SKYbrary Highlights

 

Night Visual Approaches – Understanding the Risks
Careful consideration should be given to all pertinent factors before flying a visual approach at night in preference to an instrument procedure, especially at an unfamiliar airport.
Whilst man-made obstacles in the vicinity of an airport such as buildings or towers are normally lit during the hours of darkness, natural obstacles such as hills or trees are not. As a consequence, unless there is exceptional illumination such as a full moon on new snow, natural obstacles will be largely invisible to the pilot during a night visual approach. Without due care, this factor greatly increases the potential of a CFIT accident. In fact, numerous CFIT accidents have occurred during visual approaches during hours of darkness.
Dated: December 2018


Preliminary report into Lion Air accident on 29 October 2018
On 29 October 2018, a crew had difficulty controlling the aircraft in pitch almost immediately after a day takeoff from Jakarta, and after failing to resolve the problem decided to return. No abnormal or emergency status was declared but after approximately eleven minutes airborne, contact was lost and it was found that sea surface impact had destroyed the aircraft. Successful management of apparently similar pitch control problems during the aircraft’s previous flight, after which there had been maintenance input before release to service for the accident flight, has been noted.
The Investigation is continuing.
Dated: December 2018


2019 Safety Forum – Call for Submissions
The Organising Committee for the 7th Annual Safety Forum is inviting submissions to present as a speaker.
The 2019 event is dedicated to Safety and Procedures
Dated: November 2018


Escape Routes
In many parts of the world, aircraft are routinely flown over terrain that has minimum obstacle clearance altitudes (MOCA) exceeding 10,000′. Avoidance of these areas by transiting aircraft could potentially add hundreds of extra miles to a given route and result in a substantial increase in flight time and the associated costs. To satisfy the commercial imperative while maintaining an acceptable level of safety, operators have developed escape routes and the associated procedures for use in the event of an emergency whilst overflying extensive high terrain. For routes of flight that require a predefined escape route or routes, the following information should be provided to, or developed by, the crew prior to flight:
Minimum Route Altitude
Route Segment
Escape Fix
Escape Route
Dated: November 2018


Runway lights not aligned with notified landing runway? Maybe it’s the wrong runway
On 22 December 2016, an aircraft cleared for a night approach to runway 16L at Haneda, which involved circling to the right from an initial VOR approach, instead turned left and began an approach to a closed but partially lit runway. ATC noticed and intervened to require a climb away for repositioning to the correct runway using radar vectors.
The Investigation found that the context for the crew’s visual positioning error was their failure to adequately prepare for the approach before commencing it.
Dated: November 2018


Don’t assume that a significant hazard will be rectified by somebody else – do something
On 27 October 2017, an aircraft returned to Auckland after advice from ATC that the right engine may have been affected by ingestion of FOD during engine start – a clipboard and paper left just inside the right hand engine by an employee of the airline’s ground handling contractor acting as the aircraft loading supervisor. The subsequent inspection found paper throughout the engine and minor damage to an engine fan blade and the fan case attrition liner.
The Dispatcher overseeing the departure said she had seen the clipboard inside the engine but assumed it would be retrieved before departure.
Dated: November 2018


Always respond as trained to EGPWS activations
On 12 June 2015, a crew forgot to set QNH before commencing a night non-precision approach to Kosrae which was then flown using an over-reading altimeter. EGPWS Alerts occurred due to this mis-setting but were initially assessed as false. The third of these occurred when the eventual go-around was initially misflown and descent to within 200 feet of the sea occurred before climbing.
The Investigation noted failure to action the approach checklist as well as the potential effect of fatigue on the Captain.
Dated: November 2018


2019 Safety Forum: Safety and Procedures
The 7th annual Safety Forum will be held in Brussels on 4 and 5 June 2019. The Forum will focus on Safety and Procedures.
Further information regarding the agenda and registration will be announced in the coming months.
Dated: October 2018


Should automated validation of take off performance data be mandated?
On 21 July 2017, an aircraft took off from Belfast with a significantly lower thrust setting than that intended. The aircraft became airborne just before the end of the runway but only climbed at a very shallow angle.
The Investigation is continuing but has found that the low thrust setting resulted from crew FMS input of the expected top-of-climb temperature in place of the surface temperature
Dated: October 2018


Radiation Fog
On a cloudless night, especially within a high pressure system, the land surface loses heat to the atmosphere by radiation and cools. Moist air in contact with the cooling surface also cools and when the temperature falls below the dew point for that air, fog forms. This type of fog is known as radiation fog.
Formation of Radiation Fog
Initially it may be mist that forms and then thickens into fog as the temperature drops and more water vapour condenses into water droplets in the air. Air does not conduct heat very well so in still air conditions fog may not form at all and a layer of dew or frost will form on the surface instead. However, if there is a light wind of around 5 kts, then this will mix the air in contact with the surface and the layer of fog will be thicker. With stronger winds, the fog may lift to form layers of Stratus.
Dispersal of Radiation Fog
As the sun rises, and the surface temperature increases, the air in contact with the surface will warm and the fog will gradually disperse. The fog may rise to form a low layer of stratus. If the fog is particularly thick, then it may prevent the sun from heating the surface and the fog will not clear. This situation is common in the autumn in northern Europe when some airfields may be affected by fog for many days.
Anticipating Radiation Fog
The three conditions required for radiation fog are:
clear skies, moist air, and a light wind.
Dated: October 2018


Even routine re-sectorisation creates risks which must be systematically mitigated
On 28 September 2016, a passenger jet and a light aircraft both on IFR Flight Plans came into close proximity when about to turn final on the same non-precision approach at Girona from different initial joining routes.
The Investigation found that two ACC sector controllers had issued conflicting approach clearances after losing situational awareness.
Dated: October 2018


Beware complacency when operating from familiar aerodromes
On 25 January 2016, a crew departing from and very familiar with Karup aligned their aircraft with the runway edge lights instead of the lit runway centreline and began take-off, only realising their error when they collided with part of the arrester wire installation at the side of the runway after which the take-off was rejected.
Given the familiarity of both pilots with the aerodrome, the Investigation noted that complacency had probably been a contributor factor.
Dated: October 2018


Cabin crew vigilance during disembarkation preventing serious injuries
On 12 December 2015, whilst an aircraft was beginning disembarkation of passengers via an air bridge, the bridge malfunctioned, raising the aircraft nose gear approximately 2 metres off the ground. The door attached to the bridge then failed and the aircraft dropped abruptly.|
Prompt cabin crew intervention prevented all but two minor injuries.
Dated: September 2018


Wing Growth Effect
On 24 November 2016, an aircraft being marshalled into an unmarked parking position collided with another stationary aircraft which sustained significant damage. The aircraft was being marshalled in accordance with airport procedures with wing walker assistance but a sharp corrective turn which created a ‘wing growth’ effect created a collision risk that was not seen by the marshaller.
The report provides useful educational material.
Dated: September 2018


HindSight 27
The latest edition of EUROCONTROL’s safety magazine focuses on competency and expertise.
Dated: September 2018


System Wide Events
This article considers the operational and airmanship factors of importance to flight crew experiencing a system-wide event (SWE) which is an event that affects a flight and a sufficiently wide area that all alternate routes and airfields briefed during pre-flight preparation have become unavailable. Ground facilities such as navigation beacons and air traffic services may also be affected.
Dated: September 2018


Rapid evacuation following smoke in the cabin
On 26 June 2016, thick white smoke suddenly appeared in the cabin of a fully loaded aircraft prior to engine start with the door used for boarding still connected to the air bridge. An emergency evacuation initiated by cabin crew was accomplished without injury although amidst some confusion due to a brief conflict between flight crew and cabin crew instructions.
The in-depth review of what happened and the identification of lessons for all to learn is almost unique.
Dated: September 2018


Overrun on landing events continue to happen
On 19 June 2016, an aircraft landed long at Khark Island and overran the end of the runway at speed with the aircraft only stopping because the nose landing gear collapsed on encountering uneven ground.
The Investigation attributed the accident entirely to the decisions and actions of the aircraft commander who failed to go around from an unstabilised approach, landed long and then did not ensure maximum deceleration was achieved. The monitoring role of the low experience First Officer was ineffective.
Dated: August 2018


Controller “blind spot” error leads to loss of separation
On 25 July 2016, two aircraft departing Barcelona and following their ATC instructions came into conflict and the collision risk was removed by the TCAS RA CLIMB response of one of the aircraft. The Investigation found that the controller involved had become preoccupied with an inbound traffic de-confliction task elsewhere in their sector and, after overlooking the likely effect of the different rates of climb of the aircraft, had not regarded monitoring their separation as necessary.
Dated: August 2018


Continued operation of an engine experiencing high vibration should only be considered in extreme circumstances
On 15 October 2015 an aircraft experienced significant vibration from one of the engines almost immediately after take-off. After the climb out was continued, without reducing the affected engine thrust, an uncontained failure followed 3 minutes later.
The ejected debris caused the almost simultaneous failure of the No 4 engine, loss of multiple hydraulic systems and all the fuel from one wing tank.
Dated: August 2018


Parties with a shared responsibility for operational safety need to coordinate their approaches
On 6 December 2015, an aircraft was being manoeuvred by tug from its departure gate at Singapore to the position where it was permitted to commence taxiing under its own power when the tug lost control of the aircraft, the tow bar broke and the two collided.
The Investigation attributed the collision to the way the tug was used. Some inconsistency was found between procedures for push back promulgated by the airline, its ground handling contractor and the airport operator.
Dated: July 2018


In-Flight Fire, a SKYclip
The latest safety promotion animation from EUROCONTROL focuses on in-flight fire.
Dated: July 2018


2018 Safety Forum Findings published
The Findings, Strategies and Action Opportunities from the 2018 Safety Forum, which focused on Safety Behaviours, has now been published.
Dated: July 2018


Spatial Disorientation
Somatogravic and Somatogyral illusions are the two most common forms of vestibular or ‘false sensation’ illusion. The vestibular organs are part of the human body’s mechanism for achieving posture and stability. Changes in linear acceleration, angular acceleration and vertical acceleration (gravity) which occur as a result of flight control inputs, made to accomplish a change in the flight path, are detected by the vestibular system and may create either or both of these illusions.
Dated: July 2018


Investigation identifies significant lessons for type certification and continued airworthiness
On 29 April 2016, the main rotor head and mast of a helicopter suddenly detached without warning. The accident was attributed to undetected development of metal fatigue in the same gearbox component which caused an identical 2009 accident to a variant of the same helicopter type.
Dated: July 2018


ACAS II Bulletin – “Equipment Matters”
The latest issue of EUROCONTROL’s ACAS Bulletin describes events in which the primary causes were technical anomalies either associated with TCAS, transponder, or altimeters
Dated: July 2018


The importance of an adequate pre-flight briefing…
On 17 May 2015, a crew descended their aircraft below the correct vertical profile on a visual daytime approach at Yerevan and then landed on a closed section of the runway near the displaced runway threshold. The Investigation found that the crew had failed to review relevant AIS information and had not been expecting anything but a normal approach and landing.
Dated: July 2018


Startle Effect, a SKYclip
The latest safety promotion animation from EUROCONTROL focuses on the Startle Effect.
Dated: June 2018


Report published into November 2016 fatal accident involving aircraft carrying Chapecoense football team
On 29 November 2016, an aircraft failed to complete its night charter flight to Medellín when all engines stopped due to fuel exhaustion and it crashed in mountainous terrain 10 nm from its intended destination killing almost all occupants. The Investigation noted the complete disregard by the aircraft commander of procedures essential for safe flight by knowingly departing with significantly less fuel onboard than required for the intended flight and with no apparent intention to refuel en route.
Dated: June 2018


On 29th and 30th May 2018, over 200 safety professionals met in Brussels for the 6th Safety Forum focused on Safety Behaviours – look out for the findings and safety action opportunities developed at the event which will be published before the end of June.
On Monday 28th June, over 15,000 people visited SKYbrary to view the latest of our SKYclips safety promotion animations. The growing collection collection of SKYclips is proving to be very popular with safety professionals across the aviation industry.
Help us to raise awareness of key safety issues by sharing this with your colleagues.
Dated: June 2018


Controller Blind Spot
“Blind Spot” is a type of human error. Loss of separation “Blind Spot” events are typically characterised by the controller not detecting a conflict with the closest aircraft. Such events usually occur after an incorrect descent or climb clearance. Usually there is very little (or no) time to react to such an error and most of the conflicting clearances result in an incident.
For more information, take a look at the EUROCONTROL Operational Safety Study: Blind Spots
Dated: June 2018


Is the runway wide enough for a 180 degree turn after back track?
On 18 April 2013, an aircraft was unintentionally taxied off the side of the runway during a 180° turn after backtracking the departure runway at Tabriz at night. The Investigation found that the prevailing wet runway conditions meant that the runway width alone was insufficient for the turn.
Dated: June 2018


TCAS RA High Vertical Rate, a SKYclip
The latest safety promotion animation from EUROCONTROL focuses on TCAS RA High Vertical Rate.
May 2018


Classic Mid-Air with lessons that are still relevant today
On 29 September 2006, an aircraft level at FL370 collided with opposite direction traffic at the same level, resulting in the death of all 154 occupants. A still relevant event in which a crew were sufficiently distracted by administrative tasks that they did not notice that one of them had accidently switched off the selected transponder.
Dated: May 2018


NTSB issues Investigative Update on April uncontained engine failure
On 14 April 2018, a sudden uncontained engine failure occurred to an aircraft as it climbed through approximately FL 320 abeam Philadelphia. Ejected debris broke a cabin window causing rapid decompression and the death of a passenger seated nearby. The same day, the Investigation, which is continuing, found that the failure was due to metal fatigue in a single fan blade causing it to shear from the hub.
Dated: May 2018


Stop bars mean STOP
Stop bars are a series of embedded unidirectional red lights forming a line across the taxiway. They’re an important safety feature to prevent runway incursions and apply to both aircraft and vehicles operating airside. When the stop bar is lit, pilots MUST always stop and hold position – Only proceed when Air Traffic Control gives an explicit clearance AND switches off the stop bar.
Air Traffic Controller must never issue a clearance to cross a red stop bar.
In case of contingency when stop bars are unserviceable and stuck on red the aircraft should be re-routed and if this is impossible contingency procedures must apply. In each country Air Traffic Control may have different “stop bar stuck on red” contingency procedures.” Some states require to physically disconnect the lit stop bar from its power supply. Others physically obscure the lights. And some airports provide a follow-me vehicle to lead aircraft across the lit stop bar.
Dated: May 2018


SKYclips – Pilot Fatigue
The latest safety promotion animation from EUROCONTROL focuses on Fatigue.
Dated: May 2018


The importance of recording any liquid spillage in the cabin
On 25 May 2016, an aircraft experienced a major electrical system failure soon after reaching its cruise altitude of FL 360. ATC were advised of problems and a descent to enable the APU to be started was made. This action restored most of the lost systems and the crew, not having declared an emergency, elected to complete their planned 400nm flight. The Investigation found that liquid contamination of an underfloor avionics bay had caused the electrical failure which had also involved fire and smoke without crew awareness because the smoke detection and air recirculation systems had been unpowered.
Dated: April 2018


Implications of Hydraulic Failure
On a fly by wire aircraft, will the failure result in a change of control law when the landing gear is extended?
Dated: April 2018


Short Vectoring and Glideslope Interception from Above: Guidance for Controllers
The French DSNA has produced some training videos to raise controller awareness of the impact of short vectoring on flightdeck workload and the risks associated with incepting a glideslope from above.
Dated: April 2018


Somatogravic illusion on initial climb into dark night conditions?
On 29 October 2014, an aircraft ceased its climb out soon after take-off and was subsequently found to have descended into the sea at increasing speed with the impact destroying the aircraft. The Investigation found that the aircraft had been airworthy prior to the crash and, noting a dark night departure and a significant authority gradient on the fight deck, concluded that the pilot flying had probably experienced a somatogravic illusion as the aircraft accelerated during flap retraction and made a required left turn.
Dated: April 2018


Always use available cues to confirm that you are lined up on the runway
On 7 July 2017, a crew unintentionally made and almost completed a night visual final approach to the taxiway parallel to the runway on which they had been cleared to land at San Francisco. Despite seeing lights ahead on what they presumed was the runway, they continued the approach descending over the taxiway and overhead two aircraft on it which were awaiting full length departures before commencing a go around at approximately 85 feet agl and reaching a minimum height of 59 feet agl before beginning to climb away.
Dated: March 2018


SKYclips – Speedcontrol for final approach
The latest safety promotion animation from EUROCONTROL focuses on Speedcontrol on final approach.
Dated: March 2018


HindSight 27 – Call for Articles: “Competency and Expertise”
We now welcome articles for the next HindSight magazine, especially from front line controllers and pilots. The theme of this next edition will be “Competency and Expertise”.
Dated: March 2018


The importance of in-flight access to up to date weather information
On 18 June 2013, a crew en route to Adelaide encountered un-forecast below-minima weather conditions on arrival there and decided to divert to their designated alternate, Mildura, approximately 220nm away where both the weather report and forecast were much better. However, on arrival there, an un-forecast rapid deterioration to thick fog had occurred with insufficient fuel to go anywhere else. The only available approach was flown, but despite exceeding the minimum altitude by 260 feet, no visual reference was obtained. A further approach with the reported overcast 100 feet agl and visibility 200 metres was continued to a landing.
Dated: March 2018


2018 Safety Forum Draft Agenda
The agenda for this year’s Safety Forum has been published. The Forum will focus on the topic of safety behaviours and will be held in Brussels, 29 and 30 May 2018.
Dated: March 2018


Contractors working airside requires both an adequate risk management plan and effective oversight of its implementation
On 17 October 2014, The crew of an aircraft taking off from Madrid at night detected non-runway lights ahead as they accelerated through approximately 90 knots. ATC were unaware what they might be and the lights subsequently disappeared, and the crew continued the takeoff. A reportedly unlit vehicle at the side of the runway was subsequently passed just before rotation. The Investigation found that the driver of an external contractor’s vehicle had failed to correctly route to the parallel runway which was closed overnight for maintenance but had not realised this until he saw the lights of an approaching aircraft.
Dated: March 2018


Aircraft operators need to recognise the need for risk management of circling approaches
On 29 June 2009, an aircraft making a dark-night visual circling approach to Moroni crashed into the sea and was destroyed. The Investigation found that the final impact had occurred with the aircraft stalled and in the absence of appropriate prior recovery actions and that this had been immediately preceded by two separate GWPS ‘PULL UP’ events. It was concluded that the attempted circling procedure had been highly unstable with the crew’s inappropriate actions and inactions probably attributable to their becoming progressively overwhelmed by successive warnings and alerts caused by their poor management of the aircraft’s flight path.
Dated: February 2018


Mid-air collision risk is increased by the increasing accuracy of automated navigation systems
On 5 September 2015, an aircraft cruising as cleared at FL350 collided with an opposite direction aircraft which had been assigned and acknowledged altitude of FL340. The first aircraft continued to destination with winglet damage but radio contact with the second aircraft was lost and it was subsequently radar-tracked maintaining FL350 and continuing westwards past its destination Dakar for almost an hour before making an uncontrolled descent into the sea. The Investigation found that this aircraft had a recent history of un-rectified altimetry problems which prevented TCAS activation.
Dated: February 2018


SKYclip – Readback Hearback
The latest safety promotion animation from EUROCONTROL focuses on Readback Hearback.
Dated: February 2018


Crews need to be aware of and apply winter ops SOPs
On 1 February 2015, an aircraft departed from Pamplona with slush on the runway. On landing at Madrid, the normal operation of the brake units was compromised by ice and one tyre burst damaging surrounding components and leaving debris on the runway. The Investigation concluded that the Pamplona apron, taxiway and runway had not been properly cleared of frozen deposits and that the flight crew had not followed procedures appropriate for the prevailing conditions.
Dated: February 2018


Transport Canada has issued an update on its investigation into the December 2017 crash at Fond-du-Lac
On 13 December 2017, an aircraft crashed shortly after making a night take-off from Fond-du-Lac. The aircraft was destroyed by the impact but there was no fire and only one subsequent fatality amongst the occupants. The Investigation is ongoing but preliminary information has been released which confirms that both engines were operating at impact and that a significant wreckage path through trees led up to the impact site.
Dated: January 2018


Potential head on collision averted
On 3 May 2017, two aircraft lost prescribed separation whilst tracking in opposite directions on a radar-controlled ATS route in eastern Myanmar close to the Chinese border. The Investigation found that the response of a crew to a call for another aircraft went undetected and they descended to the same level as another aircraft with the lost separation only being mitigated by intervention from the neighbouring Chinese ACC which was able to give an avoiding action turn.
Dated: January 2018


Final Call for submissions for the 2018 Safety Forum
The deadline for submissions for the 2018 Safety Forum “Safety Behaviours” is 31 January 2018. If you would like to submit a poster or presentation, then please do so now.
Dated: January 2018


The importance of commencing a go around when the previously acquired visual reference is lost
On 7 July 2014, an aircraft landing at Brunei departed the side of the runway almost immediately after touchdown. The Investigation concluded that the aircraft commander, having taken over control from the First Officer when the latter lost their previously-acquired prescribed visual reference below Decision Altitude, had then continued the approach without recognising that the only lights still visible to him were those at the right hand edge of the runway.
Dated: January 2018


The challenge of managing the risks of intersecting runway operations
On 5 October 2016, an aircraft took off at night without clearance as another aircraft was about to touch down on an intersecting runway. The landing aircraft responded promptly to the ATC go-around instruction and passed over the intersection after the other aircraft had accelerated through it during its take-off roll.
Dated: January 2018


Big fuel fed fire? – Evacuate!
On 27 June 2016, an aircraft returned to Singapore when what was initially identified as a suspected right engine oil quantity indication problem evidenced other abnormal symptoms relating to the same engine. The engine caught fire on landing. The substantial fire was quickly contained and an emergency evacuation was not performed.
Dated: January 2018


HindSight 26
The latest edition of EUROCONTOL’s aclaimed safety magazine is titled “safety at the interfaces” and focuses on successful collaboration between functions, departments, professions, and organisations.
Dated: December 2017


So you have a Safety Management System but is it effective?
On 24 February 2015, the crew of an aircraft continued an already unstable approach towards a landing despite losing sight of the runway as visibility deteriorated in blowing snow. The aircraft touched down approximately 140 metres before the start of the paved surface. The continued unstable approach was attributed by the Investigation to “plan continuation bias” compounded by “confirmation bias”. It was also found that although the aircraft operator had had an approved SMS in place for almost six years, it had not detected that approaches made by the aircraft type involved were routinely unstable.
Dated: December 2017


SOPs are there for a reason
On 6 April 2016, an aircraft overran the runway at Gällivare after a bounced night landing. The Investigation concluded that after a stabilised approach, the handling of the aircraft just prior and after touchdown, which included late and inappropriate deployment of the thrust reversers, was not compatible with a safe landing in the prevailing conditions, and that the crew briefing for the landing had been inadequate.
Dated: December 2017


Overrun avoidance means landing in the TDZ and immediate deceleration to taxi speed
On 5 June 2015, an aircraft landed long on a wet runway at Montréal and the crew then misjudged their intentionally-delayed deceleration because of an instruction to clear the relatively long runway at its far end and were then unable to avoid an overrun. The Investigation concluded that use of available deceleration devices had been inappropriate and that deceleration as quickly as possible to normal taxi speed before maintaining this to the intended runway exit was a universally preferable strategy. It was concluded that viscous hydroplaning had probably reduced the effectiveness of maximum braking as the runway end approached.
Dated: December 2017


Landings in the presence of thunderstorms near the runway present an ongoing risk to aviation safety
On 7 October 2014, an aircraft failed to maintain the runway centreline as it touched down at Montréal in suddenly reduced forward visibility and part of the left main gear departed the runway edge, paralleling it briefly before returning to it and regaining the centreline as the landing roll was completed. The Investigation attributed the excursion to a delay in corrective action when a sudden change in wind velocity occurred at the same time as degraded visual reference. It was found that the runway should not have been in use in such poor visibility without serviceable lighting.
Dated: November 2017


2018 Safety Forum – Call For Submissions
Dated: November 2017


EAPPRI v3.0 Press Release
EUROCONTROL has launched version 3 of the European Action Plan for the Prevention of Runway Incursions.
Dated: November 2017


On a NPA, monitoring the descent profile is not optional
On 29 March 2015, a crew mismanaged the descent during a night non-precision approach at Halifax and continued below MDA without the mandatory autopilot disconnection until, with inadequate visual reference, the aircraft impacted terrain and obstructions 225 metres short of the runway. The aircraft was destroyed but there were no fatalities. The Investigation found that the crew did not monitor their descent against the required vertical profile, as there was no SOP requiring them to do so, and did not recognise in time that a go around was appropriate.
Dated: November 2017


2006 cargo fire was a precursor to later fatal cargo in-flight fire events
On 7 February 2006, an aircraft was destroyed by fire which the Investigation traced to containers which it was suspected but not proved had been loaded with lithium batteries. This historically significant event serves as a reminder that aviation can be slow to respond to a growing safety threat when there are no fatalities and solutions are expensive and/or difficult.
Dated: October 2017


Emergency diversions to airports with less than the normally required AFS cover
On 5 January 2014, an aircraft en route to Singapore at night made an emergency descent and diversion to Baku after a loss of cabin pressure without further event. The Investigation attributed the pressure loss to a fatigue crack in a door. Safety Issues related to diversions to aerodromes with a fire category less than that normally required were also identified.
Dated: October 2017


Save the Date – 2018 Safety Forum on Safety Behaviours
From 1200 on Tuesday 29th May until 1500 on Wednesday 30th May 2018, safety behaviours will be the single operational issue addressed by the 6th Annual Safety Forum presented by the Flight Safety Foundation, EUROCONTROL and the European Regions Airline Association.
Dated: October 2017


Landing without ATC Clearance
The latest safety promotion animation focuses on the risk of aircraft landing without clearance.
Dated: October 2017


Willie Walsh will be the keynote speaker at IASS
Willie Walsh, chief executive of International Airlines Group (IAG), will be the keynote speaker at Flight Safety Foundation’s 70th annual International Air Safety Summit (IASS), scheduled for Oct. 23-25 in Dublin, Ireland. Walsh will open the three-day IASS 2017 on Monday morning, Oct. 23.
Dated: October 2017


The importance of using the compass to confirm you are on the correct taxiway…
On 7 December 1983, an aircraft taking off from Madrid in thick fog collided at high speed with an aircraft which did not follow its departure taxi clearance to the beginning of the same runway. This “classic” runway incursion event was a precursor to the tragedy at Linate many years later.
Dated: October 2017


SKYclip: Landing without clearance
Posted: October 2017


Hypoxia can creep up on you… learn the warning symptoms
On 14 August 2005, an aircraft crashed near Grammatiko, Greece following the incapacitation of the crew due to Hypoxia. Many of the lessons are still relevant today.
Dated: September 2017


Simultaneous Approaches to Parallel Runways
When centrelines are spaced by 9000′ or less, special procedures must be put in force to help preclude Loss of Separation between aircraft conducting simultaneous approaches.
Dated: September 2017


SKYclip – TCAS: Follow the RA
The latest safety promotion animation focuses on the need to follow the TCAS RA at all times.
Dated: September 2017


Inappropriate response to engine malfunction
On 4 February 2015, an aircraft crashed into the Keelung River in central Taipei shortly after taking off from nearby Songshan Airport after the crew mishandled a fault on one engine by shutting down the other in error. The Investigation found that the initial engine fault occurred before getting airborne and should have led to a low-speed rejected take-off.
Dated: August 2017


Tired crew, commercial pressure, night visual approach, inoperative GPWS and “black hole” effect ends in CFIT
On 5 August 2001, an aircraft with an inoperative GPWS making a night approach to Narsarsuaq by visual reference impacted terrain 4.5 nm from the aerodrome. A classic example of the ‘black hole’ effect.
Dated: August 2017


70th International Air Safety Summit (IASS)
Organized by Flight Safety Foundation and Hosted by Aer Lingus, this year’s IASS will be held in Dublin, 23-25 October 2017. This event brings together the best minds in the industry from 50+ countries to exchange information and propose new directions for making the safest mode of transportation even safer. Topics at this year’s summit include somatogravic illusions, human factors, data, remotely piloted aircraft systems, and a special maintenance and engineering track session.
Dated: August 2017


Experienced captain intentionally penetrates a line of mature thunderstorms…
On 5 September 2014, the crew of an aircraft encountered a more continuous area of convective activity en-route than expected. When it became impossible to see a way to continue through it, the aircraft commander requested, received and actioned flight path advice from the Company flight-following function. This led to the penetration of a mature thunderstorm and several minutes of severe turbulence with aircraft control lost and only regained upon exit from the storm. The Investigation found that the weather avoidance advice was based on an inappropriate source and that following it was an inappropriate command decision.
Dated: August 2017


Attempted take-off from a taxiway parallel to the departure runway not reported by Captain
On 12 July 2015, an aircraft deviated from its acknowledged clearance and lit-centreline taxiway routing and began take-off from a parallel taxiway in good night visibility, crossing a lit red stop bar in the process. When ATC observed this, the aircraft was instructed to stop which was achieved without further event. A subsequent take-off was uneventful. The crew did not report the event to their airline or their State authorities because the Captain “determined that this case did not need to be reported” and these organisations only became aware when subsequently contacted by the Investigating Agency.
Dated: August 2017


An example of the challenges of controlling aircraft in E Class airspace
On 7 July 2015, a mid-air collision occurred between a military jet and a light aircraft in VMC in Class E airspace. The investigations conducted noted the limitations of see-and-avoid and attributed the accident to the failure of the radar controller working the military aircraft to provide appropriate timely resolution of the impending conflict.
Dated: July 2017


2017 Safety Forum outputs
Videos and slide packs of the presentations from the Preventing Runway Collisions Safety Forum have been published on SKYbrary, along with the Findings, Strategies and Action Opportunities.
Dated: July 2017


70th International Air Safety Summit (IASS)
Organized by Flight Safety Foundation and Hosted by Aer Lingus, this year’s IASS will be held in Dublin, 23-25 October 2017. This event brings together the best minds in the industry from 50+ countries to exchange information and propose new directions for making the safest mode of transportation even safer. Topics at this year’s summit include somatogravic illusions, human factors, data, remotely piloted aircraft systems, and a special maintenance and engineering track session.
Dated: July 2017


Organisations must have in place procedures which deter habitual consumption of alcohol by staff on safety critical duties
On 20 October 2014, an aircraft taking off at night from Moscow Vnukovo collided with a snow plough, which had entered the same runway without clearance, shortly after rotation. Control was lost and all occupants died when it was destroyed by impact forces and post crash fire. The uninjured snow plough driver was subsequently discovered to be under the influence of alcohol.
Dated: July 2017


“Unintentional interruption of Air Traffic Service” leads to airborne conflict
On 30 June 2015 the crew of an aircraft failed to notice that their transponder had reverted to Standby. The subsequent collision risk was significantly worsened by a muddled and inappropriate ATC response.
Dated: July 2017


HindSight 25
The latest edition of EUROCONTROL’s safety magazine is focused on the potential gap between work-as-imagined and work-as-done.
Dated: June 2017


An example of the risks of operating into runways which require visual circuits constrained by terrain
On 2 December 2010, a crew briefly lost control of their aircraft after encountering a microburst and came very close to both the sea surface and a stall when turning onto night visual final at Svolvær during an otherwise uneventful circling approach.
Dated: June 2017


A very rare case of a pilot retracting the landing gear at V1
On 30 September 2015, the First Officer on an aircraft selected the gear up without warning as the Captain was in the process of rotating the aircraft for take-off. The aircraft settled back on the runway wheels up and eventually stopped near the end of the runway having sustained severe damage.
Dated: June 2017


Controller Blind Spot a SKYclip
This month’s safety promotion animation focuses on controller “blind spot”.
Dated: June 2017


Startle Effect
Startle effect can be defined as an uncontrollable, automatic reflex that is elicited by exposure to a sudden, intense event that violates a pilot’s expectations.
Dated: June 2017


Rules of Thumb
Used correctly, rules of thumb (sometimes know as “heuristics”) can assist significantly in pilot decision making and understanding.
Dated: June 2017


When sight of a previously visible runway is lost… change the plan
On 14 April 2015, a night RNAV(GNSS) approach to Hiroshima was continued below minima without the prescribed visual reference and subsequently touched down 325 metres before the runway after failing to transition to a go around initiated from a very low height. The aircraft sustained extensive damage and 28 of the 81 occupants sustained minor injuries.
Dated: May 2017


A severe case of “plan continuation bias”
On 31 July 2015 an aircraft on a private flight continued an unstabilised day visual approach and touched down with excess speed with almost 70% of the available landing distance behind the aircraft. It overran and was destroyed by impact damage and fire and all occupants died.
Dated: May 2017


The intentional pointing of laser beams at aircraft is not illegal in all countries
On 5 September 2015, an aircraft was about to commence descent on final approach at Porto when a green laser was directed at the aircraft. The Pilot Flying responded rapidly by shielding his eyes and was unaffected but the other pilot looked up, sustained flash blindness and “crew coordination was compromised”. Subsequently, the approach became unstable and a go around to an uneventful approach to the reciprocal runway direction was completed.
Dated: May 2017


Separation minima may not always provide adequate protection against wake turbulence in trail
On 29 April 2014, an aircraft being operated in accordance with ATC instructions in smooth air conditions suddenly encountered an unexpected short period of severe turbulence which led both members of the cabin crew to fall and sustain injury, one a serious injury. The Investigation concluded that the turbulence encountered was due to an encounter with the descending wake vortex of a preceding aircraft.
Dated: April 2017


Knowing that a runway is closed, would you not question a clearance to take off from it?
On 7 January 2016, an aircraft was inadvertently cleared by ATC to take off on a closed runway. The take-off was commenced with a vehicle visible ahead at the runway edge. Investigation attributed the controller error to “lost situational awareness” and noted that the pilots had, on the basis of the take-off clearance, crossed a lit red stop bar to enter the runway without explicit permission.
Dated: April 2017


Complete lack of situational awareness and failure of monitoring at a self evidently critical stage of flight
On 28 April 2014, an aircraft making a precision radar approach in IMC began descent from 1,000 feet QNH at 6nm from touchdown with the autopilot engaged and continued it until successive EGPWS ‘PULL UP’ Warnings occurred. Minimum recorded radio height was 242 feet with neither the sea nor the runway in sight.
Dated: April 2017


Preliminary Report released into 16th January crash at Bishkek
On 16 January 2017, the crew of a cargo aircraft failed to successfully complete an auto-ILS Cat 2 approach and the aircraft crashed and caught fire, killing the occupants and many more on the ground. The ongoing investigation has found that although the ILS localiser was captured and tracked normally, the aircraft remained above the glideslope throughout and flew overhead the runway before crashing just beyond it after initiation of a go around at DH was delayed. No evidence of relevant airworthiness issues has yet been found.
Dated: April 2017


The importance of monitoring operating standards by the effective use of OFDM
On 21 December 2015, a crew continued a significantly unstable approach which included prolonged repetition of ‘High Speed’ and a series of EGPWS Alerts which were both ignored and which culminated in a high speed late touchdown which ended in an overrun. The Investigation noted the systemic lack of any effective oversight of pilot operating standards.
Dated: April 2017


Tailstrike is an unappreciated risk on some aircraft types
On 5 March 2013, the aft-stationed cabin crew of an aircraft on a scheduled international passenger flight from Chicago O’Hare to Munich advised the flight crew that they had heard “an unusual noise” during take-off. Noting that nothing unusual had been heard in the flight deck and that there were no indications of any abnormal system status, the Captain decided that the flight should be completed as planned. The flight proceeded uneventfully but on arrival in Munich, it became clear that the aircraft had sustained “substantial damage” due to a tail strike on take-off and was unfit for flight.
Dated: March 2017


On some aircraft types, excessive reverse thrust can lead to rudder blanking and loss of directional control on a contaminated runway
On 5 March 2015 an aircraft veered off a snow-contaminated runway soon after touchdown after the experienced flight crew applied excessive reverse thrust and thus compromised directional control due to rudder blanking, a known phenomenon affecting the aircraft type.
Dated: March 2017


A case study of how ACAS II works
On 26 May 2013, an aircraft in Swiss Class ‘C’ airspace received a TCAS ‘Level Off’ RA against a 737 above after being inadvertently given an incorrect climb clearance by ATC. The opposing higher-altitude 737 began a coordinated RA climb from level flight and this triggered a second conflict with another 737 also in the cruise 1000 feet above which resulted in coordinated TCAS RAs for both these aircraft. Correct response to all RAs resulted in resolution of both conflicts.
Dated: March 2017


Sensory Illusions a SKYclip
This month’s safety promotion animation focuses on sensory illusions.
Dated: March 2017


Final report into Shoreham air disaster makes significant recommendations regarding regulation of air displays
The UK AAIB has published its final report into the August 2015 accident involving a Hunter T7 at the Shoreham air show. The comprehensive report is accompanied by an animation of accident manoeuvre.
Dated: March 2017


2017 Safety Forum – Agenda
The Agenda for this year’s Safety Forum (6-7 June 2017), which will focus on prevention of runway collisions, has now been published.
Dated: March 2017


A cautionary tale about the safety of protective breathing equipment
On 4 October 2014, the fracture of a hydraulic hose during a pushback was followed by dense fumes in the form of hydraulic fluid mist filling the aircraft cabin and flight deck. The aircraft was towed back onto stand and an emergency evacuation completed. During the return to stand, a PBE unit malfunctioned and caught fire when one of the cabin crew attempted to use it, which prevented use of the exit adjacent to it for evacuation.
Dated: February 2017


Rag left in aircraft caused safety issue with flight critical system
On 7 June 2013, stabiliser trim control cable, pulley and drum damage were discovered on an aircraft undergoing scheduled maintenance. The Investigation found the damage to have been due to a rag which was found trapped in the forward cable drum windings and concluded that the integrity of the system had been compromised over an extended period. The rag was traced to a specific maintenance facility.
Dated: February 2017


Plan Continuation Bias
On 29 October 2011, an aircraft on approach to Christchurch during the aircraft commander’s annual route check as ‘Pilot Flying’ continued significantly below the applicable ILS minima without any intervention by the other pilots present before the approach lights became visible and an uneventful touchdown occurred. A Safety Recommendation was made to the Regulator concerning the importance of effective management of pilot check flights.
Dated: February 2017


A safe and event free departure starts with a thorough pre-flight briefing
On 3 July 2014, an aircraft departing Houston came within 200 feet vertically and 0.61nm laterally of another aircraft after climbing significantly above the Standard Instrument Departure Procedure (SID) stop altitude of 4,000 feet believing clearance was to FL310. The crew responded to ATC avoiding action to descend and then disregarded TCAS ‘CLIMB’ and subsequently LEVEL OFF RAs which followed. The Investigation found that an inadequate departure brief, inadequate monitoring by the augmented crew and poor communication with ATC had preceded the SID non-compliance and that the crew should have followed the TCAS RAs issued.
Dated: January 2017


HindSight Magazine – Call for Articles
Articles are now being sought for the next edition of HindSight magazine which will address the topic of “Work-as-imagined and Work-as-done”.
Dated: January 2017


2017 Safety Forum – Call for submissions
The 5th Annual Safety Forum, 6-7 June 2017, will be looking at Preventing Runway Collisions to see how industry can work together and support global safety improvement. The Organising Committee invites submissions to present as a Speaker or via a Poster.
Dated: January 2017


Parallel use of local language reduces situational awareness for crews that don’t speak that language
On 25 May 2000 a UK-operated aircraft waiting for take-off at night at Paris CDG, on a taxiway angled in the take-off direction, was given a conditional line up clearance by a controller who had erroneously assumed without checking that it was at the runway threshold. After an aircraft which had just landed had passed, the aircraft began to line up unaware that another aircraft had just been cleared in French to take off from the full length and a collision occurred.
Dated: January 2017


Helicopter loss of control event linked to bearing failure in tailrotor
The UK AAIB has issued a Special Bulletin with initial findings and safety actions related to a loss of control event involving a helicopter landing on a North Sea platform on 28 December 2016.
Dated: January 2017


Comprehensive failure to pay attention to various relevant SOPs
On 25 August 2013, the type-experienced crew of an aircraft operating with one thrust reverser locked out made a late touchdown with a significant but allowable tail wind component present and overran the end of the runway. The Investigation concluded that the aircraft had been configured so that even for a touchdown within the TDZ, there would have been insufficient landing distance available. The flight crew were found not to have followed a number of applicable operating procedures.
Dated: January 2017


HindSight 24
The latest edition of EUROCONTROL’s safety magazine is dedicated to the prevention of runway collisions.
Dated: December 2016


Dangerous goods in checked baggage is an enduring safety challenge
On 7 October 2013 a fire was discovered in the rear hold of an aircraft shortly after it had arrived at its parking stand after an international passenger flight. The fire was eventually extinguished but only after substantial fire damage had been caused to the hold. The subsequent Investigation found that the actions of the flight crew, ground crew and airport fire service following the discovery of the fire had all been unsatisfactory. It also established that the source of the fire had been inadequately packed dangerous goods in passengers checked baggage on the just-completed flight.
Dated: December 2016


In electrically sourced fires, switching off the circuit is an immediate obvious action
On 5 June 2015, a DHC8-200 descending towards Bradley experienced an in-flight fire which originated at a windshield terminal block. Attempts to extinguish the fire were unsuccessful with the electrical power still selected to the circuit. However, the fire eventually stopped and only smoke remained. An emergency evacuation was carried out after landing.
Dated: December 2016


2017 Safety Forum – Call for submissions
The 5th Annual Safety Forum, 6-7 June 2017, will be looking at Preventing Runway Collisions to see how industry can work together and support global safety improvement. The Organising Committee invites submissions to present as a Speaker or via a Poster.
Dated: December 2016


The importance of avoiding unnecessary distractions prior to door closure
On 1 October 2013, an aircraft took off from a runway intersection at Porto which provided 1900 metres TORA using take off thrust that had been calculated for the full runway length of 3480 metres TORA. It became airborne 350 metres prior to the end of the runway but the subsequent Investigation concluded that it would not have been able to safely reject the take-off or continue it, had an engine failed at high speed. The event was attributed to distraction and the inappropriate formulation of the operating airline’s procedures for the pre take-off phase of flight.
Dated: December 2016


Conditional Clearances, a SKYclip
SKYclip: 1 aviation safety topic in 2 minutes.
This month’s safety promotion animation focuses on Conditional Clearances.
Dated: November 2016


A bird strike to the wing can make an aircraft un-flyable
An event which highlights the need for operators of small aircraft to assess the risk of large bird strikes at lower altitudes and fly at speeds which will put any airframe impact within the certification limits.
Dated: November 2016


Uncontained engine failure on take off roll
On 28 October 2016, an aircraft made a high speed rejected take off after a catastrophic and uncontained failure of the right engine. A successful emergency evacuation of the 170 occupants was completed as a major fuel-fed fire destroyed the failed engine and caused substantial damage to the aircraft structure. An NTSB investigation is taking place.
Dated: November 2016


Black hole situations
On 31 May 2013 the crew of a helicopter took off VFR into a dark night environment and lost control as a low level turn was initiated and did not recover. The Investigation found that the crew had little relevant experience and were not “operationally ready” to conduct a night VFR take off into an area of total darkness. Significant deficiencies at the Operator and in respect of the effectiveness of its Regulatory oversight were identified as having been a significant context for the accident.
Dated: November 2016


Save the Date – 2017 Safety Forum – Preventing Runway Collisions
From 12:00 on Tuesday 6 June until 15:00 on Wednesday 7th June 2017, PREVENTING RUNWAY COLLISIONS will be the single operational issue addressed by the 5th Annual Safety Forum presented by the Flight Safety Foundation, EUROCONTROL and the European Regions Airline Association.
Dated: November 2016


The critical importance of a full and free check of the elevators at some point prior to take off…
On 2 October 2015, the crew of a military transport aircraft attempted to depart Jalalabad without being aware that a hard shell NVG case was in place behind one of the control columns. It had been put there to keep the elevator in an up position during engines-running offloading of tall cargo at the rear. The aircraft stalled and impacted terrain 28 seconds after getting airborne.
Dated: November 2016


Callsign Confusion, a SKYclip
SKYclip: 1 aviation safety topic in 2 minutes.
This month’s safety promotion animation focuses on callsign confusion.
Dated: November 2016


Clearances for Departing and Arriving Aircraft
Amendment 7-A to PANS-ATM, is applicable from 10 November 2016 and includes changes to harmonised phraseology for issuing standard clearances to arriving and departing aircraft, including clearances to aircraft on a SID or STAR.
Dated: November 2016


The importance of using engine anti-icing proactively…
In the early hours of 24 July 2014, an aircraft crashed in northern Mali whilst en route in the vicinity of severe convective activity associated with the ITCZ. Initial findings of the continuing Investigation include that after indications of brief but concurrent instability in the function of both engines, the thrust to both simultaneously reduced to near idle and control of the aircraft was lost.
Dated: November 2016


The risk associated with requesting (or accepting) intersection departures which have not been fully prepared for
On 6 October 2014, a crew requested, accepted and continued with an intersection take off but failed to correct the takeoff performance data previously entered for a full length take off. Recognition of the error and application of TOGA enabled completion of the take-off but the Investigation concluded that a rejected take off from high speed would have resulted in an overrun.
Dated: October 2016


Many defensive barriers can be successively breached in the take off/missed approach conflict scenario
On 2 September 2013, an aircraft crew were not instructed to go around from their approach by ATC as it became increasingly obvious that another aircraft departing the same runway would not be airborne in time for a landing clearance to be issued. They initiated a go around over the threshold and then twice came into conflict with the departing aircraft as both climbed on similar tracks without ATC de-confliction, initially below the height where TCAS RAs are functional.
Dated: September 2016


Blind Spots – Inefficient conflict detection with closest aircraft
“Blind Spot” is a type of human error. Unlike other uses of the term, in air traffic control it refers to the failure to detect a problem (conflict) right in middle of the controller’s field of view.
Dated: September 2016


HindSight 24 – Call for Articles
Contributions are now being invited for the next edition of HindSight which will focus on Preventing Runway Collision.
Dated: September 2016


69th annual International Aviation Safety Summit
This year’s IASS takes place in Dubai, UAE and is hosted by Emirates.
Dated: September 2016


The importance of maintaining situational awareness when on radar vectors to approach
On 31 May 2013, an aircraft was established on the ILS LOC in day IMC with the AP and A/T engaged and APP mode selected but above the GS, when the aircraft suddenly pitched up and stick shaker activation occurred. After a sudden loss of airspeed, the crew recovered control manually and the subsequent approach was completed without further event.
Dated: August 2016


Flight data monitoring can be a means to inform maintenance intervention
On 12 December 2011, the crew of an aircraft delayed their response to an engine fire warning until the existence of a fire had been confirmed by visual inspection and then failed to follow the memory engine shutdown drill properly so that fire continued for considerably longer than it should have. The Investigation found that an improperly tightened fuel line coupling which had been getting slowly but progressively worse during earlier flights had caused the fire.
Dated: August 2016


Importance of correct use of manual tilt in order to detect and avoid significant areas of ice crystals
On 3 February 2013, a crew in the cruise in equatorial latitudes at FL340 in IMC failed to use their weather radar properly and entered an area of ice crystal icing outside the prevailing icing envelope. A short period of unreliable airspeed indications on displays dependent on the left side pitot probes followed with a brief excursion above FL340 and reversion to Alternate Law.
Dated: August 2016


A violation of minima with predictable results…
On 14 August 2012, a crew continued an approach below the prescribed MDA without having acquired the prescribed visual reference. The aircraft was then damaged by a high rate of descent at the initial touchdown in the undershoot in fog. The occurrence was not reported by either the crew or the attending licensed engineer who discovered consequent damage to the aircraft.
Dated: July 2016


A safety success story.
On 16 November 2012, Captain of an aircraft positioning for approach to Abu Dhabi at night became incapacitated due to a stroke. The First Officer took over control and declared a MAYDAY to ATC. The subsequent approach and landing were uneventful but since the First Officer was not authorised to taxi the aircraft, it was towed to the gate for passenger disembarkation.
Dated: July 2016


Automation accuracy should not be seen as a “safety enabler” for violation
On 4 March 2015, the crew of an aircraft continued an automatic non precision RNAV approach below the prescribed minimum descent altitude without having obtained any element of visual reference and when this was acquired a few seconds before the attempted landing, the aircraft was not aligned with the runway centreline and the left main gear touched down on the grass. The aircraft then left the runway completely before stopping with a collapsed nose gear and sufficient damage to be assessed a hull loss.
Dated: July 2016


2016 Safety Forum Report, presentations and videos
The Findings, Strategies and Action Opportunities from the 2016 Safety Forum have now been published. The Report along with copies of presentations and videos can now be accessed through SKYbrary.
Dated: June 2016


HindSight 23
The latest edition of EUROCONTROL’s acclaimed safety magazine focuses on situational awareness.
Dated: June 2016


Controller Detection of Manoeuvring Area Conflicts
This article describes the typical scenarios for runway conflicts not being timely detected as well as the safety barriers that could prevent such situations or mitigate the consequences.
Dated: June 2016


Understanding how directional control of an aircraft is achieved during a crosswind take off
On 2 January 2015, the commander of an aircraft suddenly lost directional control during a within-limits crosswind take off and the aircraft left the runway onto grass at approximately 80 knots. The Investigation concluded that the most likely explanation for the excursion was the absence of any rudder input as the aircraft accelerated.
Dated: June 2016


 

The potential hazard of IFR flight in Class “E” airspace
On 3 September 2014 in Class ‘E’ airspace, a light aircraft carrying out a spin recovery exercise in day VMC came very close to an aircraft climbing out of Sault Ste. Marie. Although the crew had seen the light aircraft ahead and above and temporarily levelled off, the light aircraft then began “a rapid descending turn” and a TCAS RA ‘Descend’ followed. It was judged that a turn would also be necessary but even with this, the two aircraft subsequently passed within 350-450 feet at the same altitude in opposite directions.
Dated: May 2016


The importance of adequately securing heavy loads…
On 29 April 2013, a freighter departed controlled flight and impacted terrain shortly after taking off from Bagram and was destroyed by the impact and post crash fire. The Investigation found that a sudden and significant load shift had occurred soon after take off, moving the centre of gravity aft and out of the allowable flight envelope. The Load shift was attributed to the ineffective securing techniques employed.
Dated: May 2016


An example of how not, and when not, to fly a visual approach
On 4 August 2014, an aircraft making a day visual approach at Fort McMurray after receiving an ILS/DME clearance lined up on a recently-constructed parallel taxiway and its crew were only alerted to their error shortly before touchdown, a go around being commenced from 46 feet agl. The Investigation noted that both pilots had been looking out during the final stages of the approach and had ignored important SOPs including that for a mandatory go around from an unstable approach.
Dated: April 2016


Final report published on Germanwings crash in March 2015
The BEA has published the final report into its investigation of the 24 March 2015 event when a pilot intentionally crashed an aircraft into the Alps. The Report has been published in the English, French, German and Spanish languages.
Dated: April 2016


Mountain waves and severe icing – a dangerous combination…
On 3 October 2014, the crew of an aircraft did not recognise that severe icing conditions had been encountered early enough to make a fully-controlled exit from them and although recovery from the subsequent stall was successful, it was achieved “in a non-standard manner”.
Dated: April 2016


UK civil air display review: final report Shoreham air disaster of August 2015
The UK CAA has published the final report of its review into civil air displays which followed the Shoreham air disaster of August 2015.
Dated: April 2016


An event which demonstrates how important it is to be prepared and able to respond to the unexpected…
On 4 December 2003, the crew of an aircraft approaching Bodø lost control of their aircraft after a lightning strike which temporarily blinded both pilots and damaged the aircraft such that the elevator was uncontrollable. After regaining partial pitch control using pitch trim, a second attempt at a landing resulted in a semi-controlled crash which seriously injured both pilots and damaged the aircraft beyond repair.
Dated: April 2016


Pilot inaction due to the effects of “startle” at unexpected engine failure?
On 7 October 2012, a pilot lost control of their aircraft shortly after take off from Antigua when the right engine stopped due to the presence of water in the corresponding fuel tank. The reason why the pilot had been unable to keep control of the aircraft was not explained.
Dated: April 2016


Ask yourself – is the runway visual perspective what I would expect at this point on the approach?
On 8 March 2013, the crew of an aircraft descended below controlled airspace and to within 600 feet agl when still 9nm from the landing runway at Melbourne after mismanaging a visual approach flown with the AP engaged. An EGWS Terrain Alert was followed by an EGPWS PULL UP Warning and a full recovery manoeuvre was flown. The Investigation found degraded situational awareness had followed inappropriate use of Flight Management System.
Dated: March 2016


2016 Safety Forum Agenda
The organising committee for this year’s Safety Forum have published a draft Agenda. The Safety Forum will focus on the issue of safety nets.
Dated: March 2016


A broad understanding of aircraft systems can inform responses to unexpected situations…
On 26 February 2013, the crew of an aircraft temporarily lost full control of their aircraft on a night auto-ILS approach at Keflavik when an un-commanded roll occurred during flap deployment after an earlier partial loss of normal hydraulic system pressure. The origin of the upset was found to have been a latent fatigue failure of a roll spoiler component, the effect of which had only become significant in the absence of normal hydraulic pressure and had been initially masked by autopilot authority until this was exceeded during flap deployment.
Dated: March 2016


Flying a non-standard circling approach in IMC and ignoring EGPWS warnings has a predictable outcome…
On 28 July 2010, the crew of an aircraft lost contact with the runway at Islamabad during a visual circling approach and continued in IMC outside the protected area and flying into terrain after repeatedly ignoring EGPWS Terrain Alerts and PULL UP Warnings. The Investigation concluded that the Captain had pre-planned a non-standard circuit which had been continued into IMC and had then failed to maintain situational awareness, control the aircraft through correct FMU inputs or respond to multiple EGPWS Warnings. The inexperienced First Officer appeared unwilling to take control in the absence of corrective action by the Captain.
Dated: February 2016


Be aware of the downdraft hazard in areas of uneven terrain…
On 2 December 2010, the crew of an aircraft briefly lost control of their aircraft after encountering a severe downdraft and coming very close to the sea surface and to a stall on visual finals to Svolvær at night at the end of an otherwise uneventful circling approach. After a subsequent recovery from 83 feet agl, a diversion to an alternate airport was made
Dated: February 2016


Importance of having clear procedure for rapid disembarkation when airbridges still attached
On 28 July 2013, with passengers still boarding an aircraft, an abnormal ‘burnt’ smell was detected by the crew and then thin smoke appeared in the cabin. A MAYDAY was declared and the Captain made a PA telling the cabin crew to “evacuate the passengers via the doors, only via the doors”. The resulting evacuation process was confused but eventually completed. The Investigation attributed the confused evacuation to the way it had been ordered and established that a fault in the APU had caused the smoke and fumes which had the potential to be toxic.
Dated: February 2016


ASDE is an effective Safety Net… if used
On 29 March 2014, a light aircraft being taxied by maintenance personnel at Calgary entered the active runway without clearance in good visibility at night as an aircraft was taking off. The 737 passed safely overhead. The Investigation found that the taxiing aircraft had taken a route completely contrary to the accepted clearance and that the engineer in control of the aircraft had not received any relevant training. Although the airport had ASDE in operation, a transponder code was not issued to the taxiing aircraft as required and stop bar crossing detection was not enabled at the time.
Dated: February 2016


Safety Forum 2016 – Final Call for SubmissionsIf you would like to present at the 2016 Safety Forum in Brussels 7/8 June, submit your presentation proposal by 12 February.
A supporting paper is not needed but abstracts must make it clear what the presentation will be about. The focus of the Safety Forum is Safety Nets.
Dated: February 2016


A good example of how Safety Nets save lives
On 11 April 2012, an aircraft commanded by a Training Captain who was also in charge of Air Operations for the airline was supervising a trainee Captain on a night passenger flight. The aircraft failed to establish on the Lyons ILS and, in IMC, descended sufficiently to activate both MSAW and EGPWS ‘PULL UP’ activations which prompted recovery. The Investigation concluded that application of both normal and emergency procedures had been inadequate and had led to highly degraded situational awareness for both pilots.
Dated: February 2016


Safety Forum 2016 invites you to present
If you would like to present at the 2016 Safety Forum in Brussels 7/8 June, submit your presentation proposal by 12 February.
A supporting paper is not needed but abstracts must make it clear what the presentation will be about. The focus of the Safety Forum is Safety Nets.
Dated: January 2016


The importance of anticipating when a very late go around may become necessary
On 13 December 2013, an aircraft encountered very heavy rain below 100 feet agl just after the autopilot had been disconnected for landing off an ILS approach at Jakarta. The aircraft Commander, as pilot flying, lost visual reference but the monitoring First Officer did not. A go around was neither called nor flown and after drifting in the flare, the aircraft touched down with the right main landing gear on the grass and continued like this for 500 metres before regaining the runway. The Investigation noted that prevailing SOPs clearly required that a go around should have been flown…
Dated: January 2015


HindSight 22 – Safety Nets
The 22nd edition of EUROCONTROL’s safety magazine was published in December 2015 and focuses on the subject of Safety Nets ahead of the 2016 Safety Forum…
Dated: January 2016


A reminder of the potential high fire risk associated with carriage of live oxygen generators
On 6 December 2013, an aircraft was flown from Amman to Dubai with a quantity of ‘live’ boxed chemical oxygen generators on board as cargo without the awareness of the aircraft commander. The subsequent Investigation found that this was possible because of a wholesale failure of the aircraft operator to effectively oversee operational risk implicit in sub contracting heavy maintenance…
Dated: January 2016


Runway excursion highlights organisational and regulatory oversight failings…
On 31 January 2014, an Estonian-operated BAE Jetstream 32 operating a Swedish domestic service landed long at night and failed to stop before the end of the runway.
Dated: December 2015


How can we ensure that an augmenting crew member truly adds value?
On 22 December 2013, an aircraft taxiing for departure at Johannesburg at night with an augmented crew failed to follow its correctly-acknowledged taxi clearance and one wing hit a building resulting in substantial damage to both aircraft and building and a significant fuel leak. The accident was attributed to crew error both in respect of an inadequate briefing and failure to monitor aircraft position using available charts and visual reference.
Dated: December 2015


Another incident highlighting the separation issues between departing aircraft and those on a go-around…
On 10 July 2014, an aircraft instructed to go around at Port Elizabeth by ATC came into close proximity with an A320 which had just taken off from the same runway and initiated avoiding action to increase separation. The Investigation concluded that the TWR controller had failed to effectively monitor the progress of the aircraft on final approach before issuing a take off clearance to the A320.
Dated: December 2015


Inability to control aircraft in Alternate Law leads to loss of control…
Indonesian investigators have published their report into the 28 December 2014 accident involving an Air Asia flight from Surabaya to Singapore.
Dated: December 2015


Salt aerosols cause total loss of forward visibility on aircraft operating at low level over the sea…
On 2 January 2014, the crew of an aircraft lost forward visibility due to the accumulation of a thick layer of salt deposits on the windshield whilst the aircraft was being radar positioned to an approach at Cork on a track which took it close to and at times over the sea in the presence of strong onshore winds.
Dated: November 2015


Safety Forum 2016 – Save the Date
Safety Nets will be the single operation issue to be addressed at the 2016 Safety Forum. The Forum will be held in Brussels 7-8 June 2016 and will be co-hosted by Flight Safety Foundation, EUROCONTROL, and European Regions Airline Association
Dated: November 2015


The relationship between operational error and its organisational context…
On 15 March 2008, an aircraft on a non-revenue positioning flight to a private airstrip in mountainous terrain, flown by an inadequately-briefed crew without sufficient guidance or previous relevant experience, impacted terrain under power whilst trying to locate the destination visually after failing to respond to a series of GPWS Alerts and a final PULL UP Warning. Whilst attributing the accident to the crew, the Investigation also found a range of contributory deficiencies in respect of the Operator, official charting and ATS provision and additional deficiencies in the conduct of the unsuccessful SAR activity after the aircraft became overdue.
Dated: November 2015


Aerodrome safety cases need to properly consider the two way function of a taxiway depending on the direction of runway use
On 11 October 2013, the commander of an aircraft taxiing on wet taxiways at night after landing at Zurich became uncertain of his position in relation to the clearance received and when he attempted to manoeuvre the aircraft off the taxiway centreline onto what was believed to be adjacent paved surface, it became bogged down in soft ground.
Dated: November 2015


Failure to remove shipping plugs from components is an old problem…
On 4 April 2012, the cabin pressurisation controller (CPC) on an aircraft failed during the climb. Automatic transfer to the alternate CPC was followed by a loss of cabin pressure control and rapid depressurisation because it had been inadvertently installed with the shipping plug fitted. An emergency descent and diversion followed.
Dated: October 2015


What happens when regulatory oversight fails to detect unsafe practices
On 19 August 2013, a fire occurred in the right engine of an aircraft on take off from Yellowknife. After engine shutdown, a right hand circuit was made in an attempt to land back on another runway but trees were struck and the aircraft crash-landed south of it. Emergency evacuation was successful. The Investigation found that various unsafe practices had persisted despite the regulatory approval of the Operator’s SMS.
Dated: October 2015


Emergency evacuation while attached to airbridge
On 4 November 2013, smoke began to appear in the passenger cabin of an aircraft which had just begun disembarking its 243 passengers via an airbridge after arriving at Montreal. The source was found to be a belt loader in position at the rear of the aircraft which had caught fire. Emergency evacuation using the airbridge only was ordered by the aircraft commander but cabin conditions led to other exits being used too.
Dated: October 2015


The importance of a full runway inspection after any engine failure related Rejected Take Off
On 30 January 2013, the crew of an aircraft successfully rejected its take off at Copenhagen after sudden explosive failure of the left hand engine occurred during the final stage of setting take off thrust. Full directional control of the aircraft was retained and the failure was contained, but considerable engine debris was deposited on the runway.
Dated: October 2015


The added importance of a good controller position handover when something “ad-hoc” is going on
On 22 March 2013, an aircraft inbound to Sion on a VFR clearance was flown into conflict with an IFR aircraft departing the same airport in compliance with its clearance. The prescribed separation between the two aircraft was lost in the vicinity of FL140. The Investigation concluded that an inappropriate ATC tactic had been employed in an attempt to achieve separation.
Dated: September 2015


The “obligation” sometimes felt by management pilots to fly when they shouldn’t
On 24 August 2010, an aircraft made an uncontrolled touchdown on a wet runway after the approach was continued despite not being stabilised. A lateral runway excursion onto the grass occurred before the aircraft regained the runway centreline causing substantial damage to the aircraft. The aircraft commander was the Operator’s Fleet Captain and the Investigation concluded that the length of time he had been on duty had led to fatigue which had impaired his performance.
Dated: September 2015


Got Aviation Safety Questions? Get Answers at IASS 2015.
Flight Safety Foundation’s International Air Safety Summit (IASS) is an opportunity to connect face-to-face with the best minds in aviation safety on issues like simultaneous approach operations, ground safety, and bird strike. Get answers, be informed, and be the best in your organization when it comes to flight safety.
It all happens this November 2-4, 2015 in Miami Beach, Florida, USA.
Dated: September 2015


The risks associated with misleading on smaller non-palletised cargo aircraft
On 19 October 2013, the Captain of an aircraft on a cargo flight taking off from Madang was unable to rotate the aircraft for take off and was forced to reject the take off from above V1. It was not possible to stop on the runway and the aircraft ended up semi submerged in a shallow creek beyond the airfield perimeter. The Investigation has established that the aircraft had not been loaded as instructed and as stated on the load and trim sheet, in particular in respect of the distribution of the load. The Investigation is continuing.
Dated: September 2015


UK AAIB publishing preliminary report on airshow disaster
The UK AAIB published a SPECIAL Bulleting on the 22 August 2015 crash of Hunter during a flying display at Soreham Airport.
Dated: September 2015


Flight Deck Security
This article is intended to specifically highlight the operational flight safety issues associated with flight deck security.
Dated: September 2015


Please refer to the SKYbrary website for any documents prior to this date.