Path: darkstar!agate!ucbvax!ucsd!nosc!crash!bang!bam From: bam@bang.UUCP (Bret A. Marquis) Newsgroups: rec.aviation Subject: ASI Monitor - Feb. 1991 Message-ID: <233@bang.UUCP> Date: 15 Feb 91 05:35:18 GMT Reply-To: bam@monet.berkeley.edu (Bret A. Marquis) Organization: Marquis Property Development Co., San Diego Lines: 606 The ASI Monitor is reposted on Usenet with permission of John Galipault, President, Aviation Safety Institute. ---- The February 1991 Issue of MONITOR Copyright 1991 Mike Overly, Editor John B. Galipault, President MONITOR is distributed to all supporting members of ASI as part of an annual membership fee. Material in this publication may be reproduced with the permission of the Institute. Call 800-848-7386 for membership information. Right Seat with Aviation's Best ASI's Corporate Aviation Survey Corporate aviation has had the enviable distinction of operating at a safety levels above those of major U.S. airliners for the past two years, and at almost seven times the safety level of non-corporate general aviation. By first assumption, the factors that influence these figures may seem obvious; a corporate flight department operates more like an airline than a given non-corporate pilot -- who might be meticulous and disciplined, yet lack the financial resources to seek recurrent training or equipment upgrades. But a second common assumption suggests that corporate aviation operations work under conditions that are more hazardous compared to those experienced by their commercial counterparts. Non-routine flight schedules into oftentimes unfamiliar airspace (and airports) seem risky against scenarios where commercial airline flight crews move in and out of route airports with monotonous regularity. Current economic woes have curtailed or eliminated the activities of many corporate flight departments, yet respondents to ASI's recent corporate aviation survey are in sum satisfied with their flight operations and budgets. They are, however, constantly on the lookout for new training methods and improvements in crew performance. None of this departs significantly from the image portrayed by the aviation industry in general -- excellent training and a constant vigil on crew performance are the staples of the modern pilot-in-command's survival resume. Yet image and practice are not always synonymous; some operators keep their aircraft in marginal repair, and training programs referred to as new or improved training amount in many cases to mere lip service -- or worse. Several survey respondents made it clear that they considered their closely-monitored training superior to that of larger air operations. ASI's survey of corporate flight departments was conducted in three stages, where corporate flight departments were chosen at random to answer a five-question survey. Respondents were invited to answer (anonymously) the questions as they appeared on the survey, adding new topics or deleting existing topics as they saw fit - - knowing that any new question might appear in more detail on a future survey, should it prove to be a high-frequency response among other participants. This survey method, known popularly as the Delphi technique, promises to eliminate bias on the part of the surveyor by allowing respondents to strike non-relevant or loaded questions from the survey process, and introduce new topics -- if they feel important issues have not been addressed in the survey. Since no questionnaire can hope to anticipate every facet of the subject it wishes to study, this process can be valuable -- and enlightening. Why is Corporate Aviation so Safe: Issue One . . . The absence or reduction of complacency in a corporate aviation setting as compared to commercial air carriers or non-corporate general aviation rang in at the top of ASI's recurring-survey-response list. This is a component of the assumed risk factor mentioned above -- that non-routine schedules and unfamiliar airspace increase risks for corporate air operations over commercial operations. According to the overwhelming majority of respondents, a diverse itinerary does more to keep them on their toes than keep them off balance. Some participants admitted having no special crew policies in place to guard against the classic read-all/see-none cockpit checklist, failure to gather complete flight weather information, or other traps of air crew complacency, but said that an ever- changing flight schedule served to keep flight personnel on edge. Of those implementing anti-complacency measures, unannounced flight evaluations topped the list of attention checks, followed by requirements for 15-minute or less flight log updates and/or verbal flight summations. Several operations go to greater lengths to avoid distractions that are either a direct result of or contribute to airborne complacency. The suppression of all non-flight conversation (sometimes called The Sterile Cockpit) at altitudes below 10,000 feet was mentioned by several respondents as one way they keep their crew's mind on the task at hand; one operation refuses to allow any non-flight reading material in the cockpit, period. Another built-in corporate complacency combatant is the high visibility of the flight crew, both in relation to other crew members and to high level management. No corporate air crew member is a name and number on a computer to his employers -- those employers are most likely to make up the (intimate to be sure) passenger list. There is little if any opportunity for an incompetent pilot to escape attention. Issues two and three . . . ASI was surprised to find only one respondent who felt safety suffered from budget restrictions; in every other case, those surveyed said that their budgets were at least sufficient. Many said that any training, equipment, or personnel that could be justified in the eyes of their employers would be appropriated in the aviation budget without delay. Another surprise was a unanimous response to the question "Who's in charge?" -- the answer, as in all aviation disciplines -- the captain. ASI has heard horror stories about planes pushed through bad weather by exhausted crews, all at the behest of executives in a hurry to make meetings on time, or who might simply have an acute case of get-home-itis. All survey participants stated that management takes a back seat to the pilot in command, both on the plane and in the flight go/no-go decision making -- no questions asked. The Clouds in the Silver Lining Corporate operators are not without frustrations. Less-than-priority handling by air traffic controllers was a frequently-mentioned difficulty. Jets from major airlines are given preferential treatment during takeoff and landing, according to some survey participants, forcing both corporate and non-corporate general aviation aircraft into holding patterns at times. This shortcoming again proved double-edged, however; some respondents cited such non-assured landing clearance as a factor in further reducing cockpit complacency. Those areas in which corporate flight crews would like most to see improvements are in human factors -- improved crew training and effective, communicative in-house safety offices chief among them -- rather than technology upgrades. Nearly all respondents were satisfied with their equipment; some had wish lists with such high- tech items as collision-avoidance radar on them, others wanted the seemingly unattainable: highly accurate weather information. Asked what qualities a good corporate flight operation needs to keep safety levels soaring, the composite answer was good equipment, a crew that works well together, and a strong operational safety commitment from corporate management. Of those respondents who chose to rank-order requirements for crew hiring; the ability to work well in a team atmosphere showed up ahead of total flight hour or time-in-type requirements, in many cases. High-quality, frequent training of a non-complacent team-oriented crew -- supported by an adequate operating budget -- is the profile of a safe corporate air operation, according to this survey. It's a model for all aviation communities to emulate. Some major airlines and many general aviators have based their operations on these principles with great success. Letter-to-the Editor More Nominations to the NTSB/FAA Investigative Wish List I received my Monitor and Air Line Pilot over the weekend, and was amazed to see that someone finally figured out what happened to TWA's "Hoot" Gibson -- both in your journal and in Air Line Pilot. As with "Hoot's" investigation, the NTSB has been terribly remiss in inquiring into these issues to understand their contribution to accidents. Air Line Pilot published a two-issue report on circadian dyscrhony and shiftlag during long range flying, authored by Dr. Curt Graeber. A paper authored by me and Dr. Dan Holley has been published in Occupational Medicine. In it we discuss the issue of fatigue, and the possible reasons the NTSB and FAA have ignored the issue in some accidents where fatigue may have played a role. Captain William J. Price, Instructor San Jose, CA Ten Years Ago in MONITOR... Put these over there -- and shoot me in the head while you're at it! ASI received a report from a distraught flight attendant, who witnessed the captain of an L-1011 instruct baggage handlers to remove seven boxes marked "flammable" from the lower-level baggage area of the plane and place them in the cockpit, behind the flight engineer's seat. The flight attendant stated the obvious to the captain, who would have none of it and punctuated such with language unsuitable for print in this polite publication. The flight attendant later discovered the second officer smoking during the flight. Checklist The FAA has ordered tail cone inspections on all McDonnell Douglas DC-9s after reports that two people aboard December's ill-fated DC-9 in Detroit may have died because an emergency exit handle broke when pulled. The inspections also involve the MD-80, a DC-9 variant. An NTSB report cites poor cockpit resource management as the probable cause of the 1989 crash of a Grand Canyon sightseeing plane that killed 10. The NTSB concludes that the captain of the aircraft did not properly supervise his first officer, who bounced a wing on the tarmac on his first landing try before attempting a go-around that proved fatal. A New Orleans federal appeals panel has upheld an earlier ruling by a U.S. district judge regarding the cause of the 1985 crash of Delta Flight 191 in Dallas, which killed 137. The panel found no fault with the decision that the crew of the aircraft was primarily responsible for the crash in deciding to fly through a thunderstorm at the end of the runway. Delta officials argued that air traffic controllers should be held partly responsible in the crash, saying they failed to provide important weather information on to the crew. The original ruling against Delta found that the cockpit crew had access to identical weather information. The pilot of a Korean Air DC-10 that crashed at Tripoli Airport in 1989 was found guilty of neglecting his duty as a captain when he attempted to land the plane in heavy fog. The Seoul Criminal Court sentenced the pilot to two years in prison. Sound Like a Great Idea Dept.: The FAA has christened The Aviation Safety Journal, a quarterly publication for the promotion of an increased commitment to safety by the nation's aviation industry. The first issue will feature a message from Secretary of Transportation Samuel Skinner, who says that, "The job of advancing aviation safety requires constant vigilance . . ." What is an eight-letter word for vigilance? If they'll buy a half-million dollar toilet seat, just think of what they'll pay for an automatic first class upgrade . . . In a move reminiscent of the government's early 80s utilization of financially-troubled Chrysler Corporation cars, bankrupt Eastern Airlines was recently awarded a government contract worth $100 million to fly federal employees during 1991. Eastern said it is pleased that the government "recognizes our fine record in providing safe, reliable transportation at a good value." Invite ATC to Your Next Party What mid-air danger could a VFR day showing no air traffic on radar screens possibly hold for aviators? Clear air turbulence? Bird strikes? Dangerous phenomena, both -- but not the least of a pilot's worries in the air today, despite ever more sophisticated on-board collision-avoidance systems and air traffic control radar. A very realistic aerial threat could come in hues of bright red, yellow, and blue, weigh only a few ounces, and prove the highlight of any four year old's birthday party. ASI has gathered reports of numerous near-disaster aircraft-balloon entanglements over the years, and has warned about the possibility on more than one occasion. Recently this possibility became real tragedy near Solana Beach, California, as a single-engine plane giving rush hour traffic reports encountered several helium balloons at low altitude and crashed, killing both the pilot and the traffic reporter. Helium balloons are often released by the hundreds during promotional events, all without a thought as to the potential damage they could cause, never mind any notification to local air traffic control centers. Balloons are released in both celebration and protest, but whether 100 are released for each new store opening, or one for every aborted fetus, the groups sponsoring these events are setting up potential disasters without knowing it. Weather balloons, released in less quantity (though on a regular basis) have been a concern to ASI also; many pilots report that they've been distracted by midday sun reflecting off the silver Mylar skins of the balloons. Some pilots have even mistaken the resulting bright light in the sky as that of the landing lights of an aircraft that isn't supposed to be there -- and have taken frenzied evasive action. The FAA is committed to warn aviators about weather balloons, but cannot accurately track all such activity. Helium balloon releases by private parties haven't received any scrutiny in many communities. They will in the Solana Beach area. Accidents and Incidents Accidents and incidents are compiled from ASI's Hazard Reporting System, the wire services and other government and media sources. These reports are meant to reflect the scope and cost of on-going safety problems in all aspects of aviation, and because of their timely nature do not constitute the complete or official record of accidents and incidents or their causes. United States December 11 - A twin-engine Beechcraft operated by Exec Express II Airlines struck a herd of deer on takeoff from an airport in Enid, Oklahoma, damaging the left landing gear. The pilot of the plane continued the takeoff successfully, and a spotter plane flew near the plane to evaluate damage caused by the accident. After consulting with Beechcraft officials regarding landing procedures, the crew decided to land the plane on its belly, which it safely accomplished after foam was spread on the runway in Enid. No injuries were reported. December 14 - A maintenance worker at NASA's Ames-Dryden Flight Research Facility in California found a pipe bomb on the grounds of the facility, near a building that houses maintenance supplies for space shuttles. The device was immediately removed for study by Air Force security, which determined that the explosives were not fused. The incident remains under investigation. * December 14 - A U.S. Army UH-1 Huey helicopter crashed in heavy fog near Cleveland Airport, north of Houston, killing all three aboard. The helicopter, en route to Houston from Jefferson City, Missouri, was to be deployed for U.S. troop activity in Saudi Arabia. December 15 - Smoke in the cockpit of a United Airlines 737 bound for Denver from Houston forced the crew to make an unscheduled landing at Dallas-Fort Worth International Airport. Passengers were evacuated without deploying emergency chutes; no injuries were reported. The flight was later cancelled so officials could investigate the cause of the smoke. December 22 - A Coast Guard jet on law enforcement patrol skimmed the bottom of a twin-engine Cessna over the Bimini island in the Bahamas, ripping the baggage compartment off the smaller plane and breaking a portion of the tail section off the Coast Guard plane. The accident occurred as both aircraft crossed paths at 4,000 feet. Both planes later landed safely; no injuries were reported. December 28 - an unspent .45 caliber cartridge discovered near the boarding area at Minneapolis-St. Paul International Airport delayed a Northwest Airlines flight for nearly four hours while security officials re-checked 348 passengers and their carry-on luggage. No weapons were found, and the passengers were later re-boarded. December 29 - The pilot of an Ohio Air National Guard A-7D made a safe landing at Rickenbacker Air National Guard Base (OH) after reporting landing gear trouble during a routine training mission. Fire equipment was called to the field, where the plane touched down with collapsed nose gear. The plane suffered extensive damage, but no fire resulted. December 21 - An empty USAir 737 was damaged after being pushed into a jetway by a gust of wind at Logan International Airport (Boston). The plane was taken out of service for a day while a wing was repaired, cancelling one flight. Winds clocked as high as 50 mph damaged buildings and cars in the area. January 3 - Fifty one earthquakes near Carson City, Nevada over a 14- hour period cracked a runway at a local airport, delaying some flights. Earthquakes measured as high as 4.6 on the Richter scale also caused damage to roads in the area. January 3 - Smoke filled the cabin of an American Airlines jet as it taxied on a runway at Des Moines International Airport, forcing the crew to stop between the main runway and the terminal and evacuate 97 passengers. Four were injured during the evacuation, including a flight attendant who fell to the tarmac after giving an emergency door a hard push to facilitate its opening. January 4 - A Delta Airlines MD-80 skidded on ice during freezing rain at Dallas-Fort Worth International Airport, sending the airliner off the runway and burying its nose gear in mud. No passengers were reported injured in the accident; all aboard were re-scheduled for a flight later in the day. January 4 - Flights at Newark International Airport and New York's Kennedy and La Guardia airports were grounded or diverted for several hours after air traffic controllers lost radar communication. The communications failure occurred after maintenance workers in Manhattan accidently cut a high- capacity AT and T telephone cable that housed key communications lines. New York's financial district came to a near standstill during the incident. January 5 - A twin-engine Cessna crashed on takeoff from Davis Field, in Muskogee, Oklahoma, killing all six aboard and narrowly missing a house near the air field. Light rain was present at the time of the crash; emergency vehicles were delayed in reaching the crash site by heavy snow on the ground. Authorities said that wing or engine icing was the focus of initial investigations into the crash. January 6 - A single-engine plane crashed short of the runway at Gallia- Meigs Airport (OH) after the pilot attempted an aborted a landing, but lost power. Light fog and rain were present at the time of the crash; investigators believe the engine may have failed prior to the crash. January 6 - The pilot of a single-engine Cessna attempted an aborted landing at an air field on a Lake Erie island, but could not gain speed needed for liftoff quickly enough and crashed in the water off the island. One of three aboard the plane was killed in the crash. Rescuers from the Coast Guard were initially given two different stories on the whereabouts of the wrecked plane, which hampered rescue efforts. January 8 - The crew of a Swearingen Metroliner 4 successfully landed the plane on its belly at Bismark Municipal Airport (ND) after the plane's right landing gear could not be activated. The pilot circled the airport to burn off fuel before the emergency landing. International December 8 - A Nas-332 Super Puma helicopter operated by Indonesia's Pelita Air Service exploded and crashed while shuttling oil workers to an oil rig in the South China Sea, killing 10 of 12 aboard. High winds and choppy water made rescue efforts difficult. The cause of the explosion is under investigation. December 13 - Ten were killed after a tourist plane collided with a small plane on the runway at Santo Domingo's Guerrera Airport. The tourist plane's landing path conincided with the smaller plane's takeoff path, according to authorities; investigators believe that the control tower may have made an error in directing one of the planes. * December 19 - A U.S. Navy UH-1N helicopter crashed into the Pacific Ocean near Manila, killing all four aboard. The helicopter was part of U.S. Amphibious Task Force Three, and was reportedly en route to the Persian Gulf. December 20 - A woman who claimed to have a bomb attempted to hijack an Aeroflot jet to the United States, but was quickly arrested by airport security police. The woman, who authorities said did not have a ticket for the flight, held a package that she claimed was bomb, and demanded to be flown to any U.S. city. The incident occurred as the aircraft was refueling in Volgograd. Officials did not know how the woman boarded the plane. December 27 - An Italian MB 326 crashed near Sienna, Italy while on a routine training flight, killing both aboard. Weather was reported clear at the time of the crash. December 27 - A bomb reportedly planted by a U.S.-backed Angolian rebel group exploded in Luanda International Airport, causing extensive damage to the passenger terminal but causing no serious injuries. The action is believed to be part of civil war action in Angola. December 27- Two army deserters armed with a pistol and a machine gun hijacked an Air Algerie 737 shortly after takeoff from Ghardaia, Algeria, taking the plane's crew and passengers hostage until unspecified demands were met. The plane landed in Algiers, where it remained on the ground for two days while negotiations with the hijackers continued. The hijackers later surrendered to authorities without further incident. December 29 - A Dominican Republic immigrant climbed a fence at Montreal's Dorval Airport and broke into an unoccupied twin-engine plane operated by a charter company, attempting to start the aircraft. An airport worker stopped the man, who authorities said did not know how to fly a plane. Police said the man did not like the cold weather in Canada and was stealing the plane to return to his homeland. January 7 - A Delta Airlines L-1011 was delayed for over four hours at Frankfurt International Airport while security officials there examined a suspicious suitcase that was placed aboard the plane. No illegal devices were found. The action comes as a result of heightened security at airports worldwide in response to threats made Iraq against world security. January 8 - A heavily-armed hijacker was shot and killed by a policeman disguised as an airport worker at the international airport in Lima, Peru. The hijacker, who authorities said demanded $750,000 in ransom in exchange for the passengers, commandeered the Fauccet National Airways plane halfway through a domestic flight. Two passengers were injured in the police assault. Viewpoint The Oliver Ostrich Chronicles Since the early days of information dissemination, those charged with expert status in any given field have at times sought refuge from reality, especially when speaking in public forums. With the advent of printing, and later voice and image recording technology, hundreds of head-in-the sand statements have seen permanent circulation. The animal most famous for having its head in the sand is the subject of the following list of aviation reality-denial statements. The Oliver Award nominations, made by the membership of The Ostriches Anonymous Association, are in. The association, founded by retired American Airlines Captain Dr. Robert Besco, has compiled a brief list of notable reality (or as the OAA maintains, "risk") denial statements made during recorded aviation history. They are anonymous -- some paraphrased -- in keeping with the credo of OAA, which reads in part ". . . to enlighten and entertain, never to embarrass . . ." Here are our favorites. Selected Olivers, Through the Years 1990 "My client's blood alcohol did not degrade his flight deck performance. He is an alcoholic and has a high degree of tolerance." -- Attorney 1989 "The structural failure was a rogue accident. Inspection and maintenance procedures do not need to be changed." -- Government Official 1989 "Don't you realize how much negative response your safety recommendation will generate?" -- Senior Military Officer 1988 "Since this safety procedure cannot guarantee that we will never have another accident, we should not publish it." -- Aviation Publisher 1988 "The whole industry is now so sensitized to the no-flap takeoff error that it will be many years before we are at risk from a no-flap mistake being repeated." -- Government Official (address made to a professional organization 23 months after the referenced no-flap accident, and one month before the next no-flap accident). 1986 "Why should we spend the money to fix that problem? It hasn't caused any accidents." -- Airline Executive 1984 "They will teach you about the Digital Guidance System during your Initial Line Operating Experience." -- Airline Flight Instructor 1983 "We don't need to raise our pilots' wages. We can find plenty of licensed pilots to hire at less that $1500/month." -- Airline Executive 1982 "Captain, if your only abnormal indication is a high vibration indication on No. 3 engine, you might as well continue on to your destination." -- Airline Hotline Technical Advisor (advice given two hours before the complete in-flight disintegration of a multi-million dollar engine). 1977 "The pilots involved in the accident chose to ignore everything that they were trained to do." -- Airline President 1975 "The vibration indicators are so unreliable that we should remove them from the engines." -- Jet Engine Designer 1970 "It's great to fly with fully-qualified and experienced captains. You don't have to be constantly on alert for their mistakes." -- Airline Co-pilot 1969 "We can make this cargo door lock fool proof. But we cannot make it damn fool proof." -- Aircraft Manufacturer 1968 "If you test that warning system every flight, you'll wear it out." -- Check Airman 1967 "I can squeeze in one more pass at the target before I am down to minimum fuel." -- Fighter Pilot 1965 "Blue Leader, it is my personal feeling, based on my current analysis of the situation, that you might want to reconsider your current plan of action. I recommend that you seriously consider an alternative tactic which would involve the detachment of the bogey from you six o'clock position by responding promptly with the following suggestion: 'Blue Lead, Break Hard Left, Now!'" -- Wingman (warning made after completing leadership sensitivity and assertiveness training). 1962 "We can't afford a design that will protect us from multiple failures." -- Airframe Manufacturer 1960 "A system that is triply redundant is already over designed." -- Airframe Executive 1958 "We do not need a backup for that system, it will only fail once in 1000 years." -- Airframe Manufacturer 1957 "I'm going to pass you, but don't ever do it that way on the line." -- Instructor 1956 "If we distribute educational materials to our pilots on accidents, incidents, hazards, and risks, it might be picked up by the media and put us at a competitive disadvantage." -- Airline Executive 1955 "Flying transcontinental flights of over 8 hours is unsafe unless we get paid more money per hour." -- President of Pilot's Union 1948 "It had to be pilot error. Thousands of pilots have used the three pointer altimeter without misreading it." -- Avionics Designer 1944 "The warning horn was making so much noise that I couldn't hear the tower telling me to put the landing gear down." -- Pilot and Designer 1940 "The Japanese don't have the engineering, manufacturing, or military training capability to design, build, and fly airplanes in combat that are as good as ours." -- U.S. Army Corps General 1933 "The best protection is to accept and build upon American tradition and not try to purchase freedom with gadgets such as strategic, long-range bombers." -- Secretary of War 1930 "Present-type airplanes would burn up at 500 mph. The terrific heat caused by the air resistance would melt steel." -- Prominent Author and Engineer 1926 "We can deliver the mail in any weather." -- Airmail Pilot 1920 "Professor Goddard does not know the relation of action to reaction, and of the need to have something better than a vacuum against which to react." -- Editorial in Major New York Newspaper 1914 "My son-in-law was unfortunate in that he tried to fly on a day in which there was not much lift in the air. He survived the crash through a combination of superior skill and good fortune." -- Lt. General 1913 "Can't we buy just a few airplanes and let the pilots take turns flying them?" -- U.S. President 1903 "We hope that Professor Langley will not put his substantial greatness as a scientist in further peril by continuing to waste his time, and the money involved, in further airship experiments." -- Editorial in Major New York Newspaper (published one week before the Wright brothers' first flight). 1890 "I have not the smallest molecule of faith in air navigation, other than ballooning." -- English Nobleman and Physicist 746BC "It won't matter if I fly just a little bit higher." -- Pilot of the first Ultra Light 747BC "It will be OK as long as you don't fly too close to the sun." -- Builder of the first Ultra Light Kit Those interested in applying for OAA membership may contact ASI for contact and address information. AMF __________________________ ASI's John Galipault can be reached at: 76703.402@compuserve.com