Report: Secondary

RAeS International Annual Flight Crew Training Conference – RAeS Hamilton Place – 27/28 Sept 2011

CE Meeting Summary

Agenda

Full Presentations may be available in due course

KEYNOTE ON POTENTIAL BENEFITS OF CURRENT INITIATIVES- Mark Dransfield, Mechtronix

• Numerous initiatives to improve pilot training underway
• Changes to competency based approach to pilot ab-initio, type and recurrent trg include:
  • MPL
  • ITQI
  • Unusual Attitude Recovery Trg being addressed through the RAeS sponsored Trg In Extended Envelopes (ICATEE)
  • Flt Sim Trg Device Requirements
• Stumbling blocks to these initiatives:
  • Legal constraints
  • Timely adoption
  • Mutual recognition
  • Interpretation
  • Continuous improvements

FIXED WING INITIATIVES

Best Practice and Professionalism – Robert Barnes, International Association Flight Trg Professionals (IAFTP)

• IAFTP formed to identify and share best practice for pilot training
• Ensure every pilot can document their flight experience
• An electronic CV – privately owned
• IAFTP.org website lays out these practices
• Best Practice Training for Pilots
  • Demonstrates the best way to achieve a specific standard
    • ‘Best’ means widely acknowledged
• Complimentary Initiatives
  • ICAO NGAP –competency-based
  • IATA ITQI – performance-based
  • IAFTP
  • How to achieve competency?This is being shared on Skybrary
• Lessons Learnt So Far
  • 70 practices on the website
  • Apparent lack of professionalism
  • Flt Instructor motivation – ‘a sweat shop hours builder’
    • Getting instructors to share is a challenge
    • Most active in IAFTP are retired senior pilots
• To join IAFTP
  • On the website
  • Invitation to share training practice and comment on a trg practice

International Committee for Aviation Training in Extended Envelopes

• Upset recovery due to LOC – main cause of aviation facalities
• LOC increases have increased despite design and training
• Airplane upsets causes include Stall/FCS/SD
• Why? LOC-ITraining assumptions
  • Stall not in the normal envelope for commercial flying
  • Situational Awareness is not good
  • Handling skills in regulation do not address the issue
  • Human psychology – reliable responses
• Definition of upsets include attitude and speed definitions
• Deficiencies in knowledge of all flight envelopes
• Little exposure to the stall region and managing the AOA, unloading the wing, signs of buffet and wing rock
• Insufficient training to deal with startle
  • Upset recovery and prevention of the stall training necessary
• Findings
  • Currently, sims provide most upset training
  • UPST needs specific element training
  • Airplane upset recovery documentation is available
  • Sims are useful but must avoid providing negative training
• ICATEE Training Recommendations
  • Generic skills – academics and initial trg need to be introduced
  • ICATEE Recommendations need to be co-ordinated with the FAA stall/stick pusher WG, which has issued generic stall and approach to stall recommendations with the major ac manufacurers

PABC and Global Professional Pilot Certificate Initiative – Peter Wolfe

• Growing pilot shortage – numbers and quality – threaten air safety and economic future
  • 23,000 pilots needed each year but only 15,000 being produced worldwide
• Pressure to bend the rules to get qualified pilots into commercial cockpits
• Problems will threaten safety andincrease trg cost
• Solutions:
  • ITQI by IATA has identified the need for screening/standards and the need for a statement on skills and competencies for pilots – hence GPPC proposal
• GPPC must:
  • Meet or exceed MPL and ATPL written test exam knowledge requirement
  • Provide a common standard for all new professional pilots
  • Be developed by industry and regulators
  • Test technical and non-technical standards, skill and competency
  • Be managed by an iso-accredited, independent non-profit org
• PABC must prove that GPPC meets or exceeds MPL-ATPL exams
• Must gain Regulator acceptance of the standard in advance
• Benefits include
  • Enhanced safety
  • Supports safety updates in ATPL and MPL
  • Raises standards.
  • Produces test management costs for regulators, recognises best trainers
  • Simplifies licence mobility
  • PABC is able to provide funding for 5/6 regulators to assess GPPC standard equivalence

ROTARY WING CHALLENGES

FLYING TRAINING CHALLENGES – ROTARY WING – Matt Jennings

• Flying environment often not optimised for helicopters – oil rigs, SAR, etc, therefore clearly defined procedures for Rotary Ops are difficult to set
• Helicopter Ops is a fractured industry – single engine, VFR machines
• Only a few large helicopter companies, mostly small independents
  • Access to heli sims is limited for many operators
  • Complex big heli sims are available
• Rear crew are integral to the crew but sims rarely include an integral trg opp
• Sustained reduced rate of accidents in FW but getting worse in RW overall
• Average accident rate – commuter airline 3.0, offshore 5.7, seismic ops 21.9
• Heli pilots are highly skilled but poor decision making is the problem, not flying skills
• Ab-initio heli trg
  • Sims allows heli pilots to test their decision making
  • A generic sim can help train ab-intio pilots and aid learning of the basics early
• Type Specific trg covers:
  • LPC/OPC
  • Systems knowledge handling malfunctions
  • LOFT/CRM
• Mission-Specific trg:
  • Requires a tailored device, syllabus and instruction
  • Military provision available in industry
• Today’s sims are used by med/heavy fleet users for LOFT and type training
• Devices are often FW technology adapted for RW
• Sim costs are important – must be cheaper than the ac to operate and deliver trg
• ICAO Helicopter International WG is working on providing international standards for RW sims to cover the variety of tasks from ab initio to recurrent trg
• Next phase of the work is to develop trg guidelines for heli operators to develop their own mission type trg

SIM DEVELOPMENT AND PURCHASE – REAL CHOICE FOR RW OPERATORS- Tim Rolfe, Bristows

• Long range travel is required to get heli simulator training. Quals can take 3 weeks and cost a great deal
• In 2008, Bristow decided to address this issue.
• Two sims were bought and placed at Aberdeen
• Sim development processing and testing was considerable and took 2 years
• These sims fit the requirement at Aberdeen but is not the answer globally
• A collaborative approach to developing and purchasing sims together for a number of helicopter operators is one valid proposal

RW SIMS AND THEIR USE IN WIDER OPERATIONAL ENVIRONMENT – David Sale, FSI

• Sims offer safety improvement by allowing training in specific skills and emergencies which cannot be provided inreal helicopter due to the risk
• 3D presentation would be very helpful in making training effective – but expensive
• Military has the sim capability to fulfil the total mission and crew involved
  • A sim exercise including rear crew man who had not seen helicopter emergencies before provides vital and relevant trg
  • Decision time available is demonstrated to the crewman and helps crew understanding and method of addressing the emergency actively/collectively
• SAR training is a particular mission that could benefit strongly crew training
• ‘What ifs’ can be practiced safely
• Multicrew procedures can be trained and help with effective team decision making
• Heli tasks such as forestry, wind farms, all need to be worked and trained for
• Many training accidents and hull losses can be stopped through sim use
• Future for sims in the helicopter world is strong and full of potential
• But sim training will need to be developed

DAY 2

REGULATING FLIGHT CREW TRAINING – Randy Babbitt – FAA

• Designing human error out of ac safety is very difficult
• Professionalism is the key area needing focus but can’t be mandated
• Education can be effective and error mitigations can also help address it
• After Colgan, revision of rulemaking qualification for pilots and dispatchers
  • Includes the PNF being intimately involved
  • Baseline minimum hours to get the training required completed
  • Requalification for pilot – stall, upset recovery, flt sim device trg
• Substantial rulemaking task on the FAA
• New methods and technologies for training must also be exploited
• Sophisticated technology is important in scenario building and teaching
• Progress at the FAA after direction received from Congress, post Colgan
  • Flt duty and rest – final rule awaits publishing – 8000 comments received
  • ARC final recommendations issued on 23 May – many recs already accepted
  • Stick pusher and adverse weather report due out in Nov 11
  • Rules for First Officer to operate in CAT due out shortly
• NextGen will be transformational in process, technology and delivery
  • Should be safer, efficient and environmentally sound
  • Incremental delivery not a single switchover
  • Elements of NextGen technology are already coming in
    • ADS/B is here now and benefits are being seen
  • Gulf of Mexico rig airspace is using ADS/B and is showing heli ops savings in time and fuel
  • Alaskan are saving 60 galls on every CDA into Seattle using the NextGen technology

EASA FCL REQUIREMENT AND FUTURE CHALLENGES – Jules Kneepkens

• EASA is an agency of the EU and works for Europe as a whole
• EASA built on EU regs under the EC and Parliament
• A partnership with Member States
• Rulemaking/Certification/Standardisation are its tasks
• Part FCL and Med agreed by EP
  • Flt trg instruction outside the EU is a challenge
  • Trg and experience must match Part FCL
  • Communication by crews with ATC in EU must be assured
  • Ongoing tasks on cruise relief pilots including IR/IMC
• Part ARA and ORA Opinion goes to EP shortly
  • Content is as seen in CRD
  • Requirements for NAAs in ARA
  • Management system now included
• CS for FSTDs for FW and RW
• CS Flt crews and CS sims under development
• Part FCL – common requirements for sailplanes, balloons
• Part Med – new LAPL med cert and Med assessment for cabin crew
• Challenges
  • EU rules are binding
  • National authorities must implement them
  • Transition must be smooth
  • Rule- making(RM) issues will solved as the process proceeds
  • Harmonisation of international flt crew standards required
  • Total system approach
  • Required PBN
  • Shortage of aviation professionals in the future
  • Intro/development of SESAR/NEXTGEN and MPL
• New EU/US Bilat aviation safety agreement
• EASA participation in ICAO NGAP and ITQI

THE CASE FOR CONVERGANCEunder EASA– Andrew Haines CAA

• Dangers of group think to be avoided – need for rigorous approach to risk
• New licences in EASA will be delayed in the CAA
  • Existing JAA will transfer to EASA Part FCL licence as they expire
• Why transfer? – its the law
• Exchange of data is a another key aim of convergence
• Unified convergence campaign needs to be lead by EASA
  • EHEST group demonstrates the advantage of convergence
• Align academic trg with licensing within Civil Aviation
  • Shortage of new entrants means encouragement needs
  • Vocational standards will draw on the requirements
• Flt instruction convergence is important to aid pilots standards and quality
• HF is an increasing focus for the CAA
  • Practical solutions need to be developed from the theory
• Sharing of information is another key element of the convergence aim
• Costs of unnecessary levels of regulations is another priority
• Significant Seven Task forces and the safety plan will drive towards convergence

APPLYING THE SAFETY LESSONS INTERNATIONALLY – David Miller, AAIB

• AAIB is separate from CAA and judiciary but under DFT
• France and Spain AAIB investigations have a judge in parallel which provides challenges
• UK regs are being shortened due to EASA and will impact on the AAIB
  • A Network of Investigators in Europe is being developed
• AAIB is being reduced by 20% over the next 2 years
• There are no new types of accidents or serious incidents
• Recommendations are the major AAIB output and any recommendations must be responded to within 90 days
  • AAIB respond back within 60 days
• In 2008, 70 recs made including 16 crew trg concerns – In 2010, 86 recs made including 21 crew trg concerns-22% of recs cover crew issues on average
• B777 G-YMMM accident had 9 technical safety recs had no flt trg issues
• REDU Super Puma – 27 Recs of which 7 were crew trg issues
  • ELT use, autoflight systems, stab approach, night illusions, height warning response, PNF monitoring
• REDL Super Puma – planet gears and gearbox failure – 17 tech but no crew recs
• Citation at Birmingham – 3 safety recs made for crews
  • Including descend below decision height in IMC
• Thomson partial stallat Bournemouth –1 crew rec on stall recovery
• Crew Recs should NOT be just ‘Fix and Forget’

EASA – USING SAFETY DATA TO BEST EFFECT – John Vincent, EASA

• Promoting basic airmanship from training is a key challenge
• Sharing and protecting safety information is another key issue
• EASp as an important part of the EU Strategy and Programme
• Cork accident was the only fatal in Europe this year so far – nil last year
• Goal should be reduction in the fatal accident rate
• Ideally, there should be
  • Sharing of information
  • Data analysis
  • Disseminate the analysis
  • Few measures of effectiveness
• However, trust is required to the protection of the info
  • Only fragmentary analysis at the moment so more promotion is needed
• Policy for information protection is being formulated
• EASA Internal Gp on Personnel Trg (IGPT) set up in 2010

AIRSPACE MANAGEMENT IN FLT CREW TRG- Dave Curtiss NATS

• Interaction between flightdeck and ATC has diminished in recent years
• Mismatch between understanding of each others environment
• Today’s issues:
  • Procedures to ensure an effective and efficient ATC operation
  • NATS have been working to study the pilot/ATC interface since 2006
  • Human performance is a key risk to be managed
• 122 loss of separation in 2008 due to interface being ineffective
• Now 70% less this year although the following issues remain:
  • TCAS responses – understanding the requirement and process
  • Operational callsign allocation
  • Failure to follow ATC procedures
  • Conflict outside controlled airspace
  • Inappropriate rates of turn/climb/descent
• Prevention Strategy
  • Producing shared safety objectives with shareholders
  • Promote enhanced mutual understanding
  • Educate and align procedures
  • Sharing of safety data
• The Future
  • ATM has been slow to use automation
  • Trajectory prediction is now coming in Europe
  • IFACTS to be introduced to Swanwick
    • trajectory prediction – working 18 mins ahead
    • Med term conflicts displayed to the controller
      • Sep monitor shows the closest point, 15 mins ahead
    • Clearance entry window
  • Two automated systems working together – are we ready and trained?
• Conclusion
  • Are we ready for the future challenges?
  • Need to work together to address the issues
  • Need to train together not in isolation

AN INTERNATIONAL APPROACH TO TRAINING STANDARDS – Sarah Skelton

• 32,000 cabin crew in UK
• Areas of risk:
  • Inappropriate pax behaviour
  • Chronic fatigue
  • Stress
  • Slow onset hypoxia
• Current traing is too ‘tick box’
• Operators want commonly-held approach
• Practical application of behavioural HF is important
• Need to train for the abnormal not just emergency
• Cabin crew must be 18 years old and may become SCM after 12 months
• How do you train CC for the safety issues and occurrences?
• Corporate operator ac with less than 19 pax do not need trained CC
• How do you transfer competency beyond knowledge?
• How many senior cabin crew do loft exercises?
• Recurrent training – debriefing skills training?
• Assertiveness training is now part of the CC training package
• Foreign culture varies and impacts on CC gradients
• How to train effective risk management in a high risk industry to 18/19 year old who is not risk averse?
• Conclusion:
  • Are we expecting too much from our CC?
  • Are we training them enough?
  • Do we support and empower them?

TRAINING THE BASICS – Anthony Petteford Oxford Aviation

• Motivating young people to be pilots is an issue caused by the locked cabin door
• Alternate professions are much more attractive today
• Transfer of responsibility for pilot trg gone from the airline to the student
• Some airlines have made a move back to funding to some extent
• ‘4As’ – appealing, aptitude, affordable, available slots
• Training the basics:
  • Six different regulators have been consulted to discuss new trg ideas
  • Industry now on its third generation of ab-initio pilot courses
    • 1964 – 200 hours (0 sim hours)
    • 1999-195 hours(55 sim hours)
    • 2011-MPL240 hours (155 hours sim)
• Selection of potential pilots is now being introduced
• In training the basics, Oxford seek to install a ‘Safety DNA’ covering 5 points:
  • SMS – understand it from Day 1
  • SOPs – to be followed
  • Safe Altitude – is it safe to do so
  • Stable approach – continue only if you achieve it
  • Say what you think- without fear or barrier
• Oxford also seek to instill a ‘Financial DNA’
  • Fuel – most precious
  • Funding solutions
  • Further training and testing – so we pay
  • Failure in training – so we pay
  • Future- customers are the key
• Innovation
  • MPL course now established with 3 airlines – 54 cadets trainedso far
• Oxford strategy for the future – 4 Rs
  • Recruitment
  • Retention
  • Relevance
  • Risk Reduction
  • Upset Recovery Training is key in Oxford output(8 hours total)

TRAINING PILOTS FOR THE FUTURE – Bob Scott

• Impressive level of safety – but now stubbornly stuck
• Shortage of pilots to come in the near future
• 3 main components have combined to create this shortage
  • system – pilot – accidents
• Pilots and systems are getting more and more complex
• Time available to train has reduced
• Ac now have much redundancy – pilots are system managers
• Max use of automatics leading to loss of skills
  • Remoting the pilot from the operation
• Inadequate training and support system information available
• Little impetus to stimulate further learning
• Equipment is complex and complicated – software based, not hardware
• Linear processes involved in flying in the past have been replaced by complex interactions which are not easily understood by today’s pilots
• Aviation is political and profit driven, is high cost and high profile
• Other challenges for pilots include culture, economics
• Struggle to profitability after economic crises in 2001 and 2008
• Economic mix – unpredictable costs
• Pilots careers are now uncertain and expensive
• Demand for pilots and engineers will grow over 30 years
• Just Culture surveys has seen a lack of cockpit discipline, societal issues and move to criminalisation of air accidents
• Ethics – the conflict between commercial expediency and ethical behaviour
• CRM has helped the cockpit environment
• Ethnic culture – rituals and religions
• Training methods are old fashioned – ‘teach to the test’ rather than competency
  • Guarantees success in regulatory teams but evades sound knowledge
• Pilot careers are unattractive to the young
• Science and technology of low interest in schools
• Suitable candidates are difficult to identify
• Getting students on the right track for aviation needs early action in schools
• Conclusion:
  • Aviation is imaginative and inventive but is also conservative and resistant to change
  • Pilots have been short changed in their training
  • LOC accidents – pilots involved are known to be incompetent
  • From a large airline survey – no pilots had experienced handling the ac at height in the cruise
  • The dumbing down of pilots
  • Time to redefine
  • Soft skills are taught widely but analytical skills and selection is essential
  • Novel training and education is needed

IFALPA PILOT TRAINING STANDARDS – Tanya Hauter, IFALPA

• Standards are required due to the challenges ahead
• All kinds of initiatives on training worldwide, some with pilot input but not all
• Time to bundle the experience
• Basic skills and knowledge required in ab-initio training
• Teach what is needed to fly for an airline
• How to stay proficient – recurrent training
• Workshop outcomes on these questions are on the IFALPA website
• Future flight training paper will be made available shortly
• What is needed is a pilot or a systems manager – both!
• Pilot selection
  • Interview, continuous feedback ,financial ability should not be a criteria
• Successful initial training and a strong lifetime performance is needed
• Education, medical and psychomotor skills are key
• A Pilot group must be involved in pilot selection
• Pilot Education
  • Training response structure
  • Education and airmanship
  • All equals professionalism
• Immersion training from the start
• Flexible curriculum
• Instructor cadre need to be selected and trained
• Recurrent trg – hallmarks of a good recurrent training
  • Confidential environment
  • Feedback
  • High fidelity sims
  • Briefings and debriefings
  • Real world scenarios
  • Training intervals
• Need to move away from pilot checking to training

TRAINING AND QUALIFIED INSTRUCTORS TO ACHIEVE STANDARDS IN PILOT SELECTION AND TRAINING – Christian Norden, Airbus

• Currently, only sparse statements on the quals needed to be an instructor internationally
• PANS Trg MPL does specify instructor competencies
• Rare national guidance – UKCAA has some
• Operator and TRTO level
  • Some enhanced guidelines and instructional culture
• Inconsistent content and quality of instruction
• ITQI and NGAP Initiatives available since 2008
• Fairness to trainees is vital and requires sound instruction
• Need to gain evidence and become proactive in selection of and skills needed to become an instructor
• Address the student instructor relationship – should not be too informal
• Instruction versus facilitation – latter preferred for competency approach
• Challenges
  • move away from tick box
  • competency training holistically approached
• Flt Insts are key to competent pilots
• Standardisation is vital and must apply globally

CONSISTENCY IN PILOT SELECTION – Selection Manager EPST

• Old pilots have been able to gather experience and airmanship and handling skills
• New entrants are different and the best can only be selected with sound tools
• Withdrawal of airlines from selection has made finance the key selector
• 4 elements for a selection process:
  • The standard
  • Selection tools
  • A clear and honest system report
  • Selectors
• Retention of info for new entrants is not as high due to the ease of use of technology which provides info quickly and easily – loss of incentive to retain info
• Reliance on the computer to sort problems out is rife and inculcated in new entrants

DAY 3

NEXT GENERATION OF AVIATION PROFESSIONALS – Nancy Graham ICAO

• Slight uptick in accidents over last few years
• LOC is the big killer
• RunwaySafety is the most prevalent accident type
• CFIT is the other major issue
• These 3 account for the 75% of accidents
• ICAO Global Aviation Safety Plan
  • 12 Global safety initiatives – 3 relevant to training
    • Consistent standards
    • Align industry safety strategies
    • Sufficient qualified personnel
  • Update of GASP will be issued in 2012
• ICAO is most active among State Regulators who have problems (10 States)
• Sufficient Qualified Personnel- ICAO NGAP Task Force
  • 330k pilots and 450k engineers needed over next 20 years
  • Manual of criteria for Qual of FSTD
  • Future – heli sims
• Future SESAR/NextGen– ICAO is taking an aviation system block system approach to their introduction
  • Four upgrades of equipment in scalable blocks
  • Community has come together to harmonise the way ahead

IATA IMPLEMENTATION OF ITQI- Gunther Matschnigg, IATA

• Common appreciation of accident numbers between ICAO and IATA is planned for next year
• ITQI is focussed on training and qualification of pilots
• Major shortage of personnel is expected – new ac sales underpin this conclusion
• Modernise training
  • Improve effectiveness of qualification schemes
• Identify the means to improve attractiveness of aviation as a career
• Increase global market permeability and harmonisation
• Achievements so far:
  • Evidence-based training EBT introduced
  • Instructor and evaluator qual – IEQ being developed
  • MPL introduced
  • Selection criteria – aptitude testing formulated
  • FSTD – standardisation
• Engineering
  • Competency based trg and qualification
• Next modules
  • Trg concepts implementation
  • Outreach programme
  • Permeability and harmonisation
• ITQI ready for full implementation by end of 2011
• Outreach programme together with ICAO
• Harmonisation with IATA, ICAO and others globally

MPL CURRENT POSITION – Dieter Helms IATA

• 37 States have implemented the MPL rules
• 15 States are conducting MPL
• 2010 – 1000 students enrolled and 180 graduates
• 2011 – 1700 enrolled and 550 graduates
• IATA Guidance Material and Best Practices for MPL issued
  • Developed over 18 months
  • Continuous assessment – core change from today’s tick box
  • Training task is specified
  • Nine Key Skill Assessment performance criteria are laid down
  • Grading of performance for individuals
  • A Norm is predetermined by a design team on each KSA
  • The level of completion of a task is measured by the application of the 9 KSAs and the student is graded
  • Predominant role of the TEM principle and resolution of competency dilemma
  • The 9 KSAs are input competencies whereas PANS trg phases of flight are the outputs – this forms the matrix to assess the individual against the Norm
  • Develop the role and the application of the 9 KSAs in every day ops to prepare the crew to deal with the unexpected

EVIDENCE BASED TRAININGMike Varney, IATA

• Recurrent checking mandatory items include:
  • engine failure after v1
  • single engine approach
• Evidence based training created this current focus many years ago but things have changed
• ‘Black Swan’ needs to be catered for
  • Safety Data is reactive
  • Accidents are difficult to predict
  • Pilot behaviour is difficult to predict
  • Sioux City ‘Black Swan’ – triple hyd failure on a DC10 was not predicted
• The aim of trg is to prepare for the Black Swan using the 9 KSA MPL Competencies
  • Each of which is measurable and observable
• Threats and Errors
  • Include monitoring skills as a key output of the training
• Data used in formulating the 9 KSA approach:
  • LOSA
  • FDM/FOQA
  • EBT Accident/Incident analysis
  • STEADES – IATA
  • Pilot trg study
• Priority List
  • Adverse wx
  • Automation
  • Competencies
  • Compliance
  • Go round management
  • Manual control monitoring
  • Unstable approach
  • Surprise
• Proof of Concept Phase
  • Global trails ongoing
• Delivery of product by end of 2012

IMPROVING COMPETENCE AND REDUCING OPERATIONAL RISK-David Mason – Trg Captain Emirates

• Emirates has introduced the EB in line with the MPL
• Compliance has not stopped 51 LOC incidents since 2008
  • Evidence tells you that pilots are culpable, unsuitable, inattentive
• Reliability and resilience is what is required of pilots as well as systems
• A quest for reliability has resulted in:
  • Automated ac
  • Ops policies
  • SOPs
  • Contingency procedures
• Reliability(automation) has destroyed pilot resilience
• Quality of candidates for commercial pilot careers
  • Military or major airline cadets – in decline
  • Self selected – self improvers paying their own way
  • TRTOS not necessarily accountable
  • A side effect of low cost airline model
  • Aviation is a degraded profession, less attractive
  • Solution – attract quality in to the profession
• Current pilot training output is:
  • Generally reliable but not resilient
  • Are a result of legacy regulatory training requirement
  • Not used to dealing with unlikley events
  • Exposure to piloting rather than mastery
  • Management not leadership
• Training and policies need to change to become:
  • Type relevant
  • Focus on mastery not exposure
  • Develop airmanship
  • Supportive policies
• Experience and Recency developed due to:
  • Old ac broke, got lost and scared the pilot
  • Imprecise
  • Set demands on the pilots
  • Pilot Resilience was built
• New Ac
  • Rarely fail
  • Decisions rarely made
  • If ac is always right,why check?
  • Why keep Situational Awareness when it gettable quickly
  • Crews don’t check, don’t scan
  • Don’t make decisions and are not suspicious
• Resilience package needed to build:
  • Mastery
  • Judgement, confidence and leadership
  • Scanning and manual ac control
  • Monitor and intervene
  • Manage automation but fly the ac
• Raise standards required by:
  • Evidence based training
  • Manual flying
  • Back to basics
  • Train monitoring and intervention
  • Competency base trg

HARMONISATION OF TRAINING STANDARDS for OPERATIONS- Max Wright

• In one FLYBE incident, the undercarriage wheel fell off on take-off – ipad photo taken by the pax and handed to the pilot and texted to engineering before landing
• In another incident, an EMB195 lost an engine but just a slight yaw to the right was spotted by the crew
• Pilot trg needs to address:
  • Decrease in manual flying skills
  • Decrease in average pilot experience
  • Automation increase
  • Increase traffic growth
  • Iincrease pressures on budgets
  • ATM management changes
  • Changing navigation systems

• ATQP being introduced which includes:
  • Operational analysis from FDM data
  • Provides tailored training
  • Provides structured support
  • Takes an evidence-based analysis
  • Threat and Error Management
  • Line pilot feedback
  • Continual development

• MPL – The future for Flybe pilots
  • Tailored trg solution
  • Training standards
    • consistent delivery, message, performance, appraisal, feedback,
    • consistent and continual development and budgetary battle
  • Common standards – EASA help sought

• Summary
  • Deal with the unexpected
  • Changing environment
  • Training techniques and principles
  • Specific competence evidence based
  • Trainingthe captains
  • Leadership and management

INTERNATIONAL FLT CREW STANDARDS HARMONISATION – Paul Lamy, ex-ICAO

• Good news
  • ICAO is getting globally engaged
  • Regionally and specific professional bodies are being introduced by ICAO
• Challenges
  • Limits of the aviation global village
  • Different levels of development among States
  • 25% of ICAO States generate 97% of the activity
  • Different levels of safety between regions
  • Safety is influenced by culture
  • Acceptability levels of accidents around the globe vary

Rich Jones
UKFSC
17 October 2011

International Winter Operations Conference – Montreal – 5/6 October 2011

Agenda

INTRODUCTION – Air Canada Airline Pilots Association

• Air Canada Airline Pilots Association organised this Winter Ops Conference
• ACPA aims is to lobby US and Canadian Authorities on safety issues such as:
  • Misuse of high power lasers
  • Ottawa overruns – non-compliant runways are a key issues
  • Litigation against those making mistakes impacting on reporting and creating the need for reporter protection
• This is the second such conferences ACPA has held on Winter Operations

KEYNOTE SPEAKER- Allan Macdonald On Challenger and Columbia – Two Lost Shuttles -A Launch That Should Not Have Happened

Shuttle Facts

• The Shuttle fuel pump can empty a swimming pool in 25 secs
• The 3 engines generate the equivalent of 13 Hoover dams worth of power
• Each rocket booster has over 1 million pounds of explosive and generates over 40,000 horsepower
  • Enough power generated to power 87000 homes for a day

Challenger Incident

• On the Challenger launch morning, freezing water and icicles covered the pad and the vehicle – these were not planned for and had to be chipped off prior to launch
• At lift off, the seals on the boosters were already leaking but sealed quickly initially, but re-opened at main engine boost since the vehicle flexs when the director nozzles moved the frame due to hitting a windshear region.
  • The leak re-occurred and directed the fire plume to the main tank which exploded
• Crew died on impact with the ocean at 300 mph- the cockpit tape exists indicating that the cabin was intact until this point
• Commercial, economic and military pressures to launch.
  • Plus the composition of that crew was of great public interest (a teacher)
• At the last meeting before the original launch date, the weather brief predicted rain showers in the region and that launch day was cancelled.
  • In fact that day was fine and the showers came much later
• On the next launch opp, the door handle could not be removed so it was hacked off the door by hacksaw causing another delay
• Next launch day, met man had said the temp would go down to 18F which was well below limits for the booster seals
• Based on an engineering assessment, the speaker recommended not to launch below 53F!
  • This was due to recovery of a past launch booster which had witness marks of seal leaks – when it had been 53F on that launch
• NASA challenged the assessment and wanted to re-assess the data
• Later that day, NASA said they would go ahead, because the engineers could not prove it would fail.
• NASA wanted a signature from the booster engineers was required
  • The speaker refused to sign – so his Boss did!

Accident Inquiry

• At the Presidential Commission, NASA tried to cover up the advice not to launch but speaker stood up and re-stated his advice to the Commission
• The boost company sacked the speaker from the shuttle programme until the Head of the Pres Commission intervened and he was re-instated as Head of the Task Force to fix the Shuttle seal problem – which he did.
• Columbia break-up problem caused by a single critical tile loss from 30,000 tiles. The critical tile had an aerial and mount beneath it
• Silence is the biggest threat to safety

LESSONS NOT LEARNED – DE-ICING OPERATIONS- Denis Gordon
Presentation

• Wide variety of weather encountered across Canada.
• Ground icing contamination on aircraft surfaces is caused by frost, freezing rain, ice, snow-wet and powder, slush
• Canadian regs require all contam to be removed before flt is attempted
• Accidents due to icing:
  • From 1969 to 2005 – 500 deaths caused
  • Washington – 1982. Failed to use ac anti-icing and surface de-icing
  • Denver -1987. DC9 crash
  • Dryden – 1989. Failure to de-ice
  • Stockholm – 1991. Incomplete de-icing
  • New York – 1992. Contaminated wings
  • Challengers – 2002, 2004 etc
• Employee accidents have also occurred:
  • 3 man de-icing team killed when a B747 moved forward with 2 de-icer vehicles in front of the ac wing
  • 2009, de-icer fell out of the bucket in Calgary and died
  • 2010, de-icer killed when B747horizontal stab turned over his vehicle
• New Canadian Icing Regulations have been introduced to improve safety
  • Pilots, cabin crews, flt dispatchers, de-icing operators, maintenance crew all must be trained
  • Ac Contam inspectors must be trained and qualified
  • De-icing programmes must conform to prescribed standards and the responsibility is the airline, not the provider.
  • Air ops de-icing procedures must be described in the manuals with a responsible personnel nominated for the procedures
  • Crew members observing frost or ice on wings must report to the pilot who must act by getting a re-inspection
• Safety means standards, training and audits
• Training depends on the employers requirements – extensive formal and informal = initial, recurrent, both theory and practice
• On time performance- it is important, but icing conditions require care

AC DE-ICING/ ANTI-ICING FLUID QUALIFICATION TESTING AND RESEARCH – Arlene Beisswenger

Presentation

• All de-icing and ant icing fluids can be tested only at LIMA/AMIL at University of Chicoutimi in Canada
  • Only lab in the world to meet SAE specs
• Four types of de/anti-icing fluids available
• Fluid qualifications and specs are checked or certified using a large array of test equipments and labs and wind tunnels
  • Anti-ice endurance and aerodynamic tests are carried including acceleration testing
• Viscosity and ph is measured along with stability over time
• New tests:
  • Catalytic oxidation of carbon brakes
  • Runway de-icer performance tests
  • Icephobic coating evaluation underway
    • Reducing of ice adhesion on wings by coating
    • Reduce ice accumulation and mass by coating
    • Coating to ease removal of ice from surfaces
  • However, does this coating increase drag in normal conditions?
  • Test derived to test the coating performance and its positive and negative impact and sustainability

SAE TECHNICAL COMMITTEE G12 – AC DE- ICING– LOOKING TO THE FUTURE

• SAE has Committees to study anti-icing and de-icing processes, procedures and establish standards for aircraft and runway de-icing
• The Regulators then take the data and guidance derived from the relevant SAE committee output and publish it out to the community
• SAE Meeting in Prague in May 2012 to generate the next generation of de-icing procedures
• SAE does not have any airport inputs to this work and is keen to get engaged
  • Corrosion tests of the fluids used on aircraft need to be formulated which will need the help of the airports who buy these fluids
  • Hold over times are also being examined – an airport input would be welcome at SAE
• Other SAE Committees are looking into best practice on numerous processes and equipments being used at airports
• In Canada, most airports are transiting to single de-icing provider for efficiency and safety
• IATA and SAE are looking to work closer together to harmonise de-icing procedures and methods

RESEARCH AND TESTING INNOVATIONS

• 1989 crash at Dryden caused de-icing to be taken seriously through TranCan
• The report created a major R and D programme to address the de-icing and ant-icing issues
• In 1989, only 2 types with HOT tables available
• In 2011, we now have 15 different tables for Type fluid alone
• Visibility tables produced for different snow types
• Lower on-wing viscosity values for on-wing fluids
• In 1989, no de-icing standards or best practice, now all available
• 60 qualified fluids in 2011and these are being refined all the time
• Fluids are now much more environmentally friendly
• Major equipment improvements on de-icing
• Dedicated de-icing facilities are now the norm
• Specialist de-icing companies are the norm, not self de-icing anymore
• After 20 years of focus, de-icing of ac is very mature in Canada
• Corporate knowledge is much stronger

• Recent Specific Canadian De-icing developments
• Chinook ac de-icing system
  • Tempered steam technology – steam laden air strictly controlled with glycol addition
  • Can undertake engine and fan blade de-icing in 2 mins
  • Can be used at the gate due to it being environmental friendly
  • Glycol use is much lower (61% less) and de-icing time is less
  • Underwing and undercarriage attachment being developed

• Dan Ice Hold Over Equipment
  • Automated hold over time determination tool positioned on the airport
  • Dan Ice Info fed to the flt deck directly using ACARS etc
  • Much more detailed charts and tables can be used to provide a much more accurate and flexible holdover time
  • Regulatory Approval Process being developed by TC and the FAA

• Electronic Message Board
  • Use of information message boards around the airport taxi area to provide increased info to crews on positive hold procedures and remote de-icing operations
  • More info on Deicinginnovations.com website

EUROCONTROL Laser Interference Seminar – Brussels- 10/11 October 2011

CE Meeting Summary

Agenda

Full Presentations available at
http://www.eurocontrol.int/events/seminar-laser-interference-aviation

Key Messages from Presentations

INTRODUCTION

• Lasers were addressed by ICAO when lasers started to be used by entertainment industries in the 1990s
• Eurocontrol became involved in 2009 after airline reported deliberate attacks
• Attacks are from 2 main individuals – ignorant youngsters and those with deliberate environmental concerns seeking to make themselves heard
• Safety Warning Notice message issued by Eurocontrolin July 09
  • Looked at impact on controllers and pilots – ATS and flt deck
• Mitigations consideredbut no universal solutions identified
  • Legal and judicial solutions considered
  • Health and eye damage concerns considered
• In Norway and Sweden, regulation and legal revisions on carriage of lasers in the public arena were introduced
• UK CAA undertook an ANO Revision – to improve prosecution success
• Austrian law prohibits ownership of high power lasers
• Awareness of the laser problem has been promoted in Skybrary, Hindsight, Safety Alerts etc by Eurocontrol

EVAIR LASER INTERFERENCE REPORTING – Dragica Stankovic, Eurocontrol

• EVAIR background – 107 airlines plus ANSPs report voluntarily their safety incidents into the system– 7000 ASRs on the database
• 50% increase in overall incident reporting year on year
• 2010 laser attacks reporting increased by 5 times
• There are 3/4 attacks each day across Europe
• 90% of attacks occur on approach and 6% on take off
• 68 airlines have reported attacks in the past 3 years
• 32 States have suffered lasers issues in Europe

FAA LASER ATTACK VIDEO – shown to the Seminar and can be viewed at http://www.youtube.com/watch?v=RtKSdy2KAW4

CURRENT SITUATION IN US – FAA Rep Laser Specialist

• Lasers are cheap, powerful and readily available – 1 watt for $179
• Lasers are considered by youngsters as fun but pose a danger and a serious hazard for aviation
• FAA has 2,800 attacks so far this year
• Reporting vs increased attacks – analysis shows more attacks
  • 10 attacks per day
• Most attacks are not malicious – and not youths but 35-55 years old
• Lasers are hazards more than a threats
• Mitigations in place or in development:
  • Pilots report to ATC
  • ATC report to law enforcement and the FAA, where attacks are documented
  • Military are also informed since lasers are also a security issue
  • FAA monitor collect and analyse data on laser
  • 1.7% of pilots attacked have reported medical issues
  • FBI task force established
  • Work with aviation stakeholders
  • Work with laser manufacturers to have warnings to users
  • Youtube and twitter outputs on laser attack and hazards
  • FAA will impose civil penalties – $11k fine to be imposed
  • National regulation is being sought through Congress
  • Local community action being taken on general laser attacks
  • Future:
    • Increase outreach events
    • Emphasise illegal laser use
    • Web based and direct pilot reporting made easier

UK Health Protection Agency – John O’Hagan

• Battery powered laser first marketed in 1997
• Many low tech lasers available but batteries do not last long and the device is often binned
  • No eye damage can result from these devices
• Display lasers could injure pilots but they are large, high powered and need to penetrate the cockpit
• A standard laser pens have since become much smaller and batteries last longer
• Infra red laser beams are invisible but are emitted through a colour crystal to make the wavelength visible
• Laser classification depends on laser power 0.4-1mw is Class 1- 1-5mw is Class 2
• In a UK trader’s house in Jun 2011,14000 lasers with A Class 3/4 capability were seized
• On the internet, Wicked Lasers offer a blue 1 watt for $300 and a green 1 watt at $1000
  • 1watt laser is capable of eye damage from 226 meters– direct path
  • Spread distance for the beam is important – dispersion cuts the power
  • Dangers of permanent eye damage to an ac crews are minimal
• Distraction is a danger and the effect depends more on its colour
• Message is
  • For Eye injury, the power is important and the dispersion area
  • Non-permanent damage/distraction more effected bycolour
    • Green beams even at low power are strong distractions
  • ebay has agreed to ban the sale of some lasers

Universtity of Cologne – Dr Reidenbach

• Wide range of lasers and wave lengths on the market with 20 miles+ range
• Hobby astronomers use lasers for studying the sky
• In US, 27% of laser attack reports reported beam entered the cockpit
• 5 mw laser for 60 sec can cause eye damage – direct path
• 10mw for 0.5 secs could also cause damage – direct path
• Most laser attacks on ac are green in colour = 93%
• 1 watt is 200 times brighter than an allowable laser
  • Nonetheless, a pilot cannot be permanently injured due to range and dispersion
• Permanent damage
  • Very unlikely at this stage of development
  • IR output of a laser is more significant in terms of potential damage
  • Any visual effects lasting 10 mins or more require a medical inspection
• Parameters that impact on eye damage or distraction include:
  • divergence
  • wavelength
  • mode pattern or profile – pulsing
  • distance
• Summary
  • A risk exists due to laser pointers
  • Permanent damage is unlikely at current laser powers available
  • Temp effects can be significant

UK Met Police – George Trebess

• Aviation threat UK profile – year on year attack increase with low power lasers
• Users and usage is variable and random – no suspect profile
• Laser technology being used against police, cars and trains
• Identifying evidence gaps by ACPO – police helos were the target of choice
• Aim is to build a case to prosecute for possession as per a firearm or knife
• 6 arrests in the past 12 months
• These arrests are expensive in resources required
• Action to improve prosecutions for laser abuse requires data on attacks to be gathered at the Met Police, as part of an education and evidence building process.
• Future aim to get a medium solution to be able to enhance the chances of a successful prosecution

DAY 2

PROVISION REGARDING LASER INTERFERENCE SAFETY – ICAO Met Section –

• 90% of laser attacks occur on approach, within 6 miles of touchdown
• Regulatory Provision is in Annex 11 and Annex 14 of the Chicago Convention
• ICAO established a study gp in 1999 to evaluate the laser risk
• SARPs have also been developed for these Annexes
• Guidance material also developed and shared among States
• Annex 11 says adequate steps needed to guard against attacks on aviation
  • laser beam free flight zones – LFFZ
  • laser critical flight zone – LCFZ
  • laserbeam sensitiveflight zone – LSFZ
• Manual on laser emitters and Flight Safety issued in 2003
  • deals mainly with proper use of lasers not mal-intent

PILOTS PERSPECTIVE- Jo Schoenmaker, IFALPA

• ‘An accident will occur from a laser attack in due course’
• Occurrences of attacks are increasing in Europe and US
• Main safety issue is the distraction element of the attack
• Prep for approach starts 35 mins before landing including night adaption for the vision
  • Sterile cockpit applies from 10,000’
  • Stabilised approach at 1000’ – checks complete
• Disruption to these phases is the key safety risk of laser attacks
• Example of a 3000’ – 1 sec attack – burning sensation and 4 weeks off?
• Factors of influence
  • Ac fly established routes – 5000’ – 20 sec attack mentioned
  • Colour blindness can occur after an attack – important requirement for the cockpit
  • HUD Head up display – disrupted view
  • Pilot awareness and response needed
• Challenges:
  • No awareness of the dangers by the public and perpetrators
  • It is not an offence/crime in many countries
  • No standards/no reporting system
  • Difficult to finding the perpetrators
• Way ahead
  • EU adopt Doc 9815 ICAO
  • Harmonise legal action
  • Proper penalties imposed
  • Reporting ATC to police
  • Awareness campaigns
  • Regulate possession and purchase of laser 5mw or above
  • CAA Laser WG advocated in other States
  • Specific legislation on lasers and bright lights – UK CAA example
  • UK CAA guidance to flt crews and towers
  • Prosecution – 24 successful in UK so far
  • Awareness campaign for ATC and Pilots

LASER ATTACK ON AC – IATA and AEA Paper

Same presentation content as the IFALPA Brief except:

• Pilot incapacitation reported for 1 pilot in 12% of cases and 2 pilots in 6%
• Distraction and incapacitation is the key concern and the outcome of reports
• Green laser is the main threat colour in attacks
• Conclusion:
  • Awareness of the issues needs promotion
  • Recognise laser attacks as an act of unlawful interference
  • Request to develop adequate harmonised countermeasures
  • EC needs to take an harmonised approach

LASER ATTACKS – ENAV EXPERIENCE IN ITALY

• 2010– 27 attacks per 100k flts – 2011 16 attacks per 100k flts
• Most reports are within 5-10 nm miles of the airport
• Italian attacks have decreased but are still too high
• Use of laser in prohibited in law in Italy
• Many people arrested but none charged
• In Turin, strong action taken but not effective
• Removal of web pages offering lasers on the internet
• NOTAMs issued to warn aircrews
• Training info provided to crews
• Work order provided to ATC to info police and Italian NAA
• What is needed:
  • Amend criminal legislation – currently too vague
  • Educate the public of the risks
• Towers have been attacked and a controller has suffered temporary blindness from an attack through binoculars

LASER ILLUMINATION ANSP PERSPECTIVE FROM THE NETHERLANDS

• Protection of the staff is the main aim of the Dutch ANSPs
• ATC personnel are encouraged to pass all attack info onto the authorities
• Advise staff in the same manner as aircrews
• Attack threat taken seriously but only limited action can be taken

LEGAL AND REGULATORY FEEDBACK – EUROCONTROL

• Laser attacks raised as a new safety focus in the Start Risk Control Gp in ECl
• Laser interference – severity and risk being considered
  • Effects are well known
  • States classify severity
    • Severity B – major in case of pilot injuries
      • 2-4 such instances per year
    • Severity C – significant – vision impaired
• State example of an action plan – the UK CAA plan
• Legislation needs to be taken out of the aviation domain
• Prohibition on Import, Sell Or Ownership of lasers above a certain power
• Some States requested action from European Community level
• States must amend law to make malicious use of lasers against ac and ATC personnel an offence
  • This can take a long time
• Enforcement
  • When perpetrators are caught and prosecuted
  • Specific provision for penalty in malicious use is limited
  • Need to be effective, proportional and dissuasive
    • Heavy fines or prison
• Co-operation
  • ANSP/ATCO/ Airline and police/ regulator all need to co-operate
  • Awareness guidelines leaflets may be useful
  • Procedures to follow
  • Rulemaking
  • Media usage – careful targeting – it may be counterproductive?

PRODUCT AND CONSUMER SAFETY – Thomas Fairley, European Community Health and Consumers

• Background to EC view is any risk of damage to sight for consumers
• Laser products are covered by a general product safety directive
  • Mains lasers are specifically covered by another directive
• Produces European Standard classification for laser products:
  • Class1/1M normally safe
  • More dangerous Class 2/2m , Class 3 and Class 4 are also available
• Laser pointers must not exceed 2M
• Rapex system notifies EC States of dangerous products
• Lasers can be notified under this system and then be banned
• Joint market surveillance on lasers seeks to identify problems
• Proposed way ahead on laser pointers:
  • Update the EC Standard which applies to laser pointers
  • Lay down safety requirements for all battery powered laser productsavailable to consumers, including mains powered
• Safety requirements to define laser products that are ‘child-appealing’ no higher than class 1
• All others are to be max of Class 2M
• Specific warnings for lasers above Class 2M are mandatory

NANO –STRUCTURED OPTICAL FILTERS FOR LASER SAFETY – Uni of London

• Nano-technology film being developed which is optically transparent but filters out multiband lasers
• Flexible film sticks inside the windscreen, visor or goggles/glasses
• Threat from 5mw laser which is eye hazard at 16 m
• Threat of 1000mw laser – eye hazard at 80m
• Existing solutions filter just single wavelength
• This Metamaterial film used to make an optical filter is another potential solution
• Specified light at a single wavelength is turned into heat from light
• Patent applied-for solution for a first prototype at Q1 in 2012
• ‘Lambda guard’ aims to prevents laser interference
• Filters applied to ac cockpit windscreens and visors
• Very broad cost estimate of 40k euros per ac initially – significant reductions for scale

CONCLUSION AND WAY AHEAD

Conclusions

• Laser interference is a safety issue globally
• Multidisciplinary approach required to counter the threat
• Legitimate use of lasers – (ICAO) standards already in place
• Technology is rapidly evolving for both devices and protection
• Need to harmonise measures at global and European level
  • Timely and effective inflight and post flight reporting
  • Alerting procedures to law enforcers
  • Training pilots and ATC controllers on how to manage the threat
  • Legislative and regulatory measures at EU, EASA and National level
  • Awareness campaigns
  • Guidance materials for decision-making level in States

Short Term Actions

• Review inflight and post flight reporting
• Train pilots to manage laser interference
• Awareness campaigns
• Develop current technologies
• Establish unlawful interference laws

Medium term

• Develop EU legislation
• Research future technologies

European Action

• DG Trans Rep to:
  • Laser risks to aviation to be assessed
  • DG Enterprise needs to consulted
  • DG Consumer Protection needs to be consulted

• EASA already looking at Rules
  • Issues outside of the airport fence not usually EASA responsibility
  • ICAO Annex 11 and 14 will be considered for transposition into Rules NPA on aerodrome safety
  • This seminar confirmed much of EASA’s previous thinking on the laser issue

• Fourteen International Aviation Safety Groupings have already sent a joint Proposal to the EC for their consideration and action on lasers. Available at http://www.eurocontrol.int/sites/default/files/content/documents/events/laser-interference-seminar-statement-aviation-industry-1.pdf

Rich Jones
Chief Exec
UK Flight Safety Committee
17 Oct 11

DfT Forum on an European Council Groundhandling Providers Regulation Proposal –
20 January 2012 – CAA Aviation House
CEMeeting Summary

INTRODUCTION

• European airports annually carry 800 million pax in Europe- one third of world market
• Air transport in Europe generates 120k jobs and significant cash revenue
• European Council issued a white paper on the Efficiencies to Improve Airport Capacity known as the Better Airports Package whose aims are:
• Boost capacity, improve service quality, simplify access to GH providers
• Around 60k people are involved in GH in Europe
• Estimated that 70% of delays are caused on the ground
• A 1996 EC Directive addressed the need to ease access to airports for GH services providers
• The DfT ran a Stakeholder consultation in 2010 generating 103 respondents stating:
• A need to improve quality, safety and reliability of GH
• Identified uncertainty onwho co-ordinates GH at airports
• EC decided a new regulation to address these issues should be drafted
• Balanced proposal to protect current GH companies and employees
• 19 airports in UK fall into the regulation

CONTENT OF THE PROPOSAL

• Aims of draft regulation:
  • Increase choice of GH solutions at EU airports
  • Harmonise market conditions for GH companies
    • Mutual recognition of approvals between Member States
    • Greater transparency on airport charging
    • Legal separation of airport owners and their GH arm
    • Improve GH provision tender process
  • Maximise contract length for GH at airports
  • Right retained for an airline to self handle
  • Place downward pressure on costs
  • Increase resilience of GH
• Concern about the proposal to set a licence regime which would be a cost currently not required in the UK and would be imposed on airlines.
  • 75% of MS have a licence regime in place already
  • Individual airports issue their own licences in UK – they are not a common standard across the UK – could a common licence approach be cost effective?
    • Some UK airports include performance criteria in their licence requirement
  • Airport operators are to be able to co-ordinate GH and establish common quality standards
  • Reporting requirements from airports into the Commission proposed and may carry an additional burden UK Ministers are concerned about any new regulations generally due to the cost requirement
• Transfer of personnel rights included in the regulation
• Some concern about the additional burden created by the training to raise standards and improve safety

SAFETY PROVISIONS AND CONCERNS – BETTER AIRPORTS PACKAGE

• Art 8/9 deal with qualifications and awards procedure
  • Art 8 sets the criteria of authorisation for an applicant to hold a valid licence
  • Art 9 authorisation- does not mention safety
• Art17 sets the conditions for granting an approval – allows an GH company to apply to any other MS to work in any European airport
• Art 21 requires the need for a GH Ops Manual
  • Organisation, structure, capacity, emergency response capability
• Art 23 validity of approval to operate GH lasts 5 years
• Art 26 allows mutual recognition of GH providers – valid in any MS
• Main Safety Concerns:
  • No mention of an SMS with a properly constituted org structure
    • GH company appears not to require to be part of an SMS
    • Harmonisation with EASA best practice on safety is required
  • Lack of safety/performance standards at the local level
    • Performance is likely to win out over safety
  • No common GH standards available across the EU

THE DFT CURRENT POSITION

• Existing 1996 EU Directive arrangements appear to deliver reasonable levels of efficiency among UK GH and UK airports
• Standards of GH do vary across the EU but unconvinced of the need for further regulation
• DfT needs to be convince that change is neededand their aim is to minimise the admin costs involved but to maintain safety

NEXT STAGE IN EU

• The Danish Presidency will take on the Better Airports Package starting with ground handling first, followed by the noise management and then slot allocation
• DfT will continue to consult with the meeting Reps as this issue progresses and are very open to lobbying on this GH regulation proposal.

Rich Jones
Chief Exec
UKFSC
20 January 2012

Air Accident Investigation Regulation Industry Workshop – DfT, Great Marsham St, London – 3 February 2012

CE Meeting Summary

Agenda

Regulation (EU)No 996/2010

UPDATE AND APPROACH

• Aim of the meeting was for the DFT to get early industry inputs into the UK implementation of the new EU 996/2010 Air AccidentInvestigation Regulation
• Regulation already in force but detailed planning for practical implementation now required
• This Regulation coversthe following:
  • Establishes a Network of AAIBs in Europe
  • Seeks provision of timely information on pax and dangerous goods involved in air accidents.
  • Requires airlines to have a Victim Support Plan in place
• DfT want the implementation to be proportionate and affordable for UK stakeholders
• Govt Ministers always seek to reduce regulatory impact and see robust supporting business cases for any new regulation.
• Regulation implementation will occurusing 2 statuary instruments plus guidance:
  • Provision of information on pax and dangerous cargo
  • Victim Support Plan for airlines
• Problems to be addressed by the meeting include:
  • What is an airline?
  • Who checks the implementation?
• Regs also require a national civil contingency plan for a major accident

POLICY ISSUES

AIR ACCIDENT INVESTIGATION NETWORK PROVISION

• No major change to current AAIB arrangements – AAIB is leading on this policy
• Stakeholder input on this part of the policy will take place later in the year
• Will be run as a separate line of activity by the AAIB

DEFINITION OF AN AIRLINE – 3 OPTIONS

• Option 1 – 10 or more operating employees – aligned to the UK Govt intent to minimise regulation on small businesses
• Option 2 – All Type A licence holders plus Type B doing scheduled services and north sea operators
• Option 3 – All 124 operators holding a UK operating licence
• DfT preferred Option 1 but UKFSC recommended that risk-based approach should be taken rather than definition based approach
  • Many accidents involve small operators and therefore were more likely
  • UK Safety Plan places the UK customer at its heart whatever they fly in!
  • Proportionality should be applied at the point of application depending on the airline involved
• After lengthy discussion the stakeholders present concluded that all 124 AOC operators should comply but in proportionate and risk based way

PROVISION OF A VALIDATED PASSENGER AND CARGO LIST (Art 20.1)

• Questions were:
  • What is it for?
  • Who is it for?
  • Do they need just numbers or names too?
• In discussion, stakeholders stated that accurate pax numbers were needed initially followed by names in due course
• Both pax and crew lists were needed

LIAISON OFFICER (Art 20.2)

• The Police Family Liaison Officer is the likely appointment to receive the list and BE tasked to speak to the relatives of the persons on board

PASSENGER CONTACT DETAILS IN CASE OF EMERGENCY

• Airlines will have to offer the opportunity for pax to provide contact details
• Any contact name rather than a relative is considered sufficient to meet the regulation
• DfT will check with lawyers on disposal of the information on completion of journey

CIVIL AVIATION ACCIDENT EMERGENCY PLAN (Art 21.1)

• Numerous contingency plans already exist throughout UK national and local government
  • DfT to co-ordinate the Aviation Plan within these existing plans

VICTIM ASSISTANCE PLAN (Art 21.2)

• All airlines are to have a victim assistance plan which is audited by the State(CAA)
  • Psychological support is specified in the regulation
• ERA has drawn up guidance on victim support planning for airlines.
  • Could be made available for a stakeholder group to consider to avoid duplication
• Important that the smaller operators are consulted to make the guidance proportionate
  • Include insurers, lawyers and third party providers of these services
  • Consumer voice will also have to be heard
• DfT propose a stakeholder group to form to discuss this issue within a month’s time.
  • Final guidance out by early summer for the wider group to consider

POINT OF CONTACT FOR VICTIMS AND RELATIVES (Art 21.3)

• The assumption is that the AAIB would fulfil this role – they are already doing so now.
• This is being done in concert with the police FLOs
• Experts from foreign states and airlines are also involved in these accidents where it is appropriate

Rich Jones
Chief Exec
UKFSC
3 Feb 12

Future Airspace Strategy – Class G Users’ Conference – RAeS – 15 July 2013
CE Meeting Report

Introduction

• Mark Swan opened proceedings with an overview of the SARG.
• Andrew Haines (CEO CAA) sees SARG development as good news for the GA community, old system was silo’d with GA cross-cutting staff boundaries which created inefficiencies, new system “will allow GA to thrive”.
• Capacity in SE is Govt’s biggest aviation challenge and a significant economic issue.
• National hub is required, and it has implications for routes, choice, cost and safety.Runways and concrete are critical assets but so is airspace.
• FAS is crucial for the UK and for SESAR project.Patrick Ky (Exec Director SESAR JU and DG EASA designate) has said the UK FAS is the only credible SESAR deployment plan developed so far.
• Current airspace structure is 40 years old but traffic has increased 100-fold.
• FAS work to date has focused on high-end CAT.Continuous climb after T/O would deliver £200m in financial benefits by 2030 along with improved safety and airspace utilisation.
• Compromise and realism would be required for Class G users.
• Earlier CAA proposal for mandatory Mode S had not been well received and was withdrawn.(Mark Swan intervened to state that any mandate would be an action of last resort for him.)All communities (ie GA…) must be open to progress and be prepared to harness new technology.
• For some areas, ‘best equipped, best served’ might be a legitimate mantra.
• The CAA was committed to helping the GA sector and was pressing hard for an appropriate and proportionate regulatory framework; there would be increased delegation to industry and a greater use of innovative projects and structures.
• AH re-stated his challenge to CAA staff and his commitment to the GA community to ensure that there would be no ‘gold plating’ of EASA regulations and directives.

GA Alliance – ACM Sir John Allison

• A FASOG (FAS Oversight Gp) member, he agreed that oversight was necessary and in this case effective, and endorsed the higher management commitment to helping the GA sector.
• But evidence from the GA community is that the FAS only deserved limited support.GA comprises 98% of UK aviation community and is entitled to a share of the operational and financial benefits.
• There is no analysis of benefits to GA, and non-commercial interests take a back seat.
• GA definition is too broad: top end (IFR section) is not threatened by FAS but non-commercial, non-IFR segment is.
• From the GA perspective, “It’s all about Class G.” However, the paper ‘Class G in the 21st Century’ has not even been mentioned even though the future and extent of sport and recreational GA is wholly dependent on Class G.
• Most activity is single pilot and occurs below 5000 ft.
• There are irreconcilable differences between the needs of GA and CAT in Class G.FAS 4th pillar sub group is deadlocked as a result.Airspace redesign just to accommodate CAT requirements is objectionable to the GA community.
• GA has different levels of acceptable risk, and the CAA desire to increase safety (through FAS) can only be achieved by reducing current freedoms.
• The ‘GA safari park’ concept is a non-starter, developing isolated pockets of GA activity would be crippling.
• ACPs are seen as commercial in nature, there is a perception of a hidden agenda to make all current Class G accessible to CAT, which can only be achieved by airspace redesign.
• Commerce is not everything and a holistic approach is required.
• FAS work can’t be started again from scratch but changes are certainly required to current plan. Achieving an 18000ft TA will be crucial in this.
• Summary: FAS work to date has been skewed against sport and recreation GA.

AOC 1 Gp – AVM Stu Atha

• ‘Train hard, fight easy’ is still relevant but aircraft will need airspace for training.
• Olympics air security (the only piece led by MOD) was a good example of a joint and integrated approach to airspace management.A multi-faceted response to the task produced a decision cycle that connected the cockpit and the highest levels of Govt.The aim had been to create a known environment.Key lessons had hinged on education, engagement with the relevant communities, and communication.
• Engagement with disparate communities such as GA can be very difficult.
• End of Afghanistan campaign will see approx 1000hrs of military activity transferred to the UK.
• UK low flying rate has halved in the last 10 years but will increase as the Army’s UK exercise programme (vice Germany) demands added helicopter support.
• Unlikely to see F-35 or Reaper operating at low level, but the F-35 will need large airspace blocks.
• A/c numbers and bases would be reducing (FJ at Lossiemouth, Coningsby and Marham, Training at Valley, Shawbury, Cranwell and Linton.)
• Weapons still needed to be trained for.Meteor would be a challenge: example shown of a representative engagement zone for Typhoon/Meteor, which showed airspace stretching from the Scottish border and down to the Home Counties for a single aircraft in the Midlands…
• Training would make increasing use of synthetics, balance would shift from current 80:20 live/synthetic to 50:50 by 2020.Typhoon conversion is already 60% synthetic.
• Reducing the MAC risk is still a high priority: Prevent, Detect, Avoid.Tornado CAWS rolling out in Oct 2014.
• MOD needs to understand GA and especially the glider community.
• Summary, airspace needs to be shared and flexible.

AOPA – Martin Robinson (NATMAC, chair of 4th pillar WG)

• Rights and responsibilities are interlinked and both communities need to recognise this.
• Would like to see a road map with target dates and an integrated plan for avionics.
• Conspicuity needs to be improved, need to leverage modern technology and improved navigational accuracy.
• GA should be able to use non-certified equipment where appropriate and necessary.
• Needs to be an affordable and portable single-step solution to conspicuity: noted that across Europe there is an average of 18 GA vs GA MAC per year, half of which are fatal.
• Solution may be VFR non-radio but electronically visible.
• Regulatory delay is an issue. (EASA)

Discussion: several contributors protested that they would be unable to modify ultra-lights or some vintage aircraft, and that a technical solution to the problem should be resisted.

IAOPA – Craig Spence

• Overview of IAOPA, noting ICAO accreditation, aims to represent GA in international forums in order to develop common policies.
• Focus is increased access to airports and airspace, reducing fees and costs for equipage and certification.
• US airspace modernisation has brought benefits, widespread use of RNAV and RNP has been beneficial – majority of US GA ac are GPS-equipped and 80% of GA nav work in US is GPS-based.
• In July 2012, the US had more than twice as many GNSS approaches as ground-based equivalents.
• RNAV routes through terminal airspace had proved very useful, as over-classification of airspace was a frequent issue.
• Non-GPS solutions were needed as a back-up.
• Equipment mandates needed to be avoided whenever possible.

easyJet – Rob Legg

• CAT in Class G comes in many forms, from light twins and helicopters to heavy CAT.
• Risk of MAC is increased in Class G and operators need to recognise this.
• easyJet currently operating from Inverness, Southend, Newquay, Newcastle and Belfast, but company aims to operate IFR and inside CAS whenever possible.
• SOP is to take best available ATC service, with a deconfliction service preferred.
• Only operates in Class G for access to commercially viable locations.
• Much effort on mitigating ‘Sig 7’ risks, mindful that CAT not built for ‘see and avoid ops’.Main problem is an unknown traffic environment.
• Hazards and risks are not the same for all locations.CAT operators must carry out a full risk/hazard assessment before operating outside CAS.

Summary

There were some irreconcilable differences of view presented.It has hard to argue against the point that CAT has a choice about operating in Class G whereas GA doesn’t.Discussion also revealed a perception that CAT and airport operators need only submit it to the CAA for it to be approved, further squeezing GA activity.(Mark Swan actively refuted this view.)The FAS will need to take account of the GA requirement in order to meet its mandate for fairness across the user community, but it also has a duty to the consumer.A low-cost, lightweight technical solution for increased conspicuity is a likely pre-requisite for more flexible use and sharing of airspace.

Dai Whittingham
Chief Exec
UKFSC
29 July 2013

RAeS Flight Operations Group – Farnborough-
CE Meeting Report

Introduction

The meeting started with a briefing from the Deputy Chief Inspector of Air Accidents. He referred to the ongoing challenge in the Scottish Court of Sessions where the Lord Advocate was seeking release of the CVR and FDR from the Sumbrugh helicopter accident. The law is not absolute in this area. AAIB was obliged to take a neutral position in view of its status as a Govt body. There had been limited release of CVR to legal teams in the past, and there was some precedent with the Catterick Puma accident where the CVR was played in open court, albeit this was a military accident and so not covered by ICAO Annex 13 protocols. There was an ongoing case where a private pilot was being prosecuted for the death of a passenger and disclosure of witness statements and photographs was being sought.

Protection of safety information is currently covered by an Attachment to Annex 13 and therefore lacks legal force. The work was being transferred to an Appendix, at which point the protocols would become a SARP and have the same force as other Annex and Appendix provisions.

Discussions

• Cabin baggage was recognised as an issue for operators, with cabin crews being effectively responsible for managing the situation on a sector-by-sector basis. A review was necessary and the matter would probably require EASA engagement in the long run.

• There was a review of global accidents and incidents, many of which had been covered via the UKFSC meetings. Other items were ‘open source’; a copy of the report is at attached.

• There was discussion of the vulnerability of FDM data to retrieval for support of legal actions in the event of an accident. It was felt that the prospect of tracking back data from previous flights was very unlikely unless they had generated FDM events; even then, the reports were stored in anonymised form. However, it would be prudent for operators to ensure that protocols for protecting FDM data were comprehensive.

• There had been an increase in the reporting of smoke and fume events; this was seen as improved reporting rather than increased prevalence. The SAFITA (Vol 1) paper had been further updated and would be subject to peer review prior to being re-published. There would be a briefing to ECAST in Dec 14.

• The met phenomenon of gust fronts associated with rapidly developing convective clouds was reported following an incident in South America. The matter was being raised with the Met Office User Forum with the aim of developing suitable educational material for flight crews.

• There was a suggestion that some A330 flights into Tel Aviv had suffered electronic interference when the Iron Dome system was active, which had affected the radalts and tripped one aircraft into Direct Law. There was no further information on this.

• The AAIB report into a go-around at Newcastle and subsequent landing below FRF was discussed. It was noted that ATC changes from the published MAP had contributed to the difficulties experienced by the crew. DGAC (France) had conducted a safety study that showed such changes were a precursor to undesired aircraft states. CE had tabled the matter for discussion at the forthcoming NATS SPA meeting (5 Nov).

• Airbus had calculated that 300,000 new pilots would be required by 2030. However, recruitment was generally weak, probably due to the required financial commitment, and more work needed to be done to attract young people to the industry. This should include engagement with local schools and the opportunity for people to see flight decks for themselves.

• The 2015 FOG conference would be held on 17/18 March. The theme was the Flight Operations Manager in the 21st Century and would look at the roles, skills, training and the transition from the cockpit to management roles. Workshops would provide tools and methods for flight ops managers to use in their daily work.

DONM: 27 Jan 2015

Dai Whittingham
Chief Executive
31 Oct 2014

Incident Review Meeting – 16/17 September 2014 – Instanbul

CE Meeting Report

Lithium Battery Threat

• The first presentation looked at the threats from the perspective of a Far-East operator, the presenter noting that this was an emerged risk rather than an emerging one.
• The market is worth around $10Bn USD per annum, with Hong Kong as its epicentre. China produced 5-6 Bn batteries in 2013, a growth of 30% on 2012; this was only the legal manufacturers and it was believed the illegal sector could be of similar size.
• There was huge exposure for the CAT sector. Quality of copies was reducing and risk was increasing.There were problems screening cargo and check-in, and irresponsible shippers were not declaring batteries as DG.Cargo consignments tended to be palletised but the operator would only carry them on main cargo decks rather than in holds.
• Incidents of fires had increased; one had been caused by 6 portable lamps in checked baggage that were damaged during handling and subsequently caught fire while the aircraft was in an ATC hold.
• In Aug 2013 the operator detected over 17,000 batteries; in Mar 2014 this had risen to 26,000 batteries. The operator had targeted known traders for checking of shipments and this had improved the situation, though it was probable the traders had simply shifted to other operators in the region.
• Mitigations included training for freight forwarders and shipping agents, additional information on NOTOC, random inspection of cargo, enforcement of limits on carriage of spare batteries for personal use, improvements in cabin fire-fighting capability and training, plus liaison with the regulator and industry.
• A public education programme was needed, and pax handling staff should be asking questions at the check-in stage.
• In the longer term, more work was needed on containment covers, Class C fire suppression systems and smoke/fumes mitigation measures on the flight decks (eg EVAS).There were products such as Firebane and Firesock on the market.Containment covers for pallets were available that would deal with temps of 8150 for up to 4 hours, but these weighed 50+ Kg and took 15 mins to fit.
• More work needed on packaging.Global co-operation will be needed to fix the issue.

Refuelling Fire

• A B737-900 was being refuelled at Kano at night with pax on board; ramp is drive-in drive-out.All operator SOPs were being complied with; a flight crew member was on the flight deck, 2 doors with steps were available for evacuation, fire crews were at readiness, seatbelt signs were off and the ground engineer was on headset.
• Refuelling was stopped for insufficient pressure but the bowser operator restarted.The bowser failed and caught fire, with flames reaching the right winglet.
• Engineer informed captain, who initiated the evacuation via the stairs.Some pax then attempted to return for personal possessions!
• RFFS deployed single fire truck which attempted to extinguish the fire but failed (it was too far back and the FF medium fell short.Only 1 of the 3 on-site fire trucks had been filled and a refill took too long.
• The captain returned to the flight deck (brave man) and released the parking brake, allowing local manpower to physically push the aircraft away from the bowser, which continued to burn for more than 2 hours.
• The right winglet was destroyed but the airframe was returned to service after its replacement.
• Investigation found that the fuel supply company had only started operating a month before the incident, there were no SOPs in place for bowser operators, nor for local firefighting.There were numerous failings in training and standardisation, and there had been a technical failure of the bowser.
• Aircraft operator’s SOPs were found to have been effective but the operator mandated rather than recommended the use of headsets with ground engineers when refuelling.A Safety Notice had been issued to all GH personnel including 3rd party providers and remote locations.The refuelling company was changed.
• Lessons included the requirement for safety department involvement in GH issues, a recommendation that a dedicated team was required to promote safety culture at remote locations and that active safety oversight of remote ops was crucial.Audits needed to be stringent and findings acted on ASAP.

A320 v Ground Vehicle

• An A320 was taxying to stand at Frankfurt in darkness and rain, visibility was in excess of 200m.Crew and observer felt a thump and decided they had hit a pothole which they agreed would be reported to the airport authority.They continued to park but asked for an engineer to inspect the NLG for damage on arrival.Major damage to the NLG and underside of the aircraft was subsequently identified that required NLG and MLG replacement and a gear-down ferry for airframe repairs ($2m+).
• The incident is still UI but it was quickly apparent there had been a collision with a minivan.The vehicle had bounced of the NLG and had then passed between the MLG legs; the roof was crushed downwards, the airfield ops roof lighting had been removed, and the collision was sufficient to have triggered the driver’s air bag.None of the 3 crew on the flight deck had seen the vehicle, which had approached from the beam.
• Comment from the floor included the observation that the airside driving at Frankfurt was probably the fastest at any major airport.

Ground collision – China

• An A319 struck an A320 with its wingtip when arriving on stand causing minor damage to both aircraft.The marshaller issued a very late stop signal; ‘swept wing tip growth’ was also a factor. The crew was at the end of a long day (14.5hrs) and had been given ‘impossible’ taxy instructions by ATC.They did not see the follow-me truck and ended up using a portion of the ramp reserved for service traffic.On seeing the correct taxy markings the crew stopped but too late to avert the collision.
• The investigation found the crew had followed a taxy line that had supposedly been erased but was still plainly visible under lights at night.The problem with the specific gate had been notified to the airport authorities 3 years before but no action had been taken. Ground markings were generally poor and the taxy chart and naming convention was complex and confusing.The incident occurred at 2140 hrs local on the eve of the Chinese New Year…

A320 runway excursion

• The aircraft made an ILS approach in calm wind; AP was disconnected at 500ft.The preceding aircraft had gone-around because of a layer of fog over the threshold and the captain elected to switch to PF.There was no auto-weather facility and no actual/RVR reported from ATC.
• At DA the FO called ‘runway not in sight’ but the captain called to continue.The aircraft was on LOC and GS at 50ft RA but entered the fog bank at the flare, and had developed 6.90 bank by 12ft RA.Touchdown was 18m left of the centreline and the aircraft departed the runway to the left before regaining the paved surface.The captain then taxied to the gate.
• Investigation identified probable over-confidence by the captain, who was a 9000hr instructor with 6000hrs on type.He had landed at the destination 3 days prior.The approach brief had been interrupted and was never completed; there had been no discussion of a go-around.Operator training had been amended to include discussion of visual illusions.

E145 over-run

• The aircraft was approaching in light rain to a runway of 2400m with a displaced threshold (250m) giving a 2190m LDA.The flare was long and touchdown was 540m beyond the (displaced) threshold.
• No autobrake or reverse thrust was used, and the PF released the manual braking in order to maintain directional control on the wet runway.The aircraft over-ran by 330m.No reported damage.

A320 take-off without ref speeds or flex temp

• FO was PF on last of 4 sectors, and undergoing line training.Wx was poor with CB in the vicinity.FO programmed the FMGS but the captain elected to delay while the wx improved; the eventual hold was 75 min.During taxy to the changed runway the captain discussed a new SID with ATC and received a new clearance; he entered the new SID in the MCDU.
• The crew then detected a wrong turn on the nav display which the captain attempted to clear before opting to fly the SID in HDG mode.There was no change to ref speeds or flex temperature which remained in the system memory but were inactive.
• When the throttles were advanced to the stabilisation position the FMA was not as expected and the take-off speeds were not shown.There was then an ECAM alert (ENG THR LEVERS NOT SET), at which point the captain pressed TOGA and confirmed the data by pressing the relevant key.Take-off was continued by the FO, who used the 150 default pitch.
• The crew should have updated the data when the runway was changed in the FMS.The clues for the crew were the MCDU message ‘CHECK TAKE OFF DATA’, the loss of the take-off speeds, and the display of ‘TOGA’ rather than ‘FLEX’ on the TAKE OFF THRUST element of the engine warning display.
• Finally, the crew followed the Airbus Golden Rules, which worked.

B737-800 runway excursion Tblisi

• The aircraft departed the runway during an RTO on contaminated surfaces (-6C, 7mm of slush and wet snow), with braking action assessed as good.TOGA was selected at the start of the take-off run but the aircraft veered right and the PF was unable to maintain directional control.
• Crew had (correctly) used anti-icing but had not run the engines up for 30 seconds to de-ice them.TOGA was pressed on a rolling take-off but with an existing N1 split (37.3/26.0) which developed into a major asymmetry within 3 secs (80.0/40.0).
• Crew had not waited for N1 to stabilise (in common with many other crews for this operator).Operator found shortfalls in training on supplementary procedures and no winter training on ice-shedding.A new FDM event was included to tackle the N1 stabilisation problem and the sim training programme had been revised.

B717 double shut-down

• US operator was familiarising crews with EFBs prior to roll-out across fleet. Captains were permitted to use own tablets with company-provided software.
• During initial climb, the captain placed her iPad on the throttle quadrant module of the forward pedestal.As the aircraft levelled at FL320 the A/THR commanded the throttles aft, trapping the iPad between them and the fuel cut-off switches.In retrieving the device both fuel cut-offs were turned off, shutting down the engines.
• The captain handed control to the FO but his PFD went blank (presumably with a generator coming off line) and so control reverted to the captain.The engines were successfully re-lit but no emergency was declared.The DFDR stopped recording when the left AC bus power failed, leaving a 118 sec gap in data.
• A guard for the switches was available following a single shut-down in Australia but was not fitted to the operator’s fleet.Advice is now included in the FOM.

B767-300-ER flap overspeed and slat damage

• 3 pilot crew with captain as PF, received wx warning 80 mins prior to arrival at Buenos Aires.The crew carried out a thorough briefing which included consideration of turbulence, windshear and alternates.Cabin preparation was completed early, with all pax seated prior to descent.
• Airfield was in sight throughout the event, EZE was using RWY35 with a reported wind of 360/10.At FL50 winds increased to 50 kts though there was still no obvious vertical development in the area.During the localiser intercept winds had increased to 60kts across and cloud formations were nearing the final approach path.
• The captain was having difficulty capturing the localiser and opted to descend early, so selected gear and flaps 20.Still not on the localiser, they then entered the edge of rain cloud, and at around 4000ft the TWR reported surface winds of 270/49.
• Captain called a go-around and, by then in severe turbulence, disconnected the AP and fire-walled the throttles before placing both hands on the yoke; he noted that he had exceeded the flap 20 speed limitation.On passing FL70 he reduced power, started retracting the flaps and asked for vectors to Montevideo.He then received a LE SLAT ASYMMETRY and Master Caution, along with reports from the cabin of wing damage.QRH procedures were followed and a safe landing made at Montevideo.An 8ft section of the LE slat was missing and there was impact damage to the right engine.
• DFDR showed LE SLAT DISAGREE at 230 kts and a peak speed of 346 kts with Flap 1 selected.G range was .59 to 1.4g, so ‘moderate’ turbulence, but there was a 1000ft altitude loss during the escape manoeuvre.Firewalling the throttles disabled the go-around protections in the FCS.
• Operator investigation revealed that knowledge of the windshear warning system (warnings only below 2300 ft) needed to be better, as should knowledge of automation modes. There was a general perception amongst pilots that being ‘field in sight’ meant that all was under control.There was also poor awareness of gust fronts (events occurring on the edges of gusting areas) and more information was required.(CE note: this has now been raised with the Met Office with a request for educational material.)
• More work needs to be done on training for go-arounds at intermediate altitudes.

A380 pressurisation problems and diversion

• Cabin crew advised captain on inbound leg (to LHR) that pax were complaining about a noisy door; this was a reasonably common problem but the FO inspected and captain also visited to check.
• During departure climb the noise became significantly worse (CC were unable to communicate across the length of a service trolley).Maintenance confirmed via ACARS that pressurisation was normal but there would be a further inspection on arrival.
• 5 ½ hrs into the flight, the cabin alt was seen to be varying between 7000 and 8000 ft.The crew received an ECAM Advisory when the altitude reached 8500ft.With the aircraft at FL370 the crew declared a PAN and asked Kabul for a descent but were told to ‘Standby…’An ECAM Warning was received with a cabin altitude of 10,000ft, at which point the crew called MAYDAY and began an emergency descent with a 180o turn before initiating a diversion to the en-route alternate of Ashgabat.
• The captain opted to manually lower the oxygen masks although these were scheduled to deploy automatically at 13,500ft cabin.The max cabin altitude reached was 11,600.
• Ashgabat refused to accept the diversion (possibly because the MAYDAY had not been relayed); the captain rejected an ops suggestion of Dubai because of the need to cross very high ground and instead opted for Baku, where the aircraft landed safely.The technical investigation revealed major fatigue damage to a door.
• During the national AAIB investigation a cabin crew member reported that the oxygen system in the cabin had not worked.A detailed ground examination showed the oxygen bottles had worked as designed and generated the appropriate flow of oxygen required at the relatively low cabin altitude.Further investigation revealed the crew member was a trained nurse and was used to the much higher flow rates produced by medical-grade oxygen bottles (3-4 litres/min).
• Further training issues were apparent from the incorrect usage of a mask in the crew rest facility, where it had proved possible to don a mask without pulling the lanyard to extract the safety pin.Crew training was also being conducted with hard plastic masks containing different valves from the soft plastic live item; crews had not experienced breathing through the system as fitted to the aircraft. Crew members had followed their training but there was evidently a knowledge gap that the operator has since closed, and the correct items of equipment are being used for training.

A320 volcanic ash encounter

• Aircraft was at FL360 on night sector into Jakarta, VMC.Mt Kelud had erupted, there was no NOTAM or ASHTAM, and the FPLN had been issued prior to the eruption.At the time of the eruption the aircraft was in a different FIR.ACARS was not enabled.
• Cloud encountered at 0617 local, the crew noticed St Elmo’s Fire and a strong smell of sulphur.On checking with ATC it was confirmed that there was an eruption approximately 80nm away.The crew went onto oxygen per SOPs; visible ash was then detected.
• Control passed to the captain (SOP), anti-ice was selected and the APU started, and an emergency descent initiated along with a 160o escape turn.The aircraft was in VMC at FL280 and the crew continued to destination (~1hr).
• There were no other indications of an encounter when the FDM was reviewed but a boroscope examination showed clear signs of ash ingestion; both engines required replacing.
• Internal investigation showed that all parties were familiar with VA procedures but knowledge levels were variable and people had possibly become complacent; the incident crew was well prepared for the encounter.However, NOTAMs were received from a 3rd party and covered a wide area, and the provider was unaware of the operator’s VA policy.There was no capacity for updates or flight following, there was an over-reliance on ATC for ops messages, and operations in the region had become ‘normalised’.
• Operator lessons included the need to provide crews with the latest information from FPLN generation to arrival at final destination.SOPs worked well, reinforcing the need for compliance.Training programmes should include infrequent or non-normal events.Communications systems and procedures needed to be matched to the area of operations.3rd party providers need continuous oversight.

Simultaneous parallel runway departures

• Aircraft from the same operator were departing from Istanbul 35L and 35R but had very similar callsigns.The departure clearances were issued but confused, which led to both aircraft starting the take-off roll at the same time.Both aircraft showed traffic on TCAS, which generated an RA at 1000ft.The aircraft on 35R complied, the crew on 35L attempted to avoid visually before receiving a second set of RAs with which they complied.CPA was <0.2nm horizontal and 150ft vertical.

• The investigation discovered that the callsigns were being assigned by a computer programme that took no account of phonetics and was not controlled by the Flt Ops division; assignments now use the Eurocontrol Callsign Similarity Tool for deconfliction and belong to Flt Ops. Callsigns needed to be de-linked from routes.
• The Airprox was made worse because the initial waypoint for RNAV departures from both runways was identical, so aircraft would inevitably converge.Of note, the airport is operating considerably beyond its design capacity.The PF who attempted to de-conflict visually rather than follow the RA could not explain why he had done so; TCAS compliance events have now been added to the training programme.

Landing on taxyway – Bodrum

• BJV RWY10/28 has a parallel taxyway to the north which was widened from 30-45m and PCN increased to match the main runway so that it could be used as a runway if necessary; the taxyway has PAPIs to the left and edge lighting but no special markings.
• Captain flew VOR/DME in a strong crosswind in day VMC; this NPA has a 4o offset to the right.The aircraft was landed on the taxyway but the captain only became aware of this when down to taxy speed.CVR and FDM review was ‘normal’ with all callouts and ops as expected.
• A cockpit video of test approaches flown after the event showed that the taxyway appeared to be the most obvious place to land.The captain had concentrated on flying a stable approach because of the wind conditions.His FO was inexperienced and may have been over-reliant on the captain; he would have been subject to the same visual illusion.The operator’s approach briefing template did not cover potential destination threats and there was no SOP for runway verification.
• The upgrade work had been completed over many months but with no formal notification to the authorities or the operators.None of the crews who had operated into BJV had reported the unexpected WIP.

B747-400F rejected take-off

• B747 was departing Incheon RWY33R at night, weather was 300/4, +21, and TOW 823,500lbs.The crew opted for a rolling take-off but the captain selected full power after 24 seconds as he was unhappy with the acceleration.The V1 of 152kts was called but shortly after that the forward and mid outer linings of the No 1 engine separated, producing a loud noise and yaw to the left.
• The captain initiated the RTO at 166kts (V1+14) but the No 1 thrust lever was not retarded until the aircraft had slowed to 21kts.The speedbrake did not deploy and there was no autobraking because of the position of the No 1 thrust lever.The captain had not noticed the position of the lever and the FO confused it with the speedbrake lever.The aircraft stopped with 500ft of runway remaining but 8 of 16 tyres were flat and subsequently caught fire.
• The investigation revealed deficiencies in simulator RTO training.The operator’s RTO procedure differed from the Boeing drill: the manufacturer calls for manual speedbrake selection but the operator was relying on auto-deployment.There was also a lack of standardisation of RTO callouts.The operator has since amended its manuals and training regime.

And finally…

• There have been instances of unstable approaches being generated by the design of RNAV procedures, where vertical paths have required high rates of descent.At some destinations (Phuket receives particular mention) the coded descent point, which is temperature-dependent, can occur before the FAF: above ISA temps the Phuket approach can require 1150fpm to maintain profile.
• RNAV path design may be a new hazard source and operators need to consider developing appropriate SOPs for vertical path management.

Dai Whittingham
Chief Executive
3 November 2014

Heathrow Manoeuvre Safety Team Meeting – BAA Compass Centre – 10 February 2010
CE Meeting Summary

Item 2 – Concern and Countermeasures (CCMs)- Actions

• No 49. WIP Phases around the airport at Heathrow will be published in the AIP supplement and posted on the website. Any changes to WIP phasing will be promulgated via NOTAMS.
  • NOTAMs are only in text format. BAA to investigate a MAP/picture showing NOTAMs distributed by email – Gatwick has a similar system.
  • NOTAMs will be distributed based on the Heathrow FLOPC membership list with UKFSC added
• No 54.    Runway ahead markings – Human Factors team assessment for positioning of markings being sought by NATS.
  • CAP 168 CAA consultation is ongoing now which includes the format of the RW Ahead signage – colour and shape.
• No 64.   Start-up and push communication and control changes at Heathrow are being revised and will be reflected in the Heathrow AIP in due course.
  • Current Gatwick and Manchester SOPs for pushbacks were discussed to identify best practice.
  • The change is likely to be that ac report ready to Delivery and call for Pushback on Ground.
  • Another potential change will be that the Tug crew must be ready before push back is requested, although in practice this may prove to be impractical.
  • AIP changes will come through the MAST for comment and approval first.

 Item 2 – Last Meeting Minutes  – Action Review

• 2.02 MAST input to the Heathrow website is with webmaster for action – it has been ready for publishing for some time!
• 4.03 Increasing numbers of reports of aircraft being cut up by vehicles – this is being caused by increased numbers of back of stand roadways due to development of the airport.
  • The introduction of a 10mph limit and use of a vehicle beacon is being recommended by the MAST.
• 4.04 The Driver van run in Dec 09 raised wigwag usage which is being reviewed as a result. These are currently being used ay crossing points when the CAP states only for use at Runway entrances.
• 7.01 Discussion on the publication of hotspots on airport maps, which the CAA do not support. ICAO has now issued guidance on publishing hotspots which could re-open the guidance from the CAA!
  • Replay this issue with the CAA – but these would need to be enacted carefully – Dublin is poor practice in this fashion.
• 8.01 A380 routes (Code F) are in yellow on the AIP chart but only go up to the stop bar. Request from operators to extend the yellow from the stop bar to the runway to better indicate which turn-offs landing A380s can use. BAA not convinced of the need at this stage.
• The new B747-800 freighter is Code E and a half – this may need to be addressed in the AIP in due course!

Item 3 – Feedback from FLOPC

• After poor weather during the winter, runway condition assessments were discussed extensively at FLOPC
• RJ briefed the MAST on the ICAO, FAA, EASA initiative on standardisation of runway condition measurement and reporting gained via the CAA RE TF.
• Runway condition assessments are not provided at Heathrow
  • BMI Rep re-iterated that 3mm of contamination and 25% cover = wet and this was an important factor in crosswind limit calculations.

Item 5 – NATS Safety Report

• After 2 incidents at Sierra 4 – where wig wags are in the grass – some review of positioning is being considered by NATS
• Stats for Runway Incursions
  • 19 in 2009 – 17 in 2008
  • 4 – NATS,  3 – dual attribution, 7 – vehicles, 11- Non NATS attributable
  • 1 Cat D outside of the SSE scheme
• 2010 – 2 incidents so far
  • Stop bar crosser at S4 as another ac was landing!
  • NATS attributable

Item 6 – KPIs – 2009/2008

• Aircraft accidents – 0/1
• Cat A-C – 8/2
• Cat D – 11/15
• Close proximity or collision(0) – 2/3
• Unauthorised pushbacks – 28/36
• Taxi route errors – 12/24 ( many not reported) – which indicated that Link 25/26 is a hotspot, which has a layout almost impossible to re-configure
  • New markings on previous hotspots have reduced incidents
• A380 infringes of DLSA – nil so far
• Unauthorised vehicles in LVPs -1/10
• Safeguarding – 5/9
• WIP incidents – 3/tbd
• Vehicles endangering ac – 10/(new)

Other KPI Issues

•  All airline concerns on safety at Heathrow are positively sought by NATS/MAST
• Last November, NATS ATC introduced additional information into radio communications to enhanced situational awareness for pilots.
  • Further enhancements on SA welcome
• Taxi errors require careful monitoring as a lower level indicator of potential runway incursions in future.
• All incidents of stop bar crossings on the manoeuvre area, or when green lights are on beyond a lit stop bar need to be reported into NATS safety at Heathrow.

Runway Inspections

•  New runway inspection trial is underway. Feb 2010 for 3 months
• Currently, landing RW inspections are done within natural gaps in traffic, whilst take-off RW has a dedicated inspection slot times.
• Dedicated slot time inspections on both take-off and landing runways are now being trialled.
• For the landing RW, a gap between traffic of 15 miles sep is required
• Aim of the new procedure is to:
  • Provide sufficient time to do more effective runway inspections
  • Improve the management of vehicles on the activate runway
• Instead of 1 vehicle, 2 vehicles will do the inspection in future = halving time
• Inspection vehicles will go towards the air traffic flow for safety.
• Morning inspection and afternoon inspection daily
• Feedback to NATS on any impact of new procedure requested

Item 7 – MAST Safety Strategy Review – Action Plan Latest Update issued to members for review and comment.

Item 8 – ACN Driving Incident/Offence Report Review

• 40% reduction in incidents since introduction of penalty point system introduced.

Item 9 – AOB

Nil

Next meeting – 21 April 2010

Rich Jones
Chief Exec
UK Flight Safety Committee
12 February 2010

Manoeuvre Area Safety Team Meeting – Heathrow – 11 August 2010
CE Meeting Summary

Agenda

Minutes from last Meeting

Review of Actions and CCM

• Notams and WIP – There is an opportunity for visualisation of NOTAMs and WIP on the MAST Heathrow Pages on the BAA website at http://www.heathrowairport.com/portal/site/heathrow/menuitem.044615affa2bd696848cce9e9328c1a0/
• ATC FAQ page now on the Mast area of the Heathrow website which provides pilots and drivers to exchange views with ATC
• Lesson learning Hotspot pictures on the website now to aid pilot planning
• Not all RI hotspots can be corrected and can be human factor-related E.g. Heathrow take-off only RW is a classic example of where expectation leads to no look out for aircraft on approach
• Some form of signage at the hold point on RW 27 to question pilots about their clearance to line-up will be considered
• 2 BAA/NATS Gps are to look specifically at RI at Heathrow – one to seek immediate actions to RIs and one to look at technologies available
• BMI/Spencer Norton to review Pushback radio call procedure to seek better co-ordination
• ‘Runway Vacated’ group is meeting at Heathrow to seek a clearer definition to assit controllers in making safer clearance decisions

Review of the MAST KPIs and Action Plan

• MAST agreed on the list of events to be captured for presentation for MAST information
• Discussion on taxi errors concluded that scratchpad exercises were the most effective method of identifying taxi error hotspots and that pilots would unlikely to report taxi errors by ASRs
• Pushback errors are still a problem despite several actions to address them – another pushback meeting to be called in Oct

• MAST Action Plan – to reduce RI Risk
  • Potential use of lighting to prevent RIs – write a report by the technology group including:
    • Stop bars
    • Dancing bars
    • Phased approach to 24 hour stop bar
    • SOP Aircraft lights has been investigated but too many variation amongst airlines to achieve further progress
  • Improve Use of signage – this was identified through van run usage
    • Repeat van run at dusk next in December
    • Driver van run has also taken place and identified problems and solutions on wigwags
  • Official name of wigwags are Runway Status Lights not wigwags
  • Add more photos of signs on the MAST website – could be used as part of a fun test approach to promote knowledge among pilots
  • Possible additional warning signage at the holding point will be considered but some non-ICAO compliant concerns expressed
  • Manchester have a model cow on their airfield!!!!
  • Manchester use of satnav which could be useful at Heathrow. BAA to investigate
  • Single CAT holding point – controversial on capacity with some MAST Members – hold on this issue for now
  • BAA have undertaken a Road onto Taxiway Markings and lighting Survey
  • Numerous variations at Heathrow – some good, some poor, some standard, some non-standard
  • Weather and light conditions also prevent markings working effectively
  • Overall, inconsistent and full of mixed messages
  • One recommendation being considered is to change wigwags from orange to red lens.
  • BAA and HAL to review the standard of these crossing points
  • In addition, driver training needs to able to provide the correct knowledge consistent with the situation on the ground
  • Pushback errors – New change at Heathrow
  • Only flt plan clearance will be available on the clearance freq
  • Engine start and pushback now obtained on ground freq.
  • Drivers with current approval to access and cross runways will need to re-apply for the necessary licence which requires a specific course first from 1 Oct 10
  •  Transponder fitting strategy is being considered at Heathrow with funds being sought next year. Variety of solutions underway
  • New Runway inspections routine now has been established
  • Taxi issues and concerns continue to be addressed through van runs, signage and lighting improvements
  • Driver training standards and situational awareness training with ATC input has now been introduced at Heathrow based on lessons learned

Vehicle Driver Charges – ACN Data

• Top 3 vehicle charges for Heathrow in the last quarter
  • Mobile phone usage when driving
  • Speeding
  • Failure to give way to ac – these events should be reported by the Captain to the ATC as soon as possible

AOB

• Pushback working group meeting in Oct 10 to look at the new procedure
• Construction vehicles are now being briefed on ac collision risk
• BAA FOD conference on 9/10 November at Heathrow

Rich Jones
Chief Exec
UK Flight Safety Committee
13 August 2010