how the market-leading FAiR® System diagnostic tool can be pivotal to the success of your organisation’s Just Culture policy.

Attendance is of value to all safety, risk and quality management professionals working in Flight Operations, Initial Airworthiness, Continuing Airworthiness, Maintenance and Air Traffic Management within Civil, Military and Regulatory organisations.

To find out more, register and book your place online, visit:

www.bainessimmons.com/symposium

28th - 29th September 2010

RAF Museum - London - UK

£395.00 + VAT including evening reception and dinner on 28th September

Call +44 (0)1276 855 412

for more information

(Discount available for UKFSC Members)

ContentsThe Official Publication of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE ISSN: 1355-1523 AUTUMN 2010

Editorial 2

Chairman’s Column 3

Close Call in Khartoum 4

by Mark Lacagnina

PBN - Performance Based Technology 8

SMS on Wheels 12

by Thomas Anthony

Airbus AP/FD TCAS Mode - A New Step Towards Safety Improvements 16

by Paule Botargues - Engineer, Automatic Flight Systems, Engineering

Assets and Lurking Threats – A view on Training and Safety 19

by Capt. John Bent

Staying Sharp with Age 21

by Patrick R. Veillette, Ph.D.

Members List 24

Front Cover Picture: An Airbus A380 escorted by an F18 of the Swiss Air Force. © Swiss Air Force.

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1focus autumn 10

‘If you think ground handling training is expensive,try looking at the cost of aircraft damage and delays’

EDITORIAL

In preparation for the last UKFSC Safety

Information Exchange, Members were

asked to identify their company's top three

safety concerns from the past year and

share them with the Committee during the

meeting. With over 40 companies

responding, this exercise produced a

invaluable list of current safety issues which

ranged from strategic global to operational

local as well as identifying a variety of

topics, depending on the perspective and

role of the company in question – airline,

airport, manufacturer or MRO.

One major, widely-held safety concern is thenumber of ramp and stand area incidents andthe significant cost in human and equipmentdamage being caused. In several safety forumsprior to our meeting, I had heard an oftquoted statistic which suggested that over$4Bn worth of aircraft damage per year canbe attributed to incidents in and around theramp areas of the world’s airports.

Whilst this cost is a serious worry in itself, thissituation is further exacerbated by the factthat some of this damage to the aircraft’sintegrity goes unreported by the perpetratorat the time, either through lack ofappreciation, fear of disciplinary action ordeliberate intent. Moreover, one Europeanairline association through analysis of itsMembers’ reports concluded that around 30aircraft each year get airborne with significantunreported damage, which is only discoveredonce airborne or on returning to home base.For the majority of today’s commercialtransport aircraft, damage detection anddiscovery can be reasonably straightforwardsince signs of collision can be fairly easilydetected on metals and alloys with the nakedeye. However with the rapidly increasingintroduction of carbon fibre materials intoaircraft fuselage and wing sections, this bringsa much greater challenge to damagedetection. The outer shell of a carbon fibrebody can tend to spring back into shape aftera collision without witness marks, but any de-lamination within the hidden layers andstructure are not so easily identified, nor is theconsequent degree of strength loss. This alsoassumes that the perpetrator wishes to

declare it and has been trained to understandthe potential for internal damage to thesenew types of structure.

This significant level of wasted resource maynot come as a real surprise to many safetyprofessionals across the commercial aviationsector, but it is no less disappointing that weseem unable to make any serious inroadstowards reducing it. There are some verywelcome initiatives underway. The UK CAAGround Handling Operations Safety Team hasdeveloped an excellent package of trainingguidelines for ground handling serviceproviders. Encouragingly, these have also beenadopted and promoted by the EuropeanCommercial Air Safety Team. Importantly, theguideline package was closely aligned on thevarious elements sought by the IATA SafetyAudit of Ground Operations programme; thiswas a deliberate strategy in an attempt toensure a co-ordinated and universal approachand to set a standard based on good practice.Whilst the pursuit of this comprehensive andwidely endorsed approach to ground safety isa very positive step, there remain furtherserious challenges to delivering it effectively.First, the commercial pressures exerted byairlines and resulting competition amongstground handling service providers is causingthem to pay their ramp workers poor wageswhich, in turn, inevitably attracts less capableand qualified candidates. I have heard it saidthat a survey of ramp workers at oneEuropean airport revealed an average readingage of nine.And what is more, this level of skillwas not in english.

Second, and particularly amongst the moreseasonally effected airports, the rapidthroughput of temporary and part timeworkers makes the establishment of a well-trained and motivated work force extremelydifficult to achieve. Directly and indirectly,delivery of effective training does cost moneyand is readily apportioned to the bottom lime.I wonder how many airlines place theprovision of a well trained and experiencedwork force to handle their expensive aircraftin a safe and efficient manner above thelowest available upfront cost of the groundhandling contract? Equally, I wonder how

many ground handling companies attempt toassess and then balance costs resulting fromdelays and damage with their investment intraining and retention of ground handlers onthe front line?

In the case of ground handling, the mantra of‘If you think safety is expensive, try having anaccident’ could be usefully adapted to ‘If youthink ground handling training is expensive,try looking at the cost of aircraft damage anddelays’. Seeking to understand the real costsof damage and delays generated by groundhandling services is important, but there is arelated issue to consider. Another absolutelykey component of safe ground handlingprovision is the establishment of a culture ofopen and honest reporting of errors, whichonly a professional, well-trained work forcecan really develop. Currently, reporting ofground handling incidents is poor, whichmeans that lessons are not learned and thatthe effectiveness of a company’s SafetyManagement System is undermined.

In a nutshell, effective training and culture ofopen reporting are the means by which theground handling performance can be improvedand damage and delay costs addressed.However, these can amount to nought ifcommercial pressures and inadequate rampsupervision enable short cuts to be taken onthe ramp. Therefore, I am fast reaching theconclusion that the only way to grip groundhandling standards is to subject them toregulation. The opportunity to achieve this, atleast in Europe, may eventually come tofruition. EASA has a remit from the EuropeanCouncil in its extension into aerodromeregulation which states that airport operatorsare to be responsible for the safe operations ofground handling service providers. There islittle in the way of detail at this early stage, butit is vital that this opportunity to place theregulatory spotlight on ground handling safetyis grasped firmly and the necessary disciplineimposed by the introduction of properoversight, training and supervision on groundhandling service provision.

2 focus autumn 10

by Rich Jones, Chief Executive UKFSC

CHAIRMAN’S COLUMN

Flight Data Monitoring – The Greatest Safety Enhancement?by Capt. Tony Wride, Monarch Airlines

During my time as Head of Safety

Management for Monarch Airlines I have

been working closely with the company that

provides our Flight Data Monitoring (FDM)

software to develop it to fulfil our safety

needs. By working with the software company

major enhancements have occurred to enable

me, as the airline Safety Manager, to be more

effective at maintaining safety. As a result of

this close relationship, (No we are not

married!), I was asked by them to attend the

recent FAA “Shared Vision of Aviation Safety”

in San Diego to give the American aviation

community a presentation on how we

manage safety “across the pond”! I also had

the opportunity to hear what the Americans

were doing and also find out how far behind

Europe some of them are! I couldn’t believe

that FDM was not mandated by the FAA and

that one airline seemed pleased that they

were monitoring 15% of their aircraft!

FDM, or FOQA (Flight Operations QualityAssurance) if you prefer, is now the majorFlight Safety tool in helping prevent incidentsor tragic accidents but despite this tragicaccidents still occur as seen in the recent crashin Pakistan. For most of the World FDM(FOQA) is mandated on large commercialaircraft and it could be argued that not havingan effective FDM system in an airline as partof its Safety Management System is exposingthat airline to a serious risk. The scenario Igave the attendees at the “Shared Vision”conference was; Imagine being in court with aclever lawyer asking the question “So therewas a safety programme that could haveidentified that Captain X had developed anincorrect flying technique which was the causeof the accident yet you chose not to use thatprogramme?” Even Perry Mason might have ajob countering that argument!

Initially the pilot community was very muchagainst having the ‘spy in the cockpit’ butmost pilots, certainly those in the UK, nowappreciate that the system is there to protectthem and look after their jobs. Ok, have justthrown another hand grenade at the pilots outthere reading this? What I said is a fact! TheFDM system is there, if used properly, toprotect the pilots because what it’sencouraging is adherence to StandardOperating Procedures (SOPs), which I prefer tocall Safe Operating Procedures. If every pilotin the world flew their aircraft as per SOPs I’msure the accident rate would dropdramatically. A bold statement perhaps but

look at the recent accidents that haveoccurred that have ended up laying the blameon the pilots for not following SOPs.

I have seen and heard stories from otherSafety Managers of some amazing events thatmake you ask the question “What was thepilot thinking?” Somebody levelling theaircraft shortly after take off, apparentlyavoiding birds, so they end up flying past thecrew hotel! Somebody getting high on anapproach and doing S turns to finally roll thewings level at 120ft! Somebody doing apositioning flight and rolling to over 60degrees angle of bank during the departure!Somebody doing a visual approach with aconstant turn from downwind to roll thewings level at 50ft over the threshold! All ofthese things would be fine in a military aircraftor during a display but not in a commercialaircraft with a large number of fare payingpassengers in the back! In these incidents thepilots were clearly not following SOPs anddefinitely increasing the risk to the aircraft andall aboard.

The above incidents are extremes and theFDM systems of the airlines concerned pickedup these events and alerted the Safety Team.Obviously the pilots concerned “had theircollar felt” but I still find it hard to believe thatanybody, let alone a commercial airline pilot,could be so stupid as to think they could “getaway with it”! It is perhaps this very smallgroup of pilots, who do their own thing orarrogantly think that they are better than theyactually are, that FDM was introduced tocombat.

If you want to read an interesting article andwatch an interesting video Google “1994Fairchild Air Force Base B-52 crash”. This tragicaccident was caused by the pilot “BudHolland” flying the aircraft beyond its limitsand loosing control. The accident board statedthat Bud Holland's personality significantlyinfluenced the crash sequence. USAFpersonnel testified that Holland haddeveloped a reputation as an aggressive pilotwho often broke flight safety and other rules.The rule breaking included flying belowminimum clearance altitudes and exceedingbank angle limitations and climb rates. Inother words not following SOPs!

Fortunately the majority of pilots go to workwanting to do a professional job to the best oftheir ability. Most of the time these pilots

rigidly adhere to SOPs, because they areprofessional, and they get satisfaction fromdoing a good job. Occasionally these pilotsmight trigger an FDM event because of anunintentional error or due to externalinfluences like poor ATC control. But there isanother area where FDM can help these‘normal’ pilots and prevent accidents. If anFDM system is adequately resourced andgiven the agreement by the pilot communitythen it is possible to identify an unintentional‘bad’ technique which can then be correctedbefore an accident occurs.

In the Monarch FDM system we were able toidentify a number of pilots whounintentionally, and due to the design of theAirbus rudder pedals, were applying slightbrake pressure during the take off roll. Thesepilots were advised of the unintentional errorthey were making and corrected theirtechnique. As a result the number of “Brake onTake Off” events dramatically reduced. I usethis as a classic example of Pro-Active FDMand to argue the case for FDM protocols to beless restrictive.

In the ‘Total Safety Management System’ FDMis a key tool that must be used to its fullcapability to maintain safety. Old fears aboutthe system need to be ‘laid to rest’ and thepilot community needs to appreciate thebenefits of the FDM system rather than thinkthat it is ‘out to get them’!

3focus autumn 10

focus autumn 104

Anavigation fix that was not where the

flight crew thought it was, omission of

standard callouts and a mix-up in

communication about sighting the

approach lights were among the factors

involved in an unstabilized approach that

was continued below the minimum descent

altitude (MDA) in nighttime instrument

meteorological conditions (IMC) at

Khartoum, Sudan, on March 11, 2005.

The Airbus A321 “came hazardously close tothe ground” before the crew realized theirmistake and initiated a go-around, said theU.K. Air Accidents Investigation Branch (AAIB)in its final report on the serious incident.A fewseconds later, when the aircraft was 125 ftabove ground level (AGL), the terrainawareness and warning system (TAWS)generated a “TERRAIN, PULL UP” warning.

The report said that if the go-around had beeninitiated six seconds later, the aircraft likelywould have struck the ground 1.5 nm (2.8 km)from the runway threshold.The TAWS warningoccurred between 3.4 and 5.1 seconds afterthe go-around was initiated.

“Given that procedural triggers to go aroundhad not been effective, it is of concern that thewarning system may not have providedsufficient alert time to prevent an impact withthe ground,” the report said.

The TAWS was found to have functionedaccording to applicable design and installationstandards. The system received positioninformation from the A321’s flight managementand guidance system (FMGS) based on multi-sensor area navigation calculations.1 The reportsaid that position information received directlyfrom an on-board global positioning system(GPS) receiver is more accurate and results inmore timely warnings.

Without a direct GPS feed, TAWS sensitivity isreduced when the aircraft is near the runwayto prevent nuisance warnings that might becaused by less accurate position information.If the system in the incident aircraft hadreceived position information directly fromthe on-board GPS and incorporated the latest

software changes, a “TOO LOW, TERRAIN”warning likely would have been generatedwhen the aircraft was at 240 ft AGL. “Thecurrent TAWS standards undoubtedly wereappropriate at the time of implementation,and statistics show that they havesignificantly reduced the CFIT [controlledflight into terrain] risks, most likely savingmany lives,” the report said. “However,operational experience of indirect GPSinstallations that do not directly feed GPSquality data to the TAWS ... has highlightedproblems that have been addressed by theTAWS manufacturers but that are not requiredto be implemented.

“In essence, the CFIT protection technologyhas improved, but the required minimumTAWS standards have not. Thus, significantimprovements in aviation safety in this areaare available but not mandated.”

Among recommendations based on theincident investigation, AAIB urged theEuropean Aviation Safety Agency to work withindustry on a review of TAWS design andinstallation standards “with particularemphasis on the timeliness of alerting whenclose to the runway” AAIB said, “Revisions tothese standards arising from this reviewshould apply [retroactively] to all aircraftcurrently covered by the TAWS mandate.”

Airbus A321-200

The A321 is a stretched version of the A320.The A321-200 has more fuel capacity, a highertakeoff weight and greater range than the -100.The incident airplane is an A321-231 thatwas built in 2002; it has International AeroEngines V2533-A5s rated at 146.8 kN (33,000lb thrust), a maximum takeoff weight of89,000 kg (196,209 lb) and a maximumlanding weight of 79,000 kg (174,163 lb).Source: Jane’s All the World’s Aircraft

Sandstorm

The British Mediterranean Airways flight hadoriginated in Amman, Jordan, at 2130

coordinated universal time (UTC; 2330 localtime) with l9 passengers and eightcrewmembers.2 The commander, 46, had7,400 flight hours, including 3,700 flight hoursin type.The copilot, 39, had 4,700 flight hours,including 3,200 flight hours in type.

“The weather forecast for Khartoum, obtainedbefore departure, had reported gustingnortherly winds and reduced visibility inblowing sand,” the report said. “During thecruise, and once they were in Sudaneseairspace, the copilot asked ATC [air trafficcontrol] for the latest weather report forKhartoum.” The controller said that the surfacewinds were from the north at 20 kt andvisibility was 1,000 m (5/8 mi) in blowing sand.

Runway 36 was in use. A notice to airmenadvised that the instrument landing system(ILS) was not in service. The commanderdecided to conduct the VHF omnidirectionalradio/distance measuring equipment(VOR/DME) approach. The KhartoumVOR/DME (KTM) is 0.6 nm (1.1 km) south ofthe Runway 36 approach threshold.

“Neither pilot had previously operated inblowing sand, and both were concerned aboutthe possible implications,” the report said. Thepilots found no information about blowing sandin the airline’s operations manual and usedinformation about volcanic ash for guidance.

“As a result, the pilots discussed variouspossible actions, and the commander chose toselect continuous ignition on both engines forthe approach,” the report said.

Although reported as blowing sand, themeteorological condition at Khartoum hadthe characteristics of a sandstorm. “Blowingsand is associated with strong winds whichraise the particles above ground level but nohigher than 2 m [7 ft],” the report said.“Sandstorms are usually associated withstrong or turbulent winds that raise particlesmuch higher.” The operations manualrecommended that pilots avoid flying in asandstorm whenever possible.

by Mark Lacagnina

Close Call in KhartoumConfusion reigned when an A321 was flown below minimums in a sandstorm

focus autumn 10 5

Managed Approach

Another check with ATC on weatherconditions at the airport indicated thatvisibility had improved to 3,000 m (2 mi). Thecommander decided to conduct a managednonprecision approach (MNPA) to Runway36. “This type of approach requires theautopilot to follow an approach path definedby parameters stored in the aircraft'scommercially supplied [FMGS] navigationdatabase,” the report said.

At the time, however, the airline was in theprocess of developing MNPA procedures andhad received authorization from a U.K. CivilAviation Authority (CAA) flight operationsinspector to conduct managed approachesonly in visual meteorological conditions.

The commander had conducted managedapproaches while flying for another airline.“Therefore, [he] did not consider it would be aproblem, despite the fact that the reportedvisibility was below VFR [visual flight rules]limits,” the report said. “The copilot'sacceptance of this decision illustrates thatneither pilot [realized] that not all thenecessary safeguards were in place to conductsuch approaches safely in IMC.”

While setting up for the approach, the crewrevised the MDA programmed in the FMGSdatabase to 1,650 ft because the airline'sstandard operating procedures fornonprecision approach required 50ft to beadded to the published MDA.

The pilots were not aware that a discrepancyexisted between the location of the finalapproach fix (FAF) depicted on their approachchart and the location programmed in theFMGS database. Approach charts and FMGSdatabase updates were provided by differentcommercial vendors. The chart depicted theFAF, called HASAN, at “KTM 5d” — that is, 5.0nm DME from KTM (Figure 1). The report saidthat this location resulted from the 2002Sudanese Aeronautical Information

Publication (AIP), which placed the FAF 5.0nm from both the runway threshold and KTM.“By interpolating the depicted final approachgradient, the [chart vendor] determined thatHASAN was actually 5.6 nm from the runwaythreshold,” the report said. “This coincidedwith the KTM 5 DME position.”

The FMGS database included a 2004amendment to the AIP that placed the FAF5.0 nm from the runway threshold and 4.4nm DME from KTM.

“The pilots were unaware of [the] significantdiscrepancy between the approachparameters on the approach chart and thosewithin the navigation database because theyhad not compared the two data sets beforecommencing the approach,” the report said,noting that this omission was partly the resultof the absence of a formal U.K. CAA policyand clear guidance by the airline on how toconduct managed approaches.

‘Late’ Descent

The report said, “The pilots commenced theapproach with the autopilot engaged inmanaged modes — that is, the approachprofile being determined by the FMGS insteadof pilot selections.”

At 0025 UTC (0325 local time), the aircraftcrossed the initial approach fix, JEBRA, at 4,000ft, and then completed the procedure turn tothe final approach course. During this time, thecrew asked ATC for the current visibility andwere told that it was between 1,000 m and1,200 m (3/4 mi).The crew said that the A321was fully configured for landing and stabilizedat the appropriate airspeed when it crossedthe 5.0 DME location for HASAN depicted onthe approach chart at 2,900 ft, the publishedminimum altitude for crossing the FAF.The managed approach was being conductedcorrectly by the autopilot based on the FMGSdata. Thus, the aircraft did not begin the finaldescent at 5.0 DME, as the pilots expected(Figure 2). “The aircraft began its final descent0.6 nm later than the pilots were expecting,”the report said. “Believing the aircraft washigh on the approach, the handling pilot [thecommander] changed the autopilot mode inorder to select an increased rate of descent.”

The commander intended to establish theA321 on a 3.0-degree vertical flight pathangle, which was equivalent to a descent rateof about 800 fpm at the selected airspeed. Hemistakenly believed that the autopilot was inthe track/flight path angle mode. Theautopilot actually was in the heading/verticalspeed mode, and the commander's inputcaused the autopilot to command a descent

Figure 1

KTM = Khartoum VOR/DME (VHF omnidirectional radio/distance measuring equipment);d = DME distance (nm) from KTM; IAF = initial approach fix; THR Elev = Runway 36 approachthreshold elevation; MAP = missed approach point

Source: U.K. Air Accidents Investigation Branch

6 focus autumn 10

rate of 300 fpm, rather than a 3.0-degreeflight path angle.

As the aircraft descended on final approach, itentered the sandstorm, and the crew'sforward visibility decreased rapidly. “Thecommander described the effect of the sandas like watching iron filings flying past thewindscreen,” the report said. He also notedthat the visual effect of the landing lightreflecting off the sand was disorienting.

The copilot conducted a distance/altitudecheck at 4.0 DME and found that the aircraftwas about 200 ft above the descent profileshown on the approach chart. “Thecommander stated that as the aircraftapproached 3.0 DME, it became apparent thatit was not closing with the vertical profile, andso he increased the rate of descent to about

2,000 fpm,” the report said. A few secondslater, he reduced the selected rate of descentto 1,200 fpm. “The pilot's selections resultedin a varying flight path angle that averagedabout 4.5 degrees,” the report said.

Lights in Sight?

The cockpit voice recorder (CVR) recording ofthe verbal communication between the pilotsduring the approach subsequently wasoverwritten. “It has not been possible toestablish exactly what was said between thepilots at this time,” the report said. “However,it is apparent that at some stage late in theapproach, the commander asked the copilot ifhe could see the approach lights. The copilotmistook this question to be the commanderstating that he could see the lights. As aresult, the copilot informed ATC that they

could see the approach lights and requestedconfirmation that they were cleared to land.The commander, hearing the copilot'stransmission, took this to mean that thecopilot had got the approach lights in sight.”

Standard callouts were omitted, and neitherpilot had the required visual references insight as the A321 descended below 1,650 ft— about 390 ft AGL. “Had appropriate callsbeen made at the critical moments, theywould have almost certainly prevented theconfusion that allowed the aircraft tocontinue below MDA without the requiredvisual references,” the report said.

The commander looked up and saw lights atthe one o’clock position but realized that theywere not the approach lights. A note on theapproach chart caution pilots against

Figure 2

KTM = Khartoum VOR/DME (VHF omnidirectional radio/distance measuring equipment); MDA = Minimum descent altitude

Source: U.K. Air Accidents Investigation Branch

7focus autumn 10

“confusing local street and bridge lightingwith approach and runway lights.”

The misidentified lights and the disorientingeffect of the blowing sand prompted thecommander to initiate the go-around atabout 180 ft AGL—210 ft below the MDA. Headvanced the throttles to the takeoff/go-around power setting, which automaticallyengaged the autopilot go-around mode.During this process, the aircraft sank to 125 ftAGL, where the TAWS “TERRAIN, PULL UP”warning was generated. “The commanderreported that he noted the aircraft's attitudewas 5 degrees noseup, so he pulled back onhis sidestick with sufficient force to disengagethe autopilot and increase the pitch attitudeto between 17 degrees and 20 degrees nose-up,” the report said.

The commander pulled the sidestick abouthalfway back, instead of all the way back, asrequired by the emergency procedure forresponding to the TAWS warning. He toldinvestigators that he believed he already was“overpitching the aircraft” Nevertheless, thereport said, “By nature, any [TAWS] terrainwarning requires prompt and decisive action,and the protections built into the aircraft'sflight control system allow for the applicationand maintenance of full back sidestick untilthe warning ceases.”

Two More Tries

During the missed approach, the commanderbriefed the copilot for another approach. Hedecided not to conduct another managedapproach but to use raw data and selectedautopilot modes. “The pilots also decided toleave the landing lights off for this secondapproach to prevent the disorienting effect oflight scattering off the sand.” the report said.

During the second approach, the pilots did nothave the approach lights in sight at themissed approach point, KTM, and anothermissed approach was conducted at 0049UTC. “While carrying out the go-around, thecommander could make out the runningstrobe lights below and stated that theaircraft passed slightly to the right of them,”the report said.

The pilots told investigators they becameaware that the crew of another aircraft hadconducted the ILS approach and landed onRunway 36. However, when they tuned the ILSfrequency, they found that a test code wasbeing transmitted, indicating that the ILS mustnot be used for an approach.The crew decidedto conduct another VOR/DME approach.

“While maneuvering, they heard the pilots ofanother inbound aircraft ask Khartoum Towerto confirm that the visibility was now 200 m[ 1/8 mi],” the report said. “When thisreported visibility was confirmed, the copilotimmediately questioned the tower controllerabout the current visibility at Khartoum. Theinitial reply from the controller was that thevisibility was 900 m [between 1/2 and 5/8mi], followed quickly by a correction to 800 m[ 1/2 mi] and then a further correction by thecontroller to 200 m”

The commander broke off the approach at4,000 ft and diverted to Port Sudan, wherethe aircraft was landed without furtherincident at 0214 UTC (0514 local time).

This article is based on UK. AAIB AircraftIncident Report No. 5/2007(EW/C2005/03/02).

Notes

1. FMGS is an Airbus term. Flightmanagement system (FMS) is another termused to describe the equipment.

2. British Mediterranean Airways was foundedin 1994 and operated as a British Airwaysfranchise until 2007, when it was acquiredby the U.K. airline bmi.

This story is taken from an issue of Flight

Safety Foundation’s journal, AeroSafety

World. A free subscription to the digital

version of that publication is available though

the signup form on the Foundation’s Web site

home page, www.flightsafety.org

focus autumn 108

PBNPerformance Based TechnologyFirst appearing in flightsafety Australia, this article provides a useful account of the benefits available from P B Navigation

Increasingly, airlines around the world are

capitalising on the safety, operational

and environmental benefits offered by

performance based navigation (PBN).

Flight Safety editor, Margo Marchbank,

talks to PBN specialists in Australia and

internationally about these navigation

procedures and moves towards global

harmonisation.

Performance based navigation employssatellite technology for optimal use ofincreasingly congested airspace. It also allowssafer operations into challenging terrain, andincreasingly, is being recognised for theoperational and environmental efficiencies itbrings. PBN encompasses a shift fromgroundbased navigational aids emittingsignals to aircraft receivers, to a system thatrelies more on the performance andcapabilities of equipment onboard theaircraft. Conventional route proceduresrequire an aircraft to follow the ground-basednavigational infrastructure in a point-to-pointfashion - an uneconomical use of airspace.PBN, on the other hand, fully utilises theonboard navigation capability of modernaircraft, is not tied to the ground basedinfrastructure and permits the aircraft to flymuch more economical routes (for example,polar route, jet streams etc).

Last year, 2009, was a landmark year forperformance based navigation, according tothe International Civil Aviation Organization(ICAO). Late in 2009, Flight Safety spoke toNancy Graham, head of ICAOs Air NavigationBureau, and ICAO PBN project manager,Erwin Lassooji, in Montreal. ‘As the 36th ICAOAssembly recognised in 2007, when it urgedmember states to have PBN implementationplans finalised by 2009, we will only be able torealise the full benefits of PBN through globalimplementation’, Graham explained. ‘PBN isthe single-most important project ICAO hasundertaken relating to safety, efficiency andbeing good stewards of the environment.’PBN delivers safety, environmental andoperational benefits according to Grahambecause ‘It’s the best technology we have, andit’s the best use of that technology’.

The Global PBN Task Force is driving theconcerted worldwide push for rapidimplementation of performance-basednavigation. The Task Force comprises theICAO, ICAO member states, such as the USA’sFederal Aviation Administration and CASA inAustralia, industry representation such as theInternational Air Transport Association (IATA),national air navigation service providers (forexample Airservices Australia) manufacturers.and companies designing procedures, such asthe American-based Naverus.With the GlobalPBN Task Force established during 2009, thenext task, Graham explained, was to focus onregional groups. ‘Implementation has to doneon a regional basis. We’re looking at“goteams”,’ she continued, ‘to bring togetherthe right kind of skills to supportimplementation.’ The various regional groupshave formulated specific timelines for theirrespective regions, and in early 2010, ICAO issetting up a Flight Procedures Office in Beijingto assist states in the Asia-Pacific region. Sheacknowledges that implementing PBN is achallenging task, because it is demanding,both technically, and in its performanceaspects - flight trials and training. PBN is a‘first step for the regulator, it’s a first step forthe airlines, and it’s a first step for thedesigners - all these things (the suite ofregulations, the training of personnel andhaving suitably equipped aircraft, the designof appropriate procedures) have to cometogether, but Graham stresses the committedinvolvement of the global aviationcommunity.

Implementing PBN is a challenging task, DirkNoordewier agrees. He is an air transportinspector, and CASA’s PBN project manager.‘Worldwide, there are all these, differentnavigation approvals, with differentterminology,’ he explains. ‘The whole point ofPBN is to rationalise these and getconsistency. Satellite navigation and satellitecomms have enabled aircraft to be self-sufficient, so the bit of land you’re over is nolonger the issue it used to be.’ ICAO has setdeadlines for PBN - the primary ones forAustralia were the submission of a PBNimplementation plan by the end of 2009; anda 2010-2016 timetable for implementationof approaches with vertical guidance (APV).

Australia’s PBN implementation plan hasbeen submitted, and addresses navigationauthorisations for Australian operators underCASR Part 91U. All the authorisations willalign under PBN. ICAO’s timetable forapproaches with vertical guidance requiresmember states to have APV implementation30 per cent complete by 2010, 70 per cent by2014, and fully complete by 2016. ‘APV’,Noordewier explains, ‘are an ICAO safetyinitiative with the goal of preventingcontrolled flight into terrain. APV will be thestandard instrument approach - it’s ourintention that 2D approaches will become athing of the past. PBN,’ he adds, ‘is more thanjust RNP AR.’ A focus on RNP ARunderestimates the safety and efficiencybenefits of Baro-VNAV capability for lightaircraft, and APV generally, he contends.

What is PBN?

PBN is an ICAO initiative to harmonise globalnavigation specifications. This includes allphases of flight-from oceanic and enroute, toterminal and approach procedures. PBNspecifications already implemented includeRNAV 10 and RNP 4 for oceanic operations,and RNP APCH and RNP AR APCH forapproach operations. PBN encompasses twotypes of navigation specifications: RNAV (aReaNAVigation) and RNP (required navigationperformance). Distinctions between the twoare difficult to pinpoint accurately -‘It’s oftenhard to tell the difference,’ Noordewier says.Some identify differing requirements foronboard performance monitoring and alertingas distinguishing RNAV and RNP. Areanavigation specifications, for example RNAV5,RNAV1, do not require this. Requirednavigation performance utilises the aircraft’snavigation system to integrate numeroussources of positioning data (e.g. inertial,satellite and barometric data) to providehighly accurate navigation solutions with real-time integrity monitoring and alerting. AllRNP specifications require onboardperformance and monitoring. In a flightmanagement system (FMS)-equipped aircraftthis can be achieved through AAIM (aircraftautonomous integrity monitoring) where theRNP is compared to the actual navigation

9focus autumn 10

performance (ANP). In a aircraft utilising anIFR GNSS Navigator this can be achievedthrough RAIM (receiver autonomous integritymonitoring).

Broadly, RNAV is an equipment-basednavigation concept and RNP is aperformance-based navigation concept. WithRNP, the aircraft has an onboard ‘qualitymanagement system’. Information from theglobal satellite system calculates its positionfrom the satellites in view. A timely warningis provided when the quality of that positionalsolution deteriorates below an acceptablelimit, alerting the pilot of the need todiscontinue the approach. For example, in thecase of an RNP-AR approach to an RNP valueof 0.1, we are setting the ‘alarm limit’ so thatshould the quality of the navigation solutiondeteriorate below the threshold of 0.1nm,then the alarm will sound a warning longbefore the accuracy of navigation iscompromised.

RNP APCH & RNP AR APCH

Under PBN harmonisation, all approaches arenow classified as RNP navigationspecifications.There are two broad categories:RNP APCH and RNP AR APCH. RNP APCH canbe either two-dimensional (2D) or three-dimensional (3D) and operate only to an RNPvalue of 0.3nm. RNP AR APCH is by definitiona 3D approach and operates to an RNP valueof 0.3nm and below.

There are four types of RNP APCH procedures:■ RNP APCH - LNAV: where lateral

guidance is provided by GNSS signal inspace (SIS) (currently known as RNAVGNSS procedures);

■ RNP APCH - LNAV/VNAV: where lateralguidance is provided by GNSS SIS andvertical guidance is provided bybarometric vertical navigation (Baro-VNAV);

■ RNP APCH - LP (localiser performance):where lateral guidance equivalent to alocaliser approach is provided byaugmented GNSS SIS; and

■ RNP APCH - LPV (localiser performancewith vertical guidance), where lateral andvertical guidance is provided byaugmented GNSS SIS.

RNP APCH-LNAV can be considered thesimplest RNP approach procedure providing2D instrument approaches to runwayswithout the need for ground-basednavigation facilities. RNP APCH 2D procedureshave been flown in Australia for many years,initially identified as GPS/NPA procedures andmore recently as RNAV (GNSS) procedures.These procedures are now known as RNPAPCH - LNAV.

An RNP APCH may be flown as either a two-dimensional or three-dimensional procedure.Where RNP APCH procedures involve only 2Dguidance they are classified as non-precisionapproaches (NPA); where they have 3Dguidance they are classified as approacheswith vertical guidance (APV). Therefore RNPAPCH NPA and APV can be summarised as:

■ NPA:• RNP APCH - LNAV • RNP APCH - LP

■ APV:• RNP APCH-LNAV/VNAV, and• RNP APCH - LPV.

Required navigation performance ‘authorisationrequired’, or RNP AR APCH, utilises IRS andGNSS in combination to provide far higheraccuracy and performance over an RNP APCH-to quote Naverus, by ‘allowing forpredetermined, precise, curved flight pathswhich navigate within an airspace to reducetrack miles, conserve fuel, preserve theenvironment and increase airspace capacity.’

RNP AR APCH Procedures

■ operate to RNP values as low as 0.1nm,

■ utilise radius to fix (RF) turns, and

■ have non-normal events such as enginefailure incorporated into the procedureprofile.

Australia is in a unique position inimplementing PBN technology according toDirk Noordewier. Australia's high-capacityregular public transport fleet is relativelyyoung, with an average age of around 15years, and therefore equipped with theappropriate onboard technology. Over 60 percent of Australia's domestic jet fleet is certifiedto RNP0.3 or better. Importantly, too,Australiadoes not have a high-density ground-basednav-aid network. This is on stark contrast tosomewhere like the United States, which hasan older fleet of legacy aircraft, a high densitynetwork of ground-based navigation aids, and

10 focus autumn 10

therefore a low dependency on globalnavigation satellite systems (GNSS). ‘Manycountries don’t “get” countries like us,’Noordewier explains. ‘We are almostcompletely bypassing RNAV, and goingstraight to RNP. The end result is that we’reseen as world leaders.’ Nancy Graham agrees.‘You're early adapters. Australia’s always oneof the first to do anything, especially when itcomes to safety and efficiency.’

RNP AR & Safety

It was this concern for aviation safety that led tothe development of RNP AR - to make flyinginto airports located in challenging terrain, orwith a challenging climate, safer. Juneau, Alaskais a case in point. There, a high mountainousrange flanking the Gastineau Channel createdchallenges for aviation safety. Frequently,operations into the Juneau International Airport

runway 08 had been interrupted or delayedbecause of low visibility and ceilings, and if windaffected runway 08, the opposite runway, 26,was not usable because there was no approachlanding aid and associated procedures. Theseconditions had led to hull accidents and loss oflife, as well as cancellations and diversionsbecause of bad weather. In May 1996, SteveFulton, the founder of US procedures designcompany Naverus, and Hal Anderson, bothpilots and engineers, worked with Boeingnavigation system specialists to pioneer RNP atAlaska Airlines. They designed a new RNPapproach for the airlines’ 737-400 aeroplanesflying into Juneau.

Qantas Airways was also early to recognise thesafety benefits of RNP AR for its flights intosimilarly challenging terrain in Queenstown,New Zealand. High mountains circle the airport;there is no radar; it is a popular touristdestination, and therefore can be a high trafficenvironment; and the weather can often be asignificant factor. The original approach toQueenstown was a circling approach, with anassociated risk of controlled flight into terrain.The 737-800s Qantas flies into Queenstownoffer advanced capability, so the carriercommissioned Naverus to design an RNPapproach for the port. The RNP approach givesthe pilot positive three-dimensional guidanceall the way to the Queenstown runway.According to Captain Alex Passerini, Qantastechnical pilot, ‘With RNP, if there’s a non-normal event like engine or GPS failure, the crewwill have more tools in the toolkit to managethe work, solve the problem, and extract theaeroplane if they’re at a low altitude.’

Naverus has also worked with civil aviationauthorities, air navigation service providersand airline carriers to implement ‘safety-case’RNP at Lhasa in Tibet, and Cusco in Peru. IATA;carrier LAN Peru; and the Peruvian civilaviation authority, DGAC Peru, collaborated ona new RNP approach to Cusco. GuentherMatsschnigg, senior VP, IATA safety operationsand infrastructure, argues that the, ‘RNP safetyadvantage is significant, enabling airportslocated in the most remote areas of the worldto have runway-aligned approaches withhorizontal and vertical guidance, withouthaving to install, calibrate and monitor

expensive ground-based navigation aids’. On22 May 2009, a LAN Airbus 319 completed itsfirst scheduled RNP procedures flight intoCusco with passengers, the first flight of itskind in South America.

Cusco Airport, the gateway to the populartourist destination of Macchu Pichu, has anelevation of approximately 10,860ft, and islocated at the end of a long valley surroundedby mountains reaching 15,500ft. Ten tofifteen flights a day deliver visitors to Cusco,and in the last three years, unfavourableweather has meant the cancellation ordiversion of approximately 200 operations.The new RNP procedures lower the minimumdescent altitude from 14,500ft to 11,800ft,almost eliminating such weather-induceddelays and cancellations.

RNP AR Savings

However, it soon became apparent that notonly did RNP procedures mean improvedsafety, but they could also deliver significantenvironmental and operational benefits. Theability to curve the approach path allows theaircraft to be manoeuvred around obstaclesand restricted or built-up areas, often resultingin a shorter approach when compared to thezig-zag pattern of conventional ground-basednavigation procedures.

Australia’s Brisbane Green project highlightedthese environmental and operational benefits.In 2007, Airservices Australia introduced RNPAR approach procedures at BrisbaneInternational Airport. Brisbane InternationalAirport is Australia’s third busiest, with 21international and five domestic carriersoperating aircraft ranging from turbo-propand helicopter, to heavy jets. In 2007, therewere approximately 173,000 aircraftmovements, involving in excess of 17.5million passengers. Working closely withNaverus, Qantas Airways and CASA,Airservices implemented six RNP approachesand 12 RNP departures.

The Brisbane Green project has three stages:

Stage 1 - involved 33 Qantas 737-800s

RNP approach to Lin Zhi, Tibet, a 95-mile serpentineapproach between 17-20,000 ft mountains

Comparison of approach path with radar

vectors. RNAV & RNPAR

11focus autumn 10

Stage 2 - involved Jetstar A320/A321 & AirVanuatu 737NGs

Stage 3 - Virgin Blue & other internationalcarriers, with additional aircraft types.

The Stage 1 results (2007-2008) were veryencouraging. Over 15,500 RNP procedures wereconducted, including more than 8,000approaches. Of these 8,000 procedures, 1612were flown in instrument conditions, resulting in:

■ estimated flight time savings of 4,200minutes

■ estimated 17,300nm reduction indistance flown

■ estimated jet fuel saving of more than200,000kg

■ estimated carbon dioxide emissionreduction of 650,000kg

■ reduced impact of aircraft noise

■ reduced delays for non-RNP aircraft,because of shorter arrival times for RNPaircraft.

Qantas-commissioned, proprietary RNPprocedures are used at 17 aerodromes inAustralia. Former Qantas chief pilot, ChrisManning, is a passionate advocate for RNP,and in a presentation he gave to the 2009annual Airports & Aerodromes Associationconference, argued that ‘the use of RNP isimperative if we are to get the greatestefficiencies from the system.We can’t imposeRNP on current tracks; the tracks can bedrawn according to community concerns, butthe program needs to continue apace until itis completed.’ The community concernsManning alludes to relate especially to noiselevels near airports. The Brisbane trialdemonstrated that noise emissions over built-up areas could be minimised by conductingthe RNP approach over the river, highway andindustrial areas, Chris Henry, general managerof Naverus Australasia, reasons. And inresponse to the claim from some that RNPconcentrates the noise, he replies that ‘RNPallows a flexible matrix of paths, so thatprocedurally, you can “share the noise” byhaving multiple paths to the same airport.’

While much of the PBN focus has been onapproach procedures, in no small part becauseof their safety implications, it’s important notto lose sight of the benefits harmonising globalnavigation specifications for enroute operationscan bring. ‘The potential here for significantsafety, environmental and economic benefitsshould not be overlooked,’ Dirk Noordewieremphasises. ‘There’s no point in an aircraftflying RNP4 trans-oceanic, at 30 miles’separation, only to reach an FIR boundaryrequiring 80 miles’ separation,’ he explains. ‘Inthe absence of a global standard, air trafficcontrol will group mixed traffic according to thelowest common denominator, so you cannotderive any efficiency benefit from the capabilityof the aircraft.’

Given that these procedures are still relativelynew, he says, ‘There is still a reasonably highlevel of regulatory oversight,’ but as theseprocedures become the default, that willobviously diminish. And in conclusion, he waskeen to emphasise that ‘PBN is for everyone. It’snot just airline stuff. If I’ve got a GPS IFRnavigator in my aircraft, I’ve achieved RNP 0.3LNAV standards. That’s what it means. I have tohave RAIM (receiver autonomous integritymonitoring) if I’ve got a GPS IFR navigator, andRAIM is performance monitoring’.

Reprinted with kind permission flightsafety

Australia Jan - Feb 2010 Issue 72

The Queenstown approach

focus autumn 1012

SMS on wheelsA new spin on understanding safety management systems by Thomas Anthony

For several years, we have sought to

explain the safety management

system (SMS) concept using the mental

model of pillars. Yet, SMS still remains a

mystery to many. This is not a reflection

on SMS itself but rather on the ways we

have sought to explain it.

Peter M. Senge, a senior lecturer at the

Massachusetts Institude of Technology and

founding chair of the Society for Organization

Learning, explains the function of mental

models as follows:1

None of us can carry an organization in our

minds… What we carry in our heads are images,

assumptions and stories… Our mental models

determine not only how we make sense of the

world, but also how we take action.

Our mental model of SMS is important notonly because it organizes our understandingof SMS but because it directs the action wetake and how we move forward with SMS.

With this in mind, let’s take a look at themental model created by the image of pillars(Figure 1). Pillars are singular supportivecomponents of structures such as buildingsand temples.They are strong and often clearlyidentifiable. These positive characteristics ofpillars are what led to their widespread use asa mental model for SMS. But, there are othercharacteristics of pillars that do not fit theconcept of SMS. Pillars are static.They are notdynamic; they do not characterize motion orchange. While they may be beautiful instructures such as the Panthenon, theirfunction is to support something else.They donot describe the structure as a whole.

For these reasons, the mental model of pillarshas taken us just so far with regard tounderstanding SMS.

What mental model works better? Wheels.

SMS is like a system of wheels or gears, eachof which causes the others to turn. Withouteach one functioning, none of them can turn.This mental model conjures a system in whicheach element influences the others and in

which all the elements must work togetherfor the system to function.

The three wheels of SMS are:

■ Hazard identification;

■ Risk analysis and assessment; and,

■ Risk mitigation by involved management.

Hazard identification

The first wheel represents all activities of anSMS wherby we collect information and datathat help us identify hazards (Figure 2). Theseactivities include hazard reporting systemsavailable to all employees, incident reportingsystems, such as an aviation safety actionprogram (ASAP), the U.S. NationalAeronautics and Space AdministrationAviation Safety Reporting System (ASRS) orthe U.K. Confidential Human Factors IncidentReporting Programme (CHIRP), and flight datamonitoring systems such as flight operationalquality assurance (FOQA) programmes.

Activities that collect information on hazardsinclude surveys, inspections, tests and audits,such as the line operations safety audit(LOSA). These are conducted to identify

hazards resulting from operations orperformance that do not comply withestablished standards.

The standards may be regulations, approvedprocedures or company procedures. There islittle room for argument that noncompliantperformance represents anything other thana hazard.

In his research, David Huntzinger, now vicepresident of safety and security for BaldwinAviation, has found that 60 percent of fatalaccidents involved at least one instance ofintentional noncompliance with procedure.Additionally, investigations are conducted toidentify hazards that contribute to aviationaccidents and incidents.

Finally, the hazard identification wheelincludes the change management process.James Reason, professor of psychology at theUniversity of Manchester, states, “Change inone guise or another is a regular feature oferror-producing situations.” Aviation isinherently a dynamic and ever-changingindustry that is constantly producing hazardseven as it strives to reduce them.

All the activities that are part of the hazardidentification wheel provide data on conditionsthat could result in accidents, incidents or lossin aviation operations. How important arethese data-collection processes?

Daniel Maurino, chief of the International CivilAviation Organization (ICAO) Integrated SafetyManagement Section, stated it succinctly:

“Without data, you don’t have an SMS.”

In judging whether an organization hasadequate hazard identification channels, wecan ask:Are there hazard reporting proceduresavailable for all elements of the organizationin which actions may create a hazard thatcontributes to the accident/incidentcausation chain?

In short, the hazard identification wheel is theSMS stage that includes all the processes weuse to collect hazard information.

Figure 1

Pillars model of SMS

focus autumn 10 13

Risk analysis and assessment

The second wheel of the SMS model comprisesan essentially different type of activity fromhazard identification. In the risk analysis andassessment stage, we process the data thathave been acquired in the first stage (Figure 3).

We begin by validating the hazard data toascertain that the data are true and to gaugethe extent to which the hazards exist. Then weanalyse the information according to twocriteria:

■ How severe will the losses be if thishazard occurs?

■ How likely is it that the hazard will occur?

So that this risk assessment is done properly,two more conditions must be met. First, astandard by which hazards are assessed isdeveloped and adopted by the organization.This means that all hazards are assessed usingthe same measure.This is accomplished whenan organization develops a risk assessmentmatrix upon which to base its decisionsregarding likelihood and severity.

Second, however, is the necessity that theorganization devote to the risk assessmentprocess individuals who possess theknowledge and expertise necessary to makereasonable and knowledgeable assessments.

The risk assessment matrix is not a “file andforget” tool. It must be applied by high-performing and responsible individuals withexpertise from each of the major areas of theorganization. Why not say “all majoroperational areas of the organization?”Because hazards can be created by the budgetdepartment, the training department and byhuman resources.

Hazards created by staff offices can be just asdeadly as those created by flight operations.Several accident investigations have pointed outthat management and administrative practicescan present hazards that contribute to theaccident causation sequence. Thus, individualsrepresenting all major areas of the organizationmust participate, as part of the “Safety ActionGroup,” in risk analysis and assessment.

Just as risk assessment depends on hazardidentification for data, it also depends on the

third wheel, risk mitigation by involvedmanagement to make available high-functioning and valuable employees toparticipate in the risk assessment process.

Additionally, to achieve consistently balancedand objective assessments of risk, amanagement official with authority over theentire organization should serve as the safetyadvisor, or head of the Safety Action Group.

The safety advisor is well placed as thesecretary of the Safety Action Group toprovide expertise, organization and guidance.

While the discussion of safety managementin ICAO Annex 6, Operation of Aircraft, andAnnex 14, Aerodromes, emphasizes topmanagement’s accountability for safety, whathas been missing from the SMS discussionthus far is that participation in the SafetyAction Group risk analysis and assessmentprocess also presents a valuable opportunity

for management. It is the opportunity to learnabout issues that could have the mostprofound effect upon that particularorganization: safety hazards.

Peter Senge, in his book The Fifth Discipline,shows how mental models determine how wesee our organization, its mission and our rolewithin the organization.

Senge points to a study conducted by RoyalDutch Shell in 1982 that found that of thecorporations that made up the Fortune 500 in1970, one-third of them no longer existed in1982. The reason for their extinction was inlarge part due to mental models that did notadapt to changing conditions.

To avoid the same fate, organizations mustevolve to become learning organizations.Participation by top management in theSafety Action Group is an opportunity forshared learning among all significantelements of the organization.

There is no quicker step on the route toextinction for an aircraft operator than amajor accident. Beyond this, participation inthe risk assessment process presents an

Figure 2

Hazard indentification, the first wheel

14 focus autumn 10

opportunity to develop a shared vision thathas safety as a core element.

It becomes a mechanism of learning formanagement, line and staff.

In applying the risk assessment matrix in largeorganizations that produce a great deal ofdata, it is desirable to use an automatedinformation system to quantify and classifythe hazard data and make initial assessmentsof risk.

Nevertheless, while it is important to classifyand quantify the data being reviewed in therisk assessment process, a measure ofjudgment and perspective must be applied tothe data.As an example, the number of aircrafthijackings that occurred in North America from1991 to August 2001 was zero. Was it correctthen to conclude at the end of that nearly 10-year period that the risk of a hijacking was nearzero and therefore no additional mitigationmeasures were necessary?

No, the 9/11 hijackings proved that such aconclusion was not appropriate. This level ofjudgment and perspective is best provided bymanagement, that portion of the organizationwith responsibility over the entire organization.

Involved-Management Action

ICAO Annex 6, Part 1, Section 3.2.5, has itexactly right in stating:

A safety management system shall clearlydefine lines of safety accountabilitythroughout the operator’s organization,including a direct accountability for safety onthe part of senior management.

Likewise, U.S. Federal Aviation Administration(FAA) Advisory Circular 120-92, Paragraph 8.b.(3), recognizes the essential character ofmanagement involvement and participationin the SMS process:

Management must plan, organize, direct andcontrol employees’ activities, and allocateresources to make safety controls effective. Akey factor in both quality and safetymanagement is top management’s personal,material involvement in quality and safetyactivities.Management involvement in the safetyprocess is the essential difference betweentoday’s SMS and the risk assessmentprocesses of the past. It is through SMS thatsafety is granted full consideration among theother principal issues that demand topmanagement's attention.

The third wheel in our SMS mental model isthe stage in which action is taken to mitigateunacceptable risk as determined in theprevious stage (Figure 4,). There are twopreconditions for this stage to be effective.First, the same experienced andknowledgeable individuals must be involvedin determining what mitigations will be

(a) effective and(b) reasonable to implement.

The second precondition is the involvementof top management, because topmanagement has the power to allocateresources for the mitigations and hasauthority across all competing priorities ofthe organization.

The third wheel transmits the actions requiredto mitigate the hazards to the organization.

Lubri-communication

For a system composed of wheels or gears tocontinue to operate, lubrication is required. InSMS, this lubrication is communication.Without the free flow of meaningfulcommunication, the system will come to agrinding halt. Communication means notsimply data, but the meaningful back-and-forth sharing of hazard and risk information

Management has a special role in creating anorganization that encourages thecommunication of hazard information. This isdone by establishing a reporting culture anda learning culture. A reporting cultureensures a realistic flow of hazard informationand data. A learning culture ensures thathazard/risk information generates reasonablemitigation measures and that theorganization internalizes what it has learned.A learning culture underwrites a viableorganization.

A learning culture is always asking, Why?Management establishes a reporting cultureboth by authoring a safety policy statementthat supports SMS and by advocacy andpersonal example.

Figure 3

Processing the data

15focus autumn 10

This means the modelling of behaviours, byexample that encourages the free flow ofhazard information.A reporting culture cannotbe established or sustained in an environmentcharacterized by fear and reprisal.

Although an organization may possess all thecomponent parts of an SMS, the system willhave no positive effect unless there iscommunication. Communication is influencedby mental models. As Senge says, “Two peoplewith different mental models can observe thesame event and describe it differently.” Theperceptions differ because they are viewingthe event from the perspectives of twodifferent mental models.

In SMS, the communication intrinsic to therisk assessment stage and the risk mitigationstage forces representatives of differentelements of an organization to analysehazards from single basic perspective: safety.In this way, the SMS process stimulates the

development of a shared mental model ofsafety within an organization

Moving forward

Wheels are made for movement. They aredynamic. They imply progress.

They can interact with other wheels, createmotion and keep turning. They are the meansof moving forward.

The three wheels of SMS work in coordinationwith each other to produce effectiveorganisational responses to hazards that areinherent and evolving in the aviationenvironment. The three wheels work togetherto collect hazard information, to analyse it inorder to ascertain risk and then to act upon thisassessment in mitigating unacceptable risk. Allcomponents of an SMS fit into one of thesethree primary functions: collect, analyse and act.For an effective SMS to continue operating,

management must create, encourage andsupport a reporting culture and a learningculture within its organization. Managementis the key. It is the driving wheel of the SMS,enabling the rest of the system to create riskmitigation measures.

Beyond the four safety management pillarsshown in Figure 1, ICAO Annex 6 and Annex14 identify the following five standards

requiring that an SMS:

■ Identifies safety hazards;

■ Ensures remedial action necessary tomaintain an acceptable level of safety;

■ Provides for continuous monitoring andregular assessment;

■ Aims to make continuous improvement;and,

■ Clearly defines lines of safetyaccountability, including directaccountability for safety for seniormanagement.

The wheels model integrates all these pillarsand standards into three basic functions. Ithas the advantage of making a cleardistinction between the collection activitiesand the analysis activities - that is, the hazardidentification stage and the risk analysis andassessment stage. And it emphasizes the roleof involved management as the driving wheelof SMS.

Note

1. Senge, Peter M . The Fifth Discipline: The Art & Practiceof the Learning Organization. New York:Doubleday/Currency, 2006.

Thomas Anthony is director of the Aviation

Safety and Security Program at the Viterbi

School of Engineering, University of Southern

California.

Reprinted with kind permission of

DHL’s–Safety Digest.

Figure 4

Management, the driving wheel

16 focus autumn 10

The Traffic Collision Avoidance System

(TCAS) has been introduced to reduce the

risks associated with mid-air collision threats.

Today this safety goal has globally been

reached.

However, surprise and stress created by TCASResolution Advisories may lead to non-optimumcrew response, resulting in a lack of propercommunication with ATC, undue aircraft altitudedeviations, injuries in the cabin and thejeopardizing of the aircraft's safety.

This article will review the current TCAS interfaceand procedures. It will then present the Auto PilotFlight Director (AP/FD) TCAS mode functiondeveloped by Airbus, and its numerousoperational benefits, which further enhance thepilot interfaces.

Current TCAS interface and procedures

Traffic Advisory (TA)

When the TCAS considers an intruder to be apotential threat, it generates a TA.

This advisory aims at alerting crews to theintruder’s position. TAs are indicated to the crewby:

■ An aural message, “Traffic, Traffic”

■ Specific amber cues on the NavigationDisplay, which highlight the intruder’sposition.

No specific action is expected from the crewfollowing a TA.

Resolution Advisory (RA)

If the TCAS considers an intruder to be a realcollision threat, it generates an RA.

In most cases, the TCAS will trigger a TrafficAdvisory before a Resolution Advisory.

RAs are indicated to the pilots by:

■ An aural message specifying the type ofvertical order (Climb, Descent, Monitor,Adjust...)

■ Specific red cues on the Navigation Displaymaterializing the intruder

■ Green / red zones on the Vertical SpeedIndicator (VSI) specifying the type ofmaneuver the pilot has to perform.

In order to fly the required maneuver, the pilotselects both the Auto Pilot (AP) and FlightDirectors (FD) to OFF, and adjusts the pitchattitude of the aircraft as required, so as to reachthe proper Vertical Speed (V/S). This unfamiliarflying technique increases the stress level alreadyinduced by the triggering of the ResolutionAdvisory.

AP/FD TCAS mode concept

Airbus has carried out an in-depth analysis of:

■ Needs expressed by airline pilots

■ Human factor studies linked to the TCASsystem

■ Recommenclations given by airworthinessauthorities.

This resulted in the development of a newconcept called AP/FD TCAS guidance, via theAuto Flight System (AFS), to support pilots flyingTCAS RAs.

The AP/FD TCAS mode is a vertical guidancemode built into the Auto Flight computer. Itcontrols the vertical speed (V/S) of the aircrafton a vertical speed target adapted to each RA,which is acquired from TCAS.

With the Auto Pilot engaged, it allows the pilot tofly the TCAS RA maneuvre automatically.

With the Auto Pilot disengaged, the pilot can flythe TCAS RA maneuvre manually, by followingthe TCAS Flight Director pitch bar guidance.

It has to be considered as an add-on to theexisting TCAS features (traffic on NavigationDisplay, aural alerts, vertical speed green / redzones materializing the RA on the Vertical SpeedIndicator).

In case of a TCAS RA, the AP/FD TCAS modeautomatically triggers the following:

■ If both AP and FDs are engaged, the AP/FDvertical mode reverts to TCAS mode, whichprovides the necessary guidance for the AutoPilot to automatically fly the TCASmaneuver.

■ If the AP is disengaged and FDs are engaged,the TCAS mode automatically engages asthe new FD guidance. The FD pitch barprovides an unambiguous order to the pilot,who simply has to centre the pitch bar, tobring the V/S of the aircraft on the VS target(green zone)

■ If both AP and FDs are OFF, the FD bars willautomatically reappear with TCAS modeguiding as above.

Note:At any time, the crew keeps the possibility to

disconnect the AP and the FDs, and is capable to

respond manually to a TCAS RA by flying

according to the "conventional" TCAS procedure

(i.e. flying the vertical speed out of the red band).

The AP/FD TCAS mode will behave differentlydepending on the kind of alert triggered by theTCAS:

■ In case of Traffic Advisory (TA), the AP/FDTCAS mode is automatically armed, in orderto bring crew awareness on the TCAS modeengagement if the TA turned into an RA.

■ In case of Corrective RA (“CLIMB”,“DESCEND”, “ADJUST”, etc aural alerts), theaircraft vertical speed is initially within thered VSI zone.The requirement is to fly out ofthis red zone to reach the boundary of thered / green V/S zone.

Airbus AP/FD TCAS Mode –a new step towards safety improvementsby Paule Botargues – Engineer, Automatic Flight Systems, Engineering

Figure 1: Navigation Display in case of TCAS TA

Audio: “Adjust V/S, Adjust”

Figure 2: TCAS RA HMI without AP/FDTCAS mode

Red area indicating the forbidden verticle speed domain

17focus autumn 10

Consequently:

- The TCAS longitudinal mode engages. It ensuresa vertical guidance to a vertical speed targetequal to the red / green boundary value (tominimize altitude deviation) + 200 ft/minwithin the green vertical speed zone, with apitch authority increased to 0.3g.

- All previously armed longitudinal modes areautomatically disarmed, except the altitudecapture mode (ALT*) in case of an "ADJUSTV/S" alert. This prevents an undue altitudeexcursion: indeed, in this type of RA, reaching Oft/min is always safe, as this value is neverwithin the red vertical speed zone. Therefore, ifthe altitude capture conditions are met, the

TCAS mode will safely allow to capture thetargeted flight level.

- The Auto Thrust engages in speed control mode(SPEED/MACH) to ensure a safe speed duringthe maneuver.

- The current engaged lateral mode remainsunchanged.

■ In case of Preventive RA (e.g. “MONITORV/S” aural alert), the aircraft vertical speed isinitially out of the red VSI zone. Therequirement is to maintain the currentvertical speed.

Consequently:

- The TCAS longitudinal mode engages tomaintain the current safe aircraft verticalspeed target.

- All previously armed longitudinal modes areautomatically disarmed, except the altitudecapture mode (ALT*). Indeed, as for an “ADJUSTVS” RA, levelling-off during a Preventive RA willalways maintain the vertical speed outside ofthe red area. So if the altitude captureconditions are met, the TCAS mode will allowto safely capture the targeted level, thuspreventing an undue altitude excursion.

- The Auto Thrust engages in speed control mode(SPEED/MACH) to ensure a safe speed duringthe maneuver.

- The current engaged lateral mode remainsunchanged.

■ Once Clear of Conflict, vertical navigation isresumed as follows:

- The AP/FD longitudinal mode reverts tothe"vertical speed" (V/S) mode, with a smoothvertical speed target towards the FCU targetaltitude. The ALT mode is armed to reach theFCU target altitude (ATC cleared altitude)

- If an altitude capture occurred in the course ofa TCAS RA event, once Clear of Conflict, theAP/FD longitudinal mode reverts to thealtitude capture (ALT*) or to the altitude hold(ALT) mode

- The lateral mode remains unchanged.

Audio: “Adjust V/S, Adjust”

Figure 3: PFD upon a Corrective TCAS RA with AP/FD TCAS mode

Figure 4: FMA and VSI during a TCAS sequence with AP/FD TCAS mode

18 focus autumn 10

Operational benefits

The operational benefits of the AP/FD TCASmode solution are numerous; the systemaddresses most of the concerns raised by in-lineexperience feedbacks:

■ It provides an unambiguous flying order tothe pilot

■ The flying order is adjusted to the severity ofthe RA; it thus reduces the risks ofoverreaction by the crew, minimizes thedeviations from trajectories initially clearedby ATC, and adapts the load factor of themaneuvre

■ The availability of the AP/FD TCAS modemakes it possible to define simpleprocedures for the aircrews, eliminating anydisruption in their flying technique: theprocedure is simply to monitor the AP, or tomanually fly the FD bars, when the TCASmode engages, while monitoring the VSI.

By reducing the crews' workload and stress level,the AP/FD TCAS mode should thereforesignificantly reduce:

■ Inappropriate reactions in case of ResolutionAdvisory (late, over or opposite reactions)

■ Misbehaviours when Clear of Conflict

■ Lack of adequate communications with ATC.

Note: For ATC controllers, the AP/FD TCAS mode is

totally transparent in terms of expected aircraft

reactions.

The AP/FD TCAS mode was demonstrated to alarge panel of pilots from various airlines, andwas perceived by them as a very simple andintuitive solution. It was deemed to be consistentwith the Airbus cockpit philosophy and AutoFlight system.

All agree that the AP/FD TCAS mode representsa safety improvement.

Certification schedule

The certification of the AP/FD TCAS modefunction is expected:

■ On the A380: by May 2009

■ On the A320 family:- with CFM engines, by end 2009- with IAE engines, by July 2010

■ On the A330/A340, depending on the aircrafttype, from the beginning of 2010 (A330PW/RR) to the end of 2011 (A340-500/600).

The certifcation dates for all required retrofitstandards are not yet frozen.

Reprinted with acknowledgement to Safety First

#7 February 2009

Figure 5: Safe altitude capture in TCAS mode

19focus autumn 10

by Captain John Bent – Article first published in The Journal for Civil Aviation Training

Airline technology has become more reliable and fail-safe, which should have driven down the accident rate. Instead thereseems to be an increasing rate of human failure, which is now more exposed in the man-machine system.

“Recent research shows pilot training is the best investment against catastrophic accident risk” – UK Civil Aviation Authority Study 2008

Assets and Lurking Threats –A view on Training and Safety

Since August 2005 there have been many

airline accidents where crew training

may have been a contributory factor. There

were nine to mid-2006, seven from mid-

2007 to mid-2008, 12 from mid 2008 to

mid-2009, and four since mid-2009.The five-

year data remain worrying and may be

difficult to explain by relating exclusively to

system expansion.

From a total of 37 airline accidents since August2005, 30 or more may be found to have hadhuman factors at their core. In conflict withadvances in airliner technology:

■ Training programs have generally declinedin relevance, volume and duration;

■ Rapid growth has lowered averageexperience levels;

■ Fewer military trained pilots are enteringairlines, diluting deep handling skills;

■ Motivation levels for a piloting career havechanged.

Following accident investigations, crew trainingoften features as an important corrective strategy.Sometimes the “blame and train” solution isapphed instead of a deeper look into systemic anddormant factors within an organisation, aimed atmore permanent solutions.

Perceptions

While current challenges are well understoodby training professionals, there may besignificant perception differences at executivelevel. The robustly regulated airlineenvironment is designed to protect the systemand largely does a good job. But aviationregulations cannot effectively keep up withthis rapidly advancing industry.

For example, from 1947 to 2006, when airlinesmoved from turboprops to jets, thus doublingspeed and complexity, airline pilot trainingrequirements hardly changed.

For airline executives under ever increasingpressures to reduce costs, regulators still providea perceived “security blanket”. Under costpressures, the volume and quality of trainingdelivered to crews may have shrunk toregulatory minimums, sometimes seen as

budgetary maximums - “We meet legalrequirements, don’t we?”

From the ICAO Safety Management Manual(SMM), AN/460 (2006): “Weak Managementmay see training as an expense rather than aninvestment in the future viability of theorganisation”.

A survey conducted by CAPA in 2009 asked airlinemanagements about their current concems andpriorities. Their answers were as follows (%respondent priorities): demand (76%), raisingcapital (62%), oil price volatility (58%), non fueloperating costs (40%), availability of skilledresourses (15%), technology implemental issue(11%), quality of training (2%).

While these responses are understandable from apurely business perspective, the lack of awarenessof the importance of training quality is oninterest from a safety management viewpoint.

Volatile

An identified need for training improvements,combined with an apparent lack of executiveawareness of this need, combine to produce avolatile mixture in the safety system. Thetraining pilots receive today will reside in theairline system as either a safety asset or lurkingthreat for decades to come. There is evidencefrom recent accident summaries that we areseeing the latter already. It is against thisbackdrop that ICAO has responded.

ICAO tasked a team of global experts todevelop the multi-crew pilots licence (MPL).Work began in 2000 when the industry wasrelatively slack. Contrary to popular comment,MPL was not designed for time or cost savings:the driver was relevance and quality. ICAO MPLDoc 9868 was eventually published in 2006. Abroad understanding of MPL in 2010 does notexist. Some comments on MPL follow:

■ Hours of real flight time: In simple termsof hours flown, the new MPL programprescribes minimum exposure for studentsto approximately 33% of traditional time inair. From this fact alone it is easy to dismissMPL without delving deeper. But flying hoursare no agent of effective learning withoutstructured relevance and quality instruction.

The total MPL training time in aircraft and

simulators does exceed traditional CPL programs.Simulation more than compensates for reducedflight hours and every hour of instruction isrelevant to eventual airline operations.

Beta trials have also shown how the aircraftflight training phase can be enhanced byrunning the aircraft training exercise threetimes: (a) in the related type simulator, (b) inthe aircraft, and (c) via video debrief.

■ Holistic integrated program: The MPLfootprint is integrated holistic training,ruthlessly dedicated to the airliner flightdeck, not on how to fly light singles, twins,and business jets Nevertheless fundamentalskills acquisition in Critical areas must betaught to competency - a training objectiveof great importance today:

■ Embedded training: Throughout MPLtraining crew resource management (CRM),threat and error management (TEM), andATC communications are ICAOrequirements.Although most if not all thesetraining objectives can be found in existingCPL programs, the content is often deliveredas stand-alone (box ticked) module, ratherthan a platform that remains continuouslyembedded in the syllabus.

■ Competencies: The concept of acheivingdefined competencies at every gate duringthe progam is educationally wellunderstood, but forms a significantchallenge in flight training. However, muchrecent work on task analysis andinstructiorlal design is providing bestpractice templates for MPL.

■ MPL Training aircraft: Modern trainingaircraft applied to MPL have many airline-

20 focus autumn 10

typical features by design, such as FADEC,EFIS, typed simulators, and cockpitobservation seats. Two students canobserve air exercises, and many moreground simulation.

■ MPL Simulation: Revised flight simulationtraining device (FSTD) categories will bepublished soon by ICAO as an update toDoc 9625. This expanded listing (1 -V11)results from an exhaustive program of R&Dconducted by the Royal AeronauticalSociety, which matched equipment totraining objectives. Augmenting thestandard Level D FSTD, ATC simulation(Using voice recognition system tells), isalso a requirement of MPL. As experiencedairline pilots know well, the challenge ofaccurate voice communications remains aserious safety system deficiency despitethe growing application of non-voicecommunication, and enforcement of ICAOEnglish standards at Level 4 and above.

■ Continuous enhancements: In the lastanalysis the ICAO MPL is only a bestpractice training framework, and it is up toresponsible training organisations to putappropriate “fat on the bone” But if this“fat” is not fully aligned with the MPLconcept, negative training and wastedprogram time may result.

For example, some training organisations andregulators have added the same traditionallight-twin and jet performance training to theMPL framework often found in traditional CPLtraining, possibly to provide a perceived sense ofsecurity with new program introduction, and toutilise assets which already exist. Performed inadditional non-airline aircraft, the MPL conceptis impaired, and the student may lose focus.Unnecessary cost is also added to the program.

An example of more appropriate fat on the boneis the current focus on recovery from unusualattitude (UA) training, which is a baserequirement of MPL. In response to increasing

dominance of loss of control (LOC) incidents,the industry is vigorously researching moreeffective ways to apply this training, which mustbecome a high impact component of MPL, bothin aircraft and simulators.

Suffered

MPL requires attitude change and has sufferedfrom some poor publicity in early inception.Some training organisations have marketedtheir new MPL program as “cheaper and faster”This objective was never included in the brief forthe six-year ICAO development team.

A freshly qualified general aviation pilot with aninstructors rating may have been initiallyacceptable for the CPL program decades ago,but for airline operations is not today. Manywere only instructing to build their hours foreventual airline employment, a distractingobjective, and most had no practical airlineexperience. New MPL instructor courses areemerging in recognition of the need to lift thebar of instruction to airline-relevant level.At thevery least, the instructor at the start of thestudent’s first MPL exercise must have a clearunderstanding of the ultimate purpose of thetraining: the airline pilot’s task.

MPL has already demonstrated competentgraduates in base training.The first Alteon trial of6 Chinese pilots generated positive reports fromthe flight inspectors who observed the basetraining on B737NGs in China. Competency wasachieved in six to 12 landings with pilots whohad a fraction of traditional aircraft flight time,and for whose experience level the CAAC wouldhave required 30 landings.

Many organisations are now training oroperating the MPL program and over 30 stateshave embodied MPL in their aviation legislation.Comments from IATA suggest that this licensewill eventually become the only route forcadets to enter airline operations.

In practice, there are signs that MPL may indeedbecome a slightly less expensive and shorter fullprocess abinitio-to-type rating training program.

Also emerging is the unintended consequenceof reduced aircraft fiight time in terms of lessexposure to program, and graduation delayscaused by poor weather and high density ATCactivity. Although this was never the objectiveof the development team it promises to be asignificant advantage in some flight traininglocations such as China.

Once type rated the new airiine pilot puts thelessons learnt into practice, but not all theselessons will be well remembered in the manyyears of operational service ahead. So recurrenttraining programs must evolve to match therelevance of the MPL to provide addedreinforcement and safety assurance. Thetraditional box-ticking approach requiringfrequent repetition of low probability failuresmust give way to the more broadly basedrecurrent training driven by topical need, asalready practiced by some operators.

MPL is leading the way towards the moreappropriately trained airline pilot, and forms thebasis for future recurrent training modules. Thebasic concepts of MPL are well understood bythe experienced airline instructor, who has beendelivering “work-around add-ons” for manyyears trying to strengthen the relevance ofpoorly prescribed recurrent training. While MPLsows better seeds, a follow-on process inrecurrent training is essential to sustain therequired knowledge skills and attitudes.

In parallel with new training inititives, the rawmaterial entering the commercial aviationsystem must be further optimised in selectionto ensure that future pilots are the motivated“right stuff” necessary for future safety levels.

A worthy objective, well recognised by trainingprofessionals, is to drive training programs fromsafety data. This is now becoming possible astechnology matures. Anticipating this, trainingprograms should not be set in stone but beredesigned to be maIieable.While founded on asound footprint built around task analysis,performance-measurement and competencystandards, programs should also be designed toaccommodate continuous change.

More radical action is needed to drive thetraining process to a higher level and reducehuman error in the airline system or we willprobably see more unpleasant safety outcomes.

About the Author

John Bent has been actively engaged in aviation trainingvia a 45 year piloting career spanning the RAF, GA, and 4airlines, and is currently leveraging his experience to helpestablish (with the Asia Development Assistance Board) anew MPL-based training academy in China, geared to thehighest contemporary standards realistically attainable.

Reprinted with acknowledgement to

CAT Magazine.

21focus autumn 10

Staying Sharp With Age

Alittle gray at the pilot's temples has

long been valued by operators and

passengers alike, since it signaled long

experience. But with the general economic

meltdown of 2008 that saw 401K plans

halved and pensions disappear, the gray will

become total as many business aviation

pilots who had planned on retirement in the

next five years remain in the cockpit for

quite a bit longer.

The community will benefit from that long andever more valuable piloting experience. But thedownside is an increasingly aging pilotpopulation that, statistically speaking, will sufferdeterioration in sensory, perceptual andcognitive properties, along with motor skills,alertness and endurance that are all importantto piloting excellence.

Researchers from Johns Hopkins Universityexamined accident records to determine ifaccident patterns changed according to theages of the pilots involved.The authors followed3,306 commuter air carrier and air taxi pilotswho were aged 45 to 54 years in 1987. Duringthe following 10 years, those pilotsaccumulated a total of 12.9 million flight hours,during which 66 of the pilots experiencedaviation crashes, yielding a rate of 5.1 crashesper million pilot flight hours. The authors foundthat the accident risk remained fairly stable asthe pilots aged from their late forties to theirlate fifties. They also found that flightexperience, as measured by total flight time,showed a significant protective effect againstthe risk of accident involvement. Pilots who had5,000 to 9,999 hours of total flight time had a57-percent lower risk of an accident than theirless-experienced counterparts. The positiveeffect of flight experience leveled off after totalflight time reached 10,000 hours.

So does experience offset or forestall some ofthe negative effects of aging? To a certainextent, yes ... and no. Researchers from theDepartment of Veterans Affairs and theStanford University School of Medicine foundthat expert knowledge may compensate forsome age-related declines in basic cognitiveand sensory-motor abilities. (Cognition is theimportant mental process of knowing,including aspects such as awareness,perception, reasoning and judgment.) They

studied 118 pilots aged 40 and 69 over athree-year period on items such as executingairtraffic controller communications, trafficavoidance, scanning cockpit instruments, andexecuting an approach to landing. Pilots withthe most experience had better flightsummary scores at the beginning of theexperiment and also showed less decline overtime. The study found a definite advantage ofprior experience and specialized expertise onolder pilots’ skilled cognitive performances.

One of the most common symptoms as wegrow older is the apparent increase inmemory lapses, a symptom that is not offsetby experience. The aviation environmentdemands recall and places a premium onmemory resources. We’re all forgetful onoccasion; however, with increasing age,forgetfulness becomes more frequent. TheUniversity of Michigan Health System’s

Memory and Aging tells us that after age 20,humans begin to lose brain cells and ourbodies begin to manufacture less of thechemicals needed for the brain cells tofunction.

Short-term memory is the information weremember temporarily, often for less than aminute and then it is easily replaced by newinformation. During inflight operations ourshort-term memory serves to recall a plethoraof rapid-fire directives, including often-complicated taxi clearances, new altitudesand radio frequencies, and sometimes evenmore in a single amended clearance.

And pilots are susceptible to declines in thisimportant ability. “Aging, Expertise andNarrative Processing,” a 1992 study, foundthat pilots exhibit age-related declines in therecall of aviation-related materials even

By Patrick R. Veillette, Ph.D.

CHANGES AMONG SENIOR PILOTS' MENTAL ATTRIBUTES CAN BE MANAGED AND SO THEIR EXPERTISE ENDURES.

22 focus autumn 10

though the older pilots had significantly moreexperience. “When Expertise Reduces AgeDifferences in Performance,” another study bythe same authors, found that older pilotsshowed more errors in the recall of ATCclearances.

Other leading memory problems in the agingperson include a decline in memory storage,requiring more time to learn new information,and the inability to pay attention to severalthings simultaneously. Obviously, theseproblems impact good piloting. There are yetother aspects of memory loss that have anegative effect on pilot performance. One istransience, which is forgetting informationwith the passage of time, and then, too,there’s absent-mindedness. Have you ever feltthe correct information is “on the tip of mytongue” but still unavailable? This is termed“blocking” and is another aspect of memorythat deteriorates with aging. Some of theother maladies include developing a falsememory, which is the unconscious reshapingof a memory because of personal beliefs ormood, and negative distortions of thememories of a traumatic event.

There are some steps a senior pilot can take toprevent memory loss. While genetics partiallygoverns our ability to remember, there arelifestyle changes that can help slow down thisaging effect. In its “Improving Memory:Understanding and Preventing Age-RelatedMemory Loss,” the Harvard Medical Schoolfound that leading a healthy lifestyleincluding physical health, minimal emotionalstress, limited consumption of alcohol, ahealthy diet, abstinence from smoking, and atleast six hours of quality of sleep each nightcould act synergistically to help reducememory loss. Physical activity can also reducememory loss by increasing , the flow of bloodto the brain and promoting the growth of newbrain cells. A minimum of 30 minutes ofexercise on most days is recommended. Ahealthy low-fat diet, including fruits andvegetables that contain antioxidants and fishand other foods that contain omega-3 fatsmay help nourish brain cells as well as limitthe buildup of cholesterol in the arteries.

Age-related memory loss, can also be checkedsomewhat by engaging in activities that,challenge the mind. When learning continues,the brain forms new connections between

nerve cells. This helps the brain storeinformation and retrieve information,regardless of age. The Mayo Clinic’s “How toKeep Your Mind Sharp: Prevention Action” hasan extensive list of such activities. Mentalchallenges include learning to play a musicalinstrument, learning a foreign language,changing careers, developing a new hobby,volunteering, staying informed about worldevents, reading and interacting with otherpeople.

The ability to learn new operating procedures,new aircraft systems and such definitelybecomes more difficult as a pilot ages. Recentresearch on learning has found that olderpeople tend to rely on their previousknowledge, and don't retain newly learnedmaterial in long-term memory as well. Thuswhen pilots set out to learn something newsuch as a different FMS, they’ll rely on theskills and general knowledge acquired over alonger period of time. These studies haveshown that older participants (60 to 70) wereslower and made more errors than youngerpilots, especially on tasks requiring moreinformation processing. One possible causemay lie in changes in cognitive processingassociated with increasing age.

“Age-Related Group and IndividualDifferences in Aircraft Pilot Cognition,” a jointstudy between Loyola Marymount Universityand UCLA’s Department of Psychiatry andBiobehavioral Sciences observed significantage-related differences in tests ofpsychomotor skills (mental events that havemotor consequences or vice versa),information processing speed, attention,executive ability, verbal and visual learning,and memory. The study confirms the findingsof other research on pilot cognition and aging.

This decline in a person’s cognition ears to begradual across the age range. There was noappreciable acceleration of cognitive loss withpilot age. Rather, a linear decline best describespilot cognition differences between ages 28and 62. While scientific protocol preventedauthors from extrapolating effects to pilotsmore senior, they did opine it is possible thatdecline in cognition acceles after 62.

Many of the tests in this study required timedperformance. The association of slowercompletion times with older pilots indicates,among other things, a fundamental slowing in

23focus autumn 10

psychomotor speed and cognition. Althoughsuch slowing may minimally impact pilotperformance in routine flight situations, itcould be a more significant factor in non-routine or emergency flight situations thatdemand mpt pilot analysis and decisionmaking.

The association of slower completion times

with older pilots indicates, among other things,

a fundamental slowing in psychomotor speed

and cognition.

One contributing factor to the cognitiveslowing observed in older pilots iscardiovascular status. In a study of 671 men,most of whom had been pilots or air trafficcontrollers or both, mild to moderate degreesof cardiovascular disease were associatedwith slower psychomotor performance. Muchof the typical downward trend in performancewith age is a reflection of cardiovasculardiseases rather than age, per se. Whilecardavascular-related incapacitation of a pilotresulting in an accident is rare, the vascularcondition presumably has a common andsubtle impact on pilot cognitive functioning.And a growing body of evidence suggests that"cardio" excercise can at least partiallymitigate age-related slowing across a varietyof psychological and physiological measuresand thus could potentially reduce the risk ofolder pilots in demanding, quick-response,inflight situations.

Fatigue is another important issue regardingthe performance and safety of the aging pilot.Mark Rosekind, former principal investigatorof human fatigue at the NASA Ames ResearchCenter, along with co-author Linda Connell,the director of the NASA ASRS system, foundthat with normal aging, nighttime sleepbecomes shorter, lighter and more disturbedwith more awakenings and transient arousals,and daytime sleepiness increases. Amongcrewmembers in the study of long-hauloperations, pilots aged 50 to 60 averaged 3.5times more sleep loss per day than those aged20 to 30. This correlated well with laboratorystudies that indicate greater variability amongolder persons in sleep and circadian rhythms.The NASA results, published in theaeromedical journal Aviation Space and

Environmental Medicine, noted that sleep lossof as little as one hour per night causes acumulative increase in physiologicalsleepiness during the day. Furthermore, the

magnitude of the sleep loss accumulated oversuccessive duty days can be sigmficant.

Rosekind and Connell concluded thatcountermeasures for circadian disruption andsleep loss may need to be adapted fordifferent age groups and/or circadian types.

Individuals do not age physiologically at thesame rate, and since variations in cognitivefunction between individuals increases greatlyas age increases it's extremely difficult topredict an individual's functional level. Thus a62-year-old pilot can be super sharp whereasone 18 years his junior may never be. Thisvariation made it extremely difficult foraeromedical researchers to argue for oragainst mandatory retirement ages. Someindividuals, because of genetics, health,exercise, diet and such, will continue toremain relatively sharp for their age group,whereas others were never that sharp in thefirst place or will decline at a more rapid rate.As to the question of when these aspects ofaging begin to degrade cockpit performanceenough to constitute a threat to flightoperations, the normal aeromedicalcertification provides no answer. Dr. AnthonyEvans, chief of ICAO's Aviation MedicineSection, opines, "As we don't have adequateassessment tools to accurately determinewho is in one group or another, a one-size-fits-all approach, based on average risk, is thefairest system. Without a retirement age, thelogical conclusion is that pilots will operateuntil they fail a medical or an operationalcheck. Without a cultural change, there willcontinue to be a reluctance (by medicalexaminers and check pilots) to fail anexperienced pilot, with his career (perhaps aglittering one) ending in failure." He notedthat, "Medical evaluations and simulatorchecks developed to determine whetherpilots have age-related problems would helpidentify those who are no longer fit for flight,but are far from being 100-percent accurate."

I watched a colleague go through a cognitiveevaluation after being accused of exhibitingsigns of "cognitive decline" and can attestthat it is not a process anyone wouldwelcome to maintain flying privileges. Beforeundergoing such an evaluation, consult anaeromedical advisor to assist in yourpreparation since one's pilot certificate couldbe riding on the results.There are some onlineand in-clinic preparatory courses available to

help individuals prepare, with the onlinecourses requiring self-discipline.

One of the attributes that the cognitivepsychologists will examine in making such anassessment is the subject's attention skillsincluding concentration, patience andrestrained compulsivity. Some of thecommon tests will require the pilot to learn anew sequence of letters on a computer, scanto find the correct letter and use workingmemory to store a letter's location. Thisallows clicking the letter to shift attentionquickly and move the mouse and click on thenext letter. The individual's speed andaccuracy are both graded. The tests may alsoexamine visuospatial skills by discerning linewidths, angles and completion of linedrawing. Others skills to be tested will be eye-hand coordination, deductive and inductivelogic, memory and communication.

Unfortunately in the evaluation of mycolleague two different psychologists cameup with contrary diagnoses. Because theindustry hasn't come up with a defined limitof what is acceptable performance vs.unacceptable, the aviation manager is left todecide if it is time to remove the pilot fromthe roster.

The issue of pilot aging is a tough one formanagers to handle, since they must weighexpertise and loyalty against slowed reactionand comprehension. By staying alert to thosechanges and proactive in crew pairing asuperior level of safety can be maintained.There inevitably does come a time when apilot should exit the cockpit for good, but theright time depends on the individual, not the calendar.

Reprinted with acknowledgement to

Business & Commercial Aviation

24 focus autumn 10

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Military Aviation AuthorityCapt. Al Clark RN (OPS)Wg.Cdr. Andrew G Tait (Airworthiness)

QinetiQFlt. Lt. Dominic Godwin

QinetiQ Eng.Phil Bevan

RAeSPeter Richards

RAeS Eng.Jim Rainbow

CO-OPTED ADVISERS

AAIBCapt. Margaret Dean

CAASean Parker - Grp. Safety ServicesGraham Rourke - AirworthinessSimon Williams - Flight Operations PolicyGarth Gray – Flight Operations

CHIRPPeter Tait

GASCoMike Jackson

Legal AdvisorEdward SpencerBarlow Lyde & Gilbert

NATSKaren Bolton

Royal Met. SocietyRob Seaman

UK Airprox BoardAir Cdre. Ian Dugmore

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