Beware mountain waves when flying over mountain ranges
On 6 November 2018, an aircraft in the cruise northbound over the Swiss Alps received an overspeed warning after encountering an unexpected wind velocity change but the crew did not follow the prescribed response procedure. This led initially to a climb above their cleared level and further inappropriate actions were then followed by PAN and MAYDAY declarations as control of the aircraft was briefly lost in a high speed descent to below their cleared level. The operator subsequently enhanced pilot training realism by providing it in a simulator configured for the aircraft variant operated and introduced ‘upset recovery training’.
Dated: March 2024
2024 Safety Forum – Agenda now available
The 2024 Safety Forum, which will be held at EUROCONTROL HQ, Brussels, 19-20 June 2024 is focused on Aviation Weather Resilience. Don’t miss this opportunity to join top experts and contribute to global thinking on this important topic. Registration for the event is still open.
Dated: March 2024
Mountain terrain escape routes
Overview
In commercial operations, it is highly desirable that the most direct route between two airports be flown whenever possible. Where that route involves the overflight of extensive areas of high terrain, it is critical that escape routes be developed and used in the event that an emergency requires that the aircraft must descend to an altitude that is below the Minimum Obstacle Clearance Altitude (MOCA).
Dated: March 2024
2024 Safety Forum – Registration now open
Registration is now open for the 2024 Safety Forum which will be held at EUROCONTROL HQ, Brussels, 19-20 June 2024. The theme of the Safety Forum is Aviation Weather Resilience
Posted: February 2024
The latest safety promotion animation from EUROCONTROL focuses on safety risks associated with freezing rain.
Dated: January 2024
Slightly overweight takeoff and delay to rotation leads to collision with tree
On 3 February 2022, an aircraft collided with a tree shortly after a daylight normal visibility takeoff from Puerto Carreño which resulted in engine stoppage although a subsequent restart was partially successful and a return to land was subsequently completed without further event. The collision was attributed to a combination of a slightly overweight takeoff and a slight delay in rotation which in the prevailing density altitude conditions prevented the rate of climb necessary to clear the obstacle. The context for the accident was assessed as a deficient operational safety culture at the company involved.
Dated: January 2024
Loss of situational awareness when using night vision goggles
On 22 April 2019, a helicopter was being positioned for the aeromedical evacuation the following day of a sick crewman on a fishing vessel when it was unintentionally flown into the sea at night. The three crew members were able to evacuate from the partially submerged aircraft before it sank. The accident was attributed to the single pilot’s loss of situational awareness due to loss of visual depth perception when using Night Vision Goggles. The relevant aircraft operator procedures and the applicable regulatory requirements were both found be inadequate relative to the operational risk which the flight involved.
Dated: January 2024
Multiple Line-ups (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on safety risks associated with multiple line-ups on the same runway.
Dated: December 2023
Safety Forum 2024
Call for Presentations now Open
The 2024 Safety Forum Organising Committee is inviting submissions to present as a speaker.
The theme of the Forum is Aviation Weather Resilience.
Dated: December 2023
Remote pilot killed by UAV after inappropriately set pitch trim switch went unnoticed
On 3 August 2009, control of a rotary UAV being operated by an agricultural cooperative for routine crop spraying in the south western part of South Korea was lost and the remote pilot was fatally injured when it then collided with him. The Investigation found that an inappropriately set pitch trim switch went unnoticed and the consequentially unexpected trajectory was not recognised and corrected. The context was assessed as inadequacies in the operator’s safety management arrangements and the content of the applicable UAV Operations Manual as well as lack of recurrent training for the operator’s qualified UAV remote pilots.
Dated: December 2023
Safety of Vertical Navigation on Final Approach Workshop
In October 2023, a workshop was held at EUROCONTROL HQ Brussels looking at how to maintain or improve the safety of PBN based final approach operations with barometric vertical guidance. Videos of the presentations and associated Q&A sessions are now available on SKYbrary.
Dated: November 2023
Safety Forum 2024
Call for Presentations now Open
The 2024 Safety Forum Organising Committee is inviting submissions to present as a speaker.
The theme of the Forum is Aviation Weather Resilience
Dated: November 2023
Runway incursion risk is heightened if vehicles accessing active runways are not on the same frequency as the aircraft
On 8 August 2019, an aircraft crew taking off from Comodoro Rivadavia in accordance with their clearance saw a vehicle crossing the runway ahead but based upon its distance away and speed judged that continued takeoff was safe and this then occurred. The vehicle was not authorised to cross the runway. The conflict risk was assessed as heightened by ATC use of a discrete frequency for communications with airside vehicles thereby reducing the situational awareness of both pilots and vehicle drivers. It was also noted that absence of vehicle read backs to ATC instructions was common and went unchallenged.
Dated: November 2023
Pre-flight external check
A Fight Crew Pre Flight External Check is part of the basis for the Captain’s Aircraft Acceptance which must be formally recorded in the Aircraft Technical Log prior to every flight departure. It is primarily, therefore, a general visual inspection of those aspects of fitness of the aircraft for flight which can be verified wholly or partly in that way. Incidentally it also provides an opportunity to observe the environment in which the aircraft is parked and may sometimes allow the observation of aspects of aircraft hold loading and routine aircraft servicing. It is entirely unrelated to the separate requirements for appropriately qualified aircraft maintenance technicians to carry out scheduled checks and inspections necessary for the Certificate of Release to Service to be signed and, in some cases, to remain valid for the specified duration.
Dated: November 2023
Operating an aircraft with a single HUD raises potential monitoring issues that need to be addressed
On 23 January 2020, an aircraft making a HUD-supported manual Cat 3a ILS approach to Lyon Saint-Exupéry in freezing fog conditions deviated from the required flight path localiser and reached a minimum of 265 feet AGL before a go around was initiated without initially being flown in accordance with standard procedures. The Captain involved was relatively new to type and had not previously flown such an approach in actual low visibility conditions. The Investigation was not able to determine exactly what contributed to the approach and initial go around being misflown but identified a number of possible contributors.
Dated: November 2023
Concurrent dual type rating on two very different era jet types can be problematic
On 27 October 2017, a missed approach was attempted by an aircraft in response to a predictive windshear alert on short final at Salzburg without ensuring sufficient engine thrust was set and when a stall warning followed, the correct recovery procedure was not initiated until over a minute had elapsed. Thereafter, following two holds, an approach and landing was completed without further event. The operator did not report the event in a timely or complete manner and it was therefore not possible to identify it as a Serious Incident requiring an independent investigation until almost three months after it had occurred.
Dated: October 2023
Tragic consequences of a deviation from standard working practices on TWR night shift
On 18 March 2019, an aircraft had just touched down at Subang when it collided with an unseen and apparently unlit vehicle destroying it and critically injuring its occupant. Significant left wing leading edge damage was then found. The destroyed vehicle and another one had been cleared onto the runway by ATC for routine runway maintenance purposes by a single controller who then failed to tell another colleague taking over that the runway was occupied. Use of single controller position manning was non-standard and airside vehicle and aircraft communications were routinely using different communication channels preventing situational awareness.
Dated: October 2023
Near collision on landing in thick fog following runway incursion
On 18 March 2016, at Cheongju in thick fog at night with visibility just above the minimum permitted for landing, an Airbus A319 began to enter the departure runway as a Boeing 737-800 was landing on it as cleared. Only when the 737 crew saw the other aircraft ahead when still at high speed were they able to initiate a lateral deviation and thereby avoid a collision by creating a 3 metre separation between their aircraft and the A319.The Investigation found that the A319 had exceeded the taxi clearance given by Ground Control but noted that this used poor phraseology.
Dated: October 2023
Shallow Fog: landing guidance for flight crews
Shallow fog, METAR code MIFG, is a form of radiation fog; a low-lying fog that does not obstruct horizontal visibility at a level 2 m (6 ft) or more above the surface of the earth.
Note that while horizontal visibility is not obstructed above 2 m, the fog layer may be significantly thicker than 2 m and that slant visibility — the visibility from air to ground from the aircraft while approaching the aerodrome — can be affected.
Dated: October 2023
Save the date – 2024 Safety Forum
The 11th Safety Forum is scheduled for June 19–20, 2024, at EUROCONTROL headquarters in Brussels. The Forum is organised by Flight Safety Foundation in partnership with EUROCONTROL and the European Regions Airline Association. The theme of the 2024 Safety Forum is “Aviation Weather Resilience”.
Dated: October 2023
Extra care is needed when planning and executing an approach to an uncontrolled aerodrome
On 28 April 2018, an aircraft came into close proximity with a light aircraft at the uncontrolled VFR-only aerodrome at Bremgarten during its tailwind approach to runway 23 made without contacting the designated Flight Information frequency as the other aircraft was on approach to runway-in-use 05 and in contact with Flight Information. The light aircraft pilot took avoiding action by turning north and climbing in order to avoid a collision. The crew had not prepared for the approach which was then unstabilised with late gear extension and multiple EGPWS ‘SINK RATE’ warnings annunciated.
Dated: September 2023
The importance of regular runway inspections
On 19 February 2021, an aircraft was found after a night arrival in Madrid to be missing the tread from one of its main gear tyres without the crew being aware. A search for debris on the landing runway and taxi-in route found none and the following morning, remains of the tread were seen by an aircraft departing the same runway at Palma de Mallorca. It was suspected from close inspection of the recovered debris that the tyre damage may have been initiated by undetected runway debris. The limitations of routine runway inspections even during daylight were noted.
Dated: September 2023
Taxiway Take-off (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on safety risks associated with take-off from taxiways.
Dated: September 2023
Bird Strike: Guidance for Controllers
This article provides guidance for controllers on what to expect from an aircraft experiencing the effects of a bird strike. It includes some of the considerations which will enable the controller, not only to provide as much support as possible to the aircraft concerned but, to also maintain the safety of other aircraft in the vicinity. It also speaks to concepts of bird monitoring and control and to service provision in general.
Dated: September 2023
Severe turbulence can be encountered in the vicinity of convective cloud – ensure the cabin crew are secure
On 31 July 2021, an aircraft descending through an area of convective activity, which was the subject of a current SIGMET, encountered some anticipated moderate turbulence whilst visually deviating around storm cells without reducing speed. When it appeared possible that the maximum speed may be exceeded because of turbulence, the autopilot was disconnected and a severe pitch up and then down immediately followed resulting in serious injuries to two of the four cabin crew and a passenger. This disconnection was contrary to the aircraft operator’s procedures and to the explicit training received by the pilot involved who was in command.
Dated: September 2023
A well handled and safe landing after a pitch trim failure that could have had tragic consequences
On 7 June 2021 an aircraft had just commenced its descent towards destination when both primary and secondary pitch trim systems failed resulting in excessive nose-down pitch control forces and an inoperative autopilot. The flight was completed without further event with the Pilot Flying using both hands on the control yoke to control pitch attitude manually. During the landing roll the nosewhweel steering system also failed. The pitch trim failure was attributed to probable jamming of the trim actuator due to water, possibly condensation, freezing within it. The steering system fault was attributed to a completely unrelated sensor failure.
Dated: August 2023
Heat domes and their effect on flight operations
Creation of heat domes
A heat dome is a mass of abnormally warm air that extends from the surface to well into the atmosphere. It is associated with high pressure both at the surface and aloft. Heat domes develop when the atmosphere traps hot air, as if bounded by a lid or cap. The upper air weather patterns are slow to move, referred to by meteorologists as an Omega block.
Dated: August 2023
Fuel exhaustion event – Both pilots didn’t notice that they had not refueled before departing
On 1 November 2021, a crew en-route to Fort Simpson realised that they had insufficient fuel on board to reach their intended destination and therefore decided to attempt a diversion to the nearest available airport at Fort Providence. As fuel available dwindled, one engine was shut down but after an inadvertent fuel tank selection, the initially intended diversion was no longer possible and a forced landing in a bog was successfully accomplished.
Dated: August 2023
2023 Safety Forum Conclusions
The Flight Safety Foundation has now published the report from the 2023 Safety Forum which focused on knowledge, skills and experience necessary to ensure safe operations in the future.
Dated: August 2023
Total electrical failure
On 23 February 2019, an aircraft which had recently departed Saanen was passing FL155 for cleared altitude FL240 when a total electrical failure occurred. On subsequently making contact with ATC on a hand-held personal radio, the pilot advised his intention to exit controlled airspace and complete an already commenced visual diversion to Lausanne which was then done. It was found that failure to use the prescribed normal checklists had resulted in an undetected electrical system selection error which had led to the successive discharge of both main batteries when corresponding alerts and warnings also went unnoticed.
Dated: August 2023
Planning for tropical storm events
Managing the threat of tropical storms
The weather associated with these storms is violent; torrential rain accompanied by thunder and lightning, severe turbulence within active convective cloud and frictional turbulence generated by strong winds. Static electricity may make navigation aids unreliable.
A Tropical Revolving Storm can cause significant damage to infrastructure and high loss of life. Areas affected by a significant storm can take months or even years to recover from the human, economic, and environmental damage. It is not uncommon for aircraft to be evacuated from an airport in advance of the landfall of a tropical storm. Damage and disruption to Airport and ATM infrastructure may render airports across a large area unusable, reducing the capacity and capability of ANSPs and closing, or reducing the capacity of airports.
Dated: July 2023
Critical importance of using correct QNH for RNP VNAV/LNAV approaches using baro-VNAV minima
On 23 May 2022, an aircraft came extremely close to collision with terrain as the crew commenced a go around after they did not obtain any visual reference during a RNP approach at Paris CDG for which they were using baro-VNAV reference to fly to VNAV/LNAV minima. The corresponding ILS was out of service. The Investigation has not yet completely established the context for the event but this has been confirmed to include the use of an incorrect QNH which resulted in the approach being continued significantly below the procedure MDA. Six Interim Safety Recommendations have been issued.
Dated: July 2023
Localiser signal distortion by snow accumulation
On 4 March 2019, an aircraft attempting to land off an ILS approach at Presque Isle in procedure-minima weather conditions flew an unsuccessful first approach and a second in similar conditions which ended in a crash landing abeam the intended landing runway substantially damaging the aircraft. The accident was attributed to the crew decision to continue below the applicable minima without acquiring the required visual reference and noted that the ILS localiser had not been aligned with the runway extended centreline and that a recent crew report of this fault had not been promptly passed to the same Operator.
Dated: June 2023
Point to the selected altitude when setting the PSA and obtain verbal concurrence that it is correct
On 6 January 2018, two aircraft inbound to Surabaya with similar estimated arrival times were cleared to hold at the same waypoint at FL100 and FL110 respectively but separation was lost when one continued below its cleared level of FL110. Proximity was limited to 1.9nm laterally and 600 feet vertically following correct responses to coordinated TCAS RAs. The Investigation found that all clearances / readbacks had been correct but that the crew had set FL100 instead of their FL110 clearance and attributed this to diminished performance due to the passive distraction of one of the pilots.
Dated: June 2023
Fuel – In-flight management (abnormal operations)
Abnormal operations include dispatch under MEL, fuel leak, inflight failures or planned flights in a non-standard configuration such as a gear down ferry flight. Under abnormal operations, fuel management becomes more difficult as the tools normally used for fuel monitoring, such as FMS predictions and flight plan comparison, may be invalid or misleading. In almost all circumstances involving abnormal operations, fuel is consumed at a rate which is significantly higher than normal. The principle threat during abnormal operations is fuel exhaustion.
The effect on fuel consumption of abnormal operations or configurations ranges from the subtle to the extreme.
Dated: June 2023
600 ft agl on approach, VMC and no runway in sight? Do you know where you are?
On 1 January 2020, an aircraft made an unstabilised night ILS approach to Frankfurt in good visual conditions, descending prematurely and coming within 668 feet of terrain when 6nm from the intended landing runway before climbing to position for another approach. A complete loss of situational awareness was attributed to a combination of waypoint input errors, inappropriate autoflight management and communication and cooperation deficiencies amongst the operating and augmenting flight crew on the flight deck who were all type-rated.
Dated: June 2023
Is your airport mitigating the taxiway takeoff risk?
On 6 September 2019, an aircraft began a night takeoff at Amsterdam on a parallel taxiway instead of the runway. A high speed rejected takeoff followed only on ATC instructions. The locally based and experienced crew lost situational awareness and failed to distinguish taxiway from runway lighting or recognise that the taxiway used was only half the width of the nearby runway. It was concluded that an airport commitment to prioritise mitigation of the taxiway takeoff risk based on recommendations made after a previous such event had not led to any action after pushback collisions became a higher priority.
Dated: May 2023
Vehicle on the runway at night
On 27 April 2021, the pilot of an aircraft commenced a night takeoff at Porto in good visibility without seeing a runway inspection vehicle heading in the opposite direction on the same runway. On querying sight of an opposite direction aircraft on a discrete frequency the driver was told to quickly vacate the runway. The aircraft became airborne 300 metres before reaching the vehicle and passed over and abeam it. Both vehicle and aircraft were following the controller’s clearances. The detailed Investigation confirmed controller error in a context of multiple systemic deficiencies in the delivery of runway operational safety at the airport.
Dated: May 2023
Controller response to aircraft brake problems
This article provides mainly guidance for tower/approach controllers on what to expect from an aircraft experiencing the effects of a brake problem and some of the considerations which will enable the controller, not only to provide as much support as possible to the aircraft concerned, but also maintain the safety of other aircraft at or in the vicinity of an aerodrome and of the ATC service provision in general.
Dated: May 2023
2023 Safety Forum: Knowledge, Skills and Experience for Safe Operations
Speakers from across the aviation industry will presenting their views on knowledge, skills and experience for safe operations at this year’s Safety Forum in Brussels, 7-8 June 2023. Book your place now…
Dated: April 2023
In-Flight Icing (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on the safety risks associated with in-flight icing.
Dated: April 2023
Final report into March 2019 crash of Ethiopian Airlines ET302 contains new safety recommendations
On 10 March 2019, the left stick shaker of an aircraft activated immediately after takeoff from Addis Ababa for no apparent reason and remained on. A succession of four pitch down maneuvers not initiated by the crew subsequently occurred and recovery from the final one was not achieved. Terrain impact followed a high speed dive six minutes after takeoff. The Investigation attributed the loss of control to an erroneous single source angle of attack input to the Maneuvering Characteristics Augmentation System (MCAS) from which, in the absence of an applicable non-normal procedure or appropriate training, recovery was not achievable.
Dated: April 2023
Unrecognised thrust asymmetry leads to loss of control
On 9 January 2021, an aircraft was climbing though 10,700 feet less than five minutes after departing Jakarta in daylight when it began to descend at an increasing rate from which no recovery occurred and 23 seconds later was destroyed by sea surface impact killing all 62 occupants. The Investigation concluded that the departure from controlled flight was unintentional and the result of the pilots’ inattention to their primary flight instruments when, during a turn with the autopilot engaged, an autothrottle malfunction created apparently unrecognised thrust asymmetry which culminated in a wing drop and a consequent loss of control.
Dated: March 2023
The Lifecycle of the Thunderstorm
Cumulonimbus clouds form when three conditions are met: there must be a deep layer of unstable air, the air must be warm and moist, and a trigger must cause the warm air to rise.
Dated: March 2023
Separation from unknown aircraft (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on safety risks associated with unknown aircraft.
Dated: March 2023
Selection of propellers to feather in flight leads to loss of control
On 15 January 2023, an aircraft positioning visually for an approach to Pokhara was observed to suddenly depart normal flight and impact terrain a few seconds later. All 71 occupants were killed and the aircraft destroyed by impact. A Preliminary Report published by the Accident Investigation Commission has indicated that a stall warning and subsequent loss of control was preceded by an apparently unintentional and subsequently undetected selection of both propellers to feather in response to a call for Flaps 30. The Training Captain in command was supervising the Captain flying during familiarisation training for the new Pokhara airport.
Dated: February 2023
Event highlighting need for crash resistant fuel systems
On 31 August 2019, all six occupants of a helicopter being used for a sightseeing flight in northern Norway were killed after control was suddenly lost and the helicopter impacted the terrain below where the wreckage was immediately consumed by an intense fire. The Investigation found no airworthiness issues which could have led to the accident and concluded that the loss of control had probably been due to servo transparency, a known limitation of the helicopter type. However, it was concluded that it was the absence of a crash-resistant fuel system which had led to the fatalities.
Dated: February 2023
Cabin fumes from non-fire sources
Fumes from various non-fire related sources may sometimes be experienced within the cabins of passenger aircraft.
Most modern passenger aircraft are equipped with pressurised, climate controlled, cabins. In spite of the aircraft designers’ intentions, unwanted fumes frequently permeate the interior of the aircraft. Open doors and hatches as well as certain on-board sources can introduce fumes to the cabin environment. However, the usual path of entry for fumes is via the aircraft pressurisation and air conditioning systems
Dated: February 2023
2023 Safety Forum – Registration is now open!
Registration is now open for the 2023 Safety Forum to be held in Brussels, 7-8 June. This year’s event will be dedicated to Knowledge, Skills, and Experience for Safe Operations and the Organising Committee is now inviting submissions to present as a speaker.
Dated: February 2023
HindSight 34 – Handling Surprises: Tales of the unexpected
The latest edition of EUROCONTROL’s acclaimed safety journal has now been published, featuring a diverse selection of articles from front-line staff, senior managers, and specialists in operations, human factors, safety, and resilience engineering.
Dated: February 2023
Event underlining the need for rapid disembarkation procedures
On 15 December 2019, an aircraft turned back to Sydney shortly after departure when a major hydraulic system leak was annunciated. The return was uneventful until engine shutdown after clearing the runway following which APU use for air conditioning was followed by a gradual build up of hydraulic haze and fumes which eventually prompted an emergency evacuation. The Investigation found that fluid leaking from ruptured rudder servo hose had entered the APU air intake. The resulting evacuation was found to have been somewhat disorganised with this being attributed mainly to a combination of inadequate cabin crew procedures and training.
Dated: February 2023
A reminder of the risks of flying in uncontrolled airspace
On 28 November 2020, in uncontrolled Class ‘G’ airspace, an airliner inbound to and in contact with Ballina and an en-route light aircraft tracking abeam Ballina both listening out on a shared Common Traffic Advisory Frequency (CTAF) did not recollect hearing potentially useful CTAF calls and converged on intersecting tracks with the light aircraft TCAS only selected to Mode ‘A’. The airliner received a TCAS TA but neither aircraft visually acquired the other until the minimum separation of 600 feet with no lateral separation occurred. Changes to the air traffic advisory radio service in the area were subsequently made.
Dated: February 2023
A visual approach demands good situational awareness at a busy airport
On 12 March 2019, an aircraft which had requested and been granted a visual approach to Wellington was instructed to follow another of the operator’s aircraft already in the circuit but instead turned in front of it after its crew misidentified an Airbus A320 on final as the other DHC8. The conflict was detected by ATC and advised and coordinated TCAS RAs then followed. The Investigation noted that whilst the inability of the second DHC8 crew to correctly identify the aircraft they should follow had been causal, procedures had delayed the ATC response to the automatically detected conflict.
Dated: January 2023
2023 Safety Forum – call for papers
The Organising Committee for the 2023 Safety Forum is now inviting submissions to present as a speaker. This year’s event will be dedicated to Knowledge, Skills, and Experience for Safe Operations.
Dated: January 2023
No readback? Then tell them again
On 13 February 2019, an aircraft departing Amsterdam was given a non-standard long pushback by ATC in order to facilitate the use of its stand by an incoming flight. When a another aircraft was subsequently given a normal pushback by a single tug driver working alone who was unaware of the abnormal position of the first aircraft and could not see it before or during his pushback, a collision followed. The Investigation concluded that the relevant airport safety management systems were systemically deficient and noted that this had only been partially rectified in the three years since the accident.
Dated: January 2023
Sting Jet
A Sting Jet is a meteorological phenomenon, a type of low-level jet stream, associated with some rapidly developing mid-latitude storms. The term sting jet describes the storm’s most damaging winds, which sometimes reach speeds of more than 100 kts. The name refers to the shape the cloud pattern takes, as shown on satellite imagery. As it wraps around the centre of an area of low pressure, it takes on the appearance of a scorpion’s tail. Although the strongest winds occur for only a short period of time in a very small area, perhaps only 30 miles across, they can cause significant damage and risk to life.
Dated: January 2023
A lack of situational awareness with near tragic consequences
On 2 May 2015, an aircraft deviating very significantly north of its normal route from Malabo to Douala at night because of convective weather had just turned towards Douala very close to 13,202 feet high Mount Cameroon whilst descending through 5000 feet, when an EGPWS TERRAIN AHEAD alert and ‘PULL UP’ warning prompted an 8,000 foot climb which passed within 2,100 feet of terrain when close to and still below the summit. The Investigation attributed the dangerous event primarily to a absence of the augmented crew’s situational awareness and the operator’s failure to risk-assess the route involved.
Dated: December 2022
Downburst
The latest safety promotion animation from EUROCONTROL focuses on safety risks associated with downbursts.
Dated: December 2022
A well handled response to an unusual mechanical engine failure
On 5 August 2019, an aircraft crew declared a MAYDAY immediately after clearing the landing runway at Valencia when a hold smoke warning was annunciated. An emergency evacuation was completed without injuries. This warning followed “white smoke” from the air conditioning system entering both the passenger cabin and flight deck in the four minutes before landing which had prompted the pilots to don oxygen masks. The Investigation found the white smoke was the direct consequence of an oil leak from the right engine as a result of the misalignment and breakage of a bearing and its associated hydraulic seal.
Dated: December 2022
Radiation Fog
Formation of Radiation Fog
On a cloudless night, especially within a high-pressure system, the land surface loses heat to the atmosphere by radiation and cools. Moist air in contact with cooling surface also cools and when the temperature falls below the dew point for that air, fog forms. This type of fog is known as radiation fog. Initially it may be mist that forms and then thickens into fog as the temperature drops and more water vapor condenses into water droplets in the air. Air does not conduct heat very well so in still air conditions fog may not form at all and a layer of dew or frost will form on the surface instead. However, if there is a light wind of around 5 kts, then this will mix the air in contact with the surface and the layer of fog will be thicker. With stronger winds, the fog may lift to form layers of Stratus.
Dated: December 2022
Reduced TORA (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on safety risks associated with reduced take off available as a result of work in progress or intersection take off.
Dated: December 2022
Downburst (SKYclip)
Dated: November 2022
Ground and Tower practices need to be safely integrated
On 14 November 2019, an aircraft was instructed to stop its takeoff whilst still at low speed when the controller saw snow clearance vehicles entering the runway ahead. The Investigation found that the vehicle group had been cleared to enter the active runway by the ground controller without any coordination with the tower controller and that only the monitoring of surface movement radar and the external environment visually had removed the risk of a more serious consequence arising from the incursion. The airport operator’s snow response plan was not specific to their airport and consequently of limited practical value.
Dated: November 2022
High speed auto ILS glideslope join from above, with a tailwind…
On 20 December 2019, an aircraft making a tailwind ILS approach to Toulon-Hyères with the autopilot engaged and expecting to intercept the glideslope from above had not done so when reaching the pre-selected altitude and after levelling off, it then rapidly entered a steep climb as it captured the glideslope false upper lobe and the automated stall protection system was activated. Not fully following the recovery procedure caused a second stall protection activation before a sustained recovery was achieved. The Investigation noted Captain’s relative inexperience in that rank and a First Officer’s inexperience on type.
Dated: November 2022
Carbon Monoxide Poisoning
Carbon Monoxide (CO) is a highly poisonous gas and exposure can quickly lead to short-term symptoms, long-term health issues, and even death. Prolonged and repeat exposures at lower concentrations can lead to the same conclusions.
Dated: November 2022
Pilot’s Best Practices for the Prevention of Runway Excursions
Summarising all recommendations and guidance for pilots in the Global Action Plan on the Prevention of Runway Excursions (GAPPRE), this best practice document can be implemented by flight crew in their daily routines.
Dated: November 2022
Do your SOPs require a formal cross-check of the set selected altitude?
On 29 February 2020, an aircraft inbound to Delhi lost separation against an outbound A320 from Delhi on a reciprocal track and the conflict was resolved by TCAS RA activation. The Investigation found that the inbound aircraft had correctly read back its descent clearance but then set a different selected altitude. Air Traffic Control had not reacted to the annunciated conflict alert and was unable to resolve it when the corresponding warning followed, and it was noted that convective weather meant most aircraft were requesting deviations from their standard routes which was leading to abnormally complex workload.
Dated: October 2022
When narrow body aircraft are lightly loaded, should the speed cross check be at 80kts rather than 100kts?
On 9 June 2021, an aircraft Captain performing a relatively light weight and therefore rapid-acceleration takeoff from London Heathrow recognised as the standard 100 knot call was imminent that he had no speed indication so announced and performed a high speed rejected takeoff. Subsequent maintenance inspection found that the left pitot mast was blocked by the nest of a seasonally active solitary flying insect, noting that the aircraft had previously been parked for 24 hours on a non-terminal stand. Similar events, including another rejected takeoff, then followed and a comprehensive combined Investigation found all were of similar origin.
Dated: October 2022
A circling approach requires a blend of visual navigation and aircraft control
On 7 September 2019, the crew of an aircraft completed a circling approach to runway 18R at Busan by making their final approach to and a landing on runway 18L contrary to their clearance. The Investigation found that during the turn onto final approach, the Captain flying the approach had not appropriately balanced aircraft control by reference to flight instruments with the essential visual reference despite familiarity with both the aircraft and the procedure involved. It was concluded that the monitoring of runway alignment provided by the relatively low experienced first officer had been inadequate and was considered indicative of insufficient CRM between the two pilots.
Dated: October 2022
Flight in Mountainous Terrain
For the purposes of this article, Flight in Mountainous Terrain is considered to be planned VFR flight in mountainous areas following the contours of the earth at altitudes below the height of the surrounding peaks.
Dated: October 2022
Separation of arrival and departure aircraft during circling approach (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on safety risks associated with separation of arrival and departure aircraft when circling approaches are in progress.
Dated: October 2022
Your aeromedical examiner cannot provide an accurate assessment of your health if you conceal self medication
On 27 September 2017, an aircraft Captain left the flight deck to retrieve their crew meal about 40 minutes after departing Abu Dhabi but whilst doing so he collapsed unconscious in the galley and despite assistance subsequently died. A MAYDAY was declared and a diversion to Kuwait successfully completed by the remaining pilot. The Investigation determined that the cause of death was cardiopulmonary system collapse due to a stenosis in the coronary artery. It was noted that the Captain’s medical condition had been partially concealed from detection because of his unapproved use of potentially significant self-medication.
Dated: October 2022
Bird Strike (SKYclip)
Dated: September 2022
Ground and Tower practices need to be safely integrated
On 14 November 2019, an aircraft was instructed to stop its takeoff whilst still at low speed when the controller saw snow clearance vehicles entering the runway ahead. The Investigation found that the vehicle group had been cleared to enter the active runway by the ground controller without any coordination with the tower controller and that only the monitoring of surface movement radar and the external environment visually had removed the risk of a more serious consequence arising from the incursion. The airport operator’s snow response plan was not specific to their airport and consequently of limited practical value.
Dated: September 2022
Landing without Clearance – Precursors and Defences
This article gives an in-depth description of the most common factors which may lead to landing without ATC clearance occurrences in line with identified patterns. It also summarizes the most effective barriers against such occurrences.
Dated: September 2022
First ever all engines out event after encounter with volcanic ash that is still relevant today
On 24 June 1982, an aircraft had just passed Jakarta at FL370 in night VMC when it unknowingly entered an ash cloud from a recently begun new eruption of nearby Mount Galunggung which the crew were unaware of. All engines failed in quick succession and a MAYDAY was declared. Involuntary descent began and a provisional diversion back to Jakarta, which would necessitate successful engine restarts to clear mountainous terrain en-route was commenced. Once clear of cloud with three successful engine restarts and level at FL120, the diversion plan was confirmed and completed with a visual approach from the overhead.
Dated: August 2022
Sleep deprevation can have unexpected physiological consequences
On 29 October 2019, an aircraft was descending towards its destination, Kaohsiung, when the First Officer suddenly lost consciousness without warning. The Captain declared a MAYDAY and with cabin crew assistance, he was secured clear of the flight controls and given oxygen which appeared beneficial. He was then removed to the passenger cabin where a doctor recommended continuing oxygen treatment. On arrival, he had fully regained consciousness. Medical examination and tests both on arrival and subsequently were unable to identify a cause although a context of cumulative fatigue was considered likely after three consecutive nights of inadequate sleep.
Dated August 2022
An example of when it is safer to land on an occupied runway than go around
“On 11 September 2019, an aircraft landed at night on Runway 13 at Malaga only 520 meters behind a departing aircraft which was about to become airborne from the same runway. The Investigation noted the relatively low level of aircraft movements at the time, that both aircraft had complied with their respective clearances and that the landing aircraft crew had judged it safer to land than to commence a late go around. The conflict was attributed to non-compliance with the regulatory separation minima and deficient planning and decision making by the controller.”
Dated: August 2022
Cross-checking Process
The human mind is fallible and error can occur for many reasons, for example, from a misheard message, from memory slip, or from incorrect appreciation of the situation.
Error is particularly likely in certain circumstances, especially when there is pressure to complete a task quickly (e.g. to expedite departure or during an emergency or abnormal situation), but may also occur in normal everyday situations.
Error in aviation can have severe consequences and the cross-checking process is used wherever possible to eliminate error.
Dated: August 2022
Inappropriate directional control inputs after touchdown lead to runway excursion
On 21 November 2019, with variable cross/tailwind components prevailing, an aircraft went around from its first ILS approach to Odesa before successfully touching down from its second. It then initially veered left off the runway before regaining it after around 550 meters with two of the three landing gear legs collapsed. An emergency evacuation followed once stopped. The Investigation attributed the excursion to inappropriate directional control inputs just before but especially after touchdown, particularly a large and rapid nosewheel steering input at 130 knots which made a skid inevitable. Impact damage was also caused to runway and taxiway lighting.
Dated: August 2022
Safety risks of using baro-VNAV reference to fly to VNAV/LNAV minima
On 23 May 2022, an aircraft came extremely close to collision with terrain as the crew commenced a go around after they did not obtain any visual reference during a RNP approach at Paris CDG for which they were using baro-VNAV reference to fly to VNAV/LNAV minima. The corresponding ILS was out of service. The Investigation has not yet completely established the context for the event but this has been confirmed to include the use of an incorrect QNH which resulted in the approach being continued significantly below the procedure MDA. Six Interim Safety Recommendations have been issued.
Dated: July 2022
Chartering an aircraft? Does the operator have an Air Operator Certificate?
On 8 February 2019, an aircraft overran the landing runway at Courchevel and collided with a mound of snow which caused significant damage to the aircraft but only one minor injury to a passenger. The Investigation noted the Captain’s low level of experience but the investigation effort was primarily focused on the risk which had resulted from a commercial air transport flight being conducted without complying with the appropriate regulatory requirements for such flights and without either the passengers involved or the State Safety Regulator being aware of this.
Dated: July 2022
Single-pilot resource management (SRM)
This article explains the basic idea of single-pilot resource management (SRM) and a subject treated as a subsidiary concept, aeronautical decision making (ADM). In 2020, both are considered essential to effective safety enhancements (SEs) in general aviation. Some aviation professionals colloquially refer to SRM as single-pilot CRM because of its historical connection to crew resource management used by airline flight crews.
Dated: July 2022
The Safety Forum Summary
The Safety Forum report and proceedings are published.
The summary report brings together information about sustainability related aviation safety pressures along with resilience capabilities to counter balance those pressures.
This specifically safety related perspective on aviation sustainability is the unique value of the 2022 Safety Forum.
Dated: July 2022
Brake cooling times after a high speed RTO should be calculated conservatively
On 15 August 2019, an aircraft made a high speed rejected takeoff because of increasing noise from an unsecured flight deck sliding window. Whilst subsequently taxiing during the calculated brake cooling time, fire broke out in the left main gear bay and the aircraft was stopped and an emergency evacuation was carried out whilst the fire was being successfully extinguished. The Investigation did not identify any specific cause for the brake unit fires but noted that the reject had been called when 3 knots above V1 and that the maximum speed subsequently reached had been 14 knots above it.
Dated: July 2022
Are your pilots formally trained in how to fly a visual approach?
On 22 August 2019, an aircraft positioning visually from downwind after accepting clearance to make an approach to and landing on runway 03L at Hyakuri instead lined up on temporarily closed runway 03R and did not commence a go around until around 100 feet agl after seeing a vehicle on the runway and the painted runway threshold identification. The Investigation concluded that the event was solely attributable to the individually poor performance of both the Captain and the First Officer, the latter in respect of a failure to monitor and correct the runway identification error made by the Captain
Dated: July 2022
Ice kills
On 13 December 2017, control of an aircraft was lost just after it became airborne at night from Fond-du-Lac and it was destroyed by the subsequent terrain impact. Ten occupants sustained serious injuries from which one later died and all others sustained minor injuries. The Investigation found that the accident was primarily attributable to pre-takeoff ice contamination of the airframe with an inappropriate pilot response then preventing an achievable recovery. It was found that significant airframe ice accretion had gone undetected during an inadequate pre-flight inspection and that there was a more widespread failure to recognise airframe icing risk.
Dated: June 2022
Indicated airspeed lower than expected for the power setting? What is causing the extra drag?
On 25 March 2018, the main landing gear bay door weighing 15 kg detached from an aircraft shortly after a night descent had begun but this was unknown until the flight arrived at Aurillac. The Investigation found that the root cause of the detachment was a loose securing nut which had triggered a sequence of secondary failures within a single flight which culminated in the release of the door. It was concluded that the event highlighted specific and systemic weakness in relevant airworthiness documentation and practice in relation to the lost door and the use of fasteners on this aircraft type generally.
Dated: June 2022
Wildfires: Flight planning considerations
Wildfires can have a significant impact on aviation operations, both in the areas directly affected by the fire(s), and in the surrounding region.
Flight Planning Considerations
In addition to the myriad of factors considered during normal pre-flight planning, special consideration should be given to the following:
• Visibility – Flight in accordance with Visual Flight Rules (VFR) may not be possible.
• Airspace Restrictions -Temporary flight restrictions (TFR) or other methods of airspace control may be put in place to protect firefighting operations…………..
Dated: June 2022
The inherent risk in early communication handover procedures
On 16 July 2019, an aircraft inbound to Malaga and another inbound to Seville and under area radar control lost separation after the Malaga-bound aircraft was unexpectedly given radar headings to extend its destination track miles, after early handover to a control sector which it had not yet entered. With no time to achieve resolution, the two aircraft, both descending, came within 1.3 nm of each other at the same level. The Investigation attributed the conflict to an overly-permissive Letter of Agreement between Seville Centre and Malaga Approach and recommended that it be revised to improve risk management.
Dated: June 2022
MSAW alerts triggered by the incorrect altimeter setting were not advised to the flight.
On 6 June 2020, an aircraft on approach at Abu Dhabi began a low go around from an RNAV(RNP) approach when it became obvious to the crew that the aircraft was far lower than it should have been but were unaware why this occurred until an ATC query led them to recognise that the wrong QNH had been set with recognition of the excessively low altitude delayed by haze limiting the PAPI range. The Investigation found that advice of MSAW activations which would have enabled the flight crew to recognise their error were not advised to them.
Dated: May 2022
A classic example of plan continuation bias…
On 7 August 2020, an aircraft making its second attempt to land at Calicut off a night ILS approach with a significant tailwind component became unstabilised and touched down approximately half way down the 2,700 metre-long wet table top runway and departed the end of it at 85 knots before continuing through the RESA and a fence and then dropping sharply onto a road. This caused the fuselage to separate into three pieces with 97 of the 190 occupants including both pilots being fatally or seriously injured and 34 others sustaining minor injuries.
Dated: May 2022
An aircraft without transponder – Guidance for Controllers
This article describes the best practices to be used by air traffic controllers to maximize the chance that an aircraft without transponder is detected as soon as possible and to mitigate its impact on the provision of air traffic service.
Dated: May 2022
Pilots should make themselves aware of the terrain around an unfamiliar departure airport
On 24 September 2017, an aircraft, which had just made an easterly takeoff from Hong Kong on a moonless night but in good visibility, deviated from its correctly acknowledged SID clearance towards steep terrain and a resultant EGPWS PULL UP Warning was immediately actioned resulting in a terrain clearance of approximately 670 feet. The Investigation found that the SID track deviation was caused by the inadvertently incorrect input of a SID clearance which was supposed to be issued only to locally-based operators whereas the flight concerned was being operated by a foreign operator on behalf of a locally-based one.
Dated: May 2022
A well handled uncontained engine failure
On 20 February 2021, a aircraft was climbing through 12,500 feet after takeoff from Denver when there was a sudden uncontained failure of the right engine. The associated fire did not fully extinguish in response to the prescribed non-normal procedure and on completion of a return to land, it was fully extinguished before the aircraft could be towed in for passenger disembarkation. The Investigation has already established that the failure originated in a single fan blade within which internal fatigue cracking had been initiated.
Dated: April 2022
9th Annual Safety Forum – Brussels, June 30 – July 1, 2022
In supporting efforts to become more sustainable, we must not lose sight of the potential for unintended consequences for safety and resilience when procedures and technology change. Registration is now open for this year’s Safety Forum which will focus on safe sustainability. The in-person conference is scheduled for 30 June and 1 July 2022 and will be held at the EUROCONTROL headquarters in Brussels, Belgium.
Dated: April 2022
End of the runway getting closer than usual? – set TOGA thrust
On 3 March 2021, an aircraft departing Lisbon only just became airborne before the end of runway 21 and was likely to have overrun the runway in the event of a high speed rejected takeoff. After a significant reporting delay, the Investigation established that both pilots had calculated takeoff performance using the full runway length and then performed takeoff from an intersection after failing to identify their error before FMS entry or increase thrust to TOGA as the runway end was evidently close. This was the aircraft operator’s third almost identical event at Lisbon in less than five months.
Dated: April 2022
Engine failure in the cruise
Pilot response to engine failure in the cruise
Whilst an engine failure in cruise is an uncommon occurrence, it can, and does, happen. The event, in itself, is unlikely to lead to loss of control unless the emergency is mishandled by the flight crew. Pilot prioritisation should follow the mantra Aviate, Navigate, Communicate.
Dated: April 2022
Do you know how to control direction at speeds below Vmcg?
On 23 October 2020, an aircraft taking off from Brisbane became difficult to keep on the centreline as speed increased and takeoff was rejected from a low speed. It remained on the runway and messages indicating a malfunctioning right engine were then seen. The Investigation found that one engine had surged as thrust was applied due to damage caused by a screwdriver tip inadvertently left in the engine during routine maintenance and that the pilot flying had used the rudder when attempting to maintain directional control during the reject despite its known ineffectiveness for this purpose at low speeds.
Dated: March 2022
Action plan for the prevention of airspace infringements
EUROCONTROL has published a new version 2.0 of the Action plan for the prevention of Airspace Infringements.
Dated: March 2022
Near collision on taxi in after failure to comply with taxi clearance
On 3 February 2019, two aircraft which had just landed on adjacent parallel runways almost collided during their taxi in after one failed to give way to the other at an intersection as instructed, causing the other to perform an emergency stop, which was achieved just in time to avoid a collision. Whilst not attributing direct cause to other than the crew of the aircraft, which continued high speed taxiing as the intersection was approached, the investigation identified a range of factors which had facilitated the error made.
Dated: March 2022
Civil-Military Interaction in ATM
Chicago Convention
Since the Chicago Convention explicitly states that it does not apply to state aircraft, the very presence of military aircraft means that there is a high chance that different (from ICAO) rules and procedures may be followed by such aircraft.
Dated: March 2022
Cognitive incapacitation and overload in a go-around situation
On 4 February 2020, an aircraft initiated a go around from its destination approach at 1,400 feet AAL following a predictive windshear alert unsupported by the prevailing environmental conditions but the First Officer mishandled it and the stop altitude was first exceeded and then flown though again in a descent before control as instructed was finally regained four minutes later. Conflict with another aircraft occurred during this period. The Investigation concluded the underlying cause of the upset was a lack of awareness of autopilot status by the First Officer followed by a significant delay before the Captain took over control.
Dated: February 2022
Investigation highlights importance of assessment of airworthiness of UAVs
On 4 July 2019, the operator of a UAV lost control of it and it climbed to 8000 feet into controlled airspace at a designated holding pattern for London Gatwick before falling at 5000 fpm and impacting the ground close to housing. The Investigation was unable to establish the cause of the loss of control but noted that the system to immediately terminate a flight in such circumstances had also failed, thereby compromising public safety. The approval for operation of the UAV was found to have been poorly performed and lacking any assessment of the airworthiness of the UAS.
Dated: February 2022
ACAS II Bulletin – “Near collision over Yaizu”
Twenty-one years ago, on 31 January 2001, near the city of Yaizu in Japan a midair collision between two aircraft was narrowly avoided. Although over two decades have passed since this event, the lessons learned from this accident remain valid.
The most important one – follow the RA.
Assessment of Pilot Responses to RA: IATA/EUROCONTROL Guidance Material
IATA and EUROCONTROL have jointly produced guidance on the assessment of pilot compliance to Traffic alert and Collision Avoidance System (TCAS) RAs using Flight Data Monitoring (FDM).
Dated: February 2022
HindSight 33 – Digitalisation and Human Performance
The latest edition of EUROCONTROL’s aclaimed safety magazine focuses on digitalisation and human performance.
Dated: February 2022
Failure to identify and address an airworthiness risk leads to avoidable fatal accident
On 31 December 2017, an aircraft being maneuvered at low level over Jerusalem Bay shortly after takeoff was observed to enter a steeply banked turn from which it appeared to depart controlled flight and impact the water surface below almost vertically. The Investigation concluded that the aircraft had stalled despite the exemplary proficiency record of the pilot and that in the absence of any other plausible explanation found that the loss of control was likely to have been the effect of an elevated exposure to carbon monoxide found during postmortem toxicology testing.
Dated: February 2022
TCAS RA not followed (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on safety risks associated with not following the TCAS RA.
Dated: January 2022
Entering convective weather? Put the seat belt signs on
On 15 August 2019, an aircraft descending towards destination Beijing received ATC approval for convective weather avoidance but this was then modified with both a new track requirement and a request to descend which diminished its effectiveness. A very brief encounter with violent turbulence followed but as the seat belt signs had not been proactively switched on, the cabin was not secured and two passengers sustained serious injuries and two cabin crew sustained minor injuries. The Investigation noted that weather deviation requests could usefully be accompanied by an indication of how long they were required for.
Dated: January 2022
Weather closing in? Land or turn back
On 26 January 2020, a helicopter on a night VFR passenger flight was observed to emerge from low cloud shortly after ATC had lost contact with it following a report that it was climbing to 4000 feet. It had then almost immediately crashed into terrain, destroying the aircraft and killing all its occupants. The Investigation found that the helicopter had been serviceable and that the pilot had lost control after intentionally continuing into IMC and then attempting to climb which resulted in spatial disorientation. The aircraft operator’s inadequate risk management was found to have contributed to the accident outcome.
Dated: January 2022
High Level Ice Crystal Icing : Effects on Engines
For a number of years, it has been apparent that the detail design of some gas turbine engines has made them vulnerable to the risk of sudden loss of engine thrust if high densities of small ice crystals are encountered in very cold air. This Ice Crystal Icing (ICI) hazard has not usually resulted in complete engine failure (although there have been such instances) but more than one engine may be affected simultaneously. The risk occurs outside of flight conditions which are currently defined by the regulatory authorities as “icing conditions” and therefore defined as such in the applicable Aircraft Flight Manual (AFM). In the light of evidence found during investigations of in-service occurrences of the phenomenon by engine manufacturers and the relative success of design modifications, which have resolved problems with particular engine types, the main regulatory agencies have been considering how to respond to this situation for a number of years now and have, at various points, issued interim operational guidance.
Dated: December 2021
Changing departure runway while taxiing
The latest safety promotion animation from EUROCONTROL focuses on safety risks associated with a change to the departure runway while an aircraft is taxiing out.
Dated: December 2021
Failed speed crosscheck event on take off
On 7 February 2018, an aircraft experienced an airspeed mismatch during takeoff on a post maintenance positioning flight but having identified the faulty system by reference to the standby instrumentation, the intended flight was completed without further event. After the recorded defect was then signed off as “no fault found” after a failure to follow the applicable fault-finding procedure, the same happened on the next (revenue) flight but with an air turnback made.
Dated: December 2021
Unappreciated consequences of dual control inputs…
On 20 February 2014, the mishandling of an aircraft during descent to Sydney, involving opposite control inputs, caused an elevator disconnect and a serious cabin crew injury. Post flight inspection did not discover serious structural damage caused to the aircraft and it remained in service for a further five days. The complex Investigation took over five years and examined both the seriously flawed flight crew performance and the serious continued airworthiness failures.
Dated: November 2021
1996 mid-air collision over Delhi triggered significant change in aviation safety…
On 12 November 1996, an Ilyushin IL76TD and an opposite direction Boeing 747-100 collided head on at the same level in controlled airspace resulting in the destruction of both aircraft and the loss of 359 lives. The Investigation concluded that the IL76 had descended one thousand feet below its cleared level after its crew had interpreted ATC advice of opposite direction traffic one thousand feet below as the reason to remain at FL150 as re-clearance to descend to this lower level. Fifteen Safety Recommendations relating to English language proficiency, crew resource management, collision avoidance systems and ATC procedures were made.
Dated: November 2021
Mountain Waves – guidance for flight crews
Mountain Waves are defined as oscillations to the lee side (downwind) of high ground resulting from the disturbance in the horizontal air flow caused by the high ground. They are associated with severe turbulence, strong vertical currents, and icing. The vertical currents in the waves can make it difficult for an aircraft to maintain en route altitude leading to level busts. Aircraft can suffer structural damage as a result of encountering severe clear air turbulence. Severe icing can be experienced within the clouds associated with the wave peaks
Dated: November 2021
Inappropriately rushed departure leads to runway incursion
On 25 September 2019, an aircraft about to depart from Canberra at night but in good visibility failed to follow its clearance to line up and take off on runway 35 and instead began its takeoff on runway 30. ATC quickly noticed the error and instructed the aircraft to stop which was accomplished from a low speed. The Investigation concluded that the 1030 metre takeoff distance available on runway 30 was significantly less than that required and attributed the crew error to attempting an unduly rushed departure for potentially personal reasons in the presence of insufficiently robust company operating procedures.
Dated: October 2021
Don’t disable the EGPWS
On 5 August 2019, an aircraft touched down in runway undershot at Aarhus whilst making a night ILS approach there and damage sustained when it collided with parts of the ILS LOC antenna caused a fuel leak which subsequently ignited destroying most of the aircraft. The Investigation attributed the accident to the Captain’s decision to intentionally fly below the ILS glideslope in order to touch down at the threshold and to the disabling of the EGWPS alerting function in the presence of a steep authority gradient, procedural non-compliance and poor CRM.
Dated: October 2021
Low Visibility Operations: Best practice for flight crews
Low visibility procedures exist to support Low Visibility Operations at Aerodromes when either surface visibility is sufficiently low to prejudice safe ground movement without additional procedural controls or the prevailing cloud base is sufficiently low to preclude pilots obtaining the required visual reference to continue to landing at the equivalent of an ILS Cat 1 DH/DA. It should be noted that in the latter case, surface visibility may be relatively good but the TWR visual control room may be in cloud/fog.
Dated: October 2021
Winter snow clearing, poor visibility and a runway incursion
On 28 January 2019, a departing aircraft narrowly avoided collision with part of a convoy of four snow clearance vehicles which failed to follow their clearance to enter a parallel taxiway and instead entered a Rapid Exit Taxiway and continued across the runway holding point before stopping just clear of the actual runway after multiple calls to do so. A high speed rejected takeoff led to the aircraft stopping just before the intersection where the incursion had occurred.
Dated: October 2021
The risk of severe turbulence increases considerably above and close to cumulonimbus
On 10 July 2019 an aircraft in the cruise at night at FL 400 encountered unexpectedly severe turbulence and 27 occupants were injured as a result, one seriously. The detailed Investigation concluded that the turbulence had occurred in clear air in the vicinity of a significant area of convective turbulence and a jet stream.
Dated: October 2021
Electrical Problems: Guidance for Controllers
There is no set of ready, out-of-the-box rules to be followed universally. As with any unusual or emergency situation, controllers should exercise their best judgment and expertise when dealing with the consequences related to onboard electrical failures. A generic checklist for handling unusual situations is readily available from EUROCONTROL (see Further Reading below) but it is not intended to be exhaustive and is best used in conjunction with local ATC procedures.
Dated: September 2021
Do all your pilots know how to fly an NDB approach? Are you sure?
On 29 January 2015, a crew attempting to fly an NDB approach to Bergerac, with prior awareness that it would be necessary because of pre-notified ILS and DME unavailability, descended below 800 feet agl in IMC until an almost 1000 feet per minute descent when still over 8 nm from the runway threshold triggered an EGPWS ‘TERRAIN PULL UP’ warning and the simultaneous initiation of a go-around. The Investigation found that the PF First Officer was unfamiliar with NDB approaches but had not advised the Captain which resulted in confusion and loss of situational awareness by both pilots.
Dated: September 2021
Failing to report even a minor runway excursion is not a sign of a good safety culture
On 4 October 2017, an aircraft slightly overran the end of runway 22 at Surat during an early morning daylight landing. A temporarily displaced landing threshold meant the runway length was only 1,905 metres rather than the 2,905 metre full length. The aircraft remained on a paved surface and was undamaged. Its crew did not report the excursion which was only discovered when broken runway lighting was subsequently discovered. The Investigation found that the non-precision approach made was unstable and that a prolonged float in the subsequent flare meant that only 600 metres of runway remained ahead at touchdown.
Dated: August 2021
Mitigating strategies for hot weather operations
Ambient temperature, be it hot or cold, has an effect on aircraft operations irrespective of the airport elevation. Whilst the combination of heat and high altitude, as discussed in the SKYbrary article Hot and High Operations, has a particularly detrimental impact on aviation, heat alone can also have substantial repercussions when considering safe and efficient aircraft operations. Extreme heat, common to many areas in Africa and the Middle East, is becoming increasingly more common, albeit for relatively short periods of time, in other areas of the world, including Europe, Australia and North America.
Dated: August 2021
Just because the aircraft ahead got in doesn’t mean YOU will…
On 13 September 2016, an aircraft made an unstabilised approach to Wamena and shortly after an EGPWS ‘PULL UP’ warning due to the high rate of descent, a very hard landing resulted in collapse of the main landing gear, loss of directional control and a lateral runway excursion. The Investigation found that the approach had been carried out with both the cloudbase and visibility below the operator-specified minima and noted that the Captain had ignored a delayed go around suggestion from the First Officer because he was confident he could land safely as the two aircraft ahead had done.
Dated: August 2021
Are your airline’s emergency evacuation procedures adequate for all potential scenarios?
On 3 August 2018, smoke appeared and began to intensify in the passenger cabin but not the flight deck of an aircraft taxiing for departure at Helsinki. Cabin crew notified the Captain who stopped the aircraft and sanctioned an emergency evacuation. This then commenced whilst the engines were still running and inadequate instructions to passengers resulted in a completely disorderly evacuation. The Investigation attributed this to inadequate crew procedures which only envisaged an evacuation ordered by the Captain for reasons they were directly aware of and not a situation where the evacuation need was only obvious in the cabin.
Dated: July 2021
Another lithium battery event – Thankfully this one happened on the ground
On 27 October 2019, an under-floor hold fire warning was annunciated in the flight deck of an aircraft which was about to begin taxiing. Since there were no signs of fire in the passenger cabin or during an emergency services external inspection, a non-emergency disembarkation of all occupants was made. The hold concerned was then opened and fire damage sourced to the overheated lithium battery in a passenger wheelchair. The Investigation identified a number of weaknesses in both the applicable loading procedures and compliance with the ones in place.
Dated: July 2021
Runway Identification
Accident and incident reports show that misidentification of runways by pilots – and sometimes by vehicle drivers too – can be a significant factor in both accidents and serious incidents in which a runway collision risk was created.
Dated: July 2021
Clear Air Turbulence cannot always be reliably forecast
On 2 February 2020, an aircraft in the cruise at night at FL 330 encountered unforecast clear air turbulence with the seatbelt signs off and one unsecured passenger in a standard toilet compartment sustained a serious injury as a result. The Investigation noted that a contributory factor was the inaccessibility of the handholds within the lavatory for use in case of turbulence .
Dated: June 2021
Unexpected lit red Stop Bar? STOP and then find out why
On 28 April 2018, an aircraft exited the landing runway at Perth and without clearance crossed a lit red stop bar protecting the other active runway as another aircraft was accelerating for takeoff. This aircraft was instructed to stop due to a runway incursion ahead and passed 15 metres clear of the incursion aircraft which by then had also stopped. The Investigation concluded that, after failing to refer to the aerodrome chart, the Captain had mixed up two landing runway exits of which only one involved subsequently crossing the other active runway and decided the stop bar was inapplicable.
Dated: June 2021
Intersection Take Off: Guidance for Controllers
An intersection take off is a take off that starts at a position different than the beginning of a runway. This means that some of the runway will not be available for the take off run. Benefits associated with intersection take offs include:
runway capacity improvement
reduced taxi time
noise alleviation
air pollution reduction
Dated: June 2021
Taxi instructions are not always given by licensed ATCOs
On 18 December 2018, an aircraft was instructed to taxi to a specified remote de-icing platform for de-icing prior to takeoff from Oslo. The aircraft collided with a lighting mast on the de-icing platform causing significant damage to both aircraft and mast. The Investigation found that in the absence of any published information about restricted aircraft use of particular de-icing platforms and any markings, lights, signage or other technical barriers to indicate to the crew that they had been assigned an incorrect platform, they had visually assessed the clearance as adequate.
Dated: June 2021
Is your airline is using approach plates that differ from the AIP used by ATC?
On 26 August 2019, an aircraft attempted two autopilot-engaged non-precision approaches at Birmingham in good weather before a third one was successful. Both were commenced late and continued when unstable prior to eventual go-arounds, for one of which the aircraft was mis-configured causing an ‘Alpha Floor’ protection activation. A third non-precision approach was then completed without further event. The Investigation noted an almost identical event involving the same operator four months later, observing that all three discontinued approaches appeared to have originated in confusion arising from a slight difference between the procedures of the aircraft operator and AIP plates.
Dated: June 2021
Changing Runways (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on the risks associated with changing the runway in use.
Dated: June 2021
Is upgrade training for senior cabin crew adequate in your airline?
On 1 March 2019, an aircraft left engine suffered a contained failure soon after takeoff thrust was set for a night departure from London Stansted but despite the absence of an instruction to cabin crew to begin an evacuation, they did so anyway just before the aircraft was going to be taxied clear of the runway with the Captain only aware when passengers were seen outside the aircraft. The Investigation found that an evacuation had been ordered by the senior member of the cabin crew after she was “overwhelmed” by the situation and believed her team members were “scared”.
Dated: May 2021
Landing Flare
The Landing Flare, in a fixed wing aircraft, is the transition phase between the final approach and the touchdown on the landing surface. This sub-phase of flight normally involves a simultaneous increase in aircraft pitch attitude and a reduction in engine power/thrust, the combination of which results in a decrease in both rate of descent and airspeed.
Dated: May 2021
Global Action Plan for the Prevention of Runway Excursions (GAPPRE)
Part 2 of the GAPPRE, Guidance and Explanatory Material, has now been published by the Flight Safety Foundation and EUROCONTROL….
Dated: May 2021
Repeated procedural violation results in contact with the sea…
On 9 July 2018, an aircraft continued a non-precision approach to Al Hoceima below the procedure MDA without obtaining visual reference and subsequently struck the sea surface twice, both times with a vertical acceleration exceeding structural limits before successfully climbing away and diverting to Nador having reported a bird strike. The Investigation attributed the accident to the Captain’s repeated violation of operating procedures which included another descent below MDA without visual reference the same day and the intentional deactivation of the EGPWS without valid cause. There was significant fuselage structure and landing gear damage but no occupant injuries.
Dated: April 2021
Energy Management during Approach
The flight crew’s inability to assess or to manage the aircraft’s energy condition during approach is often cited as a cause of unstabilised approaches. Crews should appreciate that fatigue will increase the likelihood that they will have difficulty in detecting that an approach is going outside normal parameters.
Dated: April 2021
Fuel contamination will result in all engines being similarly affected
On 29 March 2019, both engines of an aircraft on descent to Kansai malfunctioned in quick succession causing auto ignition to be triggered by sub-idle engine rpm but thereafter, sufficient thrust was available to safely complete the flight. The Investigation found that the cause of these malfunctions had been contamination of the fuel system with large concentrations of residue traced to a routinely applied biocide and had solidified and intermittently impeded the transfer of fuel from the tanks to the engines.
Dated: March 2021
Are your airport operator SOPs robust enough?
On 2 February 2019, an aircraft narrowly avoided collision with part of a convoy of snowplough vehicles which had entered the landing runway without clearance less than 10 seconds before touchdown and begun to position on the centreline. The Investigation found that despite the prompt initiation of a go-around on sighting the vehicles, the aircraft was likely to have cleared them by less than 100 feet. A number of opportunities for improved ground vehicle movement procedures were identified and the incursion was seen as indicative of a general need to more effectively address this risk at Canadian airports.
Dated: March 2021
Another case of an inappropriate response to an unreliable airspeed event
On 11 March 2018 an Unreliable Speed Alert occurred on an aircraft; the Captain’s airspeed increasing whilst the First Officer’s decreased. The First Officer attempted to commence the corresponding drill but the Captain’s interruptions prevented this and a (false) overspeed warning followed. The Captain’s response to both alerts was to reduce thrust, which led to a Stall Warning followed, after no response, by stick pusher activation that was repeatedly opposed by the Captain despite calls to stop from the First Officer. The stalled condition continued for almost five minutes until a 30,000 feet descent was terminated by terrain impact.
Dated: February 2021
Stabilised approach considerations for controllers
Annually, approximately 30% of commercial transport aviation accidents are runway excursions. A significant amount of these excursions are the result of unstable approaches. The responsibility for the achievement and execution of a stabilised approach lies with the flight crew, nevertheless controllers can play their part and contribute to the in achievement of a stabilised approach.
Dated: February 2021
Indonesian authorities have released a preliminary report into January 2021 loss of control event
On 9 January 2021, contact was lost with an aircraft as it approached 11,000 feet less than five minutes after departing Jakarta. It was subsequently found to have entered a rapid descent and been destroyed by sea surface impact. The Investigation is ongoing but is currently focusing on finding an explanation for the apparently uncommanded but progressive asymmetric thrust reduction which culminated in a wing drop and a consequent loss of control.
Dated: February 2021
8th Annual Safety Forum: virtual event on 10-11 February 2021
Registration is open for the 8th Annual Safety Forum, co-organized by the Flight Safety Foundation, EUROCONTROL and the European Regions Airline Association, which will take place virtually February 10-11, 2021. The event is foicused on Airport Safety and the new Global Action Plan for the Prevention of Runway Excursions (GAPPRE).
Dated: February 2021
Global Action Plan for the Prevention of Runway Excursions (GAPPRE)
The Global Action Plan for the Prevention of Runway Excursions (GAPPRE) was developed by an international group of more than 40 different organisations. Volume I, published in January 2021, contains the agreed recommendations. Volume II, to be published in February 2021, provides explanatory and guidance material and related best practices.
Dated: January 2021
Situational awareness – always monitor the big picture
On 10 September 2017, an aircraft cleared for an ILS approach at Moscow Domodedovo in visual daylight conditions descended below its cleared altitude and reached 395 feet agl whilst still 7nm from the landing runway threshold with a resultant EGPWS ‘PULL UP’ warning. Recovery was followed by an inadequately prepared second approach that was discontinued and then a third approach to a landing.
Dated: January 2021
Airspace Infringement and Aeronautical Information
The latest safety promotion animation from EUROCONTROL focuses on the importance of checking the latest aeronautical information so as to avoid unintentional airspace infringement.
Dated: January 2021
System-Wide Weather Events
This article considers the operational and airmanship factors of importance to flight crew experiencing a system-wide event (SWE) which is an event that affects a flight and a sufficiently wide area that all alternate routes and airfields briefed during pre-flight preparation have become unavailable. Ground facilities such as navigation beacons and air traffic services may also be affected.
Dated: January 2021
A persistently poor operational safety record should not be ignored
On 29 November 2018, an aircraft landed on a temporarily closed section of the runway at Dubrovnik after a visual approach in benign weather conditions. The Investigation found that the flight crew had not carried out a sufficient pre-flight review of current and available information about a major multi-phase runway reconstruction there which they were familiar with. The opportunity for better advance and real time communication with aircraft operators and their flight crew and the benefit of the recommended ‘X’ marking at the beginning of any temporarily closed part of a runway, omitted in this case, was noted.
Dated: January 2021
Yet another event involving take off performance calculation error…
On 29 August 2019, an aircraft crew used more runway than expected during a reduced thrust takeoff from Nice, although not enough to justify increasing thrust. It was subsequently found that an identical error had been made by both pilots when independently calculating takeoff performance data.
Dated: December 2020
Low level wind shear advisory? – think about what that means and what you can do about it.
On 15 August 2015, an aircraft on approach to Charlotte commenced a go around but, following a temporary loss of control as it did so, then struck approach and runway lighting and the undershoot area sustaining a tail strike before climbing away. The Investigation noted that the 2.1g impact caused substantial structural damage to the aircraft and attributed the loss of control to a small microburst and the crew’s failure to follow appropriate and recommended risk mitigations despite clear evidence of risk.
Dated: December 2020
Make sure you know what the terrain does below you on your climb out track
On 26 June 2017, an aircraft which had just taken off from Stuttgart came into conflict in Class ‘D’ airspace with a VFR light aircraft crossing its track and when, at 1,200 feet agl, the TCAS RA to descend was followed, an EGPWS Mode 3 Alert was generated. Clear of Conflict was annunciated after 10 seconds and climb resumed. The Investigation concluded that the light aircraft pilot had failed to follow the accepted ATC clearance and had caused the flight path conflict that was resolved by the A319 crew response to the TCAS RA.
Dated: November 2020
Shallow Fog – Airmanship considerations
Viewed from above, Shallow fog may not obscure aerodrome layout or runway markings but on final approach visual references may be lost, particularly in the flare. The presence of shallow fog may make taxi and takeoff difficult depending on ambient lighting conditions, the clarity of taxiway and runway markings, and the intensity of taxiway and runway lighting.
Dated: November 2020
Who ate all the pies?
On 30 May 2019, an aircraft departing from Nuuk could not be rotated at the calculated speed even using full aft back pressure and the takeoff was rejected with the aircraft coming to a stop with 50 metres of the 950 metre long dry runway remaining. The Investigation found that the actual weights of both passengers and cabin baggage exceeded standard weight assumptions with the excess also resulting in the aircraft centre of gravity being outside the range certified for safe flight.
Dated: November 2020
SOPs are there to be followed
On 16 August 2016, an aircraft’s right engine failed just over two hours into a flight from Sydney to Kuala Lumpur. It was eventually shut down after two compressor stalls and increased vibration that followed ‘exploratory’ selection of increased thrust. A ‘PAN’ declaration was followed by diversion to Melbourne in preference to other nearer alternates, during which two relight attempts were made. The Investigation found that delayed shutdown and the relight attempts were contrary to applicable procedures and the failure to divert to the nearest suitable airport had extended the time in an elevated risk environment.
Dated: October 2020
Cross Wind as a Factor in Runway Excursions
Poorly executed cross wind landings are a major cause of runway excursions. Often the outcome is associated with prevailing runway surface friction being other than dry – possibly wet, more often contaminated. Investigation of Runway Excursions on landing where the crosswind has been a significant factor usually identify one or more of the following:
Inappropriate flight crew decision to attempt a landing
Inappropriate flight crew aircraft handling
High rates of variation in surface and near-surface wind velocity
Inadequate availability of information about the state of the runway surface
performance limitations or recommendations in relation to cross wind landings
Wind, wake and turbulence induced by obstacles may affect the flight handling and performance of aircraft during take-off and landing. Generally aircraft are much more vulnerable to disturbed wind velocity profiles during the final stage of the approach than during take-off.
Dated: October 2020
Convective weather deserves the utmost respect….
On 19 April 2018, an aircraft suddenly encountered a short period of severe turbulence as it climbed from FL160 towards clearance limit FL190 during a weather avoidance manoeuvre, which resulted in a level bust of 600 feet, passenger injuries and minor damage to cabin fittings. The Investigation found that the flight had departed during a period of adverse convective weather after the crew had failed to download a pre-flight met briefing or obtain and review available weather updates.
Dated: October 2020
Aircraft on ILS approach in Class E airspace has near miss with glider…
On 15 October 2017, a business jet on base leg for an easterly ILS approach at St Gallen-Altenrhein came into close proximity with a reciprocal track glider at 5000 feet QNH in Class ‘E’ airspace in day VMC with neither aircraft seeing the other until just before their minimum separation – 0.35 nm horizontally and 131 feet vertically – occurred. The Investigation attributed the conflict to the lack of relevant traffic separation requirements in Class E airspace and to the glider not having its transponder switched on and not listening out with the relevant ATC Unit.
Dated: October 2020
Bird Strike on Final Approach
This article discusses the issues and thought processes associated with a bird strike on final approach. Crews should follow company approved emergency procedures (e.g. Company Operating Manual) and manufacturers guidance regarding the conduct of the flight, and management of aircraft systems, when such an event occurs. In the context of this article “final approach” is defined as that period of flight following the final configuration necessary for landing.
Dated: September 2020
Don’t underestimate the strength of vertical wind shear near a jet stream
On 24 June 2018, a an aircraft was briefly subjected to unexpected and severe Clear Air Turbulence (CAT) whilst level at FL300 which resulted in a serious injury to one of the cabin crew. The Investigation concluded that the turbulence had occurred because of the proximity of the aircraft to a strong jet stream and that the forecast available at pre-flight briefing had underestimated the strength of the associated vertical wind shear.
Dated: September 2020
Are Safety Management Systems failing to detect systemic complacency?
On 4 March 2019, a crew lost directional control of their aircraft as speed reduced following their touchdown at Halifax and were unable to prevent it being rotated 180° on the icy surface before coming to a stop facing the runway landing threshold. The Investigation found that the management of the runway safety risk by the airport authority had been systemically inadequate and that the communication of what was known by ATC about the runway surface condition had been incomplete. A number of subsequent corrective actions taken by the airport authority were noted.
Dated: August 2020
Unanticipated and unforecast low level wind shear
On 28 August 2018, an aircraft bounced touchdown in apparently benign conditions resulted in nose gear damage and debris ingestion into both engines, in one case sufficient to significantly reduce thrust. The gear could not be raised at go around and height loss with EGPWS and STALL warnings occurred when the malfunctioning engine was briefly set to idle. Recovery was followed by a MAYDAY diversion to Shenzen and an emergency evacuation. The Investigation attributed the initial hard touchdown to un-forecast severe very low level wind shear and most of the damage to the negative pitch attitude during the second post-bounce touchdown.
Dated: August 2020
Base training needs to take place using carefully specified operational procedures…
On 28 February 2018, an aircraft would not rotate for a touch-and-go takeoff and flightpath control remained temporarily problematic and the aircraft briefly settled back onto the runway with the gear in transit damaging both engines. A very steep climb was then followed by an equally steep descent to 600 feet agl with an EGPWS ‘PULL UP’ activation before recovery. Pitch control was regained using manual stabiliser trim but after both engines stopped during a MAYDAY turnback, an undershoot touchdown followed. The root cause of loss of primary pitch control was determined as unapproved oil in the stabiliser actuator.
Dated: August 2020
Hot Weather Operations
Ambient temperature, be it hot or cold, has an effect on aircraft operations irrespective of the airport elevation. Whilst the combination of heat and high altitude, as discussed in the SKYbrary article Hot and High Operations, has a particularly detrimental impact on aviation, heat alone can also have substantial repercussions when considering safe and efficient aircraft operations. Extreme heat, common to many areas in Africa and the Middle East, is becoming increasingly more common, albeit for relatively short periods of time, in other areas of the world, including Europe, Australia and North America.
Dated: August 2020
Learning from All Operations – Webinar
On 29-30 September 2020, The Flight Safety Foundation is holding a Webinar to promote further globally the practical implementation of the concepts of system safety thinking, resilience and safety II.
Dated: August 2020
When the size of a coffee cup becomes a safety issue….
On 6 February 2019, an aircraft Captain’s Audio Control Panel (ACP) malfunctioned and began to emit smoke and electrical fumes after coffee was spilt on it. Subsequently, the right side ACP also failed, becoming hot enough to begin melting its plastic. Given the consequent significant communications difficulties, a turnback to Shannon was made with both pilots taking turns to go on oxygen. The Investigation found that flight deck drinks were routinely served in unlidded cups with the cup size in use incompatible with the available cup holders.
Dated: July 2020
The response to a “PULL UP” warning should be rapid and instinctive
On 10 December 2015, an aircraft descended below the prescribed vertical profile in IMC during a LLZ-only approach to Billund. An EGPWS ‘PULL UP’ warning was followed by a go around instead of the prescribed response to such a warning. A minor level bust and configuration exceedance followed after which the aircraft returned to its departure airport. Prior to the LLZ-only approach, an attempt to continue with an ILS approach to the same runway with only a LLZ signal available had also ended in a go around. In both cases, there was a complete failure to maintain vertical situational awareness.
Dated: July 2020
Report published into January shooting down of Ukranian aircraft departing Tehran
On 8 January 2020, an aircraft was destroyed by a ground to air missile three minutes after takeoff from Tehran and its 176 occupants were killed. The Investigation is continuing but it has been confirmed that severe damage and an airborne fire followed the detonation of a proximity missile after a military targeting error, with subsequent ground impact. It is also confirmed that the flight was following its ATC clearance and that a sequence of four separate errors led to two missiles being fired at the aircraft.
Dated: July 2020
Flight Crew Response to on board medical emergency
On a global basis, commercial airlines serve well over a billion passengers annually. Although they are not an every day occurrence, in-flight medical emergencies, involving passengers or, on a less frequent basis, crew, are inevitable.
Dated: July 2020
The risks associated with Special ATC procedures…
On 21 April 2016, an aircraft under radar control in Class ‘E’ airspace was almost in collision with a VFR light aircraft after they closed on a constant relative bearing when inbound to Friedrichshafen in VMC. The Investigation concluded that special ATC procedures in place had entailed “systemic risk” and also identified inadequate controller coordination as contributory to a near collision.
Dated: July 2020
Mountain Waves (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on Mountain Waves (SKYclip)
Dated: April 2020
An example of “Base Effect”
On 27 June 2016, an aircraft narrowly avoided a mid-air collision with a helicopter whose single transponder had failed earlier whilst both were positioning visually as cleared to land at Marseille and after the helicopter had also temporarily disappeared from primary radar. The Investigation attributed the conflict to an inappropriate ATC response to the temporary loss of radar contact with the helicopter, aggravated by inaccurate position reports and non-compliance with the aerodrome circuit altitude by the helicopter crew.
Dated: March 2020
After landing, if there has been a fire, ask for an external inspection before taxi-in
On 16 March 2016, an engine fire occurred to an aircraft departing Budapest. After the flight crew declared a MAYDAY, the aircraft was landed in the reciprocal direction on the departure runway without further event.
Dated: March 2020
Landing Gear Problems: Guidance for Controllers
This article provides guidance for tower/approach controllers on what to expect from an aircraft experiencing the effects of landing gear problems and some of the considerations which will enable the controller, not only to provide as much support as possible to the aircraft concerned, but also maintain the safety of other aircraft at or in the vicinity of an aerodrome and of the ATC service provision in general.
Dated: March 2020
Registration is now open for the 2020 Safety Forum
This year’s Safety Forum, to be held in Brussels 3-4 June 2020, will be focused on Airport Surface Risk. Registration for the event is now open…
Dated: March 2020
How not to respond to a high speed bird strike…
On 21 June 2017, an aircraft number 2 engine began vibrating during the takeoff roll at Delhi after a bird strike. After continuing the takeoff, the Captain subsequently shut down the serviceable engine and set the malfunctioning one to TO/GA and it was several minutes before the error was recognised. After an attempted engine restart failed because an incorrect procedure was followed, a second attempt succeeded. By this time inattention to airspeed loss had led to ALPHA floor protection activation. Eventual recovery was followed by a return to land with the malfunctioning engine at flight idle.
Dated: February 2020
Attempted go-around without any thrust leads to loss of control
The final report into the August 2016 loss of control event at Dubai, published on 6 February 2020, makes numerous safety recommendations regarding pilot training that will be of interest to all operators.
Dated: February 2020
Emergency Descent: Guidance for Controllers
This article provides guidance for controllers on what to expect and how to act when dealing with an emergency descent which takes place in controlled airspace. There are some considerations which will not only enable the controller to provide as much support as possible to the aircraft involved, but to also maintain the safety of other aircraft in the vicinity and of the ATC service provision in general.
Dated: February 2020
NTSB publishes safety recommendations following pitch trim runaway event
On 6 November 2019, the crew of an aircraft which had just taken off from Atlanta experienced difficulty in maintaining pitch control after an apparent pitch trim runaway. The Investigation is continuing but has identified the root cause as wiring damage arising from incorrect installation.
Dated: February 2020
Change to the departure runway? – Rebrief
On 28 March 2018, a crew inadvertently commenced takeoff from the displaced threshold of the departure runway at Gatwick instead of the full length which was required for the rated thrust used. The Investigation found that the runway involved was a secondary one which the crew were unfamiliar with and to which access was gained by continuing along a taxiway which followed its extended centreline.
Dated: January 2020
Smoke? – follow the drills
On 3 December 2017, an aircraft en-route at FL310 was already turning back to Helsinki because of a burning smell in the flight deck when smoke in the cabin was followed by smoke in the flight deck. A MAYDAY was declared to ATC reporting “fire on board” and their suggested diversion to Turku was accepted. The situation initially improved but worsened after landing prompting a precautionary emergency evacuation.
Dated: January 2020
2020 Safety Forum – Call for submissions
This year’s Safety Forum, to be held in Brussels 3-4 June 2020, will be focused on Airport Surface Risk. The organising committee is now inviting submissions to present as speaker at the event…
Dated: January 2020
Altimeter Temperature Error Correction
What is Altimeter Temperature Error
Altimeter Temperature Error Correction is applied to altimeters to compensate for error caused by deviation from ISA conditions. Pressure altimeters are calibrated to ISA conditions. Any deviation from ISA will result in error proportional to ISA deviation and to the height of the aircraft above the aerodrome pressure datum……
Dated: January 2020
Does your stall recovery training use realistic scenarios?
On 7 April 2017, a crew did not adjust planned speed at an anticipated holding point when the level given was higher than expected. As a consequence of this and distraction, as the new holding level was approached and the turn began, stall buffet, several stick shaker activations and pilot-induced oscillations occurred when the crew failed to follow the applicable stall warning recovery procedure.
Dated: December 2019
Centerline lighting can be confused with runway edge lighting when they are the same colour
On 18 January 2016, a crew made a night takeoff from Amsterdam runway 24 unaware that the aircraft was aligned with the right side runway edge lights. After completion of an uneventful flight, holes in the right side fuselage and damage to the right side propeller blades, the latter including wire embedded in a blade leading edge, were found. The Investigation concluded that poor visual cues guiding aircraft onto the runway at the intersection concerned were conducive to pilot error and noted that despite ATS awareness of intersection takeoff risks, no corresponding risk mitigation had been undertaken.
Dated: December 2019
Situational awareness is much improved for all if everyone uses the English language
On 11 January 2018, an aircraft with a two-pilot English-speaking crew made a night takeoff from Reykjavik without clearance passing within “less than a metre” of a vehicle sanding the out-of-service and slippery intersecting runway as it rotated. The Investigation noted that the takeoff without clearance had been intentional and due to the aircraft slipping during the turn after backtracking. It also noted that the vehicle was operating as cleared by the TWR controller on a different frequency and that information about it given to an inbound aircraft on the TWR frequency had been in Icelandic.
Dated: December 2019
MAK has published the final report into the March 2016 fatal loss of control at Rostov-on-Don
On 19 March 2016, an aircraft making a second night ILS approach to Rostov-on-Don failed to complete a go around, crashing at high speed within the airport perimeter killing all 62 people on board. The Investigation concluded that the Captain had lost spatial awareness and then failed to configure the aircraft correctly or control its flightpath.
Dated: December 2019
Use of Autoland on Contaminated Runways
Autoland was originally devised to achieve approach and landing in poor visibility conditions, so it was focussed on the necessary approach and touchdown/de-rotation and not on the low friction surface case and certainly not on the variable asymmetries that, in reality, usually apply with this circumstance.
Dated: December 2019
Airspace Infringement (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on airspace infringement.
Dated: December 2019
HindSight 29
The latest edition of EUROCONTROL’s safety magazine focuses on goal conflicts and trade-offs
Dated: November 2019
NTSB issues abstract from investigation into 2018 engine failure which led to first US commercial airline fatality since 2009…
On 17 April 2018, a sudden uncontained left engine failure occurred to an aircraft climbing through FL320. Consequent damage included a broken cabin window causing rapid decompression and a passenger fatality. A single fan blade was found to have failed due to undetected fatigue. The Investigation noted that the full consequences of blade failure had not been identified during engine / airframe type certification nor fully recognised during investigation of an identical blade failure event in 2016.
Dated: November 2019
The weakness of safety barriers based solely on the vigilance of pilots and controllers…
On 7 March 2016, an aircraft entered the departure runway at an intersection contrary to an ATC instruction to remain clear after neither a trainee controller nor their supervisor noticed the completely incorrect readback. An aircraft taking off in the opposite direction was able to rotate and fly over it before either controller noticed the conflict.
Dated: November 2019
2020 Safety Forum – Call for submissions
Next year’s Safety Forum, to be held in Brussels 3-4 June 2020, will be focused on Airport Surface Risk. The organising committee is now inviting submissions to present as speaker at the event.
Dated: November 2019
Drift Down – Speed Strategies
Drift Down is a maximum thrust/minimum rate descent necessitated by an engine failure in a multi-engine aircraft in the latter stages of climb or during cruise when an aircraft cannot maintain its current altitude and terrain clearance or other factors are critical. The Drift Down procedure entails setting maximum continuous power/thrust on the operating engine(s) whilst countering any adverse yaw with rudder, and then trimming and disconnecting the autothrottle(AP)/autothrust(AT) system where applicable. (Note that on some aircraft disconnecting AT may not be required and may actually make the desired profile more difficult to achieve; as always, it is important to know, understand and carry out the manufacturers/ operators approved procedures.)
Dated: November 2019
Dive and Drive? – there are better ways to fly a non-precision approach
On 19 July 2017, a crew ignored the prescribed non-precision approach procedure for which they were cleared in favour of an unstabilised “dive and drive” technique in which descent was then continued for almost 200 feet below the applicable MDA and led to an EGPWS terrain proximity warning as a go around was finally commenced in IMC with a minimum recorded terrain clearance of 162 feet.
Dated: November 2019
Runway occupied medium term (SKYclip)
Dated: October 2019
NTSC publishes final report into October 2018 Lion Air loss of control
On 29 October 2018, a crew had difficulty controlling the pitch of their aircraft after takeoff from Jakarta and after eventually losing control, a high speed sea impact followed. The Investigation found that similar problems had also affected the aircraft’s previous flight following installation of a faulty angle-of-attack sensor and after an incomplete post-flight defect entry, rectification had not occurred. Loss of control occurred because the faulty sensor was the only data feed to an undisclosed automatic pitch down system, MCAS, which had been installed on the 737-MAX variant without recognition of its potential implications.
Dated: October 2019
Joint Authorities Technical Review: Boeing 737 MAX Flight Control System
The FAA commissioned a Review by a unique assembly of international certification authorities to review the type certification of the flight control system on the B737 MAX. The Review was published on 11 October 2019.
Dated: October 2019
Medical Emergencies – Diversion Considerations
Medical Emergency – Continue or Divert?
The decision to continue or to divert will be based, primarily, on the condition of the patient and the proximity of the planned destination. However, in some cases, it may be more prudent to divert to a location which is actually further away than the planned destination. This could occur in the case where the destination is remote with little or no medical support capability.
Dated: October 2019
Save the Date
The 2020 Safety Forum “Runway Excursion Risk Reduction” will be held in Brussels 3-4 June 2020.
Posted: October 2019
IASS 2019
The International Air Safety Summit (IASS 2019) in Taipei, 2-4 Nov, brings together aerospace and aviation safety professionals from around the globe to exchange information and propose new directions for further risk reductions. Register now…
Dated: October 2019
Pause before selecting a gear or flap movement
On 24 June 2018, the Captain of an aircraft which had just departed Liverpool inadvertently selected flaps/slats up when “gear up” was called.
Dated: October 2019
Workload Management (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on the management of high workload.
Dated: September 2019
Bird strike on final approach
The Italian authorities have issued an Eglish language report into the 2008 event when an aircraft flew through a large flock of birds on final approach to Rome Ciampino.
Dated: September 2019
Save the Date
The 2020 Safety Forum “Sharing the Skies” will be held in Brussels 4/5 June 2020.
Dated: August 2019
Net Alert 25
The latest edition of EUROCONTROL’s safety nets newsletter, titled “Last lines of defence”, reminds us of the need for safety nets and looks back over the achievements of the past 20 years.
Dated: August 2019
Risks associated with a partly automated takeoff performance calculation process
On 22 May 2015, a takeoff from Paris CDG was attempted with a thrust setting for an aircraft weight 100 tonnes less than the actual weight after an undetected crew error. Only activation of the tailstrike protection system prevented fuselage contact with the runway and this was eventually followed by the application of full thrust. The Investigation concluded that the risk of this type of event had been widely recognised for a long time but had not been adequately addressed.
Dated: August 2019
“Hot and High” Operations
Hot and High Operations refer to a combination of aerodrome altitude and temperature which have a detrimental effect on aircraft performance. There is no “universal” definition of the concept
of “hot and high” as the possible combinations of altitude and temperature affect the performance of different aircraft to varying degrees.
Dated: August 2019
Be aware of the safety risks when transiting the ITCZ
On 2 September 2013, an aircraft crossing the ITCZ at night encountered sudden severe turbulence resulting in serious injuries to a number of the cabin crew and passengers. The Investigation found that failure to detect severe convective weather was probably associated with sub-optimal use of the on-board weather radar with the severity of the encounter possibly aggravated by inappropriate contrary control inputs.
Dated: July 2019
Sioux City: 30 years since this iconic event but still worth a read
On 19 July 1989, an aircraft suffered a sudden explosive failure of the tail-mounted number 2 engine and a complete loss of hydraulics so that the aircraft could only be controlled by varying thrust on the remaining two engines…
Dated: July 2019
Fuel Dumping: Guidance for Flight Crews
Fuel Jettison, more commonly referred to as Fuel Dumping, is the intentional, controlled, jettison of fuel from an aircraft whilst in flight, most commonly to reduce the aircraft weight either prior to an emergency landing or to ensure adequate terrain clearance in the event of the loss of one or more engines.
Dated: July 2019
2019 Safety Forum Findings and Conclusions
The Findings and Conclusions from this year’s Safety Forum, focused on Safety and Procedures, have now been published along with videos of the event’s presentations…
Dated: July 2019
Are your dangerous goods acceptance procedures fit for purpose?
On 30 March 2017, a significant amount of fuel was found to be escaping from an aircraft as soon as it arrived on stand after landing at Prestwick and the fire service attended to contain the spill and manage the associated risk of fire and explosion. The Investigation found that the fuel had come from a helicopter that was part of the main deck cargo and that this had been certified as drained of fuel when it was not. The shipper’s procedures, in particular in respect of their agents in the matter, were found to be deficient.
Dated: July 2019
Level busts (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on level busts.
Dated: June 2019
A thorough investigation of an aircraft evacuation with valuable learning points
On 27 May 2016, a crew made a high speed rejected take off when departing from Tokyo after a number one engine failure warning was quickly followed by a fire warning for the same engine and ATC advice of fire visible. As the fire warning continued with the aircraft stopped, an emergency evacuation was ordered.
Dated: June 2019
Altimetry System Error
Altimetry System Error (ASE) is the difference between the altitude indicated by the altimeter display, assuming a correct altimeter barometric setting, and the pressure altitude corresponding to the undisturbed ambient pressure. (ICAO doc 9574)
Put more simply, ASE is the difference between the altitude that the pilot, ground controller and aircraft systems believe the aircraft to be at and the actual altitude. To be compliant with international standards, the ASE of an aircraft must be less than 245 ft.
Dated: June 2019
Unexpected Traffic in the Sector (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on unexpected traffic in the sector.
Dated: June 2019
Why critical maintenance tasks are not carried out on more than one engine at the same time
On 7 July 2016, a right engine fire warning was annunciated as an aircraft got airborne from New York JFK and after shutting the engine down in accordance with the corresponding checklist, an emergency declaration was followed by an immediate and uneventful return to land. The Investigation found that a fuel-fed fire had occurred because an O-ring had been incorrectly installed on a fuel tube during maintenance prior to the flight.
Dated: June 2019
Airside driving (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on airside driving.
Dated: May 2019
Peripheral vision is impaired when wearing NVGs
On 1 December 2014, a night mid-air collision occurred in uncontrolled airspace between two military tactical transport aircraft conducting VFR training flights. Substantial damage was caused but both aircraft were successfully recovered and there were no injuries. The Investigation attributed the collision to a lack of visual scan by both crews, over reliance on TCAS and complacency despite the inherent risk associated with night, low-level, VFR operations using Night Vision Goggles.
Dated: May 2019
See and avoid
When weather conditions permit, regardless of whether an operation is conducted under instrument flight rules or visual flight rules, vigilance shall be maintained by each person operating an aircraft so as to see and avoid other aircraft. When a rule of this section gives another aircraft the right-of-way, the pilot shall give way to that aircraft and may not pass over, under, or ahead of it unless well clear.” – FAA Regulation 14 CFR Part 91.113 (b).
“See and Avoid” is recognised as a method for avoiding collision when weather conditions permit and requires that pilots should actively search for potentially conflicting traffic, especially when operating in airspace where all traffic is not operating under the instructions of ATC.
Dated: May 2019
A learning opportunity regarding the risks posed by intersection takeoffs
On 30 August 2016, a crew began takeoff from London Heathrow at an intersection one third of the way along the runway using the reduced thrust calculated for a full-length take off instead of the rated thrust calculated for the intersection takeoff. As a result, the aircraft was only just airborne as it crossed the airport boundary and an adjacent public road.
Dated: May 2019
How can you determine if a runway is damp or wet?
On 11 May 2015, a crew making a night landing at Christchurch had to react quickly when braking action deteriorated and only just succeeded in preventing an overrun. The Investigation found that a damp rather than wet runway had been assumed despite recent rain and that the aircraft operator had recently changed their procedures so that a damp runway should be considered as dry rather than wet for runway performance purposes.
Dated: April 2019
Immediate departure (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on immediate departure.
Dated: April 2019
Cross wind as a factor in runway excursions on takeoff
Investigations of Runway Excursions on takeoff, where the cross wind has been a significant factor, usually identify one or more of the following factors:
Inappropriate flight crew decision to attempt a takeoff
High rates of variation in surface and near-surface wind velocity
Inadequate availability of information about the state of the runway surface
Incomplete understanding by flight crew of the aircraft performance limitations or recommendations in relation to cross wind takeoffs
Dated: April 2019
Ethiopian Airlines loss of control accident – Preliminary report published
The Ethiopian government has published a preliminary report into the Ethiopian airlines aircraft which crashed shortly after its departure from Addis Ababa on 10 March 2019….
Dated: April 2019
There is nothing more useless than runway behind you…
On 30 July 2011, an aircraft overran the wet landing runway at Georgetown after a night non-precision approach, exited the airport perimeter and descended down an earth embankment. The Investigation attributed the overrun to a touchdown almost two thirds of the way down the runway and failure to utilise the aircraft’s full deceleration capability. Indecision as to the advisability of a go-around, after a late touchdown became inevitable, was also cited as contributory to the outcome
Dated: April 2019
24/7 use of installed stop bar lighting could prevent runway incursions
On 14 February 2017, an aircraft preparing to depart Narita entered the active runway at night without clearance as another aircraft was approaching the same runway with a landing clearance. ATC observed the conflict after an alert was activated on the surface display system and instructed the approaching aircraft to go around. The Investigation noted that the stop bar lighting system was not in use because procedures restricted its use to low visibility conditions.
Dated: March 2019
2019 Safety Forum: registration now open
Registration is now open for this year’s Safety Forum to be held 4 and 5 June in Brussels. The agenda for the event, which is focused on Safety and Procedures, has also been published
Dated: March 2019
Refuelling with passengers onboard – Understanding the Risks
Aircraft refuelling and de-fuelling are accompanied by attendant hazards which must be managed sufficiently for their mitigation to acceptable levels. The issues are much the same whether the fuel source is a tanker/bowser or a fuel hydrant system. Pressure refuelling is normal for multi crew transport aircraft and business jets but gravity refuelling of these types may be available as a backup system. The kerosene fuel used by turbine engine aircraft has a higher flash/ignition point than the aviation gasoline used by piston engine aircraft but there are still potential hazards.
Dated: March 2019
Use of FDM to assess pilot compliance with TCAS RAs
EUROCONTROL and IATA have published joint guidance on the performance assessment of pilot compliance to Traffic Alert and Collision Avoidance System (TCAS) using Flight Data Monitoring…
Dated: March 2019
Low visibility takeoff (SKYclip)
The latest safety promotion animation from EUROCONTROL focuses on low visibility takeoff.
Dated: February 2019
5th Annual Singapore Aviation Safety Seminar
The 5th Singapore Aviation Safety Seminar (SASS) will be held March 5-7, 2019 and will feature presentations from local and international speakers. The theme for SASS 2019 is “Safety: What’s Making the Difference Today?”
Dated: February 2019
HindSight 28
The latest edition of EUROCONTROL’s safety magazine, titled “Change: Changing to adapt and adapting to change”, has been published.
Dated: February 2019
A cargo fire with significant lessons regarding ground emergency communications
On 22 April 2013, a lower deck smoke warning occurred on an aircraft almost 90 minutes into the cruise and over land. The warning remained on after the prescribed crew response and after an uneventful MAYDAY diversion was completed, the hold was found to be full of smoke and fire eventually broke out after all occupants had left the aircraft. The Investigation was unable to determine the fire origin but noted the success of the fire suppression system whilst the aircraft remained airborne and issues relating to the post landing response, especially communications with the fire service.
Dated: February 2019
Aimpoint Selection, a SKYclip
The latest safety promotion animation from EUROCONTROL focuses on Aimpoint Selection.
Dated: January 2019
2019 Safety Forum – Call for Submissions
The Organising Committee for the 7th Annual Safety Forum is inviting submissions to present as a speaker.
The 2019 event is dedicated to Safety and Procedures.
Dated: January 2019
Alarming story of pressing on in poor visibility
On 7 March 2017, a crew making a daylight non-precision approach at Sint Maarten continued it without having established the required visual reference to continue beyond the missed approach point and then only realised that they had visually ‘identified’ a building as the runway when visibility ahead suddenly improved. At this point the approach ground track was corrected but the premature descent which had inadvertently been allowed to occur was not noticed and only after the second of two EGPWS Alerts was a go-around initiated at 40 feet above the sea.
Dated: January 2019
An approach not certain of safe completion should not be commenced
On 27 May 2017, an aircraft attempting to complete a visual approach to Lukla in rapidly deteriorating visibility descended below threshold altitude and impacted terrain close to the runway after stalling when attempting to climb in landing configuration.
The Investigation concluded that the Captain had lost situational awareness at a critical time and had been slow to respond to the First Officer’s alert that the aircraft was too low.
Dated: January 2019
CPDLC a SKYclip
The latest safety promotion animation from EUROCONTROL focuses on CPDLC.
Dated: December 2018
Night Visual Approaches – Understanding the Risks
Careful consideration should be given to all pertinent factors before flying a visual approach at night in preference to an instrument procedure, especially at an unfamiliar airport.
Whilst man-made obstacles in the vicinity of an airport such as buildings or towers are normally lit during the hours of darkness, natural obstacles such as hills or trees are not. As a consequence, unless there is exceptional illumination such as a full moon on new snow, natural obstacles will be largely invisible to the pilot during a night visual approach. Without due care, this factor greatly increases the potential of a CFIT accident. In fact, numerous CFIT accidents have occurred during visual approaches during hours of darkness.
Dated: December 2018
Preliminary report into Lion Air accident on 29 October 2018
On 29 October 2018, a crew had difficulty controlling the aircraft in pitch almost immediately after a day takeoff from Jakarta, and after failing to resolve the problem decided to return. No abnormal or emergency status was declared but after approximately eleven minutes airborne, contact was lost and it was found that sea surface impact had destroyed the aircraft. Successful management of apparently similar pitch control problems during the aircraft’s previous flight, after which there had been maintenance input before release to service for the accident flight, has been noted.
The Investigation is continuing.
Dated: December 2018
2019 Safety Forum – Call for Submissions
The Organising Committee for the 7th Annual Safety Forum is inviting submissions to present as a speaker.
The 2019 event is dedicated to Safety and Procedures
Dated: November 2018
Escape Routes
In many parts of the world, aircraft are routinely flown over terrain that has minimum obstacle clearance altitudes (MOCA) exceeding 10,000′. Avoidance of these areas by transiting aircraft could potentially add hundreds of extra miles to a given route and result in a substantial increase in flight time and the associated costs. To satisfy the commercial imperative while maintaining an acceptable level of safety, operators have developed escape routes and the associated procedures for use in the event of an emergency whilst overflying extensive high terrain. For routes of flight that require a predefined escape route or routes, the following information should be provided to, or developed by, the crew prior to flight:
Minimum Route Altitude
Route Segment
Escape Fix
Escape Route
Dated: November 2018
Runway lights not aligned with notified landing runway? Maybe it’s the wrong runway
On 22 December 2016, an aircraft cleared for a night approach to runway 16L at Haneda, which involved circling to the right from an initial VOR approach, instead turned left and began an approach to a closed but partially lit runway. ATC noticed and intervened to require a climb away for repositioning to the correct runway using radar vectors.
The Investigation found that the context for the crew’s visual positioning error was their failure to adequately prepare for the approach before commencing it.
Dated: November 2018
Don’t assume that a significant hazard will be rectified by somebody else – do something
On 27 October 2017, an aircraft returned to Auckland after advice from ATC that the right engine may have been affected by ingestion of FOD during engine start – a clipboard and paper left just inside the right hand engine by an employee of the airline’s ground handling contractor acting as the aircraft loading supervisor. The subsequent inspection found paper throughout the engine and minor damage to an engine fan blade and the fan case attrition liner.
The Dispatcher overseeing the departure said she had seen the clipboard inside the engine but assumed it would be retrieved before departure.
Dated: November 2018
Always respond as trained to EGPWS activations
On 12 June 2015, a crew forgot to set QNH before commencing a night non-precision approach to Kosrae which was then flown using an over-reading altimeter. EGPWS Alerts occurred due to this mis-setting but were initially assessed as false. The third of these occurred when the eventual go-around was initially misflown and descent to within 200 feet of the sea occurred before climbing.
The Investigation noted failure to action the approach checklist as well as the potential effect of fatigue on the Captain.
Dated: November 2018
2019 Safety Forum: Safety and Procedures
The 7th annual Safety Forum will be held in Brussels on 4 and 5 June 2019. The Forum will focus on Safety and Procedures.
Further information regarding the agenda and registration will be announced in the coming months.
Dated: October 2018
Should automated validation of take off performance data be mandated?
On 21 July 2017, an aircraft took off from Belfast with a significantly lower thrust setting than that intended. The aircraft became airborne just before the end of the runway but only climbed at a very shallow angle.
The Investigation is continuing but has found that the low thrust setting resulted from crew FMS input of the expected top-of-climb temperature in place of the surface temperature
Dated: October 2018
Radiation Fog
On a cloudless night, especially within a high pressure system, the land surface loses heat to the atmosphere by radiation and cools. Moist air in contact with the cooling surface also cools and when the temperature falls below the dew point for that air, fog forms. This type of fog is known as radiation fog.
Formation of Radiation Fog
Initially it may be mist that forms and then thickens into fog as the temperature drops and more water vapour condenses into water droplets in the air. Air does not conduct heat very well so in still air conditions fog may not form at all and a layer of dew or frost will form on the surface instead. However, if there is a light wind of around 5 kts, then this will mix the air in contact with the surface and the layer of fog will be thicker. With stronger winds, the fog may lift to form layers of Stratus.
Dispersal of Radiation Fog
As the sun rises, and the surface temperature increases, the air in contact with the surface will warm and the fog will gradually disperse. The fog may rise to form a low layer of stratus. If the fog is particularly thick, then it may prevent the sun from heating the surface and the fog will not clear. This situation is common in the autumn in northern Europe when some airfields may be affected by fog for many days.
Anticipating Radiation Fog
The three conditions required for radiation fog are:
clear skies, moist air, and a light wind.
Dated: October 2018
Even routine re-sectorisation creates risks which must be systematically mitigated
On 28 September 2016, a passenger jet and a light aircraft both on IFR Flight Plans came into close proximity when about to turn final on the same non-precision approach at Girona from different initial joining routes.
The Investigation found that two ACC sector controllers had issued conflicting approach clearances after losing situational awareness.
Dated: October 2018
Beware complacency when operating from familiar aerodromes
On 25 January 2016, a crew departing from and very familiar with Karup aligned their aircraft with the runway edge lights instead of the lit runway centreline and began take-off, only realising their error when they collided with part of the arrester wire installation at the side of the runway after which the take-off was rejected.
Given the familiarity of both pilots with the aerodrome, the Investigation noted that complacency had probably been a contributor factor.
Dated: October 2018
Cabin crew vigilance during disembarkation preventing serious injuries
On 12 December 2015, whilst an aircraft was beginning disembarkation of passengers via an air bridge, the bridge malfunctioned, raising the aircraft nose gear approximately 2 metres off the ground. The door attached to the bridge then failed and the aircraft dropped abruptly.|
Prompt cabin crew intervention prevented all but two minor injuries.
Dated: September 2018
Wing Growth Effect
On 24 November 2016, an aircraft being marshalled into an unmarked parking position collided with another stationary aircraft which sustained significant damage. The aircraft was being marshalled in accordance with airport procedures with wing walker assistance but a sharp corrective turn which created a ‘wing growth’ effect created a collision risk that was not seen by the marshaller.
The report provides useful educational material.
Dated: September 2018
HindSight 27
The latest edition of EUROCONTROL’s safety magazine focuses on competency and expertise.
Dated: September 2018
System Wide Events
This article considers the operational and airmanship factors of importance to flight crew experiencing a system-wide event (SWE) which is an event that affects a flight and a sufficiently wide area that all alternate routes and airfields briefed during pre-flight preparation have become unavailable. Ground facilities such as navigation beacons and air traffic services may also be affected.
Dated: September 2018
Rapid evacuation following smoke in the cabin
On 26 June 2016, thick white smoke suddenly appeared in the cabin of a fully loaded aircraft prior to engine start with the door used for boarding still connected to the air bridge. An emergency evacuation initiated by cabin crew was accomplished without injury although amidst some confusion due to a brief conflict between flight crew and cabin crew instructions.
The in-depth review of what happened and the identification of lessons for all to learn is almost unique.
Dated: September 2018
Overrun on landing events continue to happen
On 19 June 2016, an aircraft landed long at Khark Island and overran the end of the runway at speed with the aircraft only stopping because the nose landing gear collapsed on encountering uneven ground.
The Investigation attributed the accident entirely to the decisions and actions of the aircraft commander who failed to go around from an unstabilised approach, landed long and then did not ensure maximum deceleration was achieved. The monitoring role of the low experience First Officer was ineffective.
Dated: August 2018
Controller “blind spot” error leads to loss of separation
On 25 July 2016, two aircraft departing Barcelona and following their ATC instructions came into conflict and the collision risk was removed by the TCAS RA CLIMB response of one of the aircraft. The Investigation found that the controller involved had become preoccupied with an inbound traffic de-confliction task elsewhere in their sector and, after overlooking the likely effect of the different rates of climb of the aircraft, had not regarded monitoring their separation as necessary.
Dated: August 2018
Continued operation of an engine experiencing high vibration should only be considered in extreme circumstances
On 15 October 2015 an aircraft experienced significant vibration from one of the engines almost immediately after take-off. After the climb out was continued, without reducing the affected engine thrust, an uncontained failure followed 3 minutes later.
The ejected debris caused the almost simultaneous failure of the No 4 engine, loss of multiple hydraulic systems and all the fuel from one wing tank.
Dated: August 2018
Parties with a shared responsibility for operational safety need to coordinate their approaches
On 6 December 2015, an aircraft was being manoeuvred by tug from its departure gate at Singapore to the position where it was permitted to commence taxiing under its own power when the tug lost control of the aircraft, the tow bar broke and the two collided.
The Investigation attributed the collision to the way the tug was used. Some inconsistency was found between procedures for push back promulgated by the airline, its ground handling contractor and the airport operator.
Dated: July 2018
In-Flight Fire, a SKYclip
The latest safety promotion animation from EUROCONTROL focuses on in-flight fire.
Dated: July 2018
2018 Safety Forum Findings published
The Findings, Strategies and Action Opportunities from the 2018 Safety Forum, which focused on Safety Behaviours, has now been published.
Dated: July 2018
Spatial Disorientation
Somatogravic and Somatogyral illusions are the two most common forms of vestibular or ‘false sensation’ illusion. The vestibular organs are part of the human body’s mechanism for achieving posture and stability. Changes in linear acceleration, angular acceleration and vertical acceleration (gravity) which occur as a result of flight control inputs, made to accomplish a change in the flight path, are detected by the vestibular system and may create either or both of these illusions.
Dated: July 2018
Investigation identifies significant lessons for type certification and continued airworthiness
On 29 April 2016, the main rotor head and mast of a helicopter suddenly detached without warning. The accident was attributed to undetected development of metal fatigue in the same gearbox component which caused an identical 2009 accident to a variant of the same helicopter type.
Dated: July 2018
ACAS II Bulletin – “Equipment Matters”
The latest issue of EUROCONTROL’s ACAS Bulletin describes events in which the primary causes were technical anomalies either associated with TCAS, transponder, or altimeters
Dated: July 2018
The importance of an adequate pre-flight briefing…
On 17 May 2015, a crew descended their aircraft below the correct vertical profile on a visual daytime approach at Yerevan and then landed on a closed section of the runway near the displaced runway threshold. The Investigation found that the crew had failed to review relevant AIS information and had not been expecting anything but a normal approach and landing.
Dated: July 2018
Startle Effect, a SKYclip
The latest safety promotion animation from EUROCONTROL focuses on the Startle Effect.
Dated: June 2018
Report published into November 2016 fatal accident involving aircraft carrying Chapecoense football team
On 29 November 2016, an aircraft failed to complete its night charter flight to Medellín when all engines stopped due to fuel exhaustion and it crashed in mountainous terrain 10 nm from its intended destination killing almost all occupants. The Investigation noted the complete disregard by the aircraft commander of procedures essential for safe flight by knowingly departing with significantly less fuel onboard than required for the intended flight and with no apparent intention to refuel en route.
Dated: June 2018
On 29th and 30th May 2018, over 200 safety professionals met in Brussels for the 6th Safety Forum focused on Safety Behaviours – look out for the findings and safety action opportunities developed at the event which will be published before the end of June.
On Monday 28th June, over 15,000 people visited SKYbrary to view the latest of our SKYclips safety promotion animations. The growing collection collection of SKYclips is proving to be very popular with safety professionals across the aviation industry.
Help us to raise awareness of key safety issues by sharing this with your colleagues.
Dated: June 2018
Controller Blind Spot
“Blind Spot” is a type of human error. Loss of separation “Blind Spot” events are typically characterised by the controller not detecting a conflict with the closest aircraft. Such events usually occur after an incorrect descent or climb clearance. Usually there is very little (or no) time to react to such an error and most of the conflicting clearances result in an incident.
For more information, take a look at the EUROCONTROL Operational Safety Study: Blind Spots
Dated: June 2018
Is the runway wide enough for a 180 degree turn after back track?
On 18 April 2013, an aircraft was unintentionally taxied off the side of the runway during a 180° turn after backtracking the departure runway at Tabriz at night. The Investigation found that the prevailing wet runway conditions meant that the runway width alone was insufficient for the turn.
Dated: June 2018
TCAS RA High Vertical Rate, a SKYclip
The latest safety promotion animation from EUROCONTROL focuses on TCAS RA High Vertical Rate.
May 2018
Classic Mid-Air with lessons that are still relevant today
On 29 September 2006, an aircraft level at FL370 collided with opposite direction traffic at the same level, resulting in the death of all 154 occupants. A still relevant event in which a crew were sufficiently distracted by administrative tasks that they did not notice that one of them had accidently switched off the selected transponder.
Dated: May 2018
NTSB issues Investigative Update on April uncontained engine failure
On 14 April 2018, a sudden uncontained engine failure occurred to an aircraft as it climbed through approximately FL 320 abeam Philadelphia. Ejected debris broke a cabin window causing rapid decompression and the death of a passenger seated nearby. The same day, the Investigation, which is continuing, found that the failure was due to metal fatigue in a single fan blade causing it to shear from the hub.
Dated: May 2018
Stop bars mean STOP
Stop bars are a series of embedded unidirectional red lights forming a line across the taxiway. They’re an important safety feature to prevent runway incursions and apply to both aircraft and vehicles operating airside. When the stop bar is lit, pilots MUST always stop and hold position – Only proceed when Air Traffic Control gives an explicit clearance AND switches off the stop bar.
Air Traffic Controller must never issue a clearance to cross a red stop bar.
In case of contingency when stop bars are unserviceable and stuck on red the aircraft should be re-routed and if this is impossible contingency procedures must apply. In each country Air Traffic Control may have different “stop bar stuck on red” contingency procedures.” Some states require to physically disconnect the lit stop bar from its power supply. Others physically obscure the lights. And some airports provide a follow-me vehicle to lead aircraft across the lit stop bar.
Dated: May 2018
SKYclips – Pilot Fatigue
The latest safety promotion animation from EUROCONTROL focuses on Fatigue.
Dated: May 2018
The importance of recording any liquid spillage in the cabin
On 25 May 2016, an aircraft experienced a major electrical system failure soon after reaching its cruise altitude of FL 360. ATC were advised of problems and a descent to enable the APU to be started was made. This action restored most of the lost systems and the crew, not having declared an emergency, elected to complete their planned 400nm flight. The Investigation found that liquid contamination of an underfloor avionics bay had caused the electrical failure which had also involved fire and smoke without crew awareness because the smoke detection and air recirculation systems had been unpowered.
Dated: April 2018
Implications of Hydraulic Failure
On a fly by wire aircraft, will the failure result in a change of control law when the landing gear is extended?
Dated: April 2018
Short Vectoring and Glideslope Interception from Above: Guidance for Controllers
The French DSNA has produced some training videos to raise controller awareness of the impact of short vectoring on flightdeck workload and the risks associated with incepting a glideslope from above.
Dated: April 2018
Somatogravic illusion on initial climb into dark night conditions?
On 29 October 2014, an aircraft ceased its climb out soon after take-off and was subsequently found to have descended into the sea at increasing speed with the impact destroying the aircraft. The Investigation found that the aircraft had been airworthy prior to the crash and, noting a dark night departure and a significant authority gradient on the fight deck, concluded that the pilot flying had probably experienced a somatogravic illusion as the aircraft accelerated during flap retraction and made a required left turn.
Dated: April 2018
Always use available cues to confirm that you are lined up on the runway
On 7 July 2017, a crew unintentionally made and almost completed a night visual final approach to the taxiway parallel to the runway on which they had been cleared to land at San Francisco. Despite seeing lights ahead on what they presumed was the runway, they continued the approach descending over the taxiway and overhead two aircraft on it which were awaiting full length departures before commencing a go around at approximately 85 feet agl and reaching a minimum height of 59 feet agl before beginning to climb away.
Dated: March 2018
SKYclips – Speedcontrol for final approach
The latest safety promotion animation from EUROCONTROL focuses on Speedcontrol on final approach.
Dated: March 2018
HindSight 27 – Call for Articles: “Competency and Expertise”
We now welcome articles for the next HindSight magazine, especially from front line controllers and pilots. The theme of this next edition will be “Competency and Expertise”.
Dated: March 2018
The importance of in-flight access to up to date weather information
On 18 June 2013, a crew en route to Adelaide encountered un-forecast below-minima weather conditions on arrival there and decided to divert to their designated alternate, Mildura, approximately 220nm away where both the weather report and forecast were much better. However, on arrival there, an un-forecast rapid deterioration to thick fog had occurred with insufficient fuel to go anywhere else. The only available approach was flown, but despite exceeding the minimum altitude by 260 feet, no visual reference was obtained. A further approach with the reported overcast 100 feet agl and visibility 200 metres was continued to a landing.
Dated: March 2018
2018 Safety Forum Draft Agenda
The agenda for this year’s Safety Forum has been published. The Forum will focus on the topic of safety behaviours and will be held in Brussels, 29 and 30 May 2018.
Dated: March 2018
Contractors working airside requires both an adequate risk management plan and effective oversight of its implementation
On 17 October 2014, The crew of an aircraft taking off from Madrid at night detected non-runway lights ahead as they accelerated through approximately 90 knots. ATC were unaware what they might be and the lights subsequently disappeared, and the crew continued the takeoff. A reportedly unlit vehicle at the side of the runway was subsequently passed just before rotation. The Investigation found that the driver of an external contractor’s vehicle had failed to correctly route to the parallel runway which was closed overnight for maintenance but had not realised this until he saw the lights of an approaching aircraft.
Dated: March 2018
Aircraft operators need to recognise the need for risk management of circling approaches
On 29 June 2009, an aircraft making a dark-night visual circling approach to Moroni crashed into the sea and was destroyed. The Investigation found that the final impact had occurred with the aircraft stalled and in the absence of appropriate prior recovery actions and that this had been immediately preceded by two separate GWPS ‘PULL UP’ events. It was concluded that the attempted circling procedure had been highly unstable with the crew’s inappropriate actions and inactions probably attributable to their becoming progressively overwhelmed by successive warnings and alerts caused by their poor management of the aircraft’s flight path.
Dated: February 2018
Mid-air collision risk is increased by the increasing accuracy of automated navigation systems
On 5 September 2015, an aircraft cruising as cleared at FL350 collided with an opposite direction aircraft which had been assigned and acknowledged altitude of FL340. The first aircraft continued to destination with winglet damage but radio contact with the second aircraft was lost and it was subsequently radar-tracked maintaining FL350 and continuing westwards past its destination Dakar for almost an hour before making an uncontrolled descent into the sea. The Investigation found that this aircraft had a recent history of un-rectified altimetry problems which prevented TCAS activation.
Dated: February 2018
SKYclip – Readback Hearback
The latest safety promotion animation from EUROCONTROL focuses on Readback Hearback.
Dated: February 2018
Crews need to be aware of and apply winter ops SOPs
On 1 February 2015, an aircraft departed from Pamplona with slush on the runway. On landing at Madrid, the normal operation of the brake units was compromised by ice and one tyre burst damaging surrounding components and leaving debris on the runway. The Investigation concluded that the Pamplona apron, taxiway and runway had not been properly cleared of frozen deposits and that the flight crew had not followed procedures appropriate for the prevailing conditions.
Dated: February 2018
Transport Canada has issued an update on its investigation into the December 2017 crash at Fond-du-Lac
On 13 December 2017, an aircraft crashed shortly after making a night take-off from Fond-du-Lac. The aircraft was destroyed by the impact but there was no fire and only one subsequent fatality amongst the occupants. The Investigation is ongoing but preliminary information has been released which confirms that both engines were operating at impact and that a significant wreckage path through trees led up to the impact site.
Dated: January 2018
Potential head on collision averted
On 3 May 2017, two aircraft lost prescribed separation whilst tracking in opposite directions on a radar-controlled ATS route in eastern Myanmar close to the Chinese border. The Investigation found that the response of a crew to a call for another aircraft went undetected and they descended to the same level as another aircraft with the lost separation only being mitigated by intervention from the neighbouring Chinese ACC which was able to give an avoiding action turn.
Dated: January 2018
Final Call for submissions for the 2018 Safety Forum
The deadline for submissions for the 2018 Safety Forum “Safety Behaviours” is 31 January 2018. If you would like to submit a poster or presentation, then please do so now.
Dated: January 2018
The importance of commencing a go around when the previously acquired visual reference is lost
On 7 July 2014, an aircraft landing at Brunei departed the side of the runway almost immediately after touchdown. The Investigation concluded that the aircraft commander, having taken over control from the First Officer when the latter lost their previously-acquired prescribed visual reference below Decision Altitude, had then continued the approach without recognising that the only lights still visible to him were those at the right hand edge of the runway.
Dated: January 2018
The challenge of managing the risks of intersecting runway operations
On 5 October 2016, an aircraft took off at night without clearance as another aircraft was about to touch down on an intersecting runway. The landing aircraft responded promptly to the ATC go-around instruction and passed over the intersection after the other aircraft had accelerated through it during its take-off roll.
Dated: January 2018
Big fuel fed fire? – Evacuate!
On 27 June 2016, an aircraft returned to Singapore when what was initially identified as a suspected right engine oil quantity indication problem evidenced other abnormal symptoms relating to the same engine. The engine caught fire on landing. The substantial fire was quickly contained and an emergency evacuation was not performed.
Dated: January 2018
HindSight 26
The latest edition of EUROCONTOL’s aclaimed safety magazine is titled “safety at the interfaces” and focuses on successful collaboration between functions, departments, professions, and organisations.
Dated: December 2017
So you have a Safety Management System but is it effective?
On 24 February 2015, the crew of an aircraft continued an already unstable approach towards a landing despite losing sight of the runway as visibility deteriorated in blowing snow. The aircraft touched down approximately 140 metres before the start of the paved surface. The continued unstable approach was attributed by the Investigation to “plan continuation bias” compounded by “confirmation bias”. It was also found that although the aircraft operator had had an approved SMS in place for almost six years, it had not detected that approaches made by the aircraft type involved were routinely unstable.
Dated: December 2017
SOPs are there for a reason
On 6 April 2016, an aircraft overran the runway at Gällivare after a bounced night landing. The Investigation concluded that after a stabilised approach, the handling of the aircraft just prior and after touchdown, which included late and inappropriate deployment of the thrust reversers, was not compatible with a safe landing in the prevailing conditions, and that the crew briefing for the landing had been inadequate.
Dated: December 2017
Overrun avoidance means landing in the TDZ and immediate deceleration to taxi speed
On 5 June 2015, an aircraft landed long on a wet runway at Montréal and the crew then misjudged their intentionally-delayed deceleration because of an instruction to clear the relatively long runway at its far end and were then unable to avoid an overrun. The Investigation concluded that use of available deceleration devices had been inappropriate and that deceleration as quickly as possible to normal taxi speed before maintaining this to the intended runway exit was a universally preferable strategy. It was concluded that viscous hydroplaning had probably reduced the effectiveness of maximum braking as the runway end approached.
Dated: December 2017
Landings in the presence of thunderstorms near the runway present an ongoing risk to aviation safety
On 7 October 2014, an aircraft failed to maintain the runway centreline as it touched down at Montréal in suddenly reduced forward visibility and part of the left main gear departed the runway edge, paralleling it briefly before returning to it and regaining the centreline as the landing roll was completed. The Investigation attributed the excursion to a delay in corrective action when a sudden change in wind velocity occurred at the same time as degraded visual reference. It was found that the runway should not have been in use in such poor visibility without serviceable lighting.
Dated: November 2017
2018 Safety Forum – Call For Submissions
Dated: November 2017
EAPPRI v3.0 Press Release
EUROCONTROL has launched version 3 of the European Action Plan for the Prevention of Runway Incursions.
Dated: November 2017
On a NPA, monitoring the descent profile is not optional
On 29 March 2015, a crew mismanaged the descent during a night non-precision approach at Halifax and continued below MDA without the mandatory autopilot disconnection until, with inadequate visual reference, the aircraft impacted terrain and obstructions 225 metres short of the runway. The aircraft was destroyed but there were no fatalities. The Investigation found that the crew did not monitor their descent against the required vertical profile, as there was no SOP requiring them to do so, and did not recognise in time that a go around was appropriate.
Dated: November 2017
2006 cargo fire was a precursor to later fatal cargo in-flight fire events
On 7 February 2006, an aircraft was destroyed by fire which the Investigation traced to containers which it was suspected but not proved had been loaded with lithium batteries. This historically significant event serves as a reminder that aviation can be slow to respond to a growing safety threat when there are no fatalities and solutions are expensive and/or difficult.
Dated: October 2017
Emergency diversions to airports with less than the normally required AFS cover
On 5 January 2014, an aircraft en route to Singapore at night made an emergency descent and diversion to Baku after a loss of cabin pressure without further event. The Investigation attributed the pressure loss to a fatigue crack in a door. Safety Issues related to diversions to aerodromes with a fire category less than that normally required were also identified.
Dated: October 2017
Save the Date – 2018 Safety Forum on Safety Behaviours
From 1200 on Tuesday 29th May until 1500 on Wednesday 30th May 2018, safety behaviours will be the single operational issue addressed by the 6th Annual Safety Forum presented by the Flight Safety Foundation, EUROCONTROL and the European Regions Airline Association.
Dated: October 2017
Landing without ATC Clearance
The latest safety promotion animation focuses on the risk of aircraft landing without clearance.
Dated: October 2017
Willie Walsh will be the keynote speaker at IASS
Willie Walsh, chief executive of International Airlines Group (IAG), will be the keynote speaker at Flight Safety Foundation’s 70th annual International Air Safety Summit (IASS), scheduled for Oct. 23-25 in Dublin, Ireland. Walsh will open the three-day IASS 2017 on Monday morning, Oct. 23.
Dated: October 2017
The importance of using the compass to confirm you are on the correct taxiway…
On 7 December 1983, an aircraft taking off from Madrid in thick fog collided at high speed with an aircraft which did not follow its departure taxi clearance to the beginning of the same runway. This “classic” runway incursion event was a precursor to the tragedy at Linate many years later.
Dated: October 2017
SKYclip: Landing without clearance
Posted: October 2017
Hypoxia can creep up on you… learn the warning symptoms
On 14 August 2005, an aircraft crashed near Grammatiko, Greece following the incapacitation of the crew due to Hypoxia. Many of the lessons are still relevant today.
Dated: September 2017
Simultaneous Approaches to Parallel Runways
When centrelines are spaced by 9000′ or less, special procedures must be put in force to help preclude Loss of Separation between aircraft conducting simultaneous approaches.
Dated: September 2017
SKYclip – TCAS: Follow the RA
The latest safety promotion animation focuses on the need to follow the TCAS RA at all times.
Dated: September 2017
Inappropriate response to engine malfunction
On 4 February 2015, an aircraft crashed into the Keelung River in central Taipei shortly after taking off from nearby Songshan Airport after the crew mishandled a fault on one engine by shutting down the other in error. The Investigation found that the initial engine fault occurred before getting airborne and should have led to a low-speed rejected take-off.
Dated: August 2017
Tired crew, commercial pressure, night visual approach, inoperative GPWS and “black hole” effect ends in CFIT
On 5 August 2001, an aircraft with an inoperative GPWS making a night approach to Narsarsuaq by visual reference impacted terrain 4.5 nm from the aerodrome. A classic example of the ‘black hole’ effect.
Dated: August 2017
70th International Air Safety Summit (IASS)
Organized by Flight Safety Foundation and Hosted by Aer Lingus, this year’s IASS will be held in Dublin, 23-25 October 2017. This event brings together the best minds in the industry from 50+ countries to exchange information and propose new directions for making the safest mode of transportation even safer. Topics at this year’s summit include somatogravic illusions, human factors, data, remotely piloted aircraft systems, and a special maintenance and engineering track session.
Dated: August 2017
Experienced captain intentionally penetrates a line of mature thunderstorms…
On 5 September 2014, the crew of an aircraft encountered a more continuous area of convective activity en-route than expected. When it became impossible to see a way to continue through it, the aircraft commander requested, received and actioned flight path advice from the Company flight-following function. This led to the penetration of a mature thunderstorm and several minutes of severe turbulence with aircraft control lost and only regained upon exit from the storm. The Investigation found that the weather avoidance advice was based on an inappropriate source and that following it was an inappropriate command decision.
Dated: August 2017
Attempted take-off from a taxiway parallel to the departure runway not reported by Captain
On 12 July 2015, an aircraft deviated from its acknowledged clearance and lit-centreline taxiway routing and began take-off from a parallel taxiway in good night visibility, crossing a lit red stop bar in the process. When ATC observed this, the aircraft was instructed to stop which was achieved without further event. A subsequent take-off was uneventful. The crew did not report the event to their airline or their State authorities because the Captain “determined that this case did not need to be reported” and these organisations only became aware when subsequently contacted by the Investigating Agency.
Dated: August 2017
An example of the challenges of controlling aircraft in E Class airspace
On 7 July 2015, a mid-air collision occurred between a military jet and a light aircraft in VMC in Class E airspace. The investigations conducted noted the limitations of see-and-avoid and attributed the accident to the failure of the radar controller working the military aircraft to provide appropriate timely resolution of the impending conflict.
Dated: July 2017
2017 Safety Forum outputs
Videos and slide packs of the presentations from the Preventing Runway Collisions Safety Forum have been published on SKYbrary, along with the Findings, Strategies and Action Opportunities.
Dated: July 2017
70th International Air Safety Summit (IASS)
Organized by Flight Safety Foundation and Hosted by Aer Lingus, this year’s IASS will be held in Dublin, 23-25 October 2017. This event brings together the best minds in the industry from 50+ countries to exchange information and propose new directions for making the safest mode of transportation even safer. Topics at this year’s summit include somatogravic illusions, human factors, data, remotely piloted aircraft systems, and a special maintenance and engineering track session.
Dated: July 2017
Organisations must have in place procedures which deter habitual consumption of alcohol by staff on safety critical duties
On 20 October 2014, an aircraft taking off at night from Moscow Vnukovo collided with a snow plough, which had entered the same runway without clearance, shortly after rotation. Control was lost and all occupants died when it was destroyed by impact forces and post crash fire. The uninjured snow plough driver was subsequently discovered to be under the influence of alcohol.
Dated: July 2017
“Unintentional interruption of Air Traffic Service” leads to airborne conflict
On 30 June 2015 the crew of an aircraft failed to notice that their transponder had reverted to Standby. The subsequent collision risk was significantly worsened by a muddled and inappropriate ATC response.
Dated: July 2017
HindSight 25
The latest edition of EUROCONTROL’s safety magazine is focused on the potential gap between work-as-imagined and work-as-done.
Dated: June 2017
An example of the risks of operating into runways which require visual circuits constrained by terrain
On 2 December 2010, a crew briefly lost control of their aircraft after encountering a microburst and came very close to both the sea surface and a stall when turning onto night visual final at Svolvær during an otherwise uneventful circling approach.
Dated: June 2017
A very rare case of a pilot retracting the landing gear at V1
On 30 September 2015, the First Officer on an aircraft selected the gear up without warning as the Captain was in the process of rotating the aircraft for take-off. The aircraft settled back on the runway wheels up and eventually stopped near the end of the runway having sustained severe damage.
Dated: June 2017
Controller Blind Spot a SKYclip
This month’s safety promotion animation focuses on controller “blind spot”.
Dated: June 2017
Startle Effect
Startle effect can be defined as an uncontrollable, automatic reflex that is elicited by exposure to a sudden, intense event that violates a pilot’s expectations.
Dated: June 2017
Rules of Thumb
Used correctly, rules of thumb (sometimes know as “heuristics”) can assist significantly in pilot decision making and understanding.
Dated: June 2017
When sight of a previously visible runway is lost… change the plan
On 14 April 2015, a night RNAV(GNSS) approach to Hiroshima was continued below minima without the prescribed visual reference and subsequently touched down 325 metres before the runway after failing to transition to a go around initiated from a very low height. The aircraft sustained extensive damage and 28 of the 81 occupants sustained minor injuries.
Dated: May 2017
A severe case of “plan continuation bias”
On 31 July 2015 an aircraft on a private flight continued an unstabilised day visual approach and touched down with excess speed with almost 70% of the available landing distance behind the aircraft. It overran and was destroyed by impact damage and fire and all occupants died.
Dated: May 2017
The intentional pointing of laser beams at aircraft is not illegal in all countries
On 5 September 2015, an aircraft was about to commence descent on final approach at Porto when a green laser was directed at the aircraft. The Pilot Flying responded rapidly by shielding his eyes and was unaffected but the other pilot looked up, sustained flash blindness and “crew coordination was compromised”. Subsequently, the approach became unstable and a go around to an uneventful approach to the reciprocal runway direction was completed.
Dated: May 2017
Separation minima may not always provide adequate protection against wake turbulence in trail
On 29 April 2014, an aircraft being operated in accordance with ATC instructions in smooth air conditions suddenly encountered an unexpected short period of severe turbulence which led both members of the cabin crew to fall and sustain injury, one a serious injury. The Investigation concluded that the turbulence encountered was due to an encounter with the descending wake vortex of a preceding aircraft.
Dated: April 2017
Knowing that a runway is closed, would you not question a clearance to take off from it?
On 7 January 2016, an aircraft was inadvertently cleared by ATC to take off on a closed runway. The take-off was commenced with a vehicle visible ahead at the runway edge. Investigation attributed the controller error to “lost situational awareness” and noted that the pilots had, on the basis of the take-off clearance, crossed a lit red stop bar to enter the runway without explicit permission.
Dated: April 2017
Complete lack of situational awareness and failure of monitoring at a self evidently critical stage of flight
On 28 April 2014, an aircraft making a precision radar approach in IMC began descent from 1,000 feet QNH at 6nm from touchdown with the autopilot engaged and continued it until successive EGPWS ‘PULL UP’ Warnings occurred. Minimum recorded radio height was 242 feet with neither the sea nor the runway in sight.
Dated: April 2017
Preliminary Report released into 16th January crash at Bishkek
On 16 January 2017, the crew of a cargo aircraft failed to successfully complete an auto-ILS Cat 2 approach and the aircraft crashed and caught fire, killing the occupants and many more on the ground. The ongoing investigation has found that although the ILS localiser was captured and tracked normally, the aircraft remained above the glideslope throughout and flew overhead the runway before crashing just beyond it after initiation of a go around at DH was delayed. No evidence of relevant airworthiness issues has yet been found.
Dated: April 2017
The importance of monitoring operating standards by the effective use of OFDM
On 21 December 2015, a crew continued a significantly unstable approach which included prolonged repetition of ‘High Speed’ and a series of EGPWS Alerts which were both ignored and which culminated in a high speed late touchdown which ended in an overrun. The Investigation noted the systemic lack of any effective oversight of pilot operating standards.
Dated: April 2017
Tailstrike is an unappreciated risk on some aircraft types
On 5 March 2013, the aft-stationed cabin crew of an aircraft on a scheduled international passenger flight from Chicago O’Hare to Munich advised the flight crew that they had heard “an unusual noise” during take-off. Noting that nothing unusual had been heard in the flight deck and that there were no indications of any abnormal system status, the Captain decided that the flight should be completed as planned. The flight proceeded uneventfully but on arrival in Munich, it became clear that the aircraft had sustained “substantial damage” due to a tail strike on take-off and was unfit for flight.
Dated: March 2017
On some aircraft types, excessive reverse thrust can lead to rudder blanking and loss of directional control on a contaminated runway
On 5 March 2015 an aircraft veered off a snow-contaminated runway soon after touchdown after the experienced flight crew applied excessive reverse thrust and thus compromised directional control due to rudder blanking, a known phenomenon affecting the aircraft type.
Dated: March 2017
A case study of how ACAS II works
On 26 May 2013, an aircraft in Swiss Class ‘C’ airspace received a TCAS ‘Level Off’ RA against a 737 above after being inadvertently given an incorrect climb clearance by ATC. The opposing higher-altitude 737 began a coordinated RA climb from level flight and this triggered a second conflict with another 737 also in the cruise 1000 feet above which resulted in coordinated TCAS RAs for both these aircraft. Correct response to all RAs resulted in resolution of both conflicts.
Dated: March 2017
Sensory Illusions a SKYclip
This month’s safety promotion animation focuses on sensory illusions.
Dated: March 2017
Final report into Shoreham air disaster makes significant recommendations regarding regulation of air displays
The UK AAIB has published its final report into the August 2015 accident involving a Hunter T7 at the Shoreham air show. The comprehensive report is accompanied by an animation of accident manoeuvre.
Dated: March 2017
2017 Safety Forum – Agenda
The Agenda for this year’s Safety Forum (6-7 June 2017), which will focus on prevention of runway collisions, has now been published.
Dated: March 2017
A cautionary tale about the safety of protective breathing equipment
On 4 October 2014, the fracture of a hydraulic hose during a pushback was followed by dense fumes in the form of hydraulic fluid mist filling the aircraft cabin and flight deck. The aircraft was towed back onto stand and an emergency evacuation completed. During the return to stand, a PBE unit malfunctioned and caught fire when one of the cabin crew attempted to use it, which prevented use of the exit adjacent to it for evacuation.
Dated: February 2017
Rag left in aircraft caused safety issue with flight critical system
On 7 June 2013, stabiliser trim control cable, pulley and drum damage were discovered on an aircraft undergoing scheduled maintenance. The Investigation found the damage to have been due to a rag which was found trapped in the forward cable drum windings and concluded that the integrity of the system had been compromised over an extended period. The rag was traced to a specific maintenance facility.
Dated: February 2017
Plan Continuation Bias
On 29 October 2011, an aircraft on approach to Christchurch during the aircraft commander’s annual route check as ‘Pilot Flying’ continued significantly below the applicable ILS minima without any intervention by the other pilots present before the approach lights became visible and an uneventful touchdown occurred. A Safety Recommendation was made to the Regulator concerning the importance of effective management of pilot check flights.
Dated: February 2017
A safe and event free departure starts with a thorough pre-flight briefing
On 3 July 2014, an aircraft departing Houston came within 200 feet vertically and 0.61nm laterally of another aircraft after climbing significantly above the Standard Instrument Departure Procedure (SID) stop altitude of 4,000 feet believing clearance was to FL310. The crew responded to ATC avoiding action to descend and then disregarded TCAS ‘CLIMB’ and subsequently LEVEL OFF RAs which followed. The Investigation found that an inadequate departure brief, inadequate monitoring by the augmented crew and poor communication with ATC had preceded the SID non-compliance and that the crew should have followed the TCAS RAs issued.
Dated: January 2017
HindSight Magazine – Call for Articles
Articles are now being sought for the next edition of HindSight magazine which will address the topic of “Work-as-imagined and Work-as-done”.
Dated: January 2017
2017 Safety Forum – Call for submissions
The 5th Annual Safety Forum, 6-7 June 2017, will be looking at Preventing Runway Collisions to see how industry can work together and support global safety improvement. The Organising Committee invites submissions to present as a Speaker or via a Poster.
Dated: January 2017
Parallel use of local language reduces situational awareness for crews that don’t speak that language
On 25 May 2000 a UK-operated aircraft waiting for take-off at night at Paris CDG, on a taxiway angled in the take-off direction, was given a conditional line up clearance by a controller who had erroneously assumed without checking that it was at the runway threshold. After an aircraft which had just landed had passed, the aircraft began to line up unaware that another aircraft had just been cleared in French to take off from the full length and a collision occurred.
Dated: January 2017
Helicopter loss of control event linked to bearing failure in tailrotor
The UK AAIB has issued a Special Bulletin with initial findings and safety actions related to a loss of control event involving a helicopter landing on a North Sea platform on 28 December 2016.
Dated: January 2017
Comprehensive failure to pay attention to various relevant SOPs
On 25 August 2013, the type-experienced crew of an aircraft operating with one thrust reverser locked out made a late touchdown with a significant but allowable tail wind component present and overran the end of the runway. The Investigation concluded that the aircraft had been configured so that even for a touchdown within the TDZ, there would have been insufficient landing distance available. The flight crew were found not to have followed a number of applicable operating procedures.
Dated: January 2017
HindSight 24
The latest edition of EUROCONTROL’s safety magazine is dedicated to the prevention of runway collisions.
Dated: December 2016
Dangerous goods in checked baggage is an enduring safety challenge
On 7 October 2013 a fire was discovered in the rear hold of an aircraft shortly after it had arrived at its parking stand after an international passenger flight. The fire was eventually extinguished but only after substantial fire damage had been caused to the hold. The subsequent Investigation found that the actions of the flight crew, ground crew and airport fire service following the discovery of the fire had all been unsatisfactory. It also established that the source of the fire had been inadequately packed dangerous goods in passengers checked baggage on the just-completed flight.
Dated: December 2016
In electrically sourced fires, switching off the circuit is an immediate obvious action
On 5 June 2015, a DHC8-200 descending towards Bradley experienced an in-flight fire which originated at a windshield terminal block. Attempts to extinguish the fire were unsuccessful with the electrical power still selected to the circuit. However, the fire eventually stopped and only smoke remained. An emergency evacuation was carried out after landing.
Dated: December 2016
2017 Safety Forum – Call for submissions
The 5th Annual Safety Forum, 6-7 June 2017, will be looking at Preventing Runway Collisions to see how industry can work together and support global safety improvement. The Organising Committee invites submissions to present as a Speaker or via a Poster.
Dated: December 2016
The importance of avoiding unnecessary distractions prior to door closure
On 1 October 2013, an aircraft took off from a runway intersection at Porto which provided 1900 metres TORA using take off thrust that had been calculated for the full runway length of 3480 metres TORA. It became airborne 350 metres prior to the end of the runway but the subsequent Investigation concluded that it would not have been able to safely reject the take-off or continue it, had an engine failed at high speed. The event was attributed to distraction and the inappropriate formulation of the operating airline’s procedures for the pre take-off phase of flight.
Dated: December 2016
Conditional Clearances, a SKYclip
SKYclip: 1 aviation safety topic in 2 minutes.
This month’s safety promotion animation focuses on Conditional Clearances.
Dated: November 2016
A bird strike to the wing can make an aircraft un-flyable
An event which highlights the need for operators of small aircraft to assess the risk of large bird strikes at lower altitudes and fly at speeds which will put any airframe impact within the certification limits.
Dated: November 2016
Uncontained engine failure on take off roll
On 28 October 2016, an aircraft made a high speed rejected take off after a catastrophic and uncontained failure of the right engine. A successful emergency evacuation of the 170 occupants was completed as a major fuel-fed fire destroyed the failed engine and caused substantial damage to the aircraft structure. An NTSB investigation is taking place.
Dated: November 2016
Black hole situations
On 31 May 2013 the crew of a helicopter took off VFR into a dark night environment and lost control as a low level turn was initiated and did not recover. The Investigation found that the crew had little relevant experience and were not “operationally ready” to conduct a night VFR take off into an area of total darkness. Significant deficiencies at the Operator and in respect of the effectiveness of its Regulatory oversight were identified as having been a significant context for the accident.
Dated: November 2016
Save the Date – 2017 Safety Forum – Preventing Runway Collisions
From 12:00 on Tuesday 6 June until 15:00 on Wednesday 7th June 2017, PREVENTING RUNWAY COLLISIONS will be the single operational issue addressed by the 5th Annual Safety Forum presented by the Flight Safety Foundation, EUROCONTROL and the European Regions Airline Association.
Dated: November 2016
The critical importance of a full and free check of the elevators at some point prior to take off…
On 2 October 2015, the crew of a military transport aircraft attempted to depart Jalalabad without being aware that a hard shell NVG case was in place behind one of the control columns. It had been put there to keep the elevator in an up position during engines-running offloading of tall cargo at the rear. The aircraft stalled and impacted terrain 28 seconds after getting airborne.
Dated: November 2016
Callsign Confusion, a SKYclip
SKYclip: 1 aviation safety topic in 2 minutes.
This month’s safety promotion animation focuses on callsign confusion.
Dated: November 2016
Clearances for Departing and Arriving Aircraft
Amendment 7-A to PANS-ATM, is applicable from 10 November 2016 and includes changes to harmonised phraseology for issuing standard clearances to arriving and departing aircraft, including clearances to aircraft on a SID or STAR.
Dated: November 2016
The importance of using engine anti-icing proactively…
In the early hours of 24 July 2014, an aircraft crashed in northern Mali whilst en route in the vicinity of severe convective activity associated with the ITCZ. Initial findings of the continuing Investigation include that after indications of brief but concurrent instability in the function of both engines, the thrust to both simultaneously reduced to near idle and control of the aircraft was lost.
Dated: November 2016
The risk associated with requesting (or accepting) intersection departures which have not been fully prepared for
On 6 October 2014, a crew requested, accepted and continued with an intersection take off but failed to correct the takeoff performance data previously entered for a full length take off. Recognition of the error and application of TOGA enabled completion of the take-off but the Investigation concluded that a rejected take off from high speed would have resulted in an overrun.
Dated: October 2016
Many defensive barriers can be successively breached in the take off/missed approach conflict scenario
On 2 September 2013, an aircraft crew were not instructed to go around from their approach by ATC as it became increasingly obvious that another aircraft departing the same runway would not be airborne in time for a landing clearance to be issued. They initiated a go around over the threshold and then twice came into conflict with the departing aircraft as both climbed on similar tracks without ATC de-confliction, initially below the height where TCAS RAs are functional.
Dated: September 2016
Blind Spots – Inefficient conflict detection with closest aircraft
“Blind Spot” is a type of human error. Unlike other uses of the term, in air traffic control it refers to the failure to detect a problem (conflict) right in middle of the controller’s field of view.
Dated: September 2016
HindSight 24 – Call for Articles
Contributions are now being invited for the next edition of HindSight which will focus on Preventing Runway Collision.
Dated: September 2016
69th annual International Aviation Safety Summit
This year’s IASS takes place in Dubai, UAE and is hosted by Emirates.
Dated: September 2016
The importance of maintaining situational awareness when on radar vectors to approach
On 31 May 2013, an aircraft was established on the ILS LOC in day IMC with the AP and A/T engaged and APP mode selected but above the GS, when the aircraft suddenly pitched up and stick shaker activation occurred. After a sudden loss of airspeed, the crew recovered control manually and the subsequent approach was completed without further event.
Dated: August 2016
Flight data monitoring can be a means to inform maintenance intervention
On 12 December 2011, the crew of an aircraft delayed their response to an engine fire warning until the existence of a fire had been confirmed by visual inspection and then failed to follow the memory engine shutdown drill properly so that fire continued for considerably longer than it should have. The Investigation found that an improperly tightened fuel line coupling which had been getting slowly but progressively worse during earlier flights had caused the fire.
Dated: August 2016
Importance of correct use of manual tilt in order to detect and avoid significant areas of ice crystals
On 3 February 2013, a crew in the cruise in equatorial latitudes at FL340 in IMC failed to use their weather radar properly and entered an area of ice crystal icing outside the prevailing icing envelope. A short period of unreliable airspeed indications on displays dependent on the left side pitot probes followed with a brief excursion above FL340 and reversion to Alternate Law.
Dated: August 2016
A violation of minima with predictable results…
On 14 August 2012, a crew continued an approach below the prescribed MDA without having acquired the prescribed visual reference. The aircraft was then damaged by a high rate of descent at the initial touchdown in the undershoot in fog. The occurrence was not reported by either the crew or the attending licensed engineer who discovered consequent damage to the aircraft.
Dated: July 2016
A safety success story.
On 16 November 2012, Captain of an aircraft positioning for approach to Abu Dhabi at night became incapacitated due to a stroke. The First Officer took over control and declared a MAYDAY to ATC. The subsequent approach and landing were uneventful but since the First Officer was not authorised to taxi the aircraft, it was towed to the gate for passenger disembarkation.
Dated: July 2016
Automation accuracy should not be seen as a “safety enabler” for violation
On 4 March 2015, the crew of an aircraft continued an automatic non precision RNAV approach below the prescribed minimum descent altitude without having obtained any element of visual reference and when this was acquired a few seconds before the attempted landing, the aircraft was not aligned with the runway centreline and the left main gear touched down on the grass. The aircraft then left the runway completely before stopping with a collapsed nose gear and sufficient damage to be assessed a hull loss.
Dated: July 2016
2016 Safety Forum Report, presentations and videos
The Findings, Strategies and Action Opportunities from the 2016 Safety Forum have now been published. The Report along with copies of presentations and videos can now be accessed through SKYbrary.
Dated: June 2016
HindSight 23
The latest edition of EUROCONTROL’s acclaimed safety magazine focuses on situational awareness.
Dated: June 2016
Controller Detection of Manoeuvring Area Conflicts
This article describes the typical scenarios for runway conflicts not being timely detected as well as the safety barriers that could prevent such situations or mitigate the consequences.
Dated: June 2016
Understanding how directional control of an aircraft is achieved during a crosswind take off
On 2 January 2015, the commander of an aircraft suddenly lost directional control during a within-limits crosswind take off and the aircraft left the runway onto grass at approximately 80 knots. The Investigation concluded that the most likely explanation for the excursion was the absence of any rudder input as the aircraft accelerated.
Dated: June 2016
The potential hazard of IFR flight in Class “E” airspace
On 3 September 2014 in Class ‘E’ airspace, a light aircraft carrying out a spin recovery exercise in day VMC came very close to an aircraft climbing out of Sault Ste. Marie. Although the crew had seen the light aircraft ahead and above and temporarily levelled off, the light aircraft then began “a rapid descending turn” and a TCAS RA ‘Descend’ followed. It was judged that a turn would also be necessary but even with this, the two aircraft subsequently passed within 350-450 feet at the same altitude in opposite directions.
Dated: May 2016
The importance of adequately securing heavy loads…
On 29 April 2013, a freighter departed controlled flight and impacted terrain shortly after taking off from Bagram and was destroyed by the impact and post crash fire. The Investigation found that a sudden and significant load shift had occurred soon after take off, moving the centre of gravity aft and out of the allowable flight envelope. The Load shift was attributed to the ineffective securing techniques employed.
Dated: May 2016
An example of how not, and when not, to fly a visual approach
On 4 August 2014, an aircraft making a day visual approach at Fort McMurray after receiving an ILS/DME clearance lined up on a recently-constructed parallel taxiway and its crew were only alerted to their error shortly before touchdown, a go around being commenced from 46 feet agl. The Investigation noted that both pilots had been looking out during the final stages of the approach and had ignored important SOPs including that for a mandatory go around from an unstable approach.
Dated: April 2016
Final report published on Germanwings crash in March 2015
The BEA has published the final report into its investigation of the 24 March 2015 event when a pilot intentionally crashed an aircraft into the Alps. The Report has been published in the English, French, German and Spanish languages.
Dated: April 2016
Mountain waves and severe icing – a dangerous combination…
On 3 October 2014, the crew of an aircraft did not recognise that severe icing conditions had been encountered early enough to make a fully-controlled exit from them and although recovery from the subsequent stall was successful, it was achieved “in a non-standard manner”.
Dated: April 2016
UK civil air display review: final report Shoreham air disaster of August 2015
The UK CAA has published the final report of its review into civil air displays which followed the Shoreham air disaster of August 2015.
Dated: April 2016
An event which demonstrates how important it is to be prepared and able to respond to the unexpected…
On 4 December 2003, the crew of an aircraft approaching Bodø lost control of their aircraft after a lightning strike which temporarily blinded both pilots and damaged the aircraft such that the elevator was uncontrollable. After regaining partial pitch control using pitch trim, a second attempt at a landing resulted in a semi-controlled crash which seriously injured both pilots and damaged the aircraft beyond repair.
Dated: April 2016
Pilot inaction due to the effects of “startle” at unexpected engine failure?
On 7 October 2012, a pilot lost control of their aircraft shortly after take off from Antigua when the right engine stopped due to the presence of water in the corresponding fuel tank. The reason why the pilot had been unable to keep control of the aircraft was not explained.
Dated: April 2016
Ask yourself – is the runway visual perspective what I would expect at this point on the approach?
On 8 March 2013, the crew of an aircraft descended below controlled airspace and to within 600 feet agl when still 9nm from the landing runway at Melbourne after mismanaging a visual approach flown with the AP engaged. An EGWS Terrain Alert was followed by an EGPWS PULL UP Warning and a full recovery manoeuvre was flown. The Investigation found degraded situational awareness had followed inappropriate use of Flight Management System.
Dated: March 2016
2016 Safety Forum Agenda
The organising committee for this year’s Safety Forum have published a draft Agenda. The Safety Forum will focus on the issue of safety nets.
Dated: March 2016
A broad understanding of aircraft systems can inform responses to unexpected situations…
On 26 February 2013, the crew of an aircraft temporarily lost full control of their aircraft on a night auto-ILS approach at Keflavik when an un-commanded roll occurred during flap deployment after an earlier partial loss of normal hydraulic system pressure. The origin of the upset was found to have been a latent fatigue failure of a roll spoiler component, the effect of which had only become significant in the absence of normal hydraulic pressure and had been initially masked by autopilot authority until this was exceeded during flap deployment.
Dated: March 2016
Flying a non-standard circling approach in IMC and ignoring EGPWS warnings has a predictable outcome…
On 28 July 2010, the crew of an aircraft lost contact with the runway at Islamabad during a visual circling approach and continued in IMC outside the protected area and flying into terrain after repeatedly ignoring EGPWS Terrain Alerts and PULL UP Warnings. The Investigation concluded that the Captain had pre-planned a non-standard circuit which had been continued into IMC and had then failed to maintain situational awareness, control the aircraft through correct FMU inputs or respond to multiple EGPWS Warnings. The inexperienced First Officer appeared unwilling to take control in the absence of corrective action by the Captain.
Dated: February 2016
Be aware of the downdraft hazard in areas of uneven terrain…
On 2 December 2010, the crew of an aircraft briefly lost control of their aircraft after encountering a severe downdraft and coming very close to the sea surface and to a stall on visual finals to Svolvær at night at the end of an otherwise uneventful circling approach. After a subsequent recovery from 83 feet agl, a diversion to an alternate airport was made
Dated: February 2016
Importance of having clear procedure for rapid disembarkation when airbridges still attached
On 28 July 2013, with passengers still boarding an aircraft, an abnormal ‘burnt’ smell was detected by the crew and then thin smoke appeared in the cabin. A MAYDAY was declared and the Captain made a PA telling the cabin crew to “evacuate the passengers via the doors, only via the doors”. The resulting evacuation process was confused but eventually completed. The Investigation attributed the confused evacuation to the way it had been ordered and established that a fault in the APU had caused the smoke and fumes which had the potential to be toxic.
Dated: February 2016
ASDE is an effective Safety Net… if used
On 29 March 2014, a light aircraft being taxied by maintenance personnel at Calgary entered the active runway without clearance in good visibility at night as an aircraft was taking off. The 737 passed safely overhead. The Investigation found that the taxiing aircraft had taken a route completely contrary to the accepted clearance and that the engineer in control of the aircraft had not received any relevant training. Although the airport had ASDE in operation, a transponder code was not issued to the taxiing aircraft as required and stop bar crossing detection was not enabled at the time.
Dated: February 2016
Safety Forum 2016 – Final Call for SubmissionsIf you would like to present at the 2016 Safety Forum in Brussels 7/8 June, submit your presentation proposal by 12 February.
A supporting paper is not needed but abstracts must make it clear what the presentation will be about. The focus of the Safety Forum is Safety Nets.
Dated: February 2016
A good example of how Safety Nets save lives
On 11 April 2012, an aircraft commanded by a Training Captain who was also in charge of Air Operations for the airline was supervising a trainee Captain on a night passenger flight. The aircraft failed to establish on the Lyons ILS and, in IMC, descended sufficiently to activate both MSAW and EGPWS ‘PULL UP’ activations which prompted recovery. The Investigation concluded that application of both normal and emergency procedures had been inadequate and had led to highly degraded situational awareness for both pilots.
Dated: February 2016
Safety Forum 2016 invites you to present
If you would like to present at the 2016 Safety Forum in Brussels 7/8 June, submit your presentation proposal by 12 February.
A supporting paper is not needed but abstracts must make it clear what the presentation will be about. The focus of the Safety Forum is Safety Nets.
Dated: January 2016
The importance of anticipating when a very late go around may become necessary
On 13 December 2013, an aircraft encountered very heavy rain below 100 feet agl just after the autopilot had been disconnected for landing off an ILS approach at Jakarta. The aircraft Commander, as pilot flying, lost visual reference but the monitoring First Officer did not. A go around was neither called nor flown and after drifting in the flare, the aircraft touched down with the right main landing gear on the grass and continued like this for 500 metres before regaining the runway. The Investigation noted that prevailing SOPs clearly required that a go around should have been flown…
Dated: January 2015
HindSight 22 – Safety Nets
The 22nd edition of EUROCONTROL’s safety magazine was published in December 2015 and focuses on the subject of Safety Nets ahead of the 2016 Safety Forum…
Dated: January 2016
A reminder of the potential high fire risk associated with carriage of live oxygen generators
On 6 December 2013, an aircraft was flown from Amman to Dubai with a quantity of ‘live’ boxed chemical oxygen generators on board as cargo without the awareness of the aircraft commander. The subsequent Investigation found that this was possible because of a wholesale failure of the aircraft operator to effectively oversee operational risk implicit in sub contracting heavy maintenance…
Dated: January 2016
Runway excursion highlights organisational and regulatory oversight failings…
On 31 January 2014, an Estonian-operated BAE Jetstream 32 operating a Swedish domestic service landed long at night and failed to stop before the end of the runway.
Dated: December 2015
How can we ensure that an augmenting crew member truly adds value?
On 22 December 2013, an aircraft taxiing for departure at Johannesburg at night with an augmented crew failed to follow its correctly-acknowledged taxi clearance and one wing hit a building resulting in substantial damage to both aircraft and building and a significant fuel leak. The accident was attributed to crew error both in respect of an inadequate briefing and failure to monitor aircraft position using available charts and visual reference.
Dated: December 2015
Another incident highlighting the separation issues between departing aircraft and those on a go-around…
On 10 July 2014, an aircraft instructed to go around at Port Elizabeth by ATC came into close proximity with an A320 which had just taken off from the same runway and initiated avoiding action to increase separation. The Investigation concluded that the TWR controller had failed to effectively monitor the progress of the aircraft on final approach before issuing a take off clearance to the A320.
Dated: December 2015
Inability to control aircraft in Alternate Law leads to loss of control…
Indonesian investigators have published their report into the 28 December 2014 accident involving an Air Asia flight from Surabaya to Singapore.
Dated: December 2015
Salt aerosols cause total loss of forward visibility on aircraft operating at low level over the sea…
On 2 January 2014, the crew of an aircraft lost forward visibility due to the accumulation of a thick layer of salt deposits on the windshield whilst the aircraft was being radar positioned to an approach at Cork on a track which took it close to and at times over the sea in the presence of strong onshore winds.
Dated: November 2015
Safety Forum 2016 – Save the Date
Safety Nets will be the single operation issue to be addressed at the 2016 Safety Forum. The Forum will be held in Brussels 7-8 June 2016 and will be co-hosted by Flight Safety Foundation, EUROCONTROL, and European Regions Airline Association
Dated: November 2015
The relationship between operational error and its organisational context…
On 15 March 2008, an aircraft on a non-revenue positioning flight to a private airstrip in mountainous terrain, flown by an inadequately-briefed crew without sufficient guidance or previous relevant experience, impacted terrain under power whilst trying to locate the destination visually after failing to respond to a series of GPWS Alerts and a final PULL UP Warning. Whilst attributing the accident to the crew, the Investigation also found a range of contributory deficiencies in respect of the Operator, official charting and ATS provision and additional deficiencies in the conduct of the unsuccessful SAR activity after the aircraft became overdue.
Dated: November 2015
Aerodrome safety cases need to properly consider the two way function of a taxiway depending on the direction of runway use
On 11 October 2013, the commander of an aircraft taxiing on wet taxiways at night after landing at Zurich became uncertain of his position in relation to the clearance received and when he attempted to manoeuvre the aircraft off the taxiway centreline onto what was believed to be adjacent paved surface, it became bogged down in soft ground.
Dated: November 2015
Failure to remove shipping plugs from components is an old problem…
On 4 April 2012, the cabin pressurisation controller (CPC) on an aircraft failed during the climb. Automatic transfer to the alternate CPC was followed by a loss of cabin pressure control and rapid depressurisation because it had been inadvertently installed with the shipping plug fitted. An emergency descent and diversion followed.
Dated: October 2015
What happens when regulatory oversight fails to detect unsafe practices
On 19 August 2013, a fire occurred in the right engine of an aircraft on take off from Yellowknife. After engine shutdown, a right hand circuit was made in an attempt to land back on another runway but trees were struck and the aircraft crash-landed south of it. Emergency evacuation was successful. The Investigation found that various unsafe practices had persisted despite the regulatory approval of the Operator’s SMS.
Dated: October 2015
Emergency evacuation while attached to airbridge
On 4 November 2013, smoke began to appear in the passenger cabin of an aircraft which had just begun disembarking its 243 passengers via an airbridge after arriving at Montreal. The source was found to be a belt loader in position at the rear of the aircraft which had caught fire. Emergency evacuation using the airbridge only was ordered by the aircraft commander but cabin conditions led to other exits being used too.
Dated: October 2015
The importance of a full runway inspection after any engine failure related Rejected Take Off
On 30 January 2013, the crew of an aircraft successfully rejected its take off at Copenhagen after sudden explosive failure of the left hand engine occurred during the final stage of setting take off thrust. Full directional control of the aircraft was retained and the failure was contained, but considerable engine debris was deposited on the runway.
Dated: October 2015
The added importance of a good controller position handover when something “ad-hoc” is going on
On 22 March 2013, an aircraft inbound to Sion on a VFR clearance was flown into conflict with an IFR aircraft departing the same airport in compliance with its clearance. The prescribed separation between the two aircraft was lost in the vicinity of FL140. The Investigation concluded that an inappropriate ATC tactic had been employed in an attempt to achieve separation.
Dated: September 2015
The “obligation” sometimes felt by management pilots to fly when they shouldn’t
On 24 August 2010, an aircraft made an uncontrolled touchdown on a wet runway after the approach was continued despite not being stabilised. A lateral runway excursion onto the grass occurred before the aircraft regained the runway centreline causing substantial damage to the aircraft. The aircraft commander was the Operator’s Fleet Captain and the Investigation concluded that the length of time he had been on duty had led to fatigue which had impaired his performance.
Dated: September 2015
Got Aviation Safety Questions? Get Answers at IASS 2015.
Flight Safety Foundation’s International Air Safety Summit (IASS) is an opportunity to connect face-to-face with the best minds in aviation safety on issues like simultaneous approach operations, ground safety, and bird strike. Get answers, be informed, and be the best in your organization when it comes to flight safety.
It all happens this November 2-4, 2015 in Miami Beach, Florida, USA.
Dated: September 2015
The risks associated with misleading on smaller non-palletised cargo aircraft
On 19 October 2013, the Captain of an aircraft on a cargo flight taking off from Madang was unable to rotate the aircraft for take off and was forced to reject the take off from above V1. It was not possible to stop on the runway and the aircraft ended up semi submerged in a shallow creek beyond the airfield perimeter. The Investigation has established that the aircraft had not been loaded as instructed and as stated on the load and trim sheet, in particular in respect of the distribution of the load. The Investigation is continuing.
Dated: September 2015
UK AAIB publishing preliminary report on airshow disaster
The UK AAIB published a SPECIAL Bulleting on the 22 August 2015 crash of Hunter during a flying display at Soreham Airport.
Dated: September 2015
Flight Deck Security
This article is intended to specifically highlight the operational flight safety issues associated with flight deck security.
Dated: September 2015
Please refer to the SKYbrary website for any documents prior to this date.