The Management of Aegean Airlines & Olympic Air is committed to the conduct of our aviation activi-ties to the highest possible safety standard. A management system is implemented which provides for the compliance with all applicable regulatory requirements, meets all applicable standards and always consider best practices, while monitoring safety compliance of all systems and established procedures. The safety of our employees and customers relies on the commitment of management to a systematic and pro-active attitude towards managing risk, identifying hazards and preventing damage/injuries.

Safety is the prime consideration and Aegean Airlines & Olympic Air recognize the importance of ap-plying human factor principles in order to achieve it. It is the duty of each staff member to understand the corporate self-disciplines required by Compliance Monitoring/Quality and Safety Standards and to partici-pate in our goal for continuous self-improvement.

Each employee is responsible for cooperating with Quality Unit in order to identify non-conformances and to the Safety Department so as to communicate any information that may affect the integrity of safety.

To promote a timely, uninhibited flow of information, Aegean Airlines & Olympic Air have promoted and established a “Just Culture” which ensures no blame will be apportioned to individuals following their reporting of mishaps, operational incidents or other risk exposures. Incidents or occurrences with elements of wilful misconduct, gross negligence or criminal acts however, will be met with disciplinary and/or legal action.

Our commitment is to:

• Enforce safety as one of the primary responsibilities of all Heads of Functional Areas / Nominated Persons / Managers;

• Ensure that compliance with applicable regulation and standards is the responsibility of all personnel;

• Support the “Just Culture” policy;

• Implement an effective management system to ensure that customer and regulatory requirements are met, and ensure that all employees are aware that Safety and Compliance is everyone’s responsibility;

• Ensure safety and risk considerations are incorporated in its business, through a documented management of change process;

• Establish and implement hazard identification and risk management processes, including a hazard reporting system, in order to eliminate or mitigate the safety risks associated with our operations

• Achieve continuous safety improvement through continuous monitoring and measurement, and adjustment of safety objectives and performance standards and achievement of these;

• Develop the skills of employees to ensure that the Safety Management System can be maintained through a process of recurrent training and an awareness program; and

• Ensure that the necessary human and financial resources are available in order to allow our activities to be carried out in accordance with Aegean Airlines & Olympic Air standards and this Safety and Quality Policy Statement.

SAFETY & QUALITY POLICYIs issued every six months by the Safety

Department of AegeAn and OlympIc AIr. It provides information of Safety related mat-ters and it is devoted to improve flight safety. It includes articles either original or reprinted from other sources, collected by individuals and conveying their own experience or knowledge from the aviation industry.

SafeLines is open to everyone who wants to participate with articles, photos even recom-mendations or ideas for a safer operation.

Safelines is of informative nature and in no case substitute regulatory publications and company procedures.

capt. Stavros christeasAEGEAN & OLYMPIC AIR Safety Manager

contents

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Safety Department would like to thank our photographer, Vassilis Porgiazis.Artwork and productionby TRIBUTE - CHROMOANALISIe-mail: xromoana@otenet.grwww.chromoanalysi.gr

04 > EDITORIAL

06 > ARE JETS SAFER THAN TURBOPROPS?

08 > COMPOSITE MATERIALS FOR AIRCRAFT STRUCTURES

14 > TRAVELING WITH A PET

17 > DEGREE OF EMERGENCY

18 > THREAT AND ERROR MANAGEMENT IN AVIATION

22 > HUMAN FACTORS VS ACCIDENT CAUSATION

25 > INCIDENT FORUM

26 > WING TIP DEVICES

30 > REPORT

34 > NEW ENTRIES IN OUR FLEET

AEGEAN Safety DepartmentCapt. Stavros Christeas Safety ManagerCapt. Nikos Chrysanthopoulos Deputy Safety ManagerCapt. Alexandros Mosialos Chief Safety InvestigatorCapt. Stavros Siannis gate Keeper Mr. Antonis Kanakis F.D.m AnalystMrs. Kalliopi Trachana Safety SpecialistMrs. Charalambia Anastasiou Safety SpecialistSCCM Panagiotis Kritikoscabin Safety coordinator Avionic Eng. Konstantinos Kourismaintenance Safety coordinatorDimitris PassakosSafety representative groundTel.: +30 210 3550623Fax: +30 210 3550179e-mail: safety@aegeanair.com

Olympic Air Safety DepartmentCapt. Stavros Christeas Safety ManagerCapt. Panagiotis Kostopoulos Deputy Safety ManagerCapt. Dimitris Malamos Safety coordinatorCapt. Giorgos Maragkakis gate KeeperMr. Antonis Kanakis F.D.m AnalystSCCM Anastasios Liakatos cabin Safety coordinatorAntonis Konstantinidis maintenance Safety coordinatorDimitris PassakosSafety representative groundTel.: +30 210 3550679Fax: +30 210 3550349e-mail: safetygroup@olympicair.com

Dimitris GerogiannisManaging Director & Accountable Manager

04 05

EDITORIAL Safety Culture in airCraft ground handling

Dear colleagues

What is culture? This is probably among the most complex and most debated questions of the social science. Addressing the concept of culture is like opening Pandora’s Box unleashing most social science concepts and, as a consequence, a host of analytical and definitional issues. The word ‘culture’ stems from the Latin colere, which means to grow or to process. Culture has to do with those aspects of hu-man life that are not aspects of biology or unprocessed physical environment. This is culture in its broadest definition every-thing that is not nature has to be seen as culture.Within the aviation society the concept usually refers to the values that the members of a group share, the norms they follow and the procedures they create. As far as organizational culture is concerned it does not imply that it is necessarily attrib-utable to an organization as a whole. On the contrary, organizations, depending on size and complexity, usually consist of multiple cultures associated with different departments, hierarchical layers, occupations and so on. In Ground Operations we see culture as the frames of reference through which information, symbols and behavior are inter-preted and the conventions for behavior, interaction and communication are generated.Ground Operations involves all aspects of aircraft handling at airports as well as aircraft movement around the airport, except when on active runways. The safety challenges of ground operations arise in part, directly from those operations. Even more important, ground operations concern the preparation of aircraft for departure in such a way that the subsequent flight will be safe and according to legislation/company procedures; for example correct loading of cargo and baggage, sufficient and verified fuel of adequate quantity and quality, etc.. Once again, last year a great effort has been done to minimize safety related incidents on the Ground. Safety Department along with Ground Operations worked on a continued plan, focused on the improvement of the Safety Culture during aircraft ground handling, which consisted of training sessions, station assessments and audits from our ground safety coordinator and our QA auditors, one to one briefings, group meetings and close supervision. On ramp handling training, special attention was particularly given to (a) Loading Height Limitations, on aircraft where vio-lation of loading height limits is considered to be safety critical and (b) the proper securing of load, where bulk compartment nets have to be properly secured and any defective items must be reported. In addition to training and education we have successfully changed processes and procedures in order to improve safety on the ground. Working closely with the Safety Departments of our ground handling providers we have placed in most of the airports safety chains to restrict passenger access under aircraft wings. The efforts made were intended to send out again our message, “AEGEAN CARES FOR SAFETY”. The measurable results of this campaign were that safety events were reduced greatly.Our effort continues this year with the campaign under the title: Important Notes for Safe Aircraft Loading. Apart from train-ing sessions to major airports from our Airport Services trainers we are going to place a poster with the campaign name in all ramp handling personnel briefing and rest areas. This poster has a check list of actions, describing correct procedures and processes of loading with very simple words and images:

1. Bags loaded in accordance to the loading instructions2. Cargo controlled by AWB number and destination3. HEA/HER completely lashed and secured4. Special loads (HUM/AVIH) loaded, lashed and secured5. No Bags/cargo is loaded over cargo hold height limitations6. Ramp agent to inform in writing Load Control about any change to the load-ing instructions prior to loadsheet release.We believe that the above will contribute towards the further improvement of our safety culture and add awareness during loading to ground personnel. We still have to be extremely vigilant during turnaround activities.

Thank you for your cooperation in the development of our Safety Culture during aircraft ground handling and maintaining our good safety record.

panos nicolaidisground Operations Director

06 07

By Capt. Filippos D. Zervos

THAN TURBOPROPS?ARE JETS SAFER

> “Let’s clear the air for those who are unsure.”

Source: Schubach Aviation

One of the most common concerns people have when hopping on an aircraft with propellers is that it lacks the safety of a jet without propellers. Why the fear? Perhaps the concern is related to the additional noise produced by turboprops. Could it also be that the sight of a pro-peller on an engine renders a perception of an amateur or more antiquated aircraft? Well, let’s clear the air for those who are unsure.

Myth Busted: Turboprops are equally as safe as jet engines. In fact, turboprops and jets both have turbine engines and are virtually the same thing.

WHAT iS THE DiFFErENcE BETWEEN A TUrBOprOp AND A JET ENGiNE?

Turboprops and jets are both built with turbine, or jet, engines. Jets have turbine engines encased with fan blades while turboprops have a propeller on the outside. This is much different than with piston engines, which also have propellers, but are much different mechanically. Turbine engines are safer and more reliable than piston engines, which are typically found in smaller aircraft.

WHAT ArE THE ADVANTAGES OF TUrBOprOp AircrAFT?

Turboprops might be a little louder, but they are actu-ally safer than jets when going into smaller runways. Why? It is related to the turboprops capabilities under short runway conditions. One of the things we look at when planning a flight is something called ‘balanced

field’. When you get up to takeoff speed, if something were to go wrong, how quickly could you stop? In a nut-shell, this is what we consider when talking about ‘bal-anced field’. Turboprops are able to respond and stop much more quickly because the propellers provide extra drag. Thus, the propellers help the aircraft stop when needed.

WHAT iS THE rEAl SAFETy QUESTiON?

Now that we understand that a turboprop is a turbine (or jet) engine with a propeller on it, let’s talk about the questions I like to ask.

the real question!!!Which is safer? The turbine or the piston engine?

Turbine engines and two engines on an airplane. Tur-bines and the redundancy of two engines present much more of an assurance of safety than pistons and single engine aircraft.

A Q400 Turboprop Engine view by a passenger window.

08 09

> “Composites are years ahead of traditional aluminum alloy and are the closest thing yet to an ideal aircraft material.”

By Agathoklis Logothetis, Line Maintenance Engineer

Source: Skybrary

iNTrODUcTiONFibrous composite materials were originally used in

small quantities in military aircraft in the 1960s, and within civil aviation from the 1970s. By the 1980s, composites were being used by civil aircraft manufac-turers for a variety of secondary wing and tail com-ponents such as rudder and wing trailing edge panels. However, it is with the advent of the latest generation of airliners, such as the Airbus A380, the world’s larg-est passenger aircraft, that these materials have been deployed extensively in primary load-carrying struc-ture. The A380 uses composite materials in its wings, which helps enable a 17% lower fuel use per passenger than comparable aircraft.

WHAT ArE cOmpOSiTES?The term composite is used to describe two or more

materials that are combined to form a structure that is much stronger than the individual components. The constituents or elements that make up the composite retain their individual identities. In other words, the

individual elements do not dissolve or otherwise merge into each other. Each can be physically identified and exhibits a boundary between each other.

In aircraft construction, most currently produced composites consist of a reinforcing material to provide the structural strength, joined with a matrix material to serve as a bonding substance. In addition, adding core material saves overall weight and gives shape to the structure. The three main parts of a fiber-reinforced composite are the fiber, matrix and interface or bound-ary between the individual elements of the composite.

rEiNFOrciNG FiBErSWhen combined with a matrix, the reinforcing fibers

give the primary strength to the composite structure. There are three common types of reinforcing fibers: fiberglass, aramid and carbon/graphite. Other fibers that aren’t quite as common include ceramic and boron. All of these fibers can be used in combination with one another (hybrids), woven in specific patterns (fiber sci-ence), in combination with other materials such as rigid

FOR AIRCRAFT STRUCTURESCOMPOSITE MATERIALS

“aerospace engineering is changing. airplanes have traditionally been made out of metal, usually alloys of aluminum; now however, composite materials

are quickly becoming recognized as the most advance substancefor fabrication of aircraft parts.”

A Q400 just got airborne out of Athens.

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foams (sandwich structures), or simply in combination with various matrix materials. Each particular compos-ite combination provides specific advantages.

Fiberglass

Fiberglass is made from small strands of molten silica glass (about 2300°F) that are spun together and woven into cloth. There are many different weaves of fiberglass available, depending on the particular application. Its widespread availabil-ity and its low cost make fiberglass one of the most popular reinforcing fibers. One of the dis-advantages of fiberglass is that it weighs more and has less strength than most other compos-ite fibers. Recently, however, when used with the newer types of matrices and with the proper use of fiber sciences, fiberglass is one of the best reinforcing fibers used in today’s advanced com-posite applications.

Aramid

An aramid, or aromatic polyamide fiber, is usually characterized by its yellow color, light weight, tensile strength, and remarkable flex-ibility. Kevlar® is a registered trademark of the El DuPont Company and is the best known and most widely used aramid. Kevlar will ordinarily stretch a great deal before it breaks, as its tensile

strength is approximately four times greater than alloyed aluminum. However, the objective in aviation is not necessarily to have stronger part, but rather to have a part that weighs much less. By using a Kevlar reinforcing fiber, a component can be fabricated with the strength of a metal counterpart, at a fraction of the weight. Aramid is an ideal material for use in aircraft parts that are subject to high stress and vibration.

carbon / Graphite

Carbon fiber, also known as graphite fiber, is a very strong, stiff reinforcement. For many years, American manufacturers used the term graphite, while European manufacturers used the term carbon. Carbon describes the fiber more cor-rectly, since it contains no graphite structure. This black fiber is very strong, stiff and used for its rigid strength characteristics. Carbon fiber com-posites are used to fabricate primary structural components, such as ribs and wing skins. Carbon is stronger in compressive strength than Kevlar, but it is more brittle. Carbon fibers are electri-cally conductive, have low thermal expansion coefficients, and have high fatigue resistance. The impact resistance of carbon fibers is less than other composite materials and may splin-ter or crack with high impact. Also, they have the problem of being corrosive when bonded to aluminum, so special corrosion techniques are employed when carbon materials are in contact with aluminum components.

Fiber ScienceThe selective placement of fibers needed to obtain the greatest amount of strength in vari-ous applications is known as fiber science. The strength and stiffness of a composite depend on the orientation of the plies to the load direction. In order to derive maximum benefit from the use

of carbon composites, it is essential to direct the fibers in the direction of the main stress. For example, the wing of an aircraft bends during take-off, landing and flight, meaning that it is subject to stress across its span. To support this, engineers orient up to 60% of the fibers along the wing skins and the span-wise internal stiffen-ers. In addition, wing skins are subject to parallel stresses known as shear stresses; to combat this, plies are directed at 45°. Components inside the wing, such as spars and ribs that are designed to bear shear stresses, are made of up to 80% of 45° plies. In this way, the direction at which the plies are laid ensures that material volume, and hence weight, is kept to a minimum consistent with adequate strength.

mATriX mATEriAlSThe function of the matrix in a composite is to hold

the reinforcing fibers in a desired position. It also gives the composite strength and transfers external stresses to the fibers. The strength of a composite lies in the ability of the matrix to transfer stress to the reinforcing fibers. A wide range of resin systems are used for the matrix portion of fiber reinforced composites. Resin is an organic polymer used as a matrix to contain the rein-forcing fibers in a composite material. The newer matrix materials display remarkably improved stress distributing characteristics, heat resistance, chemical resistance and durability. Most of the newer matrix formulas for aircraft are epoxy resins. Resin matrix systems are a type of plastic. Some com-panies refer to composites as fiber reinforced plastics. There are two general categories of plastics: thermo-plastic and thermoset. By themselves, these resins do not have sufficient strength for use in structural applications, however, when used as a matrix and reinforced with other materials, they form the high strength, lightweight structural composites used today. Thermoplastic resins use heat to form the part into the desired shape. However, this shape is not necessarily permanent. If a thermoplastic resin is reheated, it will soften and could easily change shape. One example

Airbus A318/A319/A320/A321 Composite Structure.

12 13

of a thermoplastic resin is Plexiglas®. Thermosetting resins use heat to form and irreversibly set the shape of the part. Thermosetting plastics, once cured, cannot be reformed even if they are reheated.

cOrE mATEriAlSCore material is the central member of an assembly.

When bonded between two thin face sheets, it provides a rigid, lightweight component. Composite structures manufactured in this manner are sometimes referred to as sandwich construction. Two popular core structures are foam and honeycomb. The core material gives a great deal of compressive strength to a structure. For example, the sheet metal skin on a rotor blade has a tendency to flex in flight as stress is applied. This con-stant flexing causes metal fatigue. A composite blade with a central foam core, or honeycomb, will eliminate most flexing of the skin because the core is uniformly stiff throughout the blade. Honeycomb core structure has the shape of natural honeycomb and has a very high strength-to-weight ratio. Characteristics of honey-comb cores, when used in sandwich core construction,

have a high strength-to-weight ratio, high compres-sion strength, a uniform distribution of stress, rigidity, thermal and acoustical insulation and are fire resistant. Honeycomb cores may be constructed of aluminum, Kevlar®, carbon, fiberglass, paper, Nomex®, or steel. The most common types used in aviation manufactur-ing are aluminum and Nomex. Foam core structures are available in many different types, depending on the spe-cific application. There are different densities and types of foams for high heat applications, fire resistance, repair foams, structural foams etc. When using foams in the repair operation it is important to use the proper type and density.

USESComposites today are being used throughout the

world, on helicopters, military aircraft, commercial air-craft and homebuilt. Composites are being used in the powerplants as well as the airframe designs.

Applications of composites on aircraft include:• Fairings• Flight control surfaces• Landing gear doors• Leading and trailing edge panels on the wing and stabilizer• Interior components• Floor beams and floor boards• Vertical and horizontal stabilizer primary structure on large aircraft• Primary wing and fuselage structure on new generation large aircraft• Turbine engine fan blades• Propellers.

ADVANTAGESThe greatest advantage of using com-

posites is the high strength-to-weight ratio. Since weight is the one of the key considerations for the use of any mate-rial in aircraft construction, if it can be saved, more cargo, fuel or passengers can be carried. A composite part can be designed as strong as a metal part, but with considerable weight savings. Typi-cally 20 percent or more weight reduc-tions are achieved when aluminum parts are replaced with composite structures. Composites also lend themselves well to the formation of complex, aerodynami-cally contoured shapes. The parts do not have to be flat, but can have smooth, sweep-ing contours that would be difficult and expensive to fabricate from sheet metal. The reduced drag produced by these contoured shapes, in combination with the weight savings, enables an air-craft’s range to be extended significantly. The number of parts and fasteners may be reduced by the use of com-posites, as well, simplifying construction and reducing cost. In some cases, very large structures can be manu-factured in one piece, eliminating the riveting and seams. Composites are becoming increasingly cost effective as materials and manufacturing technologies mature They may be designed to be very flexible, resist-ing vibrations, thus eliminating the problem of stress fatigue found in metal structures. Moreover, they don’t corrode like metal does. However, they do have their own problems, as they are not indestructible. Reduced wear is another advantage of using com-posites. They will flex in flight without producing

stress cracks like metal. For example propeller or helicopter rotor blades in flight have many stresses imposed on them. When made of composites, the wear is less, because the fibers can take the bending and twisting forces without developing metal fatigue. In short, composites are years ahead of traditional alu-minum alloy and are the closest thing yet to an ideal aircraft material.

references• JeppeSen Advanced composites by cindy Foreman• JEPPESEN A&P Technician Airframe Textbook• FAA Aviation Maintenance Technician Handbook - Airframe• Composite Materials Revolutionize Aerospace Engineering by Tim Edwards.

Airbus A380 composite Structure.

Airbus composites material evolution.

Airbus A380 Production Line using Composites.

Airbus A380 Structure.

14 15

TRAVELING WITH A PET

> “The first you should check is your pet documentation, its passport with number of chip (ID microchip) and its health book.”

By CCM Milka Djajic Oikonomou, Doctor of Veterinary Medicine & National Kinology judge (II FCI Group)

Before you decide to travel with your pet you should see if your pet is of some race, if this race can travel with the airline company that you have chosen and if it is welcome in the country that you have chosen to visit. Aegean pro-hibits transport of some races, which are referred to the list that you can find on Aegean official site (Travel information, Travel preparation, Travelling with pets). When you have checked the above information you can start your pet prepara-tion for the trip.

The first you should check is your pet documentation, its passport with number of chip (ID microchip) and its health book.Your pet must have done the Anti-Rabies vaccine, and it must been done at least three weeks before the trip even if it is its first time or the yearly repetition. Furthermore by the time you collect its papers, you should see if the destination country requires any specific or other type of vaccination.

One of the necessary papers to travel with a pet is also the certification by a veterinary doctor that your pet is in a good and healthy condition to make the journey. Once you have done with the paperwork you will have to deal with the necessary details in the case that your pet have any health issues, which it doesn’t necessary risk your pet’s life during the journey and also for the period of your stay at your des-tination. Make sure that for that period you have enough

pharmaceutical material.Once you have finished with the necessary health docu-

ments, before you start with the details like choosing which type of its toy you will take with you, you must make sure that the transport case is one which will not only be approved by the airline company you choose to travel, but it will also be comfortable for your pet. Whether your flight is long or not, whether your pet is small size or not, the best dimen-sions and those which are required are those that allow the pet to stroll round, comfortably sit and lie in transport cage. And for this, the maximum permitted weight for a cabin pet, including the cage, is 8 kg and that cage dimensions allow comfort and safe trip, having it under the front sit.

If your pet is traveling into Cargo, is forbidden to have inside the case toys and edibles. Because they could cause health problems during the flight, once the pet will deal with them, and that’s why if pet is not under your supervision is prohibited to have them. If you want it to feel more comfort-able you can have with it its favourite mat or blanket.

Water is also prohibited to be in the cage since during the flight it is possible to pour and make the cage unsuitable for travelling. If there is any external drinker it will be suit-able for long journeys. Whether your pet is traveling with you in the cabin or lonely in the Cargo, 12 hours before the

A pet traveling in the Cabin.

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journey do not feed it, so that there is time for digestion and to relieve the organism from sickness, nausea etc. during the trip. Also and the water will be limited and only periodically small quantities.

The thing that will help your pet to get easier the journey is the walk before it. Take a long walk with it, so its organ-ism feels that need to take rest.

If your pet have a hyperactive character, sedative pill, depending from its kilos, before the trip (always with advice and veterinary prescription) will help it.Upon entering the airplane, with pets traveling in the cabin of aircraft, it is important to follow the instructions of aircraft crew.

For its safety it is important to your pet be placed under the front seat and you sit next to the window, on this way you will not hinder the exit of another passenger and also it will have tranquility.

For the whole flight duration is very important to your pet remain inside the cage, which is already known for it, from the house remains, so by transferring into it and having the feeling that you are next to it, it will feel secure and safe. If you open its cage, and remove it out, it will understand that the outdoor area is completely unknown so or it will want to explore that or it will gain insecurities so it will want to get inside your hug, and that’s why is so important to avoid every inconvenience.

The destination is also something that you should study well before you get your pet with you on journey. If you are going from warm to quite a cold climate and have a short hair pet, particularly small size pet, it would be good to have with you and the appropriate its clothing, which will help him to adapt more easy. Other way, a long hair pet with which you change climate from cold to warm, it’s not recommended to clipping ago, only at the destination if your stay will be long and you see that there is a problem in the adaptation.

If you forgot its medicines, wherever you are, don’t panic. A veterinary doctor who can help you and give you the appropri-ate medicine with the same active substance, you will find. In emergency case any pharmacy also can be very useful.

If you can’t get enough of its food for the time that you two will be away, take much as you need for 3-4 days in order to reach until you find something that can replace it. A little bit chicken, rice and cheese with the new food is always a good choice to change food. Cookies for it, with extra vitamins will also help extra its organism.

Arriving at a new place, sprinkle at different parts of new home its toys so when it start researching home, to not look completely unknown space for it.

And in the end, be prepared that your pet will need you more than usual.

Wish you well trips with your favorite and best friends!

DEGREEOF EMERGENCY

By capt. Alexandros mosialos,Chief Safety Investigator

Source: CAA Safety Regulation Group

> “Once the situation and its implications are understood, a PAN/MAYDAY may be declared.”

pets and Airplanes can coexist.

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> “ Checklists only work if flight crews use them, the autopilot only works when engaged in the correct mode.”

MANAGEMENT IN AVIATION THREAT AND ERROR By F/O Alexandros Pappas Source: SkyBrary

Threat and Error Management (TEM) is a safety con-cept regarding aviation operations and human perfor-mance. TEM is both a safety philosophy and a practical set of techniques. The easiest way to understand TEM is to liken it to defensive driving for a motorist.

The purpose of defensive driving is not to teach people how to drive a vehicle but to emphasize in driving techniques people can use to minimize safety risks. TEM does not teach pilots how to technically fly an airplane, instead it promotes a proactive philosophy and provides techniques for maximizing safety margins.

pHilOSOpHy OF THE mODEl:ANTicipATiON > rEcOGNiTiON > rEcOVEry

Key to anticipation is accepting that while something is likely to go wrong, you can’t know exactly what or when. Anticipation builds vigilance; vigilance is the key

to recognize adverse events and errors. Recognition leads to recovery. In some cases recov-

ering safety margins has to be the first line of action. Recover first, analyze the causes later. An example

would be as follows.A flight crew selects a wrong approach in the

Flight Management System (FMS). The flight crew identifies the error during a crosscheck prior to the Final Approach Fix (FAF). However, instead of using a basic mode (e.g. heading) or manually flying the desired track, both flight crew become involved in attempting to reprogram the correct approach prior to reaching the FAF. As a result, the aircraft “stitches” through the localiser, descends late, and goes into an unstable approach. This would be an example of the flight crew getting “locked in” to error management, rather than switching to undesired aircraft state man-agement.

Flock of birds at Sofia Airport.

20 21

THE 3 cOmpONENTS OF THrEAT AND ErrOr mANAGEmENT• Threats (e.g. adverse weather)• Errors (e.g. pilot selecting a wrong automation mode)• Undesired Aircraft States (e.g. altitude deviation)

THrEATS

•AnticipatedThreats Threats which can be expected or known to the flight crew. For example, flight crews can anticipate the consequences of a thunderstorm by briefing their response in advance, or prepare for a congested airport by making sure they stay vigilant for other aircrafts during the approach.

•UnexpectedThreats Threats which can occur unexpectedly, such as an in-flight aircraft malfunction that happens suddenly without warning. In this case, flight crews must apply skills and knowledge acquired through training and operational experience.

•LatentThreats Threats which may not be obvious to flight crews and may need to be uncovered by safety analysis. Examples of latent threats include equipment design issues, optical illusions even shortened turn-around schedules.

Threats can be managed. Threat management is defined as how crews anticipate, then respond to threats and is considered as the most proactive option to maintain safety margins in flight operations. Some of the tools and techniques used in commercial aviation to manage threats

and prevent crew errors are:

• Reading weather advisories• Turning on weather radar early.• Thorough walk-arounds during pre-departure inspection.• Briefing an alternate runway in case of a late runway change.• Loading extra fuel when the destination airport is in question due to poor weather conditions.

ErrOrSFlight crew actions or inactions which lead to devia-

tions from intentions or expectations of another crew member or procedures, reduce safety margins and increase the probability of adverse events on ground or during flight.

3 ErrOr cATEGOriES:

•Aircrafthandling Deviations associated with the direction, speed, configuration of the aircraft. They can involve automation errors, such as dialing an incorrect altitude, or hand-flying errors, such as getting too fast and high during an approach.•Procedural Deviations from regulations, flight manual requirements or Standard Operating Procedures.•Communication Involve a miscommunication between the pilots, or between the crew and external agents such as ATC controllers, flight attendants or ground personnel.

UNDESirED AircrAFT STATEDefined as flight crew induced aircraft deviations of

position or speed, misapplication of flight controls, incor-rect systems configuration associated with a reduction in safety margins. Undesired aircraft states that result from ineffective threat and error management, may lead to compromising situations. They are often considered at the cusp of becoming an incident or accident. Examples given are the following:

• Lining up in the runway during approach to landing (runway incursion).• Exceeding ATC speed restrictions during an approach.• Landing long on a runway requiring maximum braking.

TEcHNiQUES EmplOyED iNSiDE TEm (SAFEGUArDS)

Flight crews, as part of their daily duties, employ coun-termeasures to maximize safety margins in flight. Some countermeasures flight crews’ employ, called “hard” safe-guards, are provided by the aviation system and they are already in place before flight crews report for duty.

The following are examples of “hard” safeguards:•TrafficCollisionAvoidanceSystem(TCAS)•GroundProximityWarningSystem(GPWS)

“Soft” safeguards are other countermeasures employed by flight crews directly related to human contribution to the safety of the flight. These are checklists, SOPs, opera-tional checks as well as personal strategies and tactics,

including skills, knowledge and attitudes developed by Crew Resource Management (CRM) training.

cONclUSiONTEM is not a revolutionary concept, but one that has

evolved gradually as a consequence of the constant drive to improve the margins of safety in aviation through prac-tical integration of Human Factors. Regardless of the type of error, the effect on safety depends on whether the flight crew detects and responds to the error before it leads to an undesired aircraft state and unsafe situation.

An important learning and training point for flight crews is the on-time switching from error management to undesired aircraft state management and the illustration of how easy it is to get locked-in to the error management phase. It is of outmost importance to mention that despite having in place the “hard” and “soft “ TEM safeguards, the last line of defense against threat, error, and undesired aircraft states, is still, ultimately, the flight crew.

Even the best designed equipment is not enough to ensure adequate Threat and Error Management perfor-mance. Checklists only work if flight crews use them, the autopilot only works when engaged in the correct mode. Effective crew coordination is the best way to manage abnormal events in multi-pilot cockpits. Review, evalua-tion of plans, inquiry, is essential to manage a flight.

Last but not least, crews that exhibit good monitoring and cross-checking, strong leadership, employ effective workload management, develop contingency plans tend to have fewer mismanaged threats as well as undesired aircraft states and commit fewer errors compared to other crews.

Threat and Error Management.

Titanic event Threat end error.

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> “Latent failures provide great, if not a greater, potential danger to health and safety as active failures.”

VS ACCIDENT CAUSATIONHUMAN FACTORS By Capt. Alexandros Mosialos,

Chief Safety InvestigatorSource: DMI Disaster Management Institute

Accidents are caused by active failures or and latent conditions which can lead to human error or violations. Active failures are the acts or conditions precipitating the incident situation. They usually involve the front-line staff, the con-sequences are immediate and can often be pre-vented by design, training or operating systems.

Latent conditions are the managerial influ-ences and social pressures that make up the culture (‘the way we do things around here’), influence the design of equipment or systems, and define supervisory inadequacies. They tend to be hidden until triggered by an event. Latent conditions can lead to latent failures: human error or violations. Latent failures may occur when several latent conditions combine in an unforeseen way. We all make errors irrespective of how much training and experience we possess or how moti-vated we are to do it right. Considering the active failures and latent conditions in an organisation the model of acci-dent where human error is main cause of accident can be shown in figure below.

people can cause or contribute to accidents (or mitigate the consequences) in a number of ways:

• Though a failure of a person can directly cause an accident. However, people tend not to make errors deliberately. We are often ‘set up to fail’ by the way our brain processes information, by our training, through the design of equipment and procedures and even through the culture of the organisation we work for.

• People can make disastrous decisions even when

they are aware of the risks. We can also misinterpret a situation and act inappropriately as a result. Both of these can lead to the escalation of an incident.• On the other hand we can intervene to stop potential accidents. Many companies have their own anecdotes about recovery from a potential incident through the timely actions of individuals. Mitigation of the possible effects of an incident can result from human resourcefulness and ingenuity.• The degree of loss of life can be reduced by the emergency response of operators and their colleagues in a team. Emergency planning and response including appropriate training can significantly improve rescue situations.

The consequences of human failures can be imme-diate or delayed and the failures can be grouped in to the following categories:

Activefailures have an immediate consequence and are usually made by front-line people such as drivers, control room staff or machine operators. In a situation where there is no room for error these active failures have an immediate impact on health and safety.

latent failures are made by people whose tasks are removed in time and space from operational activities, e.g. designers, decision makers and managers. Latent failures are typically failures in health and safety man-agement systems (design, implementation or monitoring).

Human Error is main cause of accident.

Aegean Flight Crew.

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Air SAFETy rEpOrTS FrOm AirliNES OpErATiONS

INCIDENT FORUMF R O M A V I A T I O N I N D U S T R Y

TYPE OF A/C EVENT SUMMARY

On arrival at destination the right side of the fuselage was found to be damaged in the vicinity of pitot / static probes. The damage was caused by the nose cargo safety strap which had become trapped outside the aircraft while closing the nose cargo door prior departure.

FUSELAGE DAMAGE - UNSECURED NOSE CARGO STRAP

B747-400F

The crew flew a VOR/DME approach to Runway 00. The tower reported the wind on the ground as variable 190/300°. In the flare the aircraft touched down on the runway hard and bounced. A TOGA go-around commenced as the Captain took control but the engines were slow to spool-up and the aircraft settled on runway more softly. There was sufficient runway remaining to stop, so the thrust levers were closed and the aircraft stopped on the runway.

HARD LANDINGA320

Prior to departure to XXX, an instruction to carry out a high speed taxi test was complied with. This was to verify that remedial action had been successful, following a report of the aircraft pulling left during the take-off run. Two high speed runs were carried out, but unfortunately the brake temperatures rose rapidly, causing several main wheel tyres to deflate.

MAINWHEEL TYRES DEFLATED

A330

The A321 stopped short of its intended parking position on stand 000, due to the stand guidance system not being ON. ATC were reportedly informed.The B777 was pushed back from stand XXX and its left wing struck the fin of the stationary A321 causing substantial damage to both aircraft.The flight crew of both aircraft declared a PAN and the Emergency services attended. There were no reported injuries.

GROUNDCOLLISION

AIRBUS A321 & BOEING 777

The aircraft was on its second approach into XXX following a hold due to severe winds. At approx 1000ft AAL, speed was seen to rapidly fall by 20kts as severe turbulence was encountered. The aircraft rolled rapidly to the right and an uncommanded autopilot disconnect occurred. A go-around was flown and the aircraft diverted to other airport.

WINDSHEAREMB 145

In the cruise at FL380, turbulence was felt along with speed fluctuations of +/-20kts. Altitude dropped rapidly to FL376 accompanied by an EICAS 'Altitude Alert' warning, altitude then rapidly increased to FL382. Speed was contained with manual thrust lever inputs and the autopilot remained engaged throughout, with instruments monitored and controls covered. ATC were immediately informed of the altitude deviation and a descent to FL350 was given to avoid further encounters. An immediate PA was made for passengers to be seated (the signs were already ON). One passenger suffered a shoulder injury and two cabin attendants bumped their heads. The wind was observed to vary from approx 300/90 to 300/175 within two minutes.

TURBULENCE PROBLEMS

B777

Initially a VOR approach on runway 00 was flown. This has a steep slope and following a tight and fast approach the aircraft was high and a go-around was carried out. After that the crew decided to carry out an NDB approach on rwy 00. There were CBs in the vicinity and the NDB needle fluctuated a lot. At some point the fluctuation was such that the crew perceived this as 'station passage' and started the final descent. An EGPWS warning was received and a go-around carried out.

EGPWSACTIVATION

B737-800

An A310 was being vectored for an ILS on to runway 00 at ZZZ. The A310 was cleared to and correctly read back a clearance to descend to 2500 feet but subsequently descended below cleared level to approximately 1500 feet.� The ZZZ controller detected the error and instructed the A310 to climb back to 2500 feet due to a 1200 feet. Probable cause of the event was altimeter setting error.

ATC PROBLEMA310

Examples of latent failures are:• Poor design of plant and equipment;• Ineffective training;• Inadequate supervision;• Ineffective communications;• Inadequate resources (e.g. people and equipment); and• Uncertainties in roles and responsibilities• Poor SOPs.

Latent failures provide great, if not a greater, potential danger to health and safety as active failures. Latent failures are usually hidden within an organisation until they are trig-gered by an event likely to have serious consequences.

After an accident involving human failure the inves-tigation into the causes and contributing factors often makes little attempt to understand why the human failures occurred. Finding out both the immediate and the underly-ing causes of an accident is the key in preventing similar accidents through the design of effective control measures.

Olympic Air Flight & Cabin Crew.

James Reason “Swiss Cheese” Model.

Contributing Factors to Human Error.

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By Capt. Nikolaos Nikitakis

The idea of a beneficial wingtip appendage, or “wing-tip device,” has been around since the early 20th century, when theoretical calculations first indicated that a vertical endplate added to a wingtip would reduce the induced drag.

Early on, however, reality did not live up to the theo-retical promise. The simple flat endplate turned out to be a disappointment in practice because the added viscous pro-file drag more than offsets the saving in induced drag, and the device fails to produce a net benefit. Whitcomb seems to have been the first to recognize that it is possible to reap the induced-drag benefit of an endplate, and at the same time to realize a net benefit, by keeping the additional pro-file drag to a minimum through good aerodynamic design practice.

The direct result of Whitcomb’s work is the classic near-vertical winglet. Less directly, Whitcomb’s paradigm of applying good design practice to keep the profile drag low has also contributed to the development of concepts other than the winglet. Both winglets and tapered horizon-tal span extensions have been put into commercial service, and several other device concepts have also been proposed and brought to varying levels of development.

THE BENEFiTS OF WiNGTip DEVicESFrom an aerodynamicist’s point of view, the motiva-

tion behind all wingtip devices is to reduce induced drag. Beyond that, as Whitcomb showed, the designer’s job is to configure the device so as to minimize the offsetting penal-ties, so that a net performance improvement is realized. For any particular airplane and tip device, the performance-improvement can be measured relative to the same airplane with no tip device. The positive factors and offsetting fac-tors that contribute to the performance improvement can be

listed as follows:

pOSiTiVE FAcTOrS:• Induced drag is reduced at takeoff and cruise.• Shock drag is sometimes reduced a little at cruise due to the change in spanload produced by the device.

OFFSETTiNG FAcTOrS:Profile drag is increased due to:- Increased wetted area.- Junction flows, high sectional loadings, etc.

Weight is increased due to:- The weight of the device itself.- The weight of attachment fittings.- Increases in the weight of the existing wing structure due to increases in static loads and to meet flutter and fatigue requirements.

> “A reduction in induced drag is the major positive factor contributing to any net benefit for a tip device.”

WING TIP DEVICES

nature leads us.

Examples of Wing Tip Devices.

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configuration and device size turn out to be optimum will depend on which performance objective is sought and on the design details of the baseline airplane.

A reduction in induced drag is the major positive factor contributing to any net benefit for a tip device. Unfortu-nately, there are in common circulation some misunder-standings of induced drag and induced-drag reduction, mostly stemming from mistaken ideas regarding the role of the vortex wake. To evaluate tip-device candidates cor-rectly and to understand what is likely to work and what isn’t, we must keep the correct physics in mind. The clas-sical Trefftz-plane theory isn’t perfect, but it is always a good place to start. Any tip-device performance claim that is out of line with Trefftz-plane theory is probably wrong.

Ideal-induced-drag theory (the theory of minimum induced drag for a given total lift, based on Trefftz-plane theory) is useful conceptually for understanding the rela-tive drag-reduction potentials of different device configu-rations, but it is a poor guide to the net level of benefit that can be achieved. The actual induced-drag reduction is always significantly less than ideal, substantially so in ret-rofit and derivative applications, and increases in viscous

drag and weight generally offset some of the induced-drag reduction. The structural-weight impact is always a major player in the design trades. The magnitudes of all of the offsetting factors depend strongly on the design details of the baseline airplane and the device.

A variety of tip-device configurations have been identi-fied as potentially beneficial, and analyses that take all the relevant factors into account have not found any one con-figuration to have any pronounced general advantage over the others. Inherent differences in optimized net benefit are small, on the same order as differences that could arise due to detailed design execution. This may be one of few places on an airplane configuration where a design deci-sion can, at least sometimes, be based on styling without a major impact on performance. A raked tip extension will often be the most cost-effective option, unless it exceeds a gate-clearance limit or requires expensive beefing up of the shear webs of an existing wing.

Reference:• National Test pilot School • Aerodynamics of Wing devices • Doug Mclean phD.

A net performance improvement is satisfying to an engineer, but for an airplane manufacturer or operator the objective is to realize the kind of bottom-line benefits that translate into dollars. Here is a list of the potential bottom-line benefits of tip devices, in rough order of importance, and some offsetting factors:

BENEFiTS:

IMPROVED PERFORMANCE:

• Reduced fuel burn.• Increased maximum range.• Reduced takeoff field length due to improved second segment climb.• Increased cruise altitude due to improved buffet boundary.• Increased cruise speed due to modest increase in MDD• Reduced takeoff noise.• Meet gate clearance with minimal performance penalty. • Appearance and product differentiation.

OFFSETTINg FACTORS:• Increased cost (development, recurring and purchase). • Increased development risk.

Another possible benefit that has sometimes been put for-ward is that tip devices can reduce the strength of the vortex wake, with the implication that this could lead to improved

safety or reduced separation distances on landing approach or takeoff. This one is not included on our list because the reduction in vortex strength is typically very small, and the resulting benefit is insignificant.

The main positive factor that makes the benefits possible is the reduction of induced drag. In the next section we dis-cuss the physics of induced-drag reduction and its implica-tions for the configuration of effective wingtip devices.

cONclUSiONS AND OBSErVATiONSWhen evaluating the benefits of wingtip devices it is

not sufficient to look at just the reduction in drag, or the improvement in L/D or tops-down efficiency. The real measure of the performance improvement is in bottom-line performance objectives such as fuel-burn or maxi-mum range, taking into account the weight penalty of the installation, as well as the drag reduction. Which device

Aegean A320 during flight test at Toulouse.

Airbus A350 Sharklet.

A Boeing 777 produces vortices during approach at Heathrow. Line drawing of wing tip vortices, in a non wing tip wing and in a blended (sharklet) tip device.

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used a glidepath generated by the FMC to provide vertical path guidance to the crew during the descent from the final approach fix (FAF) to the decision altitude, as opposed to the step-down method (“dive and drive”) that did not pro-vide vertical guidance and required the crew to refer to the altimeter to ensure that the airplane remained above the minimum crossing altitude at each of the approach fixes. When flown as a profile approach, the localizer approach to runway 18 had a decision altitude of 1,200 ft. mean sea level (MSL), which required the pilots to decide at that point to continue descending to the runway if the runway was in sight or execute a missed approach.As the airplane neared the FAF, the air traffic controller cleared the flight for the localizer 18 approach. However, although the flight plan for the approach had already been entered in the FMC, the Captain did not request and the First Officer did not verify that the flight plan reflected

only the approach fixes; therefore, the direct-to-KBHM1 leg that had been set up during the flight from Louisville remained in the FMC. This caused a flight plan disconti-nuity message to remain in the FMC, which rendered the glideslope generated for the profile approach meaningless. The controller then cleared the pilots to land on runway 18, and the First Officer performed the Before Landing Checklist. The airplane approached the FAF at an altitude of 2,500 ft. MSL, which was 200 ft. higher than the pub-lished minimum crossing altitude of 2,300 ft.Had the FMC been properly sequenced and the pro-file approach selected, the autopilot would have engaged the profile approach and the airplane would have begun a descent on the glidepath to the runway. However, this did not occur. Neither pilot recognized the flight plan was not verified. Further, because of the mean-ingless FMC glidepath, the vertical deviation indicator

Airbus A300-600 contacted treesand touched down outside airport

> REPORT

On August 2013, flight 1354, an Airbus A300-600, NXXXX, crashed short of runway 18 during a localizer non precision approach to runway 18 at Birmingham-Shuttlesworth International Airport (BHM), Birmingham, Alabama. The captain and first officer were fatally injured, and the airplane was destroyed by impact forces and post crash fire. The scheduled cargo flight was operating under the provi-sions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan, and dark night visual flight rules conditions prevailed at the airport; variable instrument meteorological conditions with a variable ceiling were present north of the airport on the approach course at the time of the accident. The flight originated from Louisville International Airport-Standiford Field, Louisville, Kentucky, about 0503 eastern daylight time.A Notice to Airmen (NOTAM) in effect at the time of the accident indicated that runway 06/24, the longest

runway available at the airport and the one with a preci-sion approach, would be closed from 0400 to 0500 CDT. Because the flight’s scheduled arrival time was 0451, only the shorter runway 18 with a non precision approach was available to the crew. Forecasted weather at BHM indi-cated that the low ceilings upon arrival required an alter-nate airport, but the dispatcher did not discuss the low ceilings, the single-approach option to the airport, or the reopening of runway 06/24 about 0500 with the flight crew. Further, during the flight, information about variable ceilings at the airport was not provided to the flight crew. The Captain was the pilot flying, and the First Offi-cer was the pilot monitoring. Before descent, while on the direct-to-KBHM leg of the flight, the Captain briefed the localizer runway 18 non precision profile approach, and the First Officer entered the approach into the airplane’s flight management computer (FMC). The intended method of descent (a “profile approach”)

Crash Site Diagram.

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The National Transportation Safety Board determines that the probable cause of this accident was: • The flight crew’s continuation of an unstabilized approach and their failure to monitor the aircraft’s altitude during the approach, which led to an inadvertent descent below the minimum approach altitude and subsequently into terrain.

contributing Factors to the accident were:• The flight crew’s failure to properly configure and verify the flight management computer for the profile approach.• The Captain’s failure to communicate his intentions to the First Officer once it became apparent the vertical profile was not captured.• The flight crew’s expectation that they would break out of the clouds at 1,000 feet above ground level due to incom plete weather information.• The First Officer’s failure to make the required minimums callouts.• The Captain’s performance deficiencies likely due to factors including, but not limited to, fatigue, distraction, or confusion, consistent with performance deficiencies exhibited during training.• The First Officer’s fatigue due to acute sleep loss resulting from her ineffective off-duty time management and circadian factors.

(VDI), which is the primary source of vertical path cor-rection information, would have been pegged at the top of its scale (a full-scale deflection), indicating the airplane was more than 200 ft. below the (meaningless) glidepath. However, neither pilot recognized the meaningless infor-mation even though they knew they were above, not below, the glideslope at the FAF. When the autopilot did not engage in profile mode, the Captain changed the auto-pilot mode to the vertical speed mode, yet he did not brief the First Officer of the autopilot mode change. Further, by selecting the vertical speed mode, the approach essentially became a “dive and drive” approach. In a profile approach, a go-around is required upon arrival at the deci-sion altitude (1,200 ft.) if the runway is not in sight; in a “dive-and-drive” approach, the pilot descends the airplane to the minimum descent altitude (also 1,200 ft. in the case of the localizer approach to runway 18 at BHM) and levels off. Descent below the minimum descent altitude is not per-

mitted until the runway is in sight and the air-craft can make a normal descent to the runway. A go-around is not required for a “dive and drive” approach until the airplane reaches the missed approach point at the minimum descent altitude and the runway is not in sight. Because the air-plane was descending in vertical speed mode without valid vertical path guidance from the VDI, it became even more critical for the flight crew to monitor their altitude and level off at the minimum descent altitude.About 7 seconds after the First Officer com-pleted the Before Landing Checklist, the First Officer noted that the Captain had switched the autopilot to vertical speed mode; shortly thereafter, the Captain increased the verti-cal descent rate to 1,500 feet per minute (fpm). The First Officer made the required 1,000 ft above airport elevation callout, and the Captain noted that the decision altitude was 1,200 ft. MSL but maintained the 1,500 fpm descent rate. Once the airplane descended below 1,000 ft. at a descent rate greater than 1,000 fpm, the approach would have violated the stabilized approach cri-teria defined in the company flight operations manual and would have required a go-around. As the airplane descended to the minimum descent altitude, the First Officer did not make the required callouts regarding approaching and reaching the minimum descent altitude, and the Captain did not arrest the descent at the minimum descent altitude.The airplane continued to descend, and at 1,000 ft. MSL (about 250 ft above ground level), an enhanced ground proximity warning system (EGPWS) “sink rate” caution alert was triggered. The Captain began to adjust the vertical speed in accordance with company’s trained procedure,

and he reported the runway in sight about 3.5 seconds after the “sink rate” caution alert.The airplane continued to descend at a rate of about 1,000 fpm. The First Officer then confirmed that she also had the runway in sight. About 2 seconds after reporting the runway in sight, the Captain further reduced the com-manded vertical speed, but the airplane was still descend-ing rapidly on a trajectory that was about 1 nautical mile short of the runway. Neither pilot appeared to be aware of the airplane’s altitude after the First Officer’s 1,000-ft callout. The cockpit voice recorder (CVR) then recorded the sound of the airplane contacting trees followed by an EgPWS “TOO LOW TERRAIN” caution alert.

prOBABlE cAUSE & cONTriBUTiNG FAcTOrSOn June 2015 the NTSB released a companion video http://www.youtube.com/watch?v=Dsr8C9fsYjo and the Final Report.

Birmingham, ALA LOC Rwy 18 Approach Chart.

Pictures of the aircraft involved, upon touchdown.

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Safety Dpt. Contactse-mail: safety@aegeanair.com • tel: +30 210 35.50.623 • fax: +30 210 35.50.179

e-mail: safetygroup@olympicair.com • tel: +30 210 35.50.679 • fax: +30 210 35.50.349