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AeroSafetyW O R L D

A330 CFIT IN TRIPOLI

CAUSAL FACTORS FROM LIBYAN CAA

THE JOURNAL OF FLIGHT SAFETY FOUNDATION

Smartphone distraction controversyHEMS AS350 FUEL STARVATION

Forecasts begin to convergeU.S. AIRLINE PILOT SHORTAGE

ETA for ICAO standards and manualsAIRPLANE UPSET PREVENTION

JULY 20

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fightsaety.org/IASS2013

@Flightsaety #IASS2013

66th annual International Air Safety Summit

IASS 2013

Omni Shoreham Hotel

Washington, DC, USA

october2931, 2013

IASS 2013 Te 66th Annual International Air Saety Summit (IASS) will be held October 29-31, 2013 at the Omni

Shoreham Hotel in Washington, DC, USA. Please visit website below or hotel details and urther details about the event

as they become available.
http://flightsafety.org/IASS2013http://flightsafety.org/IASS2013

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FLIGHTSAFETY.ORG| AEROSAFETY

WORLD|

JULY 2013

PRESIDENTSMESSAGE

Capt. Kevin L. Hiatt

President and CEO

Flight Safety Foundation

O

n May 15, during one of the

semi-annual meetings of our

Board of Governors, I reported

on the financial condition ofFlight Safety Foundation. The Founda-

tions financial report draws a lot of at-

tention because it speaks directly to the

organizations ability to meet its financial

obligations and to carry on with its vital

work of reducing risk in aviation.

Beginning in late 2011, as the 2012

budget was being constructed, we saw

signs that our primary funding source

membership revenue was beginning

to decrease because of a fall-off in exist-

ing member renewals and a slowdown

of new member sign-ups. Other factors

included a decrease in attendance at our

safety summits and an increase in oper-

ating costs tied to the development of a

major new safety program and to some

internal operating inefficiencies.

While the state of the world economy,

which has at least an indirect impact on

membership and conference attendance,

is beyond our control, we have taken a

number of steps to address our financial

and operational situation.

We studied where we could reduce

overhead without negatively impacting

our level of service, which essentially

meant taking a look at how efficiently

we meet the needs of our members and

the aviation community as a whole. What

resulted from that exercise was a reduc-

tion in full-time staff members from a to-

tal of 26 to 20 in our offices in Alexandria,

Virginia, U.S., and Melbourne, Australia.Technical project facilitation, executive

leadership and AeroSafety Worldproduc-

tion have been modified in order to re-

duce the overhead. Our ratio of operating

costs to total intake is 14 percent, which

is very good when compared with other

non-profit organizations.

We also are working to freshen up our

safety seminars. We want our summits

and seminars to be the most valuable

and engaging safety events you attend

each year. We recognize there are many

other conferences to choose from, so we

are working hard to make our summits

and seminars the industrys best.

I am working with our International

Air Safety Summit (IASS) and Business

Aviation Safety Summit (BASS) agenda

committees to make the Foundations

two premier events more real time,

featuring carefully vetted presentations

on more current safety and operational

topics. We will be adding interactive

technology so viewpoints and opinions

can be shared instantaneously. We also

are targeting venues that are interesting

and easy to travel to, all the while keeping

the cost as low as possible.

But what we really need is your

support. Whether you are currently a

member, or a person who is aware of us

and not a member, or someone who has

just picked up this magazine for the first

time, you need to support the Founda-tion. Our value to you and the industry

is multi-dimensional. We continually

facilitate reducing the risk in aviation

through research committees, public

and industry meeting appearances, our

magazine and website, summits, and

news media interviews. In addition,

everyone associated with aviation has a

responsibility to give back to the indus-

try that we personally gain from. We

must keep aviation as risk free as we can,

in order to continue to thrive and grow.

Without the Foundation to be that

international, independent and impar-

tial source to help facilitate the cause,

the aviation industry may not progress

as well as we have in the past. Please re-

new your membership, sign up as a new

member, attend a summit or just donate.

All these can be done on our website, and

we need you now to help us continue to

provide the service we all need!

THE FOUNDATIONNeeds Your Help

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I

FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JULY 20132

|

18

AeroSafetyWORLD

12

23

features

12 CoverStory | Libyan CAA Accident Analysis

18 MaintenanceMatters | Mitigating Technician Fatigue

23 FlightDeck |Short Supply of U.S. Airline Pilots

27 FlightOps |ICAO Finalizes Upset Prevention Changes

33 FlightOps |Crackdown on Distraction

38 StrategicIssues|Constant-Angle, Nonprecision Approaches

departments1 PresidentsMessage | The Foundation Needs Your Help

5 FoundationFocus|Lederer Legacy

7 SaetyCalendar | Industry Events

9 InBrief| Safety News

contentsJuly 2013 Vol 8 Issue 6

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AeroSafetyWORLDtelephone: +1 703.739.6700

Capt. Kevin L. Hiatt, publisher,FSF president and [email protected]

Frank Jackman, editor-in-chief,FSF director of [email protected], ext. 116

Wayne Rosenkrans, senior [email protected], ex t. 115

Linda Werfelman, senior [email protected], ext. 122

Rick Darby, associate [email protected], ex t. 113

Jennifer Moore, art director

[email protected]

Susan D. Reed, production [email protected], ex t. 123

Editorial Advisory Board

David North, EAB chairman, consultant

Frank Jackman, EAB executive secretaryFlight Safety Foundation

Steven J. Brown, senior vice presidentoperation

National Business Aviation Association

Barry Eccleston, president and CEOAirbus North America

Don Phillips, freelancetransportationreporter

Russell B. Rayman, M.D., executive directorAerospace Medical Association, retired

.

|.

NTSBw

antstoe

xtendth

ebanon

pilotsu

sing

llphone

sforpe

rsonalp

urposes

whilean

air

inopera

tion.|

:

FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JULY 2013

43 DataLink |Business Aircraft Runway Excursions46 InfoScan | NextGen Midterm Challenges

50 OnRecord | Automation Surprise

We Encourage Reprints(For permissions, go to )

Share Your Knowledge

I you have an article proposal, manuscript or technical paper that you believe would make a useul contribution to the ongoing dialogue about aviation saety, we will be

glad to consider it. Send it to Director o Publications Frank Jackman, 801 N. Fairax St., Suite 400, Alexandria, VA 22314-1774 USA or [email protected].

The publications sta reserves the right to edit all submissions or publication. Copyright must be transerred to the Foundation or a contribution to be published, and

payment is made to the author upon publication.

Sales Contact

Emerald Media

Cheryl Goldsby, [email protected] +1 703.737.6753

Kelly Murphy, [email protected] +1 703.716.0503

Subscriptions: All members o Flight Saety Foundation automatically get a subscription toAeroSafety Worldmagazine. For more inormation, please contact the

membership department, Flight Saety Foundation, 801 N. Fairax St., Suite 400, Alexandria, VA 22314-1774 USA, +1 703.739.6700 or [email protected].

AeroSafety World Copyright 2013 by Flight Saety Foundation Inc. All rights reserved. ISSN 1934-4015 (print)/ ISSN 1937-0830 (digital). Published 11 times a year.

Suggestions and opinions expressed inAeroSafety Worldare not necessarily endorsed by Flight Saety Foundation.

Nothing in these pages is intended to supersede operatorsor manuacturerspolicies, practices or requirements, or to supersede government regulations.

About the Cover

The Libyan Civil Aviation Authority has

disseminated saety fndings based on

the crash o this Airbus A330-202.

Franois-Xavier Simon

27 33

38
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FOUNDATIONFOCUS

Many of you are familiar with

the fact that the Flight SafetyFoundation has been around

for more than 65 years. You

also are aware of the work that the

Foundation does on a daily basis to

pursue its ever-important mission of

being the leading voice of aviation safety

around the world. You readAeroSafety

World, you see us in the media, you do

research on our website, use our tool

kits, etc. All of these items do not come

without a cost to the Foundation. Like

so many non-profit organizations, we

depend heavily on our membership dues

to fund our safety efforts. We value and

appreciate each member and the support

that each member gives to us. In spite of

that, membership dues are not always

enough to keep our projects and efforts

going, especially during the challenging

economic times we are facing today.

At a time of constrained resources,

increased regulation and unprec-

edented scrutiny, the aviation industrys

survival depends on safe operations.

Practices for safe operations are re-

searched, initiated and actively pub-

licized and distributed by the Flight

Safety Foundation. However, there is al-

ways more to be done. This job is never

complete. The Foundation will always

be needed in good economic times, but

even more so during the downturns.In turn, we will always need support in

order to do our work.

The Foundation is a 501(c)3 orga-

nization, which in the United States

simply means that we are recognized

as a charitable organization and we are

able to receive tax-deductible dona-

tions from companies and individuals

around the globe. It is not uncommon

for charities large and small to hold

fund-raising drives and events to help

sustain the organization, thereby keep-

ing the core activities going.

For this reason, we are kicking off

the FSF summer fund-raising drive,

highlighting the words and works of the

late Jerry Lederer, the founder of the

Foundation. Over the next few weeks,

you will be seeing interesting facts and

quotes from Jerry Lederer, as well as

projects and products that the Foun-

dation has had a hand in developing,

both past and present. Check out our

blog for our new feature Jerry Lederer

Says ... as our founder talks about

safety and the Flight Safety Founda-

tion. You will also see his comments on

Facebook, LinkedIn and Twitter.

We will be reaching out to mem-

bers and non-members alike. We will

always include a link to the dona-

tion page of the FSF website, so thatanyone who wants to is able to donate

to our cause.

The drive will culminate in the FSF

Inaugural Benefit dinner at the Nation-

al Press Club in August in Washington.

This dinner will be held to recognize

the accomplishments of the Founda-

tions past and honor Jerry Lederer, as

well as showcase the current and future

endeavors. We also hope to raise mo-

mentum to move into the future.

The Flight Safety Foundation has

recently had to adjust some of its

current practices from the way things

have been done in the past to the way

it does business now. It is essential

that we change with the times, so that

we can continue to be the impartial,

independent voice of aviation safety,

as we are known around the world. A

fund-raising drive is a new change, and

a necessary addition to our business

practice at this time. We want to create

a new path to keep the Foundations

legacy moving forward into the next 65

years and beyond. We hope that we can

count on your support.

Susan Lausch

Senior Director, Membership

and Business Development

LEDERERLegacy

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OFFICERS AND STAFF

ChairmanBoard o Governors David McMillan

President and CEO Capt. Kevin L. Hiatt

General Counseland Secretary Kenneth P. Quinn, Esq.

Treasurer David J. Barger

ADMINISTRATIVE

Manager oSupport Services and

Executive Assistant Stephanie Mack

FINANCIAL

Financial Operations

Manager Jaime Northington

MEMBERSHIP AND BUSINESS DEVELOPMENT

Senior Director oMembership and

Business Development Susan M. Lausch

Director o Eventsand Seminars Kelcey Mitchell

Seminar andExhibit Coordinator Namratha Apparao

MembershipServices Coordinator Ahlam Wahdan

Consultant, StudentChapters and Projects Caren Waddell

COMMUNICATIONS

Director oCommunications Emily McGee

GLOBAL PROGRAMS

Director oGlobal Programs Rudy Quevedo

Foundation Fellow James M. Burin

BASIC AVIATION RISK STANDARD

BARS Managing Director Greg Marshall

Past President William R. Voss

Founder Jerome Lederer19022004

MemberGuideFlight Saety Foundation801 N. Fairax St., Suite 400, Alexandria VA 22314-1774 USA

tel +1 703.739.6700 ax +1 703.739.6708 ightsaety.org

Member enrollment ext. 102Ahlam Wahdan, membership services coordinator [email protected]

Seminar registration ext. 101Namratha Apparao, seminar and exhibit coordinator [email protected]

Seminar sponsorships/Exhibitor opportunities ext. 105Kelcey Mitchell, director o events and seminars [email protected]

Donations/Endowments ext. 112Susan M. Lausch, senior director o membership and development [email protected]

FSF awards programs ext. 105

Kelcey Mitchell, director o events and seminars [email protected] product orders ext. 101Namratha Apparao, seminar and exhibit coordinator [email protected]

Seminar proceedings ext. 101Namratha Apparao, seminar and exhibit coordinator [email protected]

Website ext. 126Emily McGee, director o communications [email protected]

Basic Aviation Risk Standard

Greg Marshall, BARS managing director [email protected]

BARS Program Ofce: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia

tel +61 1300.557.162 ax +61 1300.557.182

acebook.com/lightsaetyoundation

@lightsaety

www.linkedin.com/groups?gid=1804478

S

ince 1947, Flight Saety Foundation has helped save lives around the world. The

Foundation is an international non-prot organization whose sole purpose is to

provide impartial, independent, expert saety guidance and resources or the

aviation and aerospace industry. The Foundation is in a unique position to identiy

global saety issues, set priorities and serve as a catalyst to address the issues through

data collection and inormation sharing, education, advocacy and communications. The

Foundations efectiveness in bridging cultural and political diferences in the common

cause o saety has earned worldwide respect. Today, membership includes more than

1,000 organizations and individuals in 150 countries.

FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JULY 2013

Serving Aviation Saety Interestsor More Than 65 Years

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FLIGHTSAFETY.ORG|AEROSAFETY

WORLD|

JULY 2013

SAFETYCALENDAR

Aviation safety event coming up?

Tell industry leaders about it.

I you have a saety-related conerence,

seminar or meeting, well list it. Get the

inormation to us early. Send listings to Frank

Jackman at Flight Saety Foundation, 801 N.

Fairax St., Suite 400, Alexandria, VA 22314-

1774 USA, or .

Be sure to include a phone number and/

or an email address or readers to contact

you about the event.

JULY 819 Aircrat Accident Investigation.

Southern Caliornia Saety Institute. San Pedro,

Caliornia, U.S. Denise Davalloo, , , +1 310.940.0027, ext.104.

JULY 10 Hazardous Materials Air Shipper

Certifcation Public Workshop. Lion Technology.Dedham, Massachusetts, U.S. (Boston area). Chris

Trum, ,

, +1 973.383.0800.

JULY 1011 Airline Engineering and

Maintenance Saety. Flightglobal and Flight

Saety Foundation. London. Jill Raine, , , +44 (0) 20 8652 3887.

JULY 1519 AAB International Annual

Meeting. Aircrat Accreditation Board

International. Kansas City, Missouri, U.S.

, .

JULY 1524 SMS Theory and Application.

MITRE Aviation Institute. McLean, Virginia, U.S.

Mary Beth Wigger, ,

.

JULY 1718 59th ALPA Air Saety Forum.

Air Line Pilots Association, International.

Washington. Tina Long, ,

.

JULY 2324 Aviation Human Factors and

SMS Wings Seminar. Signal Charlie. Dallas.

Kent Lewis, , ,+1 850.449.4841.

JULY 2426 16th Swinburne Aviation

Industry Conerence. Hawthorn, Victoria,

Australia. Peter Bruce,

, +61 3 9214 8507.

JULY 29AUG. 2 Fire and Explosion

Investigation. Southern Caliornia Saety

Institute. San Pedro, Caliornia, U. S. Denise

Davalloo, ,

,

+1 310.940.0027, ext.104.

JULY 31AUG. 2 Airport Wildlie Hazard

Management Workshop. Embry-Riddle

Worldwide. Dallas. .

AUG. 1216 Aircrat Perormance

Investigation. Southern Caliornia Saety

Institute. San Pedro, Caliornia, U. S. Denise

Davalloo, ,

,

+1 310.940.0027, ext.104.

AUG. 1922 ISASI 2013: Preparing the

Next Generation o Investigators. International

Society o Air Saety Investigators. Vancouver,

British Columbia, Canada. Ann Schull, , ,

+1 703.430.9668.

AUG. 2930 International AviationSaety Management Inoshare. Flight Saety

Foundation. Singapore. Namratha Apparao,

,

+1 703.739.6700, ext. 101.

SEPT. 911 NextGen Ahead Air

Transportation Modernization Conerence.

Aviation Week. Washington. .

SEPT. 2327 Unmanned Aircrat Systems.

Southern Caliornia Saety Institute. San Pedro,

Caliornia, U.S. Denise Davalloo, , ,

+1 310.940.0027, ext.104.

SEPT. 2426 MRO Europe 2013.Aviation

Week. London. .

SEPT. 2527 ALTA Aviation Law

Americas. Latin American and Caribbean Air

Transport Association. Miami. ,

+1 786.388.0222.

SEPT. 29OCT. 1 SMS/QA Symposium. DTI

Training Consortium. Disney World, Florida, U.S.

, ,

+1 866.870.5490.

OCT. 10 ACAS Monitoring Dissemination

Workshop (SESAR Project 15.04.03). Eurocontrol.

Langen (Hessen), Germany. Stanislaw Drozdowski

.

OCT. 1416 SAFE Association Annual

Symposium. SAFE Association. Reno, Nevada,

U.S. Jeani Benton, , , +1 541.895.3012.

OCT. 1516 Icing Conditions: On-Ground

and In-Flight. European Aviation Saety Agency.

Cologne, Germany. Carmen Andres ,

+49 221.89990.2205.

OCT. 1517 Saeskies Australia 2013.

Canberra, Australian Capital Territory. Doug

Nancarrow,

,

+61 (0) 2 9213 8267.

OCT. 2224 SMS II. MITRE Aviation

Institute. McLean, Virginia, U.S. Mary Beth Wigger,

, ,

+1 703.983.5617.

OCT. 2224 2013 NBAA Business Aviation

Convention & Exhibition. National Business

Aviation Association. Las Vegas..

OCT. 2931 66th International Air Saety

Summit. Flight Saety Foundation. Washington,

D.C. Namratha Apparao, , ,

+1 703.739.6700, ext. 101.

NOV. 38 CANSO Global ATM Saety

Conerence. Civil Air Navigation Services

Organisation. Amman, Jordan. Anouk

Achterhuis, , +31 (0) 23 568 5390.

NOV. 1315 10th ALTA Airline Leaders

Forum. Latin American and Caribbean Air

Transport Association. Cancn, Mexico.

,

.

DEC. 2122 European Business Aviation

Saety Conerence. Aviation Screening. Munich,

Germany. Christian Beckert, ,

, +49 7158 913 44 20.

APRIL 13, 2014 World Aviation Training

Conerence and Tradeshow (WATS 2014).

Halldale Group. Orlando, Florida, U.S. ZeniaBharucha, , +1 407.322.5605.

APRIL 1617, 2014 59th annual Business

Aviation Saety Summit (BASS 2014). Flight

Saety Foundation and National Business Aviation

Association. San Diego. Namratha Apparao,

, , +1 703.739.6700, ext. 101.
mailto:[email protected]:[email protected]://www.scsi-inc.com/AAI.phphttp://www.scsi-inc.com/AAI.phpmailto:[email protected]://bitly/XNDWUvmailto:[email protected]://www.flightglobalevents.com/mro2013http://www.flightglobalevents.com/mro2013mailto:[email protected]://www.aabi.aero/mailto:[email protected]://mai.mitrecaasd.org/sms_course/mailto:[email protected]://safetyforum.alpa.org/mailto:[email protected]://www.signalcharlie.net/Seminar+2013http://www.signalcharlie.net/Seminar+2013mailto:[email protected]://swinburne.edu.au/engineering/aviation/events/conferencemailto:[email protected]://www.scsi-inc.com/FEI.phpmailto:[email protected]:[email protected]://www.scsi-inc.com/API.phpmailto:[email protected]://www.isasi.org/mailto:[email protected]://fliglhtsafety.org/meeting/infoshare2013http://aviationweek.com/mailto:[email protected]://www.scsi-inc.com/unmanned-aircraft-systems.phphttp://www.scsi-inc.com/unmanned-aircraft-systems.phphttp://www.alta.aero/aviationlaw/2013/home.phphttp://www.alta.aero/aviationlaw/2013/home.phpmailto:[email protected]://www.dtiatlanta.com/Symposium2013.htmlhttp://www.dtiatlanta.com/Symposium2013.htmlmailto:[email protected]://bit.ly/10ok2HEmailto:[email protected]://www.safeassociation.com/http://www.safeassociation.com/mailto:[email protected]:[email protected]://webshop.easa.europa.eu/icingmailto:[email protected]://www.safeskiesaustralia.org/mailto:[email protected]://bit.ly/YJofEAhttp://www.nbaa.org/eventsmailto:[email protected]:[email protected]://flightsafety.org/aviation-safety-seminars/international-air-safety-seminarmailto:[email protected]://www.canso.orgsafetyconference2013/http://www.canso.orgsafetyconference2013/mailto:[email protected]://www.alta.aero/mailto:[email protected]://www.ebascon.eu/mailto:[email protected]://halldale.com/wats#.Ub4RyhYTZCYmailto:[email protected]://flightsafety.org/basshttp://flightsafety.org/aviation-safety-seminars/international-air-safety-seminarhttp://bit.ly/YJofEAhttp://halldale.com/wats#.Ub4RyhYTZCYhttp://flightsafety.org/bassmailto:[email protected]://fliglhtsafety.org/meeting/infoshare2013http://aviationweek.com/http://bit.ly/10ok2HEhttp://webshop.easa.europa.eu/icinghttp://swinburne.edu.au/engineering/aviation/events/conferencehttp://mai.mitrecaasd.org/sms_course/http://safetyforum.alpa.org/http://bitly/XNDWUvhttp://www.safeskiesaustralia.org/mailto:[email protected]:[email protected]:[email protected]://www.safeassociation.com/http://www.safeassociation.com/mailto:[email protected]:[email protected]://www.dtiatlanta.com/Symposium2013.htmlhttp://www.dtiatlanta.com/Symposium2013.htmlmailto:[email protected]://www.alta.aero/aviationlaw/2013/home.phphttp://www.alta.aero/aviationlaw/2013/home.phphttp://www.scsi-inc.com/unmanned-aircraft-systems.phphttp://www.scsi-inc.com/unmanned-aircraft-systems.phpmailto:[email protected]:[email protected]://www.isasi.org/http://www.scsi-inc.com/API.phpmailto:[email protected]:[email protected]://www.scsi-inc.com/FEI.phpmailto:[email protected]:[email protected]://www.signalcharlie.net/Seminar+2013http://www.signalcharlie.net/Seminar+2013mailto:[email protected]:[email protected]:[email protected]://www.aabi.aero/mailto:[email protected]://www.flightglobalevents.com/mro2013http://www.flightglobalevents.com/mro2013mailto:[email protected]:[email protected]://www.scsi-inc.com/AAI.phphttp://www.scsi-inc.com/AAI.phpmailto:[email protected]:[email protected]:[email protected]:[email protected]://www.ebascon.eu/mailto:[email protected]://www.alta.aero/mailto:[email protected]://www.canso.orgsafetyconference2013/http://www.canso.orgsafetyconference2013/mailto:[email protected]:[email protected]:[email protected]://www.nbaa.org/eventsmailto:[email protected]

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. .

Save the Date

International Aviation Safety Management

InfoShareAugust 2930, 2013

Singapore

Inaugural

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INBRIEFINBRIEF

Weather-Tower Markings

T

he U.S. National Transportation Safety Board (NTSB),

citing three fatal accidents involving small airplanes that

collided with meteorological evaluation towers (METs), is

recommending that all such towers be registered, marked and,if possible, lighted.

The NTSB issued two safety recommendations to the U.S.

Federal Aviation Administration (FAA), calling on the agency

to require tower registration and marking and to establish a

database for the required registrations.

METs defined by the NTSB as temporary structures

that measure wind speed and direction during development of

wind energy conversion facilities often are erected quickly

and without notice to the aviation community. They typically

are just under 200 ft above ground level (AGL), which is the

threshold at which FAA notification is required, and they are

unmarked and unlighted.

Pilots have reported difficulty seeing METs from the air

which has led to accidents, the NTSB said. Without measures

to enhance their conspicuity, such as marking and lighting these

structures and maintaining a record of their locations, METs

pose a continuing threat to low-altitude aviation operations

such as those involving helicopter emergency medical services,

law enforcement, animal damage control, fish and wildlife sur-

veys, agricultural applications and aerial fire suppression.

The FAA approved recommended guidelines in June 2011

for a uniform and consistent scheme for voluntarily markingMETs of less than 200 ft AGL; the guidelines did not discuss

voluntary lighting, and the FAA said recommending lighting for

the METs would not be practical because many are in remote

locations without power sources.

Ten states have acted to require at least some METs to be

marked and/or registered, and the NTSB issued recommenda-

tions for states, territories and the District of Columbia to pass

similar legislation.

Other recommendations called on the American Wind

Energy Association to revise the Wind Energy Siting Handbook

to indicate the hazards that METs present to aviation operations

and encourage voluntarily marking them [in accordance with

FAA Advisory Circular 70/7460-1, Obstruction Marking andLighting] to increase their visibility.

New Round for IOSA

An International Air Transport Association (IATA) conference has endorsed development of

an enhanced version of the IATA Operational Safety Audit (IOSA).

Enhanced IOSA is expected to be implemented by September 2015.

IATA said that the current IOSA program has laid a solid foundation for improved opera-

tional safety and security, eliminating redundant industry audits. However, audit protocols have

changed very little since IOSAs establishment in 2003, and modifications are needed to enhance

operational safety and security practices, IATA said.

The association said Enhanced IOSA will include measures to ensure continuous confor-mity with IOSA standards and recommended practices through quality control processes and

self-auditing in between IOSAs two-year audit cycle.

IATAs Ops Conference endorsed Enhanced IOSA at a May meeting in Montreal.

During the same meeting, IATA said it was joining with other organizations, including the

Association of European Airlines, Eurocontrol, the Civil Air Navigation Services Organisation

and the International Federation of Air Traffic Controllers Associations, to develop an action

plan for the Single European Sky (SES). The action plan includes plans to reduce infrastructure

duplication within the SES area by centralizing services and streamlining computer technology.

Oleg_ivano.../Dreamstime

U.S. National Transportation Safety Board

Safety News

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10

|FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JULY 2013

INBRIEF

Pushing for SES

The European Commission (EC) has moved to update regu-

lations that it says will accelerate changes in the regions air

traffic control system as it implements the Single European

Sky (SES) and avert the capacity crunch that is expected to

accompany a 50 percent increase in air traffic over the next 10

to 20 years.

The European Transport Workers Federation (EFT) is

protesting the move, which it says is placing unacceptable

pressure on air traffic management (ATM) employees.

The ECs plan calls for organisational and budgetary sep-

aration of national supervisory authorities from the air traffic

control organisations [that] they oversee while at the same

time ensuring sufficient resources are given to the national

supervisory authorities to do their tasks. Some supervisory

authorities have not had adequate funding to perform their

jobs, the EC said, adding that plans call for airlines to have

a new role in signing off air traffic control organisationsinvestment plans to ensure they are better focused on meeting

customer needs.

Another proposal would allow for more flexible operation

of the functional airspace blocks (FABs) the regional units

designed to replace the current patchwork of 27 national air

traffic control units so that the FABs could create industrial

partnerships and increase performance. At the same time,

Eurocontrols role would be strengthened to allow it to operate

centralized services more efficiently, the EC said.

Other EC proposals call for strengthening the role of the

EC in setting performance targets for European ATM in safety,

cost efficiency, capacity and environment. The performance

review body will operate with increased independence andhave the authority to issue sanctions when targets are not met.

In addition, the EC proposed that support services including meteorology, aeronautical information, communica-

tions, navigation and surveillance be provided by private

companies.

European Union Transport Commissioner Siim Kallas

said the proposals would strengthen the nuts and bolts of the

system so it can withstand more pressure and deliver ambi-

tious reforms.

The EFT, however, objected that the plans are part of a

never-ending process of liberalisation, deregulation and cost

cutting in the ATM industry.

The organization said that, although it originally sup-

ported the SES concept, it opposes mounting pressure on

workers and will oppose new plans that do not address thesocial aspects of SES.

Runway Incursion Audit

AU.S. government watchdog agency has begun an audit of

the Federal Aviation Administrations (FAAs) efforts to

prevent runway incursions.

The Department of Transportations Office of Inspector

General (OIG) said the audit is needed because of an increase

in the number of serious runway incursions from six in fiscal

year 2010 to 18 in fiscal 2012 and a 21 percent increase in

total runway incursions from 954 in fiscal 2011 to 1,150 infiscal 2012.

The FAA has reorganized its Runway Safety Office and

changed its methods of reporting runway incursions since the

last program review in 2010. The OIG said the objectives of

the audit, which was begun in late May, are to evaluate FAAs

progress in implementing initiatives to prevent runway incur-

sions and effectiveness in reporting and evaluating runway

incursions. InSapphoWeTrust/Wikimedia Commons CC-SA-BY-2.0

Tomgriger/Dreamstime.com

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INBRIEF

In Other News

Regular public transport operators in Australia and the organizations that maintain their aircraft face a June 27 deadline for

completing the transition to key elements of newmaintenance regulations. Work is continuing to update maintenance regu-

lations for charter operations, aerial work and private operations. European leaders have reached agreement on plans to unite

the continents airports and other transportation infrastructure into a unified network. The plans call for establishment of acore

transport networkby 2030.

TSB Urges Lightweight Recorders

The Transportation Safety Board of Canada (TSB), citing the

2011 crash of a de Havilland Canada DHC-3 Otter in the

Yukon, says the countrys small aircraft operators should install

lightweight recorders in their aircraft to monitor flight data.

For decades, recorded flight data has been instrumental in

advancing safety for our larger operators, said TSB Chair Wendy

Tadros. We think flight data monitoring should be an important

tool for Canadas smaller carriers, too a tool to help them man-

age safety in their operations.She noted that 91 percent of commercial aircraft accidents in

Canada and 93 percent of commercial aviation fatalities in the past

10 years have involved operators of small aircraft, and said, We

need to look at new ways of bringing these numbers down.

Recorded information will help accident investigators de-

termine the causes of accidents and develop ways of preventing

similar accidents in the future, Tadros said.

The TSB was unable to determine the cause of the March 31,

2011, crash of the DHC-3, which broke up in flight and crashed,

killing the pilot, the sole occupant.

Complications for NextGen

Uncertain funding and the possibility of future

furloughs of U.S. Federal Aviation Adminis-

tration (FAA) employees are complicating the

agencys efforts to develop the Next Generation Air

Transportation System (NextGen), FAA Adminis-

trator Michael Huerta says.

In remarks to a meeting of RTCA (formerly

known as the Radio Technical Commission for

Aeronautics), Huerta said employee furloughs

and cuts in the FAAs budget may be necessary in

the fiscal year beginning Oct. 1, unless the U.S.

Congress approves a long-term plan for federal

spending.

In May, the Department of Transportation

determined that funds were sufficient to allow

the FAA to transfer money into accounts to end

furloughs of air traffic controllers and other FAAemployees and to prevent the planned closures of

149 FAA air traffic control towers for the rest of the

current fiscal year, which ends Aug. 31.

The law that requires across-the-board spend-

ing cuts at all government agencies makes continu-

ity of NextGen programs more challenging, Huerta

said. The NextGen budget has increased from $130

million in 2007 to $1 billion for the current fiscal

year, an expansion that represents the increasing

urgency to modernize our system, Huerta said.

Trevor MacInnis/Wikimedia Commons

U.S. Federal Aviation Administration

Compiled and edited by Linda Werfelman.

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12 | FLIGHT SAFETY FOUNDATION|AEROSAFETY

WORLD|

JULY 2013

COVERSTORY


WORLD|

JULY 2013

S

urprise and hesitation prevailed during the

final seconds of an Afriqiyah Airways Air-

bus A330-202s approach to Tripoli, Libya,

the morning of May 12, 2010. The Libyan

Civil Aviation Authority (CAA) has determinedthat the aircraft was well below the minimum

descent altitude for the nonprecision approach

when the copilot, the pilot flying (PF), asked the

captain if he should initiate a go-around.

Although neither pilot had the required visual

references to proceed with the approach, seconds

passed as the aircraft continued to descend.

Finally, an aural warning generated by the terrain

awareness and warning system (TAWS) prompt-ed the captain to command a go-around.

The copilot applied full power and initiated

a climb. According to the CAAs final report, the

sensory effects of the A330s acceleration likely

BY MARK LACAGNINA Fatal

Inadequate crew coordination, an unstabilized approach and spatial

disorientation during a delayed go-around led to an A330 crash off Tripoli.

HESITATION

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Aurlien Tranchet|Airliners.net

Louaf Larb|Reuters

COVERSTORY


WORLD|

JULY 2013

caused the copilot to falsely perceive that theaircraft had entered an excessive nose-up pitch

attitude. He moved his sidestick forward, and

the climb reversed into a steep descent.

The captain assumed control, but he, too,

likely had become spatially disoriented. Instead

of pulling out of the dive, he moved his sidestick

full forward. Too late, the pilots caught sight of

the ground.

The A330 struck terrain close to the runway

threshold. The impact and post-impact fire

caused complete destruction to the aircraft, the

report said. Only one of the 104 people aboard

the aircraft survived.

Familiar Trip

The accident occurred during a scheduled 8.5-

hour flight from Johannesburg, South Africa,

with 93 passengers, eight cabin crewmembers

and an augmented flight crew of three pilots.

Tripoli is the home base for Afriqiyah Airways,

which at the time operated three A330s and six

A320 series aircraft.

The accident aircraft was manufactured in

2009. The report said that all three pilots had 516

flight hours in type. They had flown together

often and were familiar with the Tripoli airport.

The captain, 57, had a total of 17,016 flight

hours. He had flown A320, Boeing 727 and Fok-

ker 28 series aircraft for Libyan Arab Airlines

and Nouvel Air before being hired by Afriqiyah

Airways as an A320 captain in 2007. He earned

an A330 type rating in May 2009.

The copilot, 42, had 4,216 flight hours. He

held type ratings in the de Havilland Twin Otter,

A320 and A330. The report provided no details

about his previous flight experience.The relief pilot, 37, had 1,866 flight hours

and held type ratings in the A320, A330 and 727.

The crew departed from Johannesburg at

2145 local time, with the copilot at the controls.

In general, it is common practice within Afriqi-

yah Airways to designate the copilot as PF when

weather conditions do not result in difficulty in

handling the aircraft, the report said.

Locator Approach

The cruise portion of the flight was conductedat Flight Level (FL) 400 (approximately 40,000

ft). The flight took place without any notable

events until the approach, the report said.

At about 0530, air traffic control cleared the

crew to descend to FL 90. The controller said

that the weather conditions at Tripoli included

calm winds, 6 km (4 mi) visibility, a clear sky

and a temperature/dew point of 19/17 degrees C

(66/63 degrees F).

The airport had one precision approach, an

instrument landing system (ILS) for Runway 27,

but it was out of service. The VOR/DME (VHF

omnidirectional range/distance-measuring equip-

ment) facility at the airport also was out of service,

and only locator approaches were available. The

locator approach to Runway 09 was in use.

The report said that the crew conducted a

short approach briefing that included some de-

tails about the locator approach and how it would

be flown. However, essential points, such as the

intended use of the autoflight systems during the

nonprecision approach, were not discussed.

The fact that the approach briefing was

incomplete indicates that the crew did not an-

ticipate any special difficulty in the conduct and

management of the approach, the report said.

The locator approach was based on three

compass locators (nondirectional radio bea-

cons) lined up on the extended centerline of

Runway 09. The first, identified as TW, was

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MHA2,000

HL(R)53

090090090

270

270

GHARARAH301

TWN 32 39.7E013 03.1

TW

TRIPOLI435

DN 32 39.8E013 07.1

d

TRIPOLI365

GN 32 38.8E013 10.7

G

TRIPOLIVOR/DME 114.5

TPIN 32 39.7E013 09.3

TPI

MSA4,000 25 NM

from TW

MSA4,000 25 NM

from TW

MSA2,000 25 NM

from TW

MSA2,000 25 NM

from TW

270

1 MIN2,000 ft

NM10 9 8 7 6 5 4 3 2 1 0

3.9

L

TW

L

D

2,000 ft

Elevation 262 ft

Runway 09

270

090

090

1,350 ft

3.3 0.6

M

MISSED APPROACH:

Climb straight ahead

after passing L G turn

RIGHT and proceed to

TW L climbing to 2,000

and hold.

Plan and profile views

of the Runway 09

Locator instrument

approach procedure

show the alignment

of three compass

locators and the

altitude to cross

the final approach

fix inbound.

SusanReed,adaptedfrom

InternationalCivilAviationOrganization


WORLD|

JULY 2013

COVERSTORY

3.9 nm (7.2 km) from the runway threshold

and served as an initial approach fix as well as

the final approach fix. The other two beacons,

located near the approach and departure

thresholds, respectively, marked the missed

approach point and the turning point for themissed approach procedure.

Generally, in the Tripoli Terminal Control

Area, arrivals are carried out under radar vec-

toring until intercepting the extended centreline

of the final approach segment, the report said.

Investigators were unable to determine

whether the crew conducted the approach

checklist. The approach checklist seemed to

be performed, but without any formal callouts,

the report said. The only item called out by the

crew was the altimeter setting.

Early DescentThe crew established the A330 at 1,400 ft on

the final approach course, 090 degrees, about

10 nm (19 km) from the runway. The approach

chart the crew was using indicates that the air-

craft should have crossed the final approach fix,

the TW locator, at 1,350 ft before descending to

the minimum descent altitude (MDA) of 620 ft.

However, recorded flight data showed that the

A330 began an early descent about 1.1 nm (2.0

km) before reaching the f inal approach fix.

Investigators determined that the copilot

might have inadvertently entered the distance

from the TW locator to the VOR/DME (5.2

nm), rather than the distance from the locator tothe runway (3.9 nm), when he programmed the

point at which the flight management system

would begin a descent on a three-degree glide

path for the final approach.

The aircraft was descending through 1,200 ft

when the captain established radio communica-

tion with the Tripoli airport traffic controller.

The controller asked if the runway was in sight,

and the captain replied, Established inbound,

sir. The controller then told the captain to

report the field in sight.

Unexpected Fog

Shortly thereafter, the pilots heard a radio

transmission by the crew of a preceding aircraft

advising that they had encountered patches of

fog on short final before landing. This likely

surprised the A330 crew and led the captain

to focus his attention on the outside to acquire

visual reference points, rather than on coor-

dinating with the copilot and monitoring the

flight parameters, the report said. Overall,

the management of tasks during the approach

deteriorated very quickly.

Although the relief pilot was in the jump seat

during the approach, there was no evidence that

he said anything or interacted with the other

pilots in any way.

The aircraft was configured for landing

when the copilot called for the landing checklist.

However, this could not be applied at this mo-

ment in time due to exchanges between the PNF

[pilot not flying] and the tower controller, the

report said.

The aircraft crossed the TW locator at 1,020

ft 330 ft below the published crossing altitude

at 0600:01. Neither pilot apparently recog-

nized the discrepancy.

The captain was engaged in obtaining a land-

ing clearance. He asked the controller, Confirm

clear to land if we have the runway in sight? The

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It is likely that

the captain did

not expect to have

to abort the fnal

approach and the

TOO LOW TERRAIN

warning [had]

destabilized him.

Somatogravic Illusion

Perceived position of airplane

Actual position of airplane

Balance sensors

in inner ear (otoliths)As the airplane accelerates,inertia causes sensors in theinner ear to move as if the

body were tilted. This givesa false sensation of climb.

Acceleration

Without visual cues orfeedback from instruments,pilots may overcompensate

for these perceivedchanges in attitude.

S s a n R e e d a d a p t e d f r o m

U S N a C h i e f o f N a a l A i r T r a i n i n g


WORLD|

JULY 2013

COVERSTORY

controller replied, Affirmative.

Clear to land. Wind calm.

Continue

A few seconds later, the cock-

pit voice recorder captured anautomated callout of hundred

above, indicating that the air-

craft was 100 ft above the MDA.

The copilot asked in Arabic,

You see?

The captain replied,

Continue.

Company standard operat-

ing procedures (SOPs) define the

continue callout as indicat-

ing that the PNF has acquiredthe visual references required to complete the

approach and landing. However, it is almost

certain that the weather conditions (as indicated

by the previous crew), the lighting conditions

and the actual position of the aircraft in relation

to the runway threshold did not enable acqui-

sition of the external visual references required

to continue the approach below the MDA, the

report said. The captain probably hoped to

obtain visual references in the next few seconds.

Moreover, because the crew of the preced-

ing aircraft had been able to land despite the

developing fog, the A330 crew might have been

confident that they also would be able to land,

the report said.

Shortly after the copilot acknowledged the

captains instruction to continue the approach,

an automated callout advised that the aircraft

had reached the minimum, the MDA at 620

ft, or 358 ft above ground level (AGL).

Neither pilot said anything for several

seconds. The copilot likely looked up from the

instruments and, not seeing the runway, asked,

Ill go around, captain? There was no immedi-

ate reply. The report noted that the copilot did

not initiate a go-around on his own volition, as

required by SOPs.

The aircraft was descending through 490

ft 228 ft AGL when the TAWS generated

the TOO LOW TERRAIN warning.

Go around, the captain said. Go around.Go around. The copilot disengaged the autopi-

lot, applied takeoff/go-around power, pulled his

sidestick back and asked the captain to retract the

flaps and landing gear.

The captain, as PNF, did not make the ap-

propriate callouts, the report said. It is likely

that the captain did not expect to have to abort

the final approach and the TOO LOW TER-

RAIN warning [had] destabilized him, the

report said.

Somatogravic Illusion

Four seconds after disengaging the autopilot

and initiating a climb, the copilot began to apply

nose-down pitch inputs on his sidestick. The

aircraft, which had climbed to 670 ft, entered a

steep descent.

The report said that the copilot likely had

suffered spatial disorientation typical of a

somatogravic [perceptual] illusion occurring

in the absence of outside visual references.

This would have resulted from the aircraf ts

sudden acceleration affecting the balance

organs of his inner ear, creating a sensation

of being tilted backward and the fa lse percep-

tion that the pitch attitude was excessive

(although it wasnt).

His reactions likely responded to the il-

lusion, rather than to the flight instruments.

At no time was the go-around pitch attitude

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COVERSTORY

controlled, nor did the copilot fol-

low the instructions from the flight

director, the report said. Neither

crewmember seemed to be aware of the

flight path of the aircraft.

As the A330 descended, the TAWS

generated successive warnings of

DONT SINK, TOO LOW TER-

RAIN and PULL UP. Nevertheless,

seconds before impact, the captain

pressed the priority pushbutton on his

sidestick and applied a sharp nose-

down input, the report said.

The pitch attitude was 3.5 degrees

nose-down as the aircraft descended

through 500 ft. By this time, the

copilot apparently had become aware

of the aircrafts flight path and had

pulled his sidestick all the way back,

intending to recover from the dive

but not recognizing that the captain

had sidestick priority. The captain

had not announced that he was as-

suming flight control.

Shortly before impact, the cap-

tain apparently became aware of the

aircrafts proximity to the ground

and reversed his sidestick input. The

descent rate was 4,400 fpm when the

A330 clipped trees and a high-tension

power line, and struck the ground in a

nearly level attitude at 0601:14. The im-

pact occurred 1,200 m (3,937 ft) from

the runway and slightly to the right of

the extended centerline.

Postmortem examination of the

victims indicated that all fatalities re-

sulted from severe trauma, the report

said. Media accounts said that the

survivor was a 9-year-old Dutch boy.

He suffered serious injuries and was

hospitalized in Tripoli for 48 hours

before being transferred to a hospital

in the Netherlands.

Fatigue FactorInvestigators determined that fatigue

might have been a factor in the ac-

cident, though the evidence was not

conclusive. All three pilots had received

more than 15 hours of rest before

reporting for duty at Johannesburg.

Moreover, the captain had taken a rest

period during cruise flight, returning

to the cockpit at 0410, almost two

hours before the accident occurred.

The report said that the copilot and the

relief pilot likely took their rest periods

before the captain.

However, the pilots had flowntwo consecutive night flights. This

would impose a certain amount of

fatigue which might [have] degraded

the performance of the flight crew and

increased the effect of somatogravic

illusions, the report said.

The pilots performance was

likely impaired [by] fatigue, but the

extent of their impairment and the

degree to which it contributed to the

performance deficiencies that oc-curred during the f light cannot be

conclusively determined.

Lessons Not Learned

The report noted that a similar event

had occurred 14 days before the ac-

cident: The captain and the copilot had

conducted the same locator approach

in the same aircraft on April 28. The

approach was similar in having been

unstabilized and marked by a prema-

ture descent. However, it terminated

with a missed approach initiated slight-

ly above the MDA and was followed by

an uneventful go-around and landing

on Runway 27.

The crew did not report the

go-around, as required, to Afriqiyah

Airways. The investigation committee

confirmed that analysis of the April 28

flight was not performed and the

crew had not reviewed and fully under-

stood what had happened during the

April 28 flight, the report said.

Tis article is based on the Libyan Civil

Aviation Authoritys Final Report o Ariqiyah

Airways Aircraf Airbus A330-202, 5A-ONG,

Crash Occurred at ripoli (Libya) on

12/05/2010, February 2013. Te report is avail-

able at .

Airbus A330-200

The two-engine A330 and the our-engine A340 were developed simulta-

neously by Airbus and share many systems and structural eatures. The

base-model A330-300 entered service in January 1994, a ew months ater

the A340.

The A330-200 is an extended-range version o the -300 that was introduced

in 1998 with a shorter uselage and higher uel capacity. Both models have

General Electric CF6-80, Pratt & Whitney PW 4000 or Rolls-Royce Trent 700 series

turboan engines rated at about 70,000 lb (31,752 kg) thrust.

The A330-200 accommodates 253 passengers in a twin-aisle cabin and

has maximum weights o 230,000 kg (507,063 lb) or takeo and 180,000 kg

(396,832 lb) or landing. Typical operating speed is 0.82 Mach, and maximum

range with reserves is 6,650 nm (12,316 km).

In 2012, maximum takeo weight was increased to 240,000 kg (529,109 lb) to

accommodate extra uel capacity and increase range to 7,050 nm (13,057 km).

Currently, 484 A330-200s are in operation worldwide.Sources: Airbus,Janes All the Worlds Aircraft

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http://noplanenogain.org/

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18

|FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JULY 2013

MAINTENANCEMATTERS

In April 2010, after a base maintenance check

at Exeter, England, a Bombardier DHC-8-

102 was flown uneventfully to East Midlands

Airport to be repainted. During the return

ferry flight to Exeter, the right engine developed

a significant oil leak and lost oil pressure, so the

flight crew shut the engine down. Subsequently,

the crew noticed the left engine also leaking oil,

with a fluctuating oil pressure, so they diverted

to Bristol, where they landed safely.

The oil leaks were traced to damaged O-

ring seals within the oil cooler fittings on both

engines. Both oil coolers had been removed and

refitted during the maintenance at Exeter. It was

probably during re-installation that the O-ring

seals were damaged.1

During the investigation carried out by

the U.K. Air Accidents Investigation Branch

(AAIB), it was found that over the 17-week

period leading up to the end of a C-check, one

of the maintenance technicians working on the

aircraft had worked an average of 57 hours per

week, which was nine hours per week more than

allowed by the European Working Time Direc-

tive (WTD). The investigation also found that

during the 10 days prior to the aircrafts arrival

at Exeter, the same technician had averaged 15.7

work hours per day, resulting in the 11-hour

UntiringEfforts

BY MARIO PIEROBON

Fatigue among maintenance technicians can be

mitigated by fatigue reporting, bio-mathematical

models and shift-change management.

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MAINTENANCEMATTERS

post-shift rest entitlement in the WTD being

significantly curtailed. The technician reported

that he did not consider himself fatigued during

this period. However, he also said that during

the leak checks on the incident aircraft he felt

tired and had a lot on his mind, trying to get theaircraft ready for its scheduled painting slot, al-

though it was not an unusual level of tiredness.2

The AAIB said that a technician tasked to

work a 10-day period, with just one day off in

the middle, averaging 15.7 hours per day, is a

safety concern, particularly if not monitored

by the approved maintenance organization

(AMO). The AAIB also noted that the AMO

involved in this occurrence had no policy on the

maximum hours for a technician to work in any

24-hour period and relied on every technicianand manager, after undergoing human factors/

performance training, to communicate to their

supervisors the risk of fatigue. The AAIB said

that individuals who have undergone this train-

ing probably will be very responsible and will

request time off when they feel that they need it.

However, for some individuals this may not be

the case, particularly when they have a strong

desire to complete the job they have started

and when there is a financial incentive to work

longer hours, the report said.3

According to the AAIB, there is also evi-

dence from fatigue research that people are not

very good at detecting their degradation in per-

formance as they become fatigued. Therefore,

the responsibility for managing fatigue should

belong to the AMO and not just the individual.

The AAIB, however, notes that in Europe Part

145 (Annex II to Commission Regulation [EC]

No 2042/2003) states that the AMO needs to

take human performance limitations into ac-

count when planning maintenance tasks and,

although not specifically stated, this should in-

clude maintenance technician fatigue. However,

the acceptable means of compliance (AMC) and

guidance material (GM) to Part 145 currently do

not explain how this should be accomplished.4

In response to a safety recommendation

issued by the AAIB following this serious inci-

dent, EASA in early 2013 published a Notice of

Proposed Amendment (NPA) to EU Regulation

2042/2003 on continuing airworthiness to add

AMC and GM in Part 145 on how approved

maintenance organizations should manage and

monitor the risk of maintenance technician fa-

tigue as part of their requirement to take humanperformance limitations into account.

Working Time Directive

Unlike aircraft crewmembers whose duty time

is regulated by ad hoc and specific regulation,

aircraft maintenance engineers duty time is

standardized and regulated by the generic and

rather vague Council Directive 2003/88/EC (the

WTD), which leaves the door open to many

interpretations and exceptions, says Marco

Giovannoli, an aircraft systems engineer at Eti-had Airways and a fatigue and safety specialist.

The directive contains many opportunities

for derogation, or exception, which mainte-

nance organizations can use to circumvent the

limits. The directive states that derogations may

be made from the rest periods in the case of

activities involving the need for continuity of

service or production, particularly in industries

where work cannot be interrupted on technical

grounds. Also, derogations may be made by col-

lective workforce agreements.

Even without the derogations, the WTD

has been interpreted by some to mean that the

minimum daily rest period of 11 hours means

providing 11 hours of rest aftera working

period that could be up to 24 hours. Therefore,

maintenance organizations need to have clear

fatigue management plans that monitor their

staff working hours and working patterns to

reduce the risk of fatigue-related maintenance

errors. The published NPA (2013-01) is actu-

ally attempting to standardize across Europe the

interpretation of the working time directives for

aircraft maintenance operations.

With NPA 2013-01, EASA is filling a regula-

tory gap compared with other aviation regulatory

environments such as Canada and the United

States. According to the AAIB, Transport Canada

has published two NPAs (2004-047 and 2004-

049) which propose requirements for an AMO to

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20 |FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JULY 2013

MAINTENANCEMATTERS

manage atigue-related risks through a

saety management system (SMS).

o support these proposed regula-

tions, ransport Canada has published

guidelines or a atigue risk manage-

ment system (FRMS) that provides amethod or quantiying atigue risk on

a numerical scale using knowledge o

working hours and rest periods. he

AAIB also ound that the U.S. Federal

Aviation Administration (FAA) has set

up a maintenance atigue working group

to review the need or regulatory limits

on working hours or maintenance

technicians.5

Fatigue Risk ManagementEASAs new requirements or atigue risk

management are part o a larger rule-

making eort related to SMS in main-

tenance and continuing airworthiness

management organizations. Approved

maintenance organizations are going to be

required by EASA to implement an FRMS.

An FRMS needs to be careully

planned. o some extent, maintenance

organizations can draw rom already

produced research in relation to light

crews atigue, including the FRMS

Implementation Guide or Operators

jointly released by the International

Air ransport Association, the Interna-tional Civil Aviation Organization and

the International Federation o Air Line

Pilots Associations in 2011.

However, there are inherent di-

erences between aircrat maintenance

technicians work, working environ-

ment and associated atigue issues and

those o light crews. It becomes neces-

sary or a maintenance organization

planning an FRMS to properly consider

the maintenance-speciic atigue issues.

Reporting Fatigue

Fatigue should be a joint concern o

technicians, organizations and national

aviation authorities (NAAs). Without

proper and eective oversight by avia-

tion authorities, maintenance organiza-

tions may not have a strong enough

incentive to monitor and mitigate

atigue issues. In this situation, the NPA

is going to play an important role, as it

requires a rule-enorcing eort rom

European NAAs or atigue manage-

ment. More important, however, is

going to be the actual cultural transor-mation within maintenance organiza-

tions themselves.

Aircrat maintenance engineers

should be encouraged to report to su-

pervisors their degraded perormance

caused by atigue, and they should not

ace veiled threats o repercussions

rom their managers, says Giovannoli.

Nowadays i a pilot reports atigue,

[the reporting] is considered proes-

sional, conversely an engineer callingin atigued may be demonized. For a-

tigue to be consistently reported, tech-

nicians need a better understanding o

their atigue perormance limitations.

here is a strong subjective compo-

nent concerning atigue, and thereore

it is important to clearly illustrate the

various indicators and symptoms o

atigue and the possible methods o

osetting it, such as caeine, which

normally is the common counteracting

method used by aircrat maintenance

engineers, says Giovannoli.

echnicians should be advised about

correct sleep practices and good health.

Recommended levels o physical activ-

ity should be regularly practiced and a

balanced way o lie should be ollowed.

Moreover, managers and supervisors

should be properly trained to perceive

atigue symptoms and be empowered

to take corrective actions, even i these

could be perceived as detrimental to

organizational productivity, he said.

Vigilance Issues

Vigilance decrement is a orm o

short-term atigue to which aircrat

maintenance technicians are highly sus-

ceptible, especially during inspection

Vigilance Decrement Over Time

90

80

70

60

50

40

30

20

10

0

10 20 30 40 60 70 90 100 110 120 130 140

Vigilanceeectiveness%

Time (min)

Source: Australian Transport Safety Bureau

Figure 1

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MAINTENANCEMATTERS

tasks. his orm o atigue should be

particularly monitored by AMOs.

Alan Hobbs, in a report issued by

the Australian ransport Saety Bureau,

discussed vigilance issues. During the

Second World War it was ound thatater about 20 minutes at their posts,

radar operators became much less likely

to detect obvious targets, he said. his

problem applies to many monitor-

ing tasks where the search targets are

relatively rare. Aircrat inspection, the

checking o medical X-rays and quality

control inspection in actories are areas

where vigilance decrements may oc-

cur6 (Figure 1, p. 20).

Vigilance decrement applies par-ticularly to detection tasks where the

person is required to passively monitor

a situation that is boring and monoto-

nous, such as inspecting large numbers

o turbine blades. he limiting actor

is the ability to keep attention on the

task. For example, during the visual

inspection o an aircrat, a maintenance

worker may look directly at a deect,

yet i their attention is occupied with

other demands, the deect may not be

recognised. In general, inspection tasks

that involve variety and regular breaks

are less likely to suer rom vigilance

decrement.7

Bio-Mathematical Fatigue Models

Several sotware models are available

rom vendors as practical tools or

estimating work-related atigue associ-

ated with shit workers duty schedules.

Some o the models can be used with

any duty schedule, in which hours o

work (i.e., start/end times o work peri-

ods) are the sole input.

he main advantage o bio-math-

ematical atigue models is that they

allow the generation o qualitative and

quantitative orecasts o human atigue

based on a set o equations.8

Giovannoli, however, recognizes

such models intrinsic limitations, as

they do not consider the workers

individual variables and the conditions

around him, such as task diiculties,

working conditions and perception oatigue, which may drastically increase

the individuals actual level o atigue.

It is recommended to integrate a

bio-mathematical model in a wider-

ranging FRMS, he said. However,

available models should be careully

considered and validated beore imple-

mentation. One example o guidance

or the selection o bio-mathematical

models suitable or atigue risk man-

agement in aviation maintenance hasbeen provided by the Australian Civil

Aviation Saety Authority (CASA).

In its publication, Bio-Mathematical

Fatigue Modelling in Civil Aviation

Fatigue Risk Management, CASA

identiies opportunities or integrat-

ing models into a holistic FRMS while

developing management systems and

a corporate culture that understand

the uses and limitations o qualitative/

quantitative model predictions, use

their outputs with caution and in the

context o other operational opportuni-

ties and constraints, and adopt comple-

mentary multi-layered strategies to

proactively identiy and manage atigue

risk.9

CASA also discusses key actors to

consider when selecting and apply-

ing a bio-mathematical atigue model.

hese include the type o data to be

used as inputs, the physiological actors

described by the model components,

types o output predictions and their

relevance to task risks or other out-

come variables, data used or validation

and their level o equivalence to the

operational environment and subject

population, and the interpretation o

predictions or use in decision making.

CASA states that all these actors must

be considered, relative to the speciic

operational environment or their

intended use.10

In the application guidance mate-

rial, CASA provides an overview o sixbio-mathematical models rom com-

mercial and academic organizations

together with their related products and

services. CASA also provides a eature

comparison table and a discussion o

eatures in the context o commercial

aviation applications.

A sotware model that has been de-

veloped explicitly or light crew atigue

monitoring should not be selected, as it

may not allow or proper collection andelaboration o relevant inormation in a

maintenance environment.

Shift Work and Maintenance Errors

According to a study by Dawson and

Reid, Recent research has shown that

moderate sleep deprivation o the

kind experienced by shit workers can

produce eects very similar to those

produced by alcohol. Ater 18 hours o

being awake, mental and physical per-

ormance on many tasks is aected as

though the person had a blood alcohol

concentration o 0.05 percent. Boring

tasks that require a person to detect

a rare problem, like some inspection

jobs, are most susceptible to atigue

eects.11

Studies have shown, Hobbs said,

that 24-hour circadian rhythms inlu-

ence human error, with many aspects o

human perormance at particularly low

levels in the early morning. Memory

and reaction time are at their worst at

around 0400, and the chance o error

is increased. here appears to be an

increased risk o maintenance errors on

night shits.12

Hobbs said, It has been ound

that when maintenance technicians

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MAINTENANCEMATTERS

are experiencing sleepiness, they are at

increased likelihood o errors involving

ailures to carry out intentions, such as

memory lapses and perceptual errors.12

Sleepiness, however, seems to be less

likely to lead to mistakes o thinking suchas procedural misunderstandings.13

Twelve-Hour Shifts

welve-hour maintenance shits are

becoming increasingly common,

Hobbs said. In some cases, a com-

panys move to 12-hour shits is driven

by employee preerence rather than

management pressure. When compared

with eight-hour shits, 12-hour shits

oer certain advantages, such as lesscommuting time over the course o a

week, more days o, and the oppor-

tunity to complete more work in each

shit, with ewer handovers o tasks

between shits. Although workers tend

to be more atigued at the end o a 12-

hour shit than at the end o an eight-

hour shit, they sometimes report ewer

health problems and better sleep on a

12-hour shit pattern than when on an

eight-hour pattern.14

At present, there is no conclusive

evidence to indicate that extending

the duration o shits rom eight to

12 hours will increase the probability

o accidents or injuries. Nevertheless,

12-hour shits may not be appropriate

in all cases. Whenever a change is being

made to 12-hour shits, it is essential

to evaluate the eects o the change on

worker well-being and work quality.

Quite possibly, the most signiicant

eects o 12-hour shits would show

themselves on the journey home rather

than at work.15

Rotating Shifts

Rotating-shit workers may never

entirely become accustomed to a work

schedule, because the timing o shits is

constantly changing, Giovannoli said.

Direction and speed o rotation can

aect the adaptation to rotating shits.

Direction o rotation means the or-

der o changes to shits. wo common

types o rotation are orward, whenrotation is day to evening to night; and

backward, when rotation is day to night

to evening. Speed o rotation means the

number o consecutive working days

beore a shit change.

he current atigue science litera-

ture reports that a rapid (two to ive

days) orward-rotating shit system re-

duces mental and physical perormance

degradation and enables aster recovery

o both sleep and social activities. Incontrast, the ast backward-rotating

shit system is linked with reduced

physical and psychological health and

higher atigue.16

Night shit should not last more

than 10 hours including overtime and

two consecutive night shit blocks in

a row should not be allowed; with not

more than eight night shits in every

month, says Giovannoli. Furthermore,

night shit should not be extended

beyond 0800 and ater a night shit

block, two days o should be granted,

to provide enough rest time beore the

next shit, which in the orward rota-

tion is a morning shit.

he ideal o a totally non-atigued

technician may not be achievable in the

actual workplace, yet avoiding adverse

outcomes o atigue on saety and pro-

ductivity should be the objective while

implementing an FRMS. Empowering

atigue reporting, using bio-mathemati-

cal atigue models and properly manag-

ing work shits are valuable strategies

or targeted atigue risk management in

maintenance organizations.

Mario Pierobon works in business development

and project support at Great Circle Services in

Lucerne, Switzerland.

Notes

1. U.K. Air Accidents Investigation Branch

(AAIB),AAIB Bulletin 6/2011.

2. AAIB.

3. AAIB.

4. AAIB.

5. AAIB.

6. Hobbs, Alan. An Overview o Human

Factors in Aviation Maintenance.

Australian Transport Safety Bureau, AR

2008 055. December 2008.

7. Hobbs.

8. Australian Civil Aviation Saety Authority

(CASA). Bio-Mathematical Fatigue

Modelling in Civil Aviation Fatigue RiskManagement Application Guidance.

2010.

9. CASA.

10. CASA.

11. Dawson, D.; Reid, K. (1997). Equating

the perormance impairment associated

with sustained wakeulness and alcohol

intoxication. Journal of the Centre for Sleep

Research, 2, 1-8. Cited in Hobbs (2008).


Factors in Aviation Maintenance. ASB

ransport Saety Report Aviation

Research and Analysis ReportAR 2008 055,

December 2008.

13. Hobbs, A.; Williamson, A. (2003).

Associations between errors and contribut-

ing actors in aircra maintenance. Human

Factors, 45, 186-201. Cited in Hobbs (2008).


Factors in Aviation Maintenance. ASB

ransport Saety Report Aviation

Research and Analysis ReportAR 2008 055,

December 2008.

15. Hobbs.

16. Vangelova, Katia. Te Efect o Shi Rotation

on Variations o Cortisol, Fatigue and Sleep

in Sound Engineers. Industrial Health, 46,

490493 (2008); cited in Giovannoli, Marco,

Fatigue Monitoring to Improve Productivity

and Saety in Aviation Maintenance. City

University London (2008).

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WORLD|

JULY 2013

The oten-orecast shortage o U.S. airline

pilots may inally come to pass, ed by a

perect storm o increasing demand or

new pilots, mounting retirements by baby-

boomer pilots and declining interest among young

people in airline careers, industry experts say.

A recent study by researchers rom several

U.S. universities reinorced the conclusions

o Boeings 2012 projection that the next two

decades will bring an unprecedented demand

or new pilots. Filling those jobs may not be

easy, the university study said.

he study orecast the hiring o more

than 95,000 pilots in the United States over

the next 20 years as a result o the combined

eects o new aircrat growth, pilot retire-

ments and pilot attrition rom the industry

or reasons other than retirement, as well

as government regulations especially rest

and duty time requirements that will limit the

number o hours pilots may work that may

lead to an increase in the number o required

new pilots.1

he Boeing study had orecast a need or

460,000 new pilots worldwide by 2032, includ-

ing 69,000 in North America (Figure 1, p. 24).

he Asia Paciic region will account or about

40 percent o the total worldwide need; that

number will include 71,300 in China alone.

he study cautioned that, in many regions o

the world, a pilot shortage is already here and

noted that the Asia Paciic region, in particular,

is experiencing delays and operational inter-

ruptions due to pilot scheduling constraints.2

he university study, which was conducted

at the request o an aviation industry stakehold-

ers group, acknowledged the ailure o requent

past warnings o an impending pilot shortage

to come to ruition, as well as conusion about

exactly what constitutes a shortage.Spiritartist/iStockphoto

FLIGHTDECK

BY LINDA WERFELMAN

Despite frequent warnings, an

actual shortage of airline pilots

would be the first since the 1960s.

ShortSupply

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Forecast New Pilot Demand Through 2031

40%

22%

15%

9%

8%3% 3%

Asia Pacic 185, 600

Europe 100,900

North America 69,000

Latin America 42,000

Middle East 36,100

CIS 11,900

Africa 14,500

Total 460,000

Region Pilots

CIS = Commonwealth of Independent States

Source: The Boeing Company

Figure 1


Does pilot shortage reer to a situation where

the lack o available qualiied pilots results in op-

erational disruptions, such as changes in schedule

or reduction o lights? the studys authors asked.

Using this deinition, the last pilot shortage oc-

curred in the 1960s. In this era, it was noted thatthousands o hours o lights by major airlines

had to be canceled and operations adjusted due to

the unavailability o qualiied pilots to hire.

Or does a pilot shortage mean a lowering o

hiring requirements to dip into the next wave o

applicants who, o course, still meet FAA [U.S.

Federal Aviation Administration] requirements

but are not at the top o the light experience

hierarchy? here is evidence to support this

was the case at the regional carriers in the most

recent hiring wave o 2007 and 2008.ypically, U.S. airlines have ound enough

qualiied pilots by hiring retired military pilots

and others rom civilian sources.

What is dierent now? the study asked

beore outlining several new considerations:

Recentlimitedhiringatmajorairlines;

Anincreaseinretirementsfrommajor

airlines over the next ew years;

Expansionofairlines;

Asmallernumberofnewflightinstruc-

tors who say they want careers with the

airlines; and,

Alegislativerequirementforairlinepilots

to possess airline transport pilot (AP)

certiicates which typically require

1,500 light hours.

he hiring o pilots or major airlines stimulates

demand or pilots throughout the industry, the

study said, adding that the unanswered question

now is whether hiring over the next ew years

will provide enough o a stimulus to develop an

adequate, continuous supply o pilots.

About 45,000 pilots are expected to retire

rom major airlines in the next 20 years, and with

18,000 current regional pilots, the industry willace a shortall unless a signiicant number o

new pilots enter the work orce, the study said.

Current projections indicate there will

be disruptions in the pilot labor supply unless

industrymarket undamentals change, more

pilots can be enticed into an airline pilot career

or the regulatory environment changes, the re-

port said. A status quo projection indicates that

there will be a shortage o around 35,000 pilots

(Figure 2, p. 25).

CFI Survey

he university study included a survey o certi-

ied light instructors (CFIs), gauging their

interest in an airline career, Kent Lovelace,

chairman o the Department o Aviation at

the University o North Dakota and one o the

studys authors, said during a panel discussion

inMayattheRegionalAirlineAssociations

(RAAs)annualmeetinginMontreal.

Its not so much how many pilots are out

there, but how many want to pursue the career,

Lovelace said, noting that many CFIs trained in

the United States plan to return to their native

countries to continue their aviation careers.

he survey, administered to 1,636 CFIs,

ound that 54 percent are planning on an

airline career. Nine percent o those ques-

tioned said they had abandoned their interest

in a career with the airlines because o the

A status quo

projection indicates

that there will be a

shortage of around

35,000 pilots.

FLIGHTDECK

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Forecast Shortages of Pilots to Staff the U.S. Airline Fleet

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Cumulativenumberofpilo

ts

Yearlynumberofpilots

Yearly shortage Cumulative shortage

2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031

Source: Higgins, James; Lovelace, Kent; Bjerki, Elizabeth et al.An Investigation of the United States Airline Pilot Labor Supply. 2013.

Figure 2


WORLD|

JULY 2013

requirement or irst oicers to possess an AP.

An additional 33 percent said the requirement

had prompted them to reconsider their plans to

ly or the airlines.

he requirement included in a 2010 law

let room or exceptions to the 1,500-light-

hour requirement or military pilots and or new

pilots who graduate rom our-year colleges with

aviation degrees (ASW, 12/12, p. 43). he speci-

ics o those exceptions will be clariied in a rule

expected to be issued later this year by the FAA.

he numbers o CFIs hoping or airline ca-

reers are dramatically lower than they have been

in the past, Lovelace said, noting that 10 or 15

years ago, 75 to 90 percent o those questioned

said that they wanted to ly or an airline and

they knew which airline and which equipment.

Today,LovelacetoldtheRAA,ifyoucon-

vince 100 percent o those [the 54 percent] to

pursue an airline career, you dont have a sup-

ply problem. Nevertheless, he added, airlines

must actively persuade

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