Battling the Attraction of Distraction

No pilot is immune from the potentially fatal attraction of distraction, especially when it is produced by dealing with technology.

Excerpted from FAA Safety Briefing May-June 2016. Just sharing! All credits to the authors and the publisher.

Photo by Maj. Robert Bowden, Civil Air Patrol

By SUSAN PARSON

A while back — in the January/February 2014 issue of this magazine, to be precise — I offered a confessional piece called “The Lost Art of Paying Attention.” I wrote about how painfully easy it is to succumb to the subtle tyranny of technology. Our glorious glowing gadgets tempt us to shirk not only our see-and-avoid responsibilities, but also a vast swath of the flight management work. They lull us away from the discipline of critical thinking and true situational awareness, a term that implies far more than a position check on the moving map.

And, as Sabrina Woods wrote in “Surprise!” (FAA Safety Briefing – March/April 2016), the cockpit is becoming quite a busy place as more and more technological upgrades become available. Dazzling electronic and LCD flight deck arrays are replac­ing traditional analog gauges. Electronic flight bags (EFB) can tell you almost everything you want to know with the swipe of a finger. ADS-B In and Out monitor traffic. Once you’ve hit that desired altitude and cruise speed, an autopilot can take over, leaving you to sit back, relax, and observe the progress of your flight. Everything is perfect … until suddenly nothing makes sense.

No pilot is immune from the potentially fatal attraction of distraction, especially when it comes to dealing with technology. New technologies are the focus of this issue, but you can also be distracted by the vagaries of older gadgets, or by the quirks of a “FrankenPlane” aircraft with new avionics stitched in beside the original equipment. So we thought that some of the cautions offered before bear repeating.

Manage the Machines

Technology and automation applied to an actively-managed flight can magnify its safety and efficiency, but when applied to a non-managed flight, they can very efficiently get you into very big trouble. Regardless of how good they are, today’s avionics and handheld devices do not have sufficient intelligence to do more than exactly what we com­mand them to do. If we issue the wrong commands because of inattention or incomplete understanding of the technology, the flight will potentially go off track in every possible way.

Know Your Equipment

You need to know the equipment cold. When I teach the use of GPS moving map navigators, I stress the importance of knowing how to precisely navigate both the mechanical structure (aka the “knobology”) and the library structure — that is, how to efficiently find and display the information you need for any given phase of flight. You need to know its normal and abnormal operations, so you can avoid those pesky and potentially dangerous “what’s it doing” situations. You need to know its limitations — what the technology can do for you and, equally impor­tant, what functions are simply beyond its capability.

Set the Tripwires

As Kenny Rogers sang in “The Gambler,” you need to “know when to hold `em, and know when to fold `em.” If you find yourself baffled, confused, or in any way uncertain about what the technology is doing, it’s time to turn it off and reorient yourself. That certainly applies to the autopilot, but it also includes panel-mount, hand-held, or tablet-based navigators if you don’t understand where they are taking you — or if you have any doubts as to the safety of the suggested course. Never forget that the magenta line can guide you direct to anywhere … including direct through regulatory obstacles (e.g., restricted/prohibited/controlled airspace), man-made obstacles, or natural ones such as terrain.

Stay Focused

If you are lucky enough to have a good autopilot, it’s great to have “George” tend to the basic flying chores while you — at least in theory — focus on more important things like positional awareness and, more broadly, overall situational awareness (e.g., status of weather, fuel, engine indications). The challenge, of course, is to actually direct that freed-up mental and physical capacity to those more important positional and situation awareness considerations. That means overcoming the very human tendency to lapse into “fat, dumb, and happy” complacency that could cause you to miss something like an abnormal indication on an engine gauge. Find ways to keep yourself continu­ously in the loop. For example:

• Use callouts to maintain positional awareness (e.g., “crossing WITTO intersection, next waypoint is MITER intersection”).
• Announce changes to heading, altitude, and frequency.
• Record those changes in an abbreviated navigation log. The act of speaking and writing bolsters your awareness.
• Announce any change to navigation source (e.g., “switching from GPS to VLOC”) and autopilot modes. I encourage pilots to read each item on the autopilot status display aloud every time there is a change stating which modes are armed and which modes are engaged.

Today’s technology provides the foundation for an unprecedented level of situational awareness. We just have to use it for that purpose, and pay atten­tion in order to repel the all-too-human attraction to technological distractions that could detract from flight safety.

Susan Parson (susan.parson@faa.gov, or @avi8rix for Twitter fans) is editor of FAA Safety Briefing. She is an active general aviation pilot and flight instructor.

X-Ray Vision and Alphabet Soup

 By JAMES WILLIAMS

Synthetic vision displayed on a cockpit display. Photo courtesy of Avidyne

I may be part of the last generations to remember the ads for X-ray glasses that appeared in the back of comic books and magazines aimed at young people. These mail-order novelties usually sold for a few quarters, or dollars in the later years. Of course they weren’t exactly legit, but who wouldn’t be willing to risk a few bucks for even the slightest chance for such power? Well, as it turns out, the power of “X-ray” vision is not so much of a far-fetched novelty anymore — at least in aviation.

We now have two technologies that allow us to literally see through the dark and the clouds. While there is some overlap in this technology, this article will focus on Enhanced Vision (EV) and Synthetic Vision (SV), rather than night vision. For more information on night vision, please see the articles listed in the Learn More section. EV and SV use very different approaches and technologies to give you a bright and clear picture of the outside world, no matter how dark or cloudy the sky may be. Naturally, each of these approaches has its advantages and drawbacks.

Synthetic Vision

SV is by far the more accessible in terms of cost and equipment. It relies on marrying technologies already included in many avionics suites and even some hand-held systems. SV uses a detailed and high quality database of terrain features and obstacle data to create a virtual ‘world.’ The SV system uses an accurate aircraft position provided by an on-board GPS to display this virtual world around your aircraft. The advantage of this system is that regardless of the weather or light conditions, you will have a “clear view” out of the front of the aircraft. You could literally paper the windshield of the aircraft (not a suggestion, mind you!) and still see outside. It’s important to remember that SV is not a navigational system. SV designed to improve situational and terrain awareness and is not intended, or authorized, to be used as a navigational system. There are two potential faults though — location data and database information. While GPS is usually very reliable, its weak signal is vulnerable to interference. Although, the FCC has done a great job of shielding GPS frequencies, the possibility exists that someone transmitting on or near those frequencies could potentially jam the GPS. And of course there’s the potential for active interference or spoofing, but that’s usually limited to military action. These GPS issues are not a fault with SV and apply to any system that uses GPS.

The other potential issue is the quality and currency of the database used to create the virtual world your aircraft is relying on for safe navigation. While terrain is pretty much static, obstacles are constantly changing. This is probably the biggest issue with SV, because what you’re seeing may not be a 100 percent accurate depiction of the actual world outside. In other words, your SV system is only as good as the its foundational database. So it is worth investigating how adept a system is at creating and updating that database.

But perhaps the best advantage SV has is its relatively low cost. You can add it to many popular flight instrument systems or even utilize systems built into accessories like a portable GPS unit, or an app on your tablet. There are many variables, so it’s worth investigating which one best suits your needs.

Enhanced Vision

EV may seem like a close cousin of Synthetic Vision, but it’s actually a very different technology. EV uses sensors on the aircraft to “see through” weather or darkness. While this sensor comes in a variety of forms, by far the most common is infrared (IR), which senses temperature differences and produces a high quality real-time image of the outside scene. EV allows a pilot to see through darkness, smoke, haze, smog, dust, light fog, and even rain. In heavier conditions, EV may lose some of its ability relative to SV, but what it shows you is what’s actually out there, not what the database says should be out there.

There are a wide variety of EV systems on the market and prices vary greatly, for good reason. The older and more advanced systems use a super cooled IR sensor to allow the sensor to more easily detect the temperature differences. However, these systems EV allows a pilot to see through darkness, smoke, haze, smog, dust, light fog, and even rain. require a mechanical means of cooling, which limits the number of aircraft that can support this added equipment and which can add significantly to the installation cost. Previously, EV was the purview of high-end business jets as an installation could run close to a million dollars. Even on the cheaper end it probably was between $250,000 and $500,000. More recently, new systems have come onto the market that don’t require mechanical cooling. With this new generation, we’re looking at a ballpark figure of $25,000. While still a significant investment, this price point brings EV to the realm of possibility for GA.

Synthetic vision displayed on an iPad.Photo courtesy of ForeFlight

The key advantage of EV is that what you see is what’s actually outside. There’s no concern about the location inaccuracies or the database being out of date. That being said, the very significant cost difference, many thousands of dollars vs. a few hundred, means that EV isn’t nearly as accessible as SV.

What Difference Does One Little Letter Make?

Some eagle-eyed readers may have noticed I’m using EV in lieu of Enhanced Flight Vision Systems (EFVS) or Enhanced Vision Systems (EVS). You may have also noticed I didn’t mention anything about the operational credit that is given to EFVS on approaches. This was intentional. While it may seem like the only difference is one little letter, it’s not — at least as far as FAA regulations are concerned. First and foremost, the regulations permit a qualified EFVS to be used in lieu of natural vision to descend below DA/DH or MDA down to an altitude of 100 feet above the touchdown zone elevation provided all of the requirements of 91.175(l) are met. Those requirements include enhanced flight visibility, visual reference, and other operating requirements. Second, to qualify as an EFVS, the sensor image must be displayed on a Head Up Display (HUD) along with the other required flight information and flight symbology specified in 91.175(m). The EFVS imagery and other cues which are referenced to the imagery and external scene topography must be presented so they are aligned with and scaled to the external view. EVS does not meet these requirements. This becomes a big issue for fitting an EFVS in most small GA aircraft. So while the information presented on an EVS might be very similar to that of an EFVS, the lack of a HUD will prevent the EVS from using the operational credit that an EFVS would receive.

Like Peanut Butter and Jelly

Some things just go together. While we’ve largely compared these two systems independently, there is a compelling argument for combining them. Although you could operate these independent systems side by side, a more powerful solution is what’s called a Combined Vision System. “A CVS is based on a combination of different technologies that may include both real-time and computer-generated images,” Terry King, an Engineering Psychologist and FAA expert explains. “While no CVSs are currently approved for operational credit, the regulations make provision for the FAA to approve ‘for credit’ operations for future CVSs that might be certified and operationally approved for these operations.” King adds, “Depending on the operation, this may require an operator to obtain authorization to conduct these operations.”

Each system has its limitations and advantages.Used independently or in combination, these systems will improve situational awareness and safety. If your budget can justify it, Synthetic Vision and Enhanced Vision can give you those X-ray glasses you always wanted but didn’t get as a kid.

James Williams is FAA Safety Briefing’s associate editor and photo editor. He is also a pilot and ground instructor.

Excerpted from FAA Safety Briefing May-June 2016 http://www.faa.gov/news/safety_briefing/

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By Laura Duque-Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter@SafelyWith. Human Factors information almost every day 

Armavia A320 crash during go-around at night in poor meteorological conditions

Learning from the recent past. Armavia Flight 967 departed Yerevan (EVN) at 00:47 on a scheduled flight to Sochi (AER). Weather at Sochi was poor with rain and poor visibility. During final approach, the weather deteriorated quickly and the controller instructed the flight crew to abort the approach and to make a climbing right hand turn to an altitude of 600 m. The aircraft was flying at 300 m and performed a climbing turn to 450 m. Simultaneously the groundspeed dropped and the Airbus descended until it contacted the water and broke up. Wreckage sank to a depth of 700 m.Organizational deficiencies, lack of adequate training, fatigue, and spatial disorientation were identified as contributing factors to the accident.

In the Flydubai accident Interim Report, the investigation team recommended, among other things:

– To repeatedly study and analyze the applicability of recommendations to prevent accidents and incidents during go-around, developed by the BEA based on the safety study related to Aeroplane state awareness during go-round (ASAGA) (Already published in this blog on March, 20^th, 2016 Going around with all engines operating)

– To repeatedly study and analyze the implementation of safety recommendations issued by investigation teams of the accident involving the Boeing 737-500 aircraft registered VQ-BBN on 17.11.2013 at Kazan Airport (Already published on this blog on April, 9^th, 2016 Tatarstan B735 crash during go-around at night. Learning from the recent past).

-To repeatedly study and analyze the implementation of safety recommendations issued by investigation teams of the accident involving the A320 aircraft registered EK 32009 on 3.05.2006 near Sochi Airport (Here it is !!).

Photo © ErwynS 

Межгосударственный авиационный комитет (МАК) – Interstate Aviation Committee Air Accident Investigation Commission (IAC) final report.

Aircraft type: A320

Registration No:. ЕК-32009

Serial Number: 547

State of Registry: Armenia

Owner: Funnel, George Town, Cayman Islands

Operator: Armavia Airlines

Aviation Oversight Authority: Civil Aviation Administration of Republic of Armenia

Date and time of the accident: 2 May 2006 at 22.13 UTC (3 May 2006 at 02h13 local time)

Accident site: In the Black Sea near Sochi airport,

Factual Information

History of Flight

On 2 May 2006 the Armavia A320, registered EK-32009, was undertaking passenger flight RNV 967 from Zvartnots (Yerevan, Armenia) to Adler (Sochi, Russia).

Preliminary preparation of the crew was conducted on 23-24 May 2006 under the guidance of the airline’s Flight Director, in accordance with the requirements of ROLRGA RA-2000, Section 7.2.1.

Pre-flight briefing of the crew was conducted on the day of departure, under the guidance of the Captain, in accordance with the requirements of ROLRGA RA-2000, Section 8.2.1

On 2 May 2006 at 19.30 the crew passed the pre-flight medical examination.

The crew’s pre-flight rest period exceeded 24 hours. In accordance with ROLRGA RA-2000 and Work-Rest Norms for civil aircraft crews from the Republic of Armenia, each crew member is individually responsible for adherence to the pre-flight rest regime. It should be noted that it was difficult for the crew to take adequate rest during the day before the night flight, due to impairment of bio-rhythms. That is most likely why, in their cockpit conversations the crew members mentioned that they had not got enough sleep.

In order to make their decision for departure, the crew obtained the observed weather data and the weather forecast for the takeoff, landing and alternate aerodromes that met the requirements for IFR flights.

According to the documents submitted, the airplane takeoff weight and the center of gravity were 62,712 kg and 29.9% mean aerodynamic chord, i.e. within the A320 FCOM limitations.

There were 113 occupants on board: 105 passengers (including 5 children and 1 baby), 2 pilots, 5 flight attendants and 1 engineer.

The airplane took off from Zvartnots airport at 20:47. Takeoff, climb and cruise were uneventful. The first communication between the Sochi approach controller and the crew took place at 21:10:20. At that moment, the airplane was beyond the coverage area of Sochi aerodrome radar. Up until 21:17 the approach controller and the crew discussed the observed and forecast weather, and as a result, the crew decided to return to Yerevan. At 21:26:37, after the decision had already been made, the crew asked the controller about the latest observed weather. At 21:30:49 the controller informed the crew that visibility was 3,600 m and the cloud ceiling 170 m. At 21.31.14, the crew decided to continue the flight to Sochi airport.

The next communication with the approach controller was at 22:00:45. At that moment the airplane was descending to an altitude of 3,600 m heading to GUKIN point and was being tracked by the Sochi radar. The approach controller cleared the airplane for descent to 1,800 m and reported the observed weather at Sochi, as at 22:00, for runway 06, which was above the aerodrome minimum. Then the crew was handed over to the holding and tower controllers and was cleared for descent to 600 m, as per aerodrome pressure QNH 1016 hPa, before entering the turn to final. While performing the turn to final, the runway extended centerline was overshot.

Having eliminated the deviation, the airplane started descending along the glide slope, following the approach pattern.

At 22:10:45 the crew reported extension of the landing gear and their readiness for landing. In response, they were advised of the distance of 10 km and weather 4000 x 190, and were cleared for landing. However, about 30 seconds later, the controller advised the crew of the observed cloud ceiling at 100 m and instructed them to stop their descent and carry out a right turn and climb up to 600 m and also to get in touch with the holding controller.

The last communication with the crew was at 22:12:35. After that, the crew did not respond to any of the controller’s calls.

At 22:13:03 the airplane struck the water, was destroyed and sank.

Photo (C) gettyimages.com  

Findings

(Note: Findings 1 to 7 were omitted on purpose, by Living Safely with Human Error)

…

8. Armavia does not exercise operational supervision of the A320 aircraft crews’ flights by using flight recorder information, which made it impossible to fully evaluate the professional skill level of the flight crew members.

9. According to the data presented, the pre-flight rest of the crew prior to the departure to the Sochi airport consisted of over 24 hours at home. However, the crew’s cockpit conversations indicated their fatigue, which could have influenced the outcome of the flight. The flight was performed at night when the probability of mistakes is especially high.

10. The meteorological and air navigation support for the flight met the requirements of the existing regulatory documents. Air traffic control service personnel, including personnel from the areas of responsibility in Sochi, Yerevan, Tbilisi, and Rostov, had valid licenses as civil aviation specialists with the required ratings.

11. At the time of the accident the meteorological conditions were complicated and did not correspond to the meteorological minima of the runway 06 of the Sochi airport due to the «cloud ceiling» parameter. In the time before the accident, the weather conditions at Sochi airport were unstable. The crew was informed of the weather changes by the air traffic controller in a timely manner. Inaccuracies committed by the air traffic controller while reporting the weather were not directly connected with the cause of the aircraft accident, but they influenced the initial decision of the crew to return to the departure aerodrome .

12. The emotional reaction of the crew to the air traffic controller’s information about the actual weather changes below the established meteorological minima was negative and could have led to an increase in the psycho-emotional strain of the crew members during the final stage of flight.

13. The approach for a landing on runway 06 was made with the use of ILS in an automatic mode. There was no deviation of the aircraft from the established glide slope profile. All the radio navigation aids at Sochi airport were fully serviceable.

14. The tower controller’s instruction to abort the descent and perform a right hand climbing turn to 600 m that was given to the crew after the cloud ceiling decreased below the established minima for RW 06, did not fully comply with the provisions of the controller’s operational manual, though it did not directly influence the outcome of the flight. According to the AIP of Russia, the controller had a right to refuse the landing. It should be noted that a number of AIP items contradict each other and are ambiguous.

15. According to the Armavia Operations Manual, the crew must initiate the go-around maneuver on receiving weather information below the minimums, even if the reliable visual contact is established with the runway or with landmarks.

16. At the beginning of the aborted approach maneuver, the crew did not comply with the standard go-around procedure stipulated by the FCOM, regarding applying takeoff thrust, retracting flaps by one step and retracting the landing gear. The climb in the OPEN CLIMB mode and the right-hand turn in the HDG mode were carried out under autopilot control in the landing configuration with the auto-thrust working in the speed hold mode. The landing gear was extended until the end of the flight. The mode in question is not described in the A320 AFM.

17. During flight under autopilot control, the LOW ENERGY WARNING signal was activated. The crew had properly reacted to this warning by setting the thrust levers in the takeoff position in full compliance with the AFM. It must be noted that the crew actions on activation of this warning are specified in the ABNORMAL PROCEDURE section of the A320 QRH.

18. Simultaneously with an increase in engine power, the crew (the Captain) switched off the autopilot in the normal manner using the take-over pushbutton on the side stick.

Most probably, the cause of the autopilot disengagement was the fact that the aircraft dynamics and attitude during this maneuver were unexpected by the Captain: pitch angle +21º, roll angle +25º, decrease in speed, the activated «SPEED SPEED SPEED», warning as well as the fact that he could not predict further changes in these parameters. Throughout the rest of the flight, the airplane was controlled manually, with the both FDs switched on.

19. After disengagement of the autopilot, the Captain was pilot flying. His actions, originally, led to the plane making a stabilized turn to the right with a roll of about 20 degrees, climbing at a rate of 2-3 m/s and accelerating. The stabilized turn proceeded until the magnetic heading attained the value differing from the runway heading by 90 degrees. Subsequently, the Captain controlled the plane to descend with a pitch angle up to 12 degrees pitch down and a roll angle up to 40 degrees to the right, which at maximum continuous power resulted in a substantial increase in IAS and the vertical rate of descent, as well as in activation of EGPWS and CRC warnings (excessive speed in flight with high-lift devices extended). The actual reason for such actions by the Captain could not be determined. Probably, such inadequate piloting was caused by the lack of monitoring of such flight parameters as pitch, altitude, and roll, at night in difficult weather conditions with a background of fatigue and psycho-emotional stress.

20. After the activation of the EGPWS warning, both pilots made control inputs simultaneously. The take-over button was not pressed by either of the pilots. The control inputs by the Captain and the co-pilot, both in roll and pitch were not coordinated and made in opposite directions. The DUAL INPUT warning was not activated because of its lower priority compared to the EGPWS warning. Before the airplane collided with the water the crew had almost completed retraction of the wing high-lift devices in several steps (the slats were still moving).

Neither of the pilots was monitoring the aircraft descent parameters or fulfilled the FCOM requirements for crew actions after EGPWS warning activation, which are stated in the “EMERGENCY PROCEDURE” Section of the A320 QRH.

The crew’s attention might have been distracted by a long 20-second controller’s message regarding a change in the approach procedure, which was recorded by the CVR along with the EGPWS and CRC warnings that were sounding in the background. The controller issued the message in accordance with the controller’s operational manual after the crew contacted him.

21. Experiments on the simulators showed:

– Provided that the standard «GO AROUND» and «MISSED APP» procedures prescribed by the FCOM are followed, the aircraft performs the go-around maneuver with no difficulties, in both the automatic and director modes.

– In the case where the autopilot remains engaged, while the aircraft is performing a maneuver similar to that in the accident flight, the autopilot normally completes the go-around procedure, with a maximum pitch angle not exceeding 21.5º, the short-time decrease of speed not exceeding 10-12 kt, with activation of the «SPEED SPEED SPEED» warning, and without activation of the α – FLOOR function.

– If after activation of the «PULL UP» warning the FCOM recommendations are implemented, for the parameters similar to those in the accident flight (indicated airspeed 270…280 kt, pitch angle -5.5º…-6.5º, roll angle about zero and the wing high-lift devices in the 18º/0º position), the decrease in altitude during aircraft recovery from descent is about 200…230 ft.

Photo (C)  www.gettyimages.com 

Conclusion

The fatal crash of the “Armavia” A-320 EK-32009 was a CFIT accident that happened due to collision with the water while carrying out a climbing maneuver after an aborted approach to Sochi airport at night with weather conditions below the established minima for runway 06.

While performing the climb with the autopilot disengaged, the Captain, being in a psycho-emotional stress condition, made nose-down control inputs due to the loss of pitch and roll awareness. This started the abnormal situation.

Subsequently, the Captain’s inputs in the pitch channel were insufficient to prevent the development of the abnormal situation into the catastrophic one.

Along with the inadequate control inputs of the Captain, the contributing factors to development of the abnormal situation into the catastrophic one were also the lack of necessary monitoring of the aircraft descent parameters (pitch attitude, altitude, vertical speed) by the co-pilot and the absence of proper reaction by the crew to the EGPWS warning.

Shortcomings found during investigation

1. During descent and approach, the crew constantly had irrelevant conversations that had nothing to do with the crew operations manual and therefore violated the requirements of ROLRGA RA-2000, Section 8.3.4.

2. The A320 FCTM, which was approved by the Civil Aviation Administration of the Republic of Armenia and according to which Captain G.S. Grigoryan passed his training before starting solo flights with the airline, does not contain the requirement for passing the Upgrade to Captain program. Captain G.S. Grigoryan did not pass this training. This training program was made mandatory in the next revision of the FCTM.

3. The Flight Operations Department of Armavia does not comply with the provisions of ROLRGA RA Section 11.2 and ICAO Annex 6 Part 1 Chapter 3, which require airlines to analyze fight operations with the use of the FDR and CVR recordings for aircraft with the certified MTOW exceeding 27 000 kg.

4. In violation of ROLRGA RA-2000 Sections 4.5.33 and 6.1.5, Armavia airline does not keep records on the approaches and landings in complicated weather conditions performed by their Captains.

5. The following deficiencies were identified in air traffic management:

– At 21:16 the approach controller of the Sochi aerodrome advised the crew of the trend weather forecast for landing as 150 by 1500 and did not identify the trend as “AT TIMES”. This inaccuracy committed by the controller while reporting the weather to the crew was not directly connected with the cause of the aircraft accident, but it influenced the initial decision of the crew to return to the departure aerodrome.

– At 22:01:37 the approach controller advised the crew of the observed weather at Sochi aerodrome as at 22:00 and by mistake said the cloud ceiling was “considerable 1800”, instead of 180 m, however, this did not influence the Captain’s decision.

– At 22:03:29 the crew did not report, and the holding controller did not request the crew to report the selected system and mode of approach, which does not meet the requirements of the Holding Controller’s Operation Manual, Section 4, item 4.2.1, of Sochi aerodrome.

– At 22:11:38 the final controller at Sochi aerodrome was informed by the weather observer on the actual weather at Sochi aerodrome with the cloud ceiling at 100 m, which was below the established minima (cloud ceiling 170 m, visibility 2500 m). Based on this information, the final controller instructed the crew: “Abort descent, clouds at 100 m, right-hand climbing turn to 600 meters”. The controller’s actions did not comply with the requirements of the Civil Flight Operations Guidance 85 Section 6.5.16 and the Final Controller’s Operation Manual, items 4.3 and 4.3.1. However, according to the AIP of Russia the controller had a right to forbid the landing. It should be noted that a number of AIP items contradict each other and are ambiguous.

6. Meteorological support:

– The weather forecast for the Sochi aerodrome for the period from 18:00 to 03:00 was not verified with regard to visibility in the “At times” group;

– In violation of the Guidance for Meteorological Support in Civil Aviation 95, Sections 4.3.1 and 4.4.1 d) and the Instruction for meteorological support at Sochi aerodrome, the observer did not complete the special weather report at 22:11, when the cloud ceiling descended to 100 m, i.e. to a value stipulated in Annex 8 of the Criteria For Issuance of a Special Weather Report;

– The recommendation for ATIS broadcast content stipulated in the joint Order No. 62/41 “On approval and implementation of Instruction for ATIS broadcast content in English and Russian languages” of 20.03.2000 issued by the Federal Air Transport Administration and Hydrometeorology and Environment Monitoring Service was not entirely fulfilled.

7. A320 aircraft:

– In course of reading out the FDR data, a number of discrepancies were found in the documentation describing the logic of binary signal recordings;

– While performing maneuvers in the landing configuration with the auto pilot and auto thrust engaged, the LOW ENERGY WARNING may sound, which Airbus considers as an abnormal situation.

Photo © Michael Nikel 

SAFETY RECOMMENDATIONS

1. To aviation administrations of the CIS countries:

– To conduct briefings with the flight crews, controllers and technical and engineering personnel to review the circumstances and the causes of the accident.

– To ensure fulfillment of the requirements of ICAO Annex 6 Part 1 Chapter 3 for mandatory analysis of performed flight operations based on the CVR and FDR recordings for the aircraft with a certified MTOW exceeding 27000 kg.

– To draw the attention of A320 crews to the necessity of the immediate response to activation of the EGPWS warning (even if other warnings are on at the same time) in the case of instrument flight, or flight in difficult weather conditions, or flight in the mountains. To introduce the relevant exercises in the simulator training programs to practice these actions.

– To consider the advisability of extending these recommendations to other aircraft types.

– To review the necessity of enhancing crew simulator training in the section on flying in Flight Director mode, especially during approach and go-around.

– To bring the content of the AIP, as well as the ATC controllers’ job descriptions and operations manuals, into compliance with the standards and practices recommended by ICAO, with regard to clearance for approach and landing.

2. To aviation administrations of CIS countries jointly with the industrial and scientific and research organizations:

– To organize and conduct research into the conditions under which a crew may lose spatial orientation and/or upset aircraft attitude may develop, and to issue practical recommendations to enhance flight safety, in particular, to evaluate the effect of in-flight acceleration illusions. Based on the research, to develop and introduce a specialized course for recurrent training of crews that should contain both classroom and flying training.

3. To the Civil Aviation Administration of the Republic of Armenia and Armavia airline administration:

– To include in the A320 FCTM the mandatory requirement for trainee Captains to pass the Upgrade to Captain program.

– To keep records on approaches performed in difficult weather conditions by A320 crews, in accordance with the regulatory documents relating to the organization of flight operations in civil aviation of the Republic of Armenia.

– To organize FDR and CVR readouts for analysis of A320 flight operations, in order to reveal any errors and deficiencies in crews’ piloting technique, and to develop measures for their prevention.

– To point out to aircraft crews that, irrelevant conversations in the cockpit, especially during the climb and descent phases, are prohibited.

– To consider the necessity of enhanced simulator training for A320 crews.

– To develop a procedure for storage of A320 operational documentation that would regulate the conditions of keeping the originals and copies of the documents by both Sabena Technics and Armavia airline.

4. To the Federal Air Navigation Service of the Russian Federation:

– To review the possibility of updating of AIP of the RF and other regulatory documents for the purpose of unification of ATC procedures for issuing instructions for go-arounds to aircraft operated by domestic and foreign airlines, and to incorporate the relevant amendments into the Rules and Phraseology for In-flight Radio Communications and ATC.

– To review the possibility of incorporation of the Air Traffic Service procedures in the aerodrome services provided in accordance with ICAO recommendations (Document 4444, Attachment 11) and the Order No. 103/DV-116 of 26.10.95 issued by Department of Air Transport.

5. To the Federal Service for Hydrometeorology and Environmental Monitoring:

– To review the possibility of purchasing and installing of a new Doppler weather radar at the civil aviation meteorological station in Sochi.

– To undertake measures to eliminate the shortcomings in the meteorological support to civil flight operations at Sochi aerodrome brought to light in the course of the investigation.

6. To the federal state unitary enterprise “State Corporation for Air Traffic Management»:

– To restore complete ATIS broadcasting for Sochi aerodrome, including weather data.

– To clarify to controllers of the Sochi Air Traffic Support of the groups of BECMG and TEMPO changes in the weather forecasts for the aerodrome and of the two-hour “trend” weather forecasts.

7. To Airbus:

– To eliminate the discrepancies in the documentation describing the logic of the binary signals recorded by the FDR.

– To introduce in the A320 FCOM information clarifying specific features of activation of the OPEN CLIMB mode in various flight conditions.

– To introduce in the A320 FCOM a warning about possible activation of the LOW ENERGY WARNING, when the aircraft performs maneuvers in the landing configuration with considerable changes in pitch and roll angles.

– To review the expediency of alteration of the type and/or priority of the EGPWS warning to ensure more reliable pilots’ response to its activation.

8. To eliminate the shortcomings revealed during the investigation of the aviation accident.

Excerpted from Межгосударственный авиационный комитет (МАК) – Interstate Aviation Committee Air Accident Investigation Commission (IAC) final report 

FURTHER READING

1. Flydubai accident Interim Report
2. The Head-Up Illusion: do you remember it?
3. Tatarstan B735 crash during go-around at night. Learning from the recent past
4. Descent below minimum permitted altitude, final report
5. Going around with all engines operating
6. Speaking of going around
7. Loss of flight crew airplane state awareness
8. Let’s go around

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By Laura Victoria Duque Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter@SafelyWith. Human Factors information almost every day 

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The Organizational Influences behind the aviation accidents & incidents

On February 12, 2009, about 2217 eastern standard time, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121. Night visual meteorological conditions prevailed at the time of the accident.

The safety issues discussed in the NTSB final report focus on strategies to prevent fatigue, remedial training, pilot training records, operational procedures, training procedures, Federal Aviation Administration (FAA) oversight, flight operational quality assurance programs, the FAA’s use of safety alerts for operators to transmit safety-critical information, use of personal portable electronic devices on the flight deck, and weather information provided to pilots. Safety recommendations concerning these issues were addressed to the FAA.

Photo: The wreckage of Continental flight 3407 (Photo credit AP)

The Organizational Influences

“Accidents come in many sizes, shapes and forms and are the result of a sequence of events or a serial development. It is now broadly recognized that accidents in complex systems occur through the concatenation of multiple factors, where each may be necessary but none alone sufficient, they are only jointly sufficient to produce the accident.

All complex systems contain such potentially multi-causal conditions, but only rarely do they arise thereby creating a possible trajectory for an accident. Often these vulnerabilities are “latent”, i.e. present in the organization long before a specific incident is triggered. Furthermore, most of them are a product of the organization itself, as a result of its design (e.g. staffing, training policy, communication patterns, hierarchical relationship,) or as a result of managerial decisions.”

THE ORGANIZATIONAL ACCIDENTS (1)

“Major accidents occur in complex productive systems, had been extensively investigated and the reports had made it clear that the performance of those at the sharp end (who may or may not have made errors, but mostly did) was shaped by local workplace conditions and upstream organizational factors. It became obvious that one could not give an adequate account of human error without considering these contextual system issues.”

“Short-term breaches may be created by the errors and violations of front-line operators, however, latent conditions – longer-lasting and more dangerous gaps- are created by the decisions of designers, builders, procedure writers, top-level managers and maintainers. A condition is not a cause, but it is necessary for a causal factor to have an impact. All top-level decisions seed pathogens into the system, and they need not be mistaken. The existence of latent conditions is a universal in all organizations, regardless of their accident record.”

“No one failure, human or technical, is sufficient to cause an accident. Rather, it involves the unlikely and often unforeseeable conjunction of several contributing factors arising from different levels of the system. The concurrent failure of several defenses, facilitated, and in some way prepared, by suboptimal features of the organization design, is what defines an organizational accident.”

“Organizations, whether they are a result of natural evolution or design, generally function in a hierarchical fashion. This means that actions, decisions and directives made at a higher level are passed on to a lower level, where they either are implemented directly, or interpreted in some way before they are passed on to the next level below, etc. The basic principle of organizational control is simply that higher levels control what happens at lower levels, although control more often is in terms of goals (objectives) and criteria than instructions that must be carried out to the letter.”

“The very basis for the principle used to explain accidents as failures at anyone of these stages is that management decisions propagate downwards and progressively turn into productive activity; Bad management decisions propagate downwards and progressively turn into unsafe activity, and possibly accidents.

However, we have known, at least since the days of David Hume (1711-1776), that causes must be prior to effects, e.g., that A must happen before B. But we also know that the temporal orderliness of two events does not mean that A necessarily is the cause of B. Such a conclusion is logically invalid and furthermore disregards the role of coincidences.”

“Accidents are due to a combination of specific events and the failure of one or more barriers – or of all barriers if they are serial rather than parallel- that should have prevented a hazard from resulting in a loss. The failed barriers can be found at any level of the organization or – what is essentially the same thing – at any stage of the developments that led to the accident. This is consistent with the view that “everybody’s blunt end is somebody else’s sharp end”.”

“The understanding of how accidents occur has during the last eighty years or so undergone a rather dramatic development. The initial view of accidents as the natural culmination of a series of events or circumstances, which invariably occur in a fixed and logical order (Heinrich, 1931), has in stages been replaced by a systemic view according to which accidents result from an alignment of conditions and occurrences each of which is necessary, but none alone sufficient (e.g., Bogner, 2002).

Indeed, it may even be argued that the adaptability and flexibility of human performance is the reason both for its efficiency and for the failures that occur, although it is rarely the cause of the failures. In that sense even serious accidents may sometimes happen even though nothing failed as such.

Adopting this view clearly defeats conventional accident models, according to which accidents are due to certain (plausible) combinations of failures. This is the logic of functions as represented, e.g., by the fault tree. But the fault tree only shows representative accidents. The more unusual accidents cannot be captured by a fault tree, one reason being that there are too many conjunctive conditions. What we see in accidents is that confluences occur, and predictive accident models must therefore not only recognize that confluences occur but also provide a plausible explanation of why they happen. If we relax the requirement that every accident must involve the failure of one or more barriers, the inescapable conclusion is that we need accident analysis methods that look equally to individual as to organizational influences. In other words, models of “human error” and organizational failures must be complemented by something that could be called socio-technical or systemic accident models

This line of thinking corresponds to the Swedish MTO model- Människa (Man) – Teknik (Technology) – Organisation. MTO considers accidents are due to a combination of human, technological and organizational factors giving the three groups equal importance. It promotes a view of accidents as due to a combination of the three groups related to performance variability. Performance variability management accepts the fact that accidents cannot be explained in simplistic cause-effect terms, but that instead, they represent the outcome of complex interactions and coincidences which are due to the normal performance variability of the system, rather than actual failures of components or functions. (One may, of course, consider actual failures as an extreme form of performance variability, i.e., the tail end of a distribution.) To prevent accidents there is therefore, a need to be able to describe the characteristic performance variability of a system, how such coincidences may build up, and how they can be detected. This reflects the practical lesson that simply finding one or more “root” causes in order to eliminate or encapsulate it is inadequate to prevent future accidents. Even in relatively simple systems, new cases continue to appear, despite the best efforts to the contrary.”

WHY DO AIRCRAFT CRASH? (2)

“The annals of aviation history are littered with accidents and tragic losses. Since the late 1950s, however, the drive to reduce the accident rate has yielded unprecedented levels of safety to a point where it is now safer to fly in a commercial airliner than to drive a car or even walk across a busy New York city street. Still, while the aviation accident rate has declined tremendously since the first flights nearly a century ago, the cost of aviation accidents in both lives and dollars has steadily risen. As a result, the effort to reduce the accident rate still further has taken on new meaning within both military and civilian aviation.

Even with all the innovations and improvements realized in the last several decades, one fundamental question remains generally unanswered: “Why do aircraft crash?” The answer may not be as straightforward as one might think. In the early years of aviation, it could reasonably be said that, more often than not, the aircraft killed the pilot. That is, the aircraft were intrinsically unforgiving and, relative to their modern counterparts, mechanically unsafe. However, the modern era of aviation has witnessed an ironic reversal of sorts. It now appears to some that the aircrew themselves are more deadly than the aircraft they fly (Mason, 1993; cited in Murray, 1997). In fact, estimates in the literature indicate that between 70 and 80 percent of aviation accidents can be attributed, at least in part, to human error (Shappell & Wiegmann, 1996). Still, to off-handedly attribute accidents solely to aircrew error is like telling patients they are simply “sick” without examining the underlying causes or further defining the illness.

So what really constitutes that 70-80 % of human error repeatedly referred to in the literature? Some would have us believe that human error and “pilot” error are synonymous. Yet, simply writing off aviation accidents merely to pilot error is an overly simplistic, if not naive, approach to accident causation. After all, it is well established that accidents cannot be attributed to a single cause, or in most instances, even a single individual (Heinrich, Petersen, and Roos, 1980). In fact, even the identification of a “primary” cause is fraught with problems. Rather, aviation accidents are the end result of a number of causes, only the last of which are the unsafe acts of the aircrew (Reason, 1990; Shappell & Wiegmann, 1997a; Heinrich, Peterson, & Roos, 1980; Bird, 1974).”

The Human Factors Analysis and Classification System- HFACS describes four levels of failure: 1) Unsafe Acts, 2) Preconditions for Unsafe Acts, 3) Unsafe Supervision, and 4) Organizational Influences.

What some call Root Cause NEVER is in the airman is in the organization.

 The Organizational Influences leading to the Unsafe Supervision behind the Preconditions for Unsafe Acts of Air Crew.

Photo: The Asiana Airlines Boeing 777 plane after it crashed while landing in San Francisco. Photograph: Jed Jacobsohn/Reuters

“Fallible decisions of upper-level management directly affect supervisory practices, as well as the conditions and actions of operators. Unfortunately, these organizational errors often go unnoticed. Generally speaking, the most elusive of latent failures revolve around issues related to resource management, organizational climate, and operational processes.

Organizational Influences

1. Resource Management. This category encompasses the realm of corporate-level decision making regarding the allocation and maintenance of organizational assets such as human resources (personnel), monetary assets, and equipment/facilities. Generally, corporate decisions about how such resources should be managed center around two distinct objectives – the goal of safety and the goal of on-time, cost effective operations. In times of prosperity, both objectives can be easily balanced and satisfied in full. However, there may also be times of fiscal austerity that demand some give and take between the two. Unfortunately, history tells us that safety is often the loser in such battles and, as some can attest to very well, safety and training are often the first to be cut in organizations having financial difficulties. If cutbacks in such areas are too severe, flight proficiency may suffer, and the best pilots may leave the organization for greener pastures.

Excessive cost-cutting could also result in reduced funding for new equipment or may lead to the purchase of equipment that is sub optimal and inadequately designed for the type of operations flown by the company. Other trickle-down effects include poorly maintained equipment and workspaces, and the failure to correct known design flaws in existing equipment. The result is a scenario involving unseasoned, less-skilled pilots flying old and poorly maintained aircraft under the least desirable conditions and schedules. The ramifications for aviation safety are not hard to imagine.

2. Organizational Climate refers to a broad class of organizational variables that influence worker performance. Formally, it was defined as the “situationally based consistencies in the organization’s treatment of individuals” (Jones, 1988). In general, however, organizational climate can be viewed as the working atmosphere within the organization.

One telltale sign of an organization’s climate is its structure, as reflected in the chain-of-command, delegation of authority and responsibility, communication channels, and formal accountability for actions. Just like in the cockpit, communication and coordination are vital within an organization. If management and staff within an organization are not communicating, or if no one knows who is in charge, organizational safety clearly suffers and accidents do happen (Muchinsky, 1997).

An organization’s policies and culture are also good indicators of its climate. Policies are official guidelines that direct management’s decisions about such things as hiring and firing, promotion, retention, raises, sick leave, drugs and alcohol, overtime, accident investigations, and the use of safety equipment. Culture, on the other hand, refers to the unofficial or unspoken rules, values, attitudes, beliefs, and customs of an organization. Culture is “the way things really get done around here.”

When policies are ill-defined, adversarial, or conflicting, or when they are supplanted by unofficial rules and values, confusion abounds within the organization. Indeed, – However, the Third Law of Thermodynamics tells us that, “order and harmony cannot be produced by such chaos and disharmony”. Safety is bound to suffer under such conditions.

3. Operational Process. This category refers to corporate decisions and rules that govern the everyday activities within an organization, including the establishment and use of standardized operating procedures and formal methods for maintaining checks and balances (oversight) between the workforce and management. For example, such factors as operational tempo, time pressures, incentive systems, and work schedules are all factors that can adversely affect safety. As stated earlier, there may be instances when those within the upper echelon of an organization determine that it is necessary to increase the operational tempo to a point that overextends a supervisor’s staffing capabilities.

Therefore, a supervisor may resort to the use of inadequate scheduling procedures that jeopardize crew rest and produce sub-optimal crew pairings, putting aircrew at an increased risk of a mishap. However, organizations should have official procedures in place to address such contingencies as well as oversight programs to monitor such risks.

Regrettably, not all organizations have these procedures nor do they engage in an active process of monitoring aircrew errors and human factor problems via anonymous reporting systems and safety audits. As such, supervisors and managers are often unaware of the problems before an accident occurs. Indeed, it has been said that “an accident is one incident to many” (Reinhart, 1996). It is incumbent upon any organization to fervently seek out the operattional dangers and risks and plug them up before they create a window of opportunity for catastrophe to strike.

The Unsafe Supervision behind the Preconditions for Unsafe Acts of Air Crew

Recall that in addition to those causal factors associated with the pilot/operator, Reason (1990) traced the causal chain of events back up the supervisory chain of command. As such, we have identified four categories of unsafe supervision: inadequate supervision, planned inappropriate operations, failure to correct a known problem, and supervisory violations.

1. Inadequate Supervision. The role of any supervisor is to provide the opportunity to succeed. To do this, the supervisor, no matter at what level of operation, must provide guidance, training opportunities, leadership, and motivation, as well as the proper role model to be emulated. Unfortunately, this is not always the case. sound professional guidance and oversight is an essential ingredient of any successful organization. While empowering individuals to make decisions and function independently is certainly essential, this does not divorce the supervisor from accountability. The lack of guidance and oversight has proven to be the breeding ground for many of the violations that have crept into the cockpit.

Some examples of inadequate supervision are (not limited to):

• Failed to provide guidance
• Failed to provide operational doctrine
• Failed to provide Oversight
• Failed to provide Training
• Failed to provide Qualifications
• Failed to provide Track performance

2. Planned Inappropriate Operations. Occasionally, the operational tempo and/or the scheduling of aircrew is such that individuals are put at unacceptable risk, crew rest is jeopardized, and ultimately performance is adversely affected. Such operations, though arguably unavoidable during emergencies, are unacceptable during normal operations. Therefore, the second category of unsafe supervision, planned inappropriate operations, was created to account for these failures.

Some examples of inappropriate planned operations are (not limited to):

• Failed to provide correct data
• Failed to provide adequate brief time
• Improper manning
• Mission not in accordance with rules/regulations
• Provided inadequate opportunity for crew rest

3. Failure to Correct a Known Problem. The third category of known unsafe supervision, Failed to Correct a Known Problem, refers to those instances when deficiencies among individuals, equipment, training or other related safety areas are “known” to the supervisor, yet are allowed to continue unabated. The failure to correct the behavior, either through remedial training or, if necessary, removal from flight status, the failure to consistently correct or discipline inappropriate behavior certainly fosters an unsafe atmosphere and promotes the violation of rules.

Some examples of failure to correct a known problem are (not limited to):

• Failed to correct document in error
• Failed to identify an at-risk aviator
• Failed to initiate corrective action
• Failed to report unsafe tendencies

4. Supervisory Violations. Supervisory violations, on the other hand, are reserved for those instances when existing rules and regulations are willfully disregarded by supervisors. Supervisors have been known occasionally to violate the rules and doctrine when managing their assets. For instance, there have been occasions when individuals were permitted to operate an aircraft without current qualifications or license. Likewise, it can be argued that failing to enforce existing rules and regulations or flaunting authority are also violations at the supervisory level. While rare and possibly difficult to cull out, such practices are a flagrant violation of the rules and invariably set the stage for the tragic sequence of events that predictably follow.

Some examples of supervisory violations are (not limited to):

• Authorized unnecessary hazard
• Failed to enforce rules and regulations
• Authorized unqualified crew for flight

No one thing “causes” accidents. Accidents are produced by the confluence of multiple events, task demands, actions taken or not taken, and environmental factors. Each accident has unique surface features and combinations of factors.What some call Root Cause NEVER is in the airman is in the organization.

To be continued on Normalization of Deviance: when non-compliance becomes the “new normal”

REFERENCES

Excerpted from

1. Revisiting The « Swiss Cheese » Model Of Accidents. J. Reason, E. Hollnagel, J Paries. European Organisation for the Safety Of Air Navigation- EUROCONTROL. Eurocontrol Experimental Centre.  EEC Note No. 13/06. Project Safbuild. Issued: October 2006.
2. DOT/FAA/AM-00/7 U.S. Department of Transportation, Federal Aviation Administration, The Human Factors Analysis and Classification System–HFACS. Scott A. Shappell, Douglas A. Wiegmann. February 2000
3. Loss of Control on Approach Colgan Air, Inc.Operating as Continental Connection Flight 3407 Bombardier DHC-8-400, N200WQ Clarence Center, New York. February 12, 2009. Accident Report NTSB/AAR-10/01 National PB2010-910401

FURTHER READING

1. Unstable approach and hard landing. Final report
2. The numerous safety deficiencies behind Helios Airways HCY 522 accident

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Not long ago I was saying to a dear friend that serious incidents and accidents do not occur overnight, are just the tip of the iceberg. They are the result of decisions that create conditions and situations that remain dormant in the environment for a long time waiting for someone to put the last link in the error chain. Our flight crews avoid every day that chain to be completed, until one day some of them will not be able to.

There is no doubt that flight crews should be responsible for their actions and we expect them to do their work with professionalism, to study a lot, to deeply know their aircraft, to be disciplined, to adhere to the standard operating procedures, to take care of themselves, to sleep good and sufficient, to not self-medicate. But you can not with a decision, pretend they to bear the blame for the mistakes and failures of an entire system.

Root Cause NEVER is in the airman, is in the organization.

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By Laura Duque-Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitterr@SafelyWith. Human Factors information almost every day 

Sleep loss and blood alcohol equivalency

A review of 182 major NTSB investigations completed between 1 January 2001 and 31 December 2012 found that 20% of these investigations identified fatigue as a probable cause, contributing factor, or a finding. The presence of fatigue varied between among the modes of transportation, ranging from 40% of highway investigations to 4% of marine investigations.

Using a standardized performance test in, both, sleep loss and alcohol consumption conditions, investigators could provide a blood alcohol concentration metric to compare results from the sleep loss condition. Results demonstrated that after 17 hours of continuous wakefulness, cognitive psychomotor performance decreased to a level equivalent to a blood alcohol concentration of 0.05%. After 24 hours of continuous wakefulness, performance was approximately equal to a blood alcohol concentration of 0.10%.(Dawson D and Reid K. Fatigue, alcohol and performance impairment. Nature, 388:235, 1997.)

Fatigue, sleep loss, and circadian disruption created by flight operations can degrade performance and alertness, we all know that. Scientific examination of these physiological considerations has established a direct relationship to errors, accidents, and safety, we all know that, too. But, despite that knowledge fatigue remains an ever present danger in flight operations.

Extensive data are available that clearly establish fatigue as a significant safety concern in all modes of transportation and in 24-hr shiftwork settings. However, there are other associated costs of fatigue, such as decreased performance and productivity, financial costs of accidents and reduced productivity, and potential liability issues.

Fatigue refers to a physiological state of reduced mental or physical performance capability in which there is a decreased capacity to perform cognitive tasks and an increased variability in performance. It is also associated with tiredness, weakness, lack of energy, lethargy, depression, lack of motivation, and sleepiness. Fatigue is an enabler of poor judgment and decision-making, slowed reaction times, and loss of situational awareness and control. It degrades a person’s ability to stay awake, alert, and attentive to the demands of controlling a vehicle safely. Therefore, fatigue can impair a crew member’s alertness and ability to safely operate an aircraft or perform safety-related duties and it is a risk factor for occupational safety, performance effectiveness, and personal wellbeing. To make matters worse, fatigue actually impairs the ability to judge just how fatigued a person really is.

Fatigue results from an imbalance between:

• The physical and mental exertion of all waking activities (not only duty demands); and
• Recovery from that exertion, which (except for recovery from muscle fatigue) requires sleep.

Moreover, fatigue is associated with sleep loss, extended wakefulness, high mental and/or physical workload (mental and/or physical activity), long unbroken periods of work (now known as ‘time-on-task’ fatigue), and circadian phase (performance and alertness levels are largely influenced by the complex interaction between sleep and the 24-hour biological clock).

The multiple flight legs, long duty hours, limited time off, early report times, less-than-optimal sleeping conditions, rotating and non-standard work shifts and jet lag pose significant challenges for the basic biological capabilities of pilots, crewmembers, and shift workers. Humans simply are not designed to operate under the pressured 24/7 schedules that often define aviation operations, whether the operations are short-haul commercial flights, long-range transoceanic operations, or around-the-clock and shift work operations.

For all the above managing fatigue is a very complex task that must go far beyond flight/duty/rest time limitations. All these factors preclude a simple solution. There is no a simple and unique one-size-fits-all approach strategy that works for everybody.

The complexity and diversity of operational requirements demand a variety of approaches. Concept development should be initiated to move beyond current flight/duty/rest regulatory schemes and toward operational models that provide flexibility and maintain the safety margin. Managing fatigue must take into account operational differences and differences among crewmembers.and requires a comprehensive approach that focuses on research, education, and training, technologies, treatment of sleep disorders, hours-of-service regulations, and on- and off-duty scheduling policies and practices.

Nonetheless, it is critical that the core human requirement for sleep be managed effectively and operations should reflect the fact that the basic properties of the circadian clock directly affect an operator’s performance, productivity, and safety.

Scientific evidence has remarked the vital importance of adequate sleep (not just rest) for restoring and maintaining all aspects of waking function and the importance of daily rhythms in the ability to perform mental and physical work and in sleep propensity (the ability to fall asleep and stay asleep). Therefore, pilots and other aviation personnel, particularly those performing overnight operations especially during the window of circadian low, must be deeply and recurrently trained about the physiology of sleep and circadian rhythm and the causes, effects and risks associated with fatigue as well as its prevention and mitigation strategies, personal responsibility during non-work periods, rest environments, and commuting and/or napping. The fatigue training should include personnel involved in crew scheduling and senior management too.

Ultimately, fatigue-related accidents can be avoided with a combination of science-based regulations, comprehensive fatigue risk management programs, and individual responsibility.

Being the first part of Fatigue, an ever-present danger, series.

Sources: 1. FATIGUE RISK MANAGEMENT SYSTEM (FRMS)IMPLEMENTATION GUIDE FOR OPERATORS. ICAO, IATA, IFALPA. July 2011

2. FAA Advisory Circular AC No: 120-100. Subject: Basics of Aviation Fatigue. Federal Aviation Administration, June 7th, 2010.

3. FROM LABORATORY TO FLIGHT DECK: PROMOTING OPERATIONAL ALERTNESS
Mark R. Rosekind, Ph.D.1, LCDR David F. Neri, Ph.D. 1,2, and David F. Dinges, Ph.D. 3
1NASA Ames Research Center, 2United States Navy Medical Service Corps, 3University of Pennsylvania School of Medicine.

4. NTSB Most wanted list 2016. Reduce Fatigue-Related Accidents. National Transportation Safety Board, January 2016.

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By Laura Duque-Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter@SafelyWith. Human Factors information almost every day 

 

Unrecoverable deviation from the intended flight path

Just reviewing!

Right after Runway Excursions, Loss of Control In-flight (LOC-I) was the second category of airplane and helicopter accidents and the leading cause of fatalities in commercial aviation between 2010 and 2014. (IATA Safety Report 2014) (EASA Annual Safety Review 2013)

Loss of Control In-flight (LOC-I) refers to accidents in which the flight crew was unable to maintain control of the aircraft in flight, resulting in an unrecoverable deviation from the intended flight path.

While few in number, LOC-I accidents are almost always catastrophic; 97% of LOC-I accidents between 2010 and 2014 involved fatalities to passengers and/or crew. Over this period, 9% of all accidents were categorized as LOC-I. LOC-I accidents contributed to 43% of fatalities during the past five years (1,242 out of 2,541). There were six LOC-I accidents in 2014, all of which involved fatalities. Given this severity, LOC-I accidents represent the highest risk to aviation safety.

It is recognized that accidents are generally the consequence of a chain of events, and not the result of just one causal factor.

Analysis of LOC-I accident data indicated that LOC-I can result from engine failures, icing, stalls or other circumstances that interfere with the ability of the flight crew to control the motion of the aircraft. It is one of the most complex accident categories, involving numerous contributing factors that act individually or, more often, in combination. These contributing factors include latent conditions in the system, external threats to the flight crew, errors in the handling of those threats and undesired aircraft states from deficiencies in managing these threats or errors

There are multiple paths that lead to LOC-I situations, such as inadequate crew resource management, high fatigue levels among crew members, lack of manual handling skills in general and in particular on the edge of the flight envelope, over-reliance on automation and, last but not least, design issues.

Photo: http://idt-engineering.com/wp-content/uploads/2012/05/Splash-Page-737Landscape-v2.001.jpg

FURTHER READING

1. Loss of flight crew airplane state awareness 

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By Laura Victoria Duque Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter@SafelyWith Human Factors information almost every day

 

Stall Prevention and Recovery

Just sharing! All credits to the FAA

U.S. Department of Transportation
Federal Aviation Administration
Advisory Circular
Subject: Stall Prevention and Recovery Training Date: 11/24/15

Date: 11/24/15
AC No: 120-109A

Initiated by: AFS-200 Change:

This advisory circular (AC) provides guidance for training, testing, and checking pilots to ensure correct responses to impending and full stalls. For air carriers, Title 14 of the Code of Federal Regulations (14 CFR) part 121 contains the applicable regulatory requirements. Although this AC is directed to part 121 air carriers, the Federal Aviation Administration (FAA) encourages all air carriers, airplane operators, pilot schools, and training centers to use this guidance for stall prevention training, testing, and checking. This guidance was created for operators of transport category airplanes; however, many of the principles apply to all airplanes. The content was developed based on a review of recommended practices developed by major airplane manufacturers, labor organizations, air carriers, training organizations, simulator manufacturers, and industry representative organizations.

This AC includes the following core principles:
• Reducing angle of attack (AOA) is the most important pilot action in recovering from an impending or full stall.
• Pilot training should emphasize teaching the same recovery technique for impending stalls and full stalls.
• Evaluation criteria for a recovery from an impending stall should not include a predetermined value for altitude loss. Instead, criteria should consider the multitude of external and internal variables that affect the recovery altitude.
• Once the stall recovery procedure is mastered by maneuver-based training, stall prevention training should include realistic scenarios that could be encountered in operational conditions, including impending stalls with the autopilot engaged at high altitudes.
• Full stall training is an instructor-guided, hands-on experience of applying the stall recovery procedure and will allow the pilot to experience the associated flight dynamics from stall onset through the recovery.

This revision of AC 120-109 reflects new part 121 regulatory terms and incorporates the full stall training requirement of Public Law 111-216. Considerable evaluation of the full flight simulator (FFS) must occur before conducting full stall training in simulation. Reference Appendix 5 for FFS evaluation considerations.
John S. Duncan
Director, Flight Standards Service

CHAPTER 1. BACKGROUND INFORMATION

1-1. GENERAL. Based on accident review, a concern exists within the Federal Aviation Administration (FAA) and industry regarding loss of control in-flight (LOC-I) accidents and incidents. A recurring causal factor in LOC-I accidents and incidents is the pilot’s inappropriate reaction to impending stalls and full stalls. Evidence exists that some pilots are failing to avoid conditions that may lead to a stall, or are failing to recognize the insidious onset of an impending stall during routine operations in both manual and automatic flight. Evidence also exists that some pilots may not have the required skills or training to respond appropriately to an unexpected stall. Stall training should always emphasize reduction of angle of attack (AOA) as the most important response when confronted with an impending or full stall. This advisory circular (AC) provides best practices on training, testing, and checking of impending stalls and training of full stalls, including recommended recovery procedures.

1-2. CANCELLATION. This AC cancels AC 120-109, Stall and Stick Pusher Training, dated August 6, 2012.

1-3. SUMMARY OF CHANGES. Many minor changes have been made to improve clarity, accuracy, completeness, and consistency. Significant changes include the following:
• Additional information to support the requirement for stall recovery training.
• Added regulatory requirements contained in the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers final rule issued November 12, 2013 and associated supporting information.
• Updated information in Appendix 5, FFS Considerations.
• Updated and/or added the following definitions: stall prevention training, stall recovery training, full stall, stall warning, and secondary stall warning.

1-4. AIR CARRIERS CONDUCTING TRAINING IN AIRPLANES.

a. Stall Prevention Training. Although the training in this AC is designed to be conducted in a flight simulation training device (FSTD), those operators using airplanes for training can incorporate into their training programs all of the academic elements and some of the flight training elements. Operators should carefully select flight training maneuvers and employ risk mitigation strategies. Airplanes used for flight training elements should be those designed for the specific maneuvers being conducted, and training programs should use instructors specifically qualified to conduct stall training in airplanes. The FAA recommends that any operator conducting stall training in airplanes follow the guidance and associated risk mitigation strategies contained in ICAO’s Doc 10011, Manual on Aeroplane Upset Prevention and Recovery Training.

b. Stall Recovery Training. For Title 14 of the Code of Federal Regulations (14 CFR) part 121 air carriers, § 121.423(c) requires an instructor-guided, hands-on experience of recovery from full stall and stick pusher activation, if equipped, to be conducted in a Level C or higher full flight simulator (FFS). Air carriers are encouraged to use the highest fidelity level FFS available. In accordance with § 121.423, part 121 air carriers may submit a request to the Administrator for approval of a deviation from the FFS requirements to conduct the extended envelope training using an alternative method to meet the learning objectives of § 121.423.

1-5. PART 121 REQUIREMENTS (§ 121.423(c) and Part 121 Appendices E and F). All part 121 air carriers, including those who train under an Advanced Qualification Program (AQP), are required to conduct stall prevention training, and beginning March 12, 2019, all part 121 air carriers must conduct instructor-guided, hands-on experience of recovery from full stall and stick pusher activation, if equipped. The requirement for part 121 pilots to receive stall recovery training is statutorily mandated in Public Law 111-216, Section 208. The FAA does not have the authority to exempt any part 121 air carrier from this requirement.

1-6. ADVANCED QUALIFICATION PROGRAMS. For simplicity, because part 121 subpart N and appendices E and F contain the requirements for stall prevention and recovery training, the terminology used in this AC is consistent with those regulations. Therefore, the term checking is used and the terms for the training categories defined in § 121.400 are used. Air carriers with an AQP should make terminology adjustments, as appropriate. Regardless of the type of training program, the instructor-guided, hands-on experience of recovery from full stall and stick pusher activation, if equipped, is a training maneuver that is not checked or evaluated. Air carriers with an AQP should use this AC in conjunction with the current edition of AC 120-54, Advanced Qualification Program.

1-7. DEFINITIONS/TERMS. To provide greater clarity for the training community, stall terminology in this AC has been simplified. For the purpose of this AC, the following definitions and terms are provided:

a. Angle of Attack (AOA). The angle between the oncoming air, or relative wind, and a reference line on the airplane or wing.

b. Crew Resource Management (CRM). Effective use of all available resources: human resources, hardware, and information.

c. Flight Simulation Training Device (FSTD). An FFS or a flight training device (FTD).

d. Full Stall. Anyone, or combination of, the following characteristics: (a) an uncommanded nose-down pitch that cannot be readily arrested, which may be accompanied by an uncommanded rolling motion; (b) buffeting of a magnitude and severity that is a strong and effective deterrent to further increase in AOA; (c) no further increase in pitch occurs when the pitch control is held at the full aft stop for 2 seconds, leading to an inability to arrest descent rate; (d) activation of a stick pusher.

e. Impending Stall. An AOA that causes a stall warning. In this AC, impending stall means the same as the AOA for an approach-to-stall or the first indication of stall.

f. Landing Configuration. Landing gear extended and the flaps set at an approved setting for a normal landing.

g. Maneuver-Based Training. Training that focuses on a single event or maneuver in isolation.

h. Scenario-Based Training (SBT). Training that incorporates maneuvers into real-world experiences to cultivate practical flying skills in an operational environment.

i. Secondary Stall. A premature increase in AOA that results in another full stall during stall recovery, prior to a stable flight condition being established.

j. Secondary Stall Warning. A reoccurrence of a stall warning.

k. Stall Event. An impending stall or a full stall.

l. Stall Prevention Training. Ground and flight instruction to recognize and to avert an impending stall, and to reinforce the application of the stall recovery procedure for an impending or full stall.

m. Stall Recovery Procedure. The correct, airplane-specific actions developed by the operator, in consultation with their airplane manufacturer, that their pilots apply to return the airplane to safe flight after a stall. If consultation is impracticable, the stall recovery template in Appendix 1 can be used.

n. Stall Recovery Training. Instructor-guided, hands-on experience of applying the stall recovery procedure for a full stall.

o. Stall Warning. An alert furnished either through inherent aerodynamics, such as buffeting, or by synthetic means, such as a stick shaker or a persistent aural-and-visual cue, giving clear indications prior to a full stall to allow a pilot to prevent a full stall. See 14 CFR part 25, § 25.207.

p. Startle. An uncontrollable, automatic muscle reflex, raised heart rate, blood pressure, etc., elicited by exposure to a sudden, intense event that violates a pilot’s expectations.

q. Stick Pusher. A safety system that applies downward elevator pressure to assist in the avoidance, identification, or recovery of a full stall.

r. Surprise. An unexpected event that violates a pilot’s expectations and can affect the mental processes used to respond to the event.

s. Takeoff or Maneuvering Configuration. The airplane’s normal configuration for takeoff, approach, go-around, or missed approach until all flaps/slats are retracted. Retractable landing gear may be extended or retracted.

t. Transfer of Training. The degree to which what was learned in training (e.g., classroom FSTD) can be applied on-the-job (e.g., flight operations). In this context, “negative transfer of training” is when knowledge or skills learned in the classroom or FSTD impede those necessary in the aircraft.

u. Uncoordinated Flight. Flight with slipping or skidding.

v. Undesired Aircraft State. A condition that unacceptably reduces safety margins, including low energy situations.

1-8. RELATED REGULATIONS. Title 14 CFR parts 25, 61, 91 subpart K (part 91K), 121, 125, 135, 141, and 142.

1-9. RELATED FAA GUIDANCE (current edition).
• Safety Alerts for Operators (SAFO) 10012, Possible Misinterpretation of the Practical Test Standards (PTS) Language “Minimal Loss of Altitude”.
• Information for Operators (InFO) 10010, Enhanced Upset Recovery Training.
• Airline Transport Pilot and Aircraft Type Rating Practical Test Standards for Airplane.
• Commercial Pilot Practical Test Standards for Airplane, Single-Engine Land (SEL), Multiengine Land (MEL), Single-Engine Sea (SES), Multiengine Sea (MES).
• Order 8900.1, Volume 2, Air Operator, Air Agency Certification.
• Order 8900.1, Volume 3, General Technical Administration.
• Order 8900.1, Volume 5, Airman Certification.
• AC 120-51, Crew Resource Management (CRM).
• AC 120-54 Advanced Qualification Program.
• AC 120-90, Line Operations Safety Audits (LOSA).
• AC 120-111, Upset Prevention and Recovery Training.

1-10.RELATED REFERENCES.
• Airplane Upset Recovery Training Aid, http://www.faa.gov/other_visit/aviation_industry/airline_operators/training/media/AP_UpsetRecovery_Book.pdf.
• Defensive Flying for Pilots: An Introduction to Threat and Error Management, Ashleigh Merritt, Ph.D. and James Klinect, Ph.D. (The University of Texas Human Factors Research Project 1- The LOSA Collaborative), http://www.skybrary.aero/bookshelf/books/1982.pdf.
• An Evaluation of Several Stall Models for Commercial Transport Training, J. Schroeder, J. Cohen, D. Shikany, D. Gingras, and P. Desrochers, AIAA Modeling and Simulation Technologies Conference, National Harbor, MD, Jan. 2014. Available at http://www.faa.gov/pilots/training/media/Evaluation_of_Stall_Models_for_Training.pdf.

CHAPTER 2. STALL TRAINING CURRICULUMS

2-1. GENERAL.

a. Common Guidance. This chapter provides common guidance for all stall prevention and recovery training curriculums, while Chapters 4 and 5 provide detailed information for stall prevention training and checking and stall recovery training, respectively. An effective stall training curriculum should provide pilots the knowledge and skills to avoid undesired aircraft states that increase the risk of encountering a stall event or, if not avoided, to respond correctly and promptly to a stall event. The reason for using the term “stall event” is to emphasize that the recovery technique for an impending stall or full stall is the same.

b. Stall Event Training. Stall event training must include both ground and flight training. The training methodology should follow the building block approach of first introducing essential concepts and academic understanding during ground training before progressing to the practical application of those skills in an FFS. Similarly, familiarity with airplane characteristics and development of basic recovery handling skills through maneuver-based training should precede their application in scenario-based training. This progressive approach leads to a more complete appreciation of how to recognize an impending stall, respond appropriately in situations of surprise, and recover effectively when required. Training providers should develop training curriculums that provide pilots with the knowledge and skills to recognize, prevent, and recover from unexpected stall events. These training curriculums should contain the elements described in this AC.

c. Envelope-Protected Airplanes. Envelope-protected airplanes have, in general, demonstrated a lower rate of stall accidents and incidents; however, the rate is not zero. Stall accidents and incidents in envelope-protected airplanes typically occur when the protections have failed, requiring the pilot to return the aircraft to safe flight using a degraded flight control mode. As such, it is important to carefully develop the stall prevention and recovery training for envelope-protected aircraft so that (1) the failure path(s) to reach the degraded modes are understood, (2) pilots learn to identify the rarely occurring impending or full stalls, and (3) pilots demonstrate they have the skill to return the aircraft to safe flight with the degraded flight control laws. Although the potential failures that lead to degraded modes must be understood by pilots, handling multiple failures should not be a component of maneuver-based stall training. The simulator should be placed in a degraded mode by the instructor, clearing all warnings and cautions associated with the failures before the stall training begins. Training providers should seek manufacture guidance for preferred methods of placing the simulator in degraded modes.

2-2. TRAINING GOALS. Desired training goals for stall prevention and recovery training include the following:

a. Proper recognition of operational and environmental conditions that increase the likelihood of a stall event.

b. Knowledge of stall fundamentals, including factors that affect stall speed and any implications for the expected flight operations.

c. Understanding of the stall characteristics for the specific airplane.

d. Proper aeronautical decision-making skills to avoid stall events (e.g., effective analysis, awareness, resource management, mitigation strategies, and breaking the error chain through airmanship and sound judgment).

e. Proper recognition of an impending stall in varied conditions and configurations.

f. The effects of autoflight, flight envelope protection in normal and degraded modes, and unexpected disconnects of the autopilot or autothrottle/autothrust.

g. Proper recognition of when the flight condition has transitioned from the prevention phase and into the recovery phase.

h. Proper application of the stall recovery procedure.

2-3. TRAINING REQUIREMENTS (§§ 121.418, 121.419, 121.423, 121.424, and 121.427). While basic aerodynamics and stall training are accomplished as part of a pilot’s private, commercial, and airline transport pilot (ATP) certifications, it is important to reinforce this basic training throughout a pilot’s career. Training providers should ensure that pilots are thoroughly familiar with the characteristics associated with the specific airplane. Training providers should also understand that some pilots may need to unlearn previous stall recovery procedures based on their prior experience. This AC describes the stall event training that a pilot should receive when employed by a part 121 air carrier. The essential concepts of stall training should be stand-alone training. Once the concepts are mastered, stall training may be incorporated into other training areas (e.g., CRM, adverse weather training, etc.). Air carriers must include stall event training for pilots during:
• Initial training,
• Transition training,
• Differences and related aircraft differences training (if differences exist),
• Upgrade training,
• Requalification training (if applicable), and
• Recurrent training.

2-4. INSTRUCTOR/EVALUATOR STANDARDIZATION (§§ 121.413 and 121.414). Instructors and evaluators should receive training in the subject areas contained in this AC. Knowledge of these subject areas ensures accurate stall event training and minimizes the risk of negative transfer of training.

a. Instructor/Evaluator Training. Instructor/evaluator training should focus on the practical application of these principles and the evaluation of a pilot’s understanding of the airplane’s operating characteristics. Instructors should:
• Demonstrate knowledge of all subject areas of this advisory circular;
• Demonstrate proficiency in all skill areas of this advisory circular; and
• Demonstate proficiency in conducting maneuver-based and scenario-based stall prevention and recovery training.

b. Understanding of FFS Limitations. Instructors/evaluators must have a clear understanding of the FFS limitations that may influence the stall event training and checking including:
• Significant deviations from a particular FFS’s acceptable training envelope; and
• G loading awareness/accelerated stall—factors absent from the FFS’s cues that could be experienced in flight and the effect on the airplane behavior and recovery considerations.

2-5. RECOVERY PROCEDURES. This AC emphasizes using the same procedure for both stall prevention and stall recovery. Previous training and evaluation profiles that required a specific set of pilot-initiated, precise entry procedures have been replaced with realistic scenarios. Additionally, recovery profiles that emphasize zero or minimal altitude loss and the immediate advancement of maximum thrust have been eliminated. Recovery procedures now emphasize:
• Disconnecting the autopilot and autothrottle/autothrust systems,
• Reducing the airplane’s AOA immediately,
• Controlling roll after reducing the airplane AOA,
• Managing thrust appropriately, and
• Returning the airplane to the desired flight path.

2-6. FLIGHT STANDARDIZATION BOARD (FSB) REPORTS. When developing stall prevention and recovery training, air carriers should consult the FSB report, if available, for the specific airplane type. The Training Areas of Special Emphasis, and any other recommendations pertaining to stall, should be reviewed.

CHAPTER 3. GROUND/ACADEMIC TRAINING

3-1. ACADEMIC KNOWLEDGE. Academic instruction establishes the foundation from which situational awareness (SA), insight, knowledge, and skills are developed. Academic knowledge should proceed from the general to the specific. Including accident, incident, Aviation Safety Action Program (ASAP), flight operations quality assurance (FOQA), or Aviation Safety Reporting System (ASRS) data from stall-related events is a useful way of bringing theoretical knowledge into an operational perspective.
NOTE: The FAA strongly recommends incorporation of applicable sections of the Airplane Upset Recovery Training Aid on stall aerodynamics and high altitude stalls into air carrier stall training programs. The Airplane Upset Recovery Training Aid is available at: http://www.faa.gov/other_visit/aviation_industry/airline_operators/training/media/AP_UpsetRecovery_Book.pdf.

3-2. KNOWLEDGE AREAS. The following knowledge areas should be included in all airplane training curriculums:

a. Recovery Procedures. Proper recovery procedures should emphasize that a reduction of the AOA is required to initiate recovery of all stall events. Additional information to incorporate into recovery training includes:
(1) Recognition of impending stall indications and understanding of the need to initiate the stall recovery procedure at an impending stall.
(2) For airplanes equipped with a stick pusher, recommended recovery actions in response to stick pusher activation.
(3) Avoiding cyclical or oscillatory control inputs to prevent exceeding the structural limits of the airplane.
(4) Structural considerations, including explanation of limit load, ultimate load, and the dangers of combining accelerative and rolling moments (i.e., the rolling pull) during recovery.
(5) The necessity for smooth, deliberate, and positive control inputs to avoid unacceptable load factors and secondary stalls.
(6) AOA must be reduced prior to controlling roll.
(7) Effectiveness of control surfaces and the order in which the control surfaces lose and regain their effectiveness (e.g., spoilers, ailerons, etc.).
(8) If a terrain awareness warning system (TAWS) warning is encountered during recovery from a low altitude stall event, recovery from the stall warning should take precedence. Once the airplane recovers from the stall event, then execute the TAWS escape maneuver.

b. Factors Leading to a Stall Event. An awareness of the factors that may lead to a stall event during automated and manual flight operations including:
• AOA versus pitch angle;
• Rate of onset including rate of airspeed decay (both low and high);
• Airplane configuration and condition including weight, center of gravity (CG), landing gear, flaps/slats, spoilers/speed brakes, etc.;
• Asymmetric loading including thrust asymmetries, wing loading due to roll or yaw transients or uncoordinated flight;
• G loading;
• Bank angle;
• Thrust and lift vectors;
• Thrust required versus thrust available;
• Wind shear;
• Altitude;
• Mach effects;
• Situational Awareness
• Mode confusion, including unexpected/unannounced mode changes;
• Unexpected transition from automated to manual flight; and
• Contamination (ice), including the effect of icing on stall speed and stall warnings.

c. Airplane-Specific Systems Knowledge.
(1) Understanding of AOA indicators (if installed) or interpretation of other representations of AOA such as pitch-limit indicators or speed display symbology that can assist in stall prevention.
(2) Specific stall and low speed buffet characteristics unique to the airplane type and any implications for the expected flight operations and airplane-specific stall recovery procedure (e.g., underwing mounted engines, t-tail, propellers, etc.).
(3) For envelope protected airplanes, stall protection capabilities in normal and degraded modes.
(4) Thrust settings and its application.
(5) Autothrottle/autothrust protection.
(6) Awareness of autoflight mode indications.
(7) Incorrect use of (including input errors) flight path automated systems.
(8) Operation and function of stall protection systems in normal, abnormal, and emergency situations, including the hazards of overriding or ignoring stall protection system indications. Awareness of the factors that may lead such systems to fail, as well as degraded modes, indications, or behaviors that may occur with system failures.

d. High Altitude Considerations.
(1) Buffet boundary and margins in flight planning and operational flying.
(2) Lower margins for stall onset and recovery (i.e., coffin corner) and possible buffet cueing differences on the high-speed versus the low-speed margin.
(3) Principles of high altitude aerodynamics, performance capabilities, and limitations; including high altitude operations and flight techniques (i.e., the need to avoid secondary stall by extended nose-down recovery, compared to lower altitudes).
(4) Differences in airplane performance (e.g., thrust available) during high versus low altitude operations, the effects of those differences on stall recovery, and the anticipated altitude loss during a recovery.
e. Airplane Certification Differences. Differences between transport category airplane certification and general aviation airplane certification regarding use of flight controls at high AOA. For example, if the roll control system is compromised and the ailerons are unable to produce the required roll recovery, the rudder may be used with care during stall prevention and recovery. To maintain structural integrity, it is important to guard against control reversals—avoid rapid full-scale reversal of control deflections.
f. Example Events. Although significant emphasis should be placed on preventing stall events, it is important for pilots to understand that, although rare, stall events continue to occur. Studying the causes and contributing factors of stall events give pilots more knowledge to help prevent or if necessary, recover from a stall event. A review of stall-related accidents, incidents, ASAP, FOQA, and ASRS data for the specific airplane type or class should be included in ground training.

CHAPTER 4. STALL PREVENTION TRAINING AND CHECKING

4-1. GENERAL. This chapter provides specific information for training and checking stall prevention (formerly approach-to-stall), which is required by 14 CFR part 121 appendices E and F. Prevention training provides pilots with the skills to recognize conditions that increase the likelihood of a stall event if not effectively managed. Prevention training must include the operator’s standard operating procedures (SOP) and CRM for proper avoidance techniques and threat mitigation strategies.

4-2. SIMULATOR TRAINING (§ 121.424). Training providers are encouraged to use the highest level FFS available when developing their stall prevention and recovery training curriculums. The primary emphasis is to provide the pilot with the most realistic environment possible during impending stall training and checking. Simulator training can either be maneuver-based or scenario-based; both methods are discussed in detail below.
NOTE: Instructors and check pilots must be familiar with the limitations of a particular FSTD and ensure that all pilots undergoing training and checking are aware of these limitations to mitigate negative transfer of training.

a. Maneuver-Based Training. This training focuses on the mastery of an individual task or tasks. Maneuver-based training applies to both prevention and recovery training. It should emphasize the development of the required perception and motor skills to satisfactorily accomplish stall prevention and recovery. Limited emphasis should be placed on decision-making skills during maneuver-based training.

(1) Configurations. Maneuver-based training should include impending stalls in the following configurations required by part 121 appendix E, and § 121.424:
• Takeoff or maneuvering,
• Clean, and
• Landing.

(2) Conditions. Impending stalls in the above three configurations should be trained using the following conditions, as appropriate:
(a) Level flight and turns using a bank angle of 15 to 30 degrees;
(b) Manual and automated (autopilot and/or autothrottle/autothrust, if installed) flight;
NOTE: It may be difficult to use autothrottle/autothrust during maneuver-based training, since the autothrottle/autothrust is usually disconnected and thrust reduced to idle. However, it is important to teach disconnecting the autopilot and autothrottle/autothrust during stall prevention training and, if the integration of the autoflight systems permit it, to develop scenarios with the autothrottle/autothrust engaged.
(c) Visual and instrument flight conditions;
(d) High altitudes near the airplane’s maximum altitude and low altitudes within 500 feet above ground level (AGL); and
(e) Various weights and CG locations within airplane limitations.

(3) Emphasis Items. The following items should be emphasized during maneuver-based training:
(a) Recovery Procedures.
1. Reducing AOA is the proper way to recover from a stall event. Pilots must accept that reducing the airplane’s AOA will normally result in altitude loss. The amount of altitude loss will be affected by the airplane’s operational environment (e.g., entry altitude, airplane weight, density altitude, bank angle, airplane configuration, etc.). At high altitudes, stall recovery will likely require losing several thousand feet.
2. Declare an emergency if necessary. Do not delay recovery due to degrading airspeed or a stall event to obtain air traffic control (ATC) clearance to a lower altitude.
3. Understanding that early recognition and return of the airplane to a controlled and safe state are the most important factors in surviving stall events. Only after recovering to a safe maneuvering speed and AOA should the pilot focus on establishing an assigned heading, altitude, and airspeed.
4. An abrupt pitch-up or trim change can occur when the autopilot unexpectedly disconnects during a stall event. This dramatic pitch-up or trim change typically adds an unexpected physical challenge to the pilot when trying to reduce AOA. In some airplanes, this may be aggravated by an additional pitch up when the pilot increases thrust during stall recovery.
5. Secondary stall warnings are indicative of a pilot prioritizing minimum loss of altitude over proper stall recovery or flight control inputs that are too aggressive. In some airplanes, depending on AOA representations, it may be difficult to determine the point where the pitch can begin to be increased and a momentary secondary stall warning may be encountered. A secondary stall warning is acceptable as long as AOA is promptly reduced and the airplane’s limitations are not exceeded.
6. Air carriers should develop stall prevention evaluation strategies that are a direct reflection to the aircraft type. Between different aircraft types and variations of an aircraft type there is a broad range of available airspeed/AOA/energy information to the pilot. Therefore, an evaluation of a stall prevention with an attitude direction indicator (ADI) that has sufficient information to determine the flight envelope (pitch limit indicators, speed tape with low speed awareness, airspeed trend needles) should be more stringent. Obviously with this expectation, the assumption is made that the air carrier’s stall training prepares the pilot to interpret this information in low energy states. Conversely, a stall prevention evaluation of a pilot that has limited flight envelope information could allow momentary reactivations of the stall warning after the pilot has reduced the AOA to cease the stall warning and is attempting to return the aircraft to safe flight.

(b) Factors Leading to a Stall Event.
1. How changes to factors such as weight, G loading, CG, bank angle, altitude, and icing affect the handling characteristics and stall speeds of the airplane.
2. Inappropriate use or inadequate monitoring of autoflight modes can be a contributing factor to a stall event. For example, climbing in vertical speed can lead to a stall event when pilots do not notice the airspeed reducing as the altitude increases; whereas, climbing in modes such as indicated airspeed or flight level change can protect against unnoticed deceleration in a climb.

(c) Airplane-Specific Knowledge.
1. Impending stall characteristics for the specific airplane, including buffeting of a severity that may make it difficult to read the instruments.
2. Review of AOA indicators (if installed) or interpretation of other representations of AOA such as pitch-limit indicators or speed display symbology that can assist in stall prevention.
3. Noises associated with stick shakers, autopilot, and autothrottle/autothrust disconnect alarms can cause confusion in the cockpit.
4. The effects of malfunctioning or deferred equipment on stall protection and stick pusher systems.

(d) Altitude Effects.
1. Differences between high and low altitude stalls, pitch rate sensitivity of flight controls (due to lack of aerodynamic damping), and amount of altitude loss required for recovery.
2. Thrust available for recovery, and lack of airflow through engines at high AOA (reinforces reduction of AOA must precede any increase of thrust).

b. Scenario-Based Training (SBT). The goal of SBT is to develop decision-making skills relating to stall prevention and recovery during Line-Oriented Flight Training (LOFT). Emphasis should be placed on preventing conditions that may lead to a stall event. SBT would normally be used after a pilot demonstrates proficiency in maneuver-based training and during advanced stages of training, such as upgrade training and recurrent training.

(1) Scenarios. When possible, scenarios should include accident, incident, ASAP, FOQA, and/or ASRS data to provide realistic opportunities to see how threat situations may develop and how they should be managed during line operations. Sample SBT lesson plans are provided in Appendix 3.

(2) Briefing. Pilots should not normally be briefed that they are receiving SBT. The concept is line-oriented flying, which allows the pilots to recognize and manage the expected or unexpected stall threats as they develop during normal operations. However, situations may arise where pilots exhibit excellent stall prevention skills and initiate a recovery prior to the complete unfolding of a scenario. That is the desired objective. In those instances, the instructor has the discretion whether to repeat the scenario and then showing and discussing how the many cues typically cascade as the event progresses. Such explanations can reinforce a pilot’s knowledge and allow sharpening of awareness and prevention skills.

4-3. USING SURPRISE IN TRAINING. Surprise has been a factor in stall incidents and accidents. Although it may be difficult to create surprise in the training environment, if achieved, surprise events may provide a powerful lesson for the crew. The goal of using surprise in training is to provide the crew with a surprise experience to reinforce timely application of the effective recovery technique under potentially confusing circumstances. Considerable care should be used in surprise training to avoid a negative learning experience. Surprise should not be used during checking. Stall prevention training should incorporate event conditions and variables typical of an unintentional stall that are likely to result in surprise due to the unexpected stall development, presentation, and behavior.

4-4. CHECKING PARAMETERS. The check pilot is responsible for establishing the flight conditions associated with the impending stall configuration being checked. The pilot may fly the entry profile but is not being checked on the entry, except for recognition of the deteriorating flight situation. The satisfactory completion of the event is based on the pilot’s timely and proper recognition of the impending stall and then proper application of the stall recovery procedure.

4-5. CHECKING CRITERIA. Checking of prevention, recognition, and recovery from an impending stall should be evaluated on the timely and proper response to the impending stall including effective use of available energy; the criteria should not focus on altitude loss. The check pilot should consider the variables present at the time of the impending stall and their effect on the recovery. Checking criteria are:
• Prompt recognition of impending stall,
• Correct application of the stall recovery procedure, and
• Recovering without exceeding the airplane’s limitations.
NOTE: Training providers should adjust their impending stall checking criteria as appropriate and train their check pilots in these changes. The primary goal of checking should be to evaluate a pilot’s immediate recognition and response to an impending stall and their timely, correct accomplishment of the stall recovery procedure.

4-6. REALISTIC SETTINGS FOR CHECKING. In the FFS, an impending stall checking module should be maneuver-based with an entry altitude consistent with normal operating environments. The entry parameters, including Weight and Balance (W&B), should be within airplane limitations to ensure adequate performance for recovery from an impending stall. During checking, the pilot should be checked on recovering from the impending stall.

4-7. DEBRIEFING. Debriefing pilots on their performance in both training and checking is essential. Providing pilots with specific feedback on the recovery procedures including whether recovery control inputs were excessive, insufficient, or had cyclic control reversals will assist pilots in improving their recovery procedures and will also address the implications of G-load differences in simulation. If the recovery exceeds the limitations of the FSTD, instructors must make the pilot aware to avoid negative transfer of training.

CHAPTER 5. STALL RECOVERY TRAINING

5-1. GENERAL. This chapter provides specific information for training stall recovery, which is an instructor-guided, hands-on experience of applying the stall recovery procedure for a full stall. Recovery from a full stall, including stick pusher activation, if equipped, is required by § 121.423, but is not checked.

5-2. FULL STALL TRAINING. Full stall training provides pilots with the hands-on experience of the airplane handling characteristics and cues (e.g., increased buffet, reduced stability and control, and roll off) near and at full stall. The focus of full stall training should be maneuver based. Scenario-based training is better reserved for assessing stall prevention skills. In addition to providing the full stall experience, the following emphasis items should be highlighted by the instructor:
• Discussion of the objective of increasing the AOA beyond an impending stall to experience full stall characteristics, as these full stall characteristics may be significantly different from those they experienced in flying lighter aircraft in their primary training.
• Differences in flight cues and flight/control characteristics in full stall as compared to cues in stall prevention training. If an aircraft exhibits more than one of the ways a full stall is defined, these conditions should be trained.
• Proper recovery once full stall is identified. If full stall is represented by stick pusher activation, pilots must allow the stick pusher to activate before completing the recovery.

5-3. FULL STALL TRAINING MANEUVER. During training for full stall, the pilot may be asked, for demonstration purposes, to call out some aural and visual indications of the impending stall, but defer response until directed to recover, in order to experience the aircraft’s handling qualities in the full stall regime. Such training provides the pilot with an instructor-guided, hands-on experience of recovering from a full stall. Appendix 4 includes an example of Full Stall Experience Training.

5-4. STICK PUSHER. For airplanes equipped with a stick pusher, stall recovery training includes ground training and practical training in an FFS. It is important for pilots to experience the sudden forward movement of the control yoke/stick during a stick pusher activation. From observations, most instructors state that, regardless of previous academic training, pilots usually resist the stick pusher on their first encounter. Usually, they immediately pull back on the control yoke/stick rather than releasing pressure as they have been taught. Therefore, pilots must receive practical stick pusher training in an FFS to develop the proper response (allowing the pusher to reduce AOA) when confronted with a stick pusher activation. Stick pusher training should be completed as a demonstration/practice exercise, including repetitions, until the pilot’s reaction is to permit the reduction in AOA even at low altitudes. Pilot response to a deliberate activation of the pusher is not a checked maneuver.

To download the complete Advisory Circular and its annexes  http://www.faa.gov/…/document.information/documentID/1028646

Photo:http://apstraining.com/faa-improvements-to-upgrade-stall-training-in-the-future/

FURTHER READING

1. Loss of flight crew airplane state awareness 
2. Descent below minimum permitted altitude, final report
3. The Head-Up Illusion: do you remember it?
4. Armavia A320 crash during go-around at night in poor meteorological conditions
5. Tatarstan B735 crash during go-around at night. Learning from the recent past
6. Going around with all engines operating
7. Speaking of going around

**********************

By Laura Victoria Duque Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter@SafelyWith. Human Factors information almost every day

 

Loss of flight crew airplane state awareness

One of the links in the causal chain of Loss of Control In-flight (LOC-I) accidents is the flight crew losing airplane state awareness, especially in the basic attitude of the airplane or/and the energy state of the airplane, and then not regaining it.

Excerpted from AeroSafety World February 2015, Airplane State Awareness by Wayne Rosenkrans. Some paragraphs and graphics have been omitted and some little changes in the format (from paragraph to list) have been made. The photos and images are not from the original article.

Photo: McDonnell_Douglas_MD-82_(HK-4374X) 

AeroSafety World February 2015

SUMMITS IASS

Airplane State Awareness 

CAST safety enhancements will help flight crews recognize — and respond immediately — to subtle overbank, deceleration and pitch threats.

BY WAYNE ROSENKRANS

… Unlike the technology and training that have been credited over the last 20 years with reducing by half the world’s controlled flight into terrain (CFIT) accidents  “We see a little bit of progress [on LOC-I] but not nearly as much as we’d like. … Loss of control–in flight is … not as monolithic in its causes and outcomes as some of the other accident categories like midair collision or CFIT. Therefore, it doesn’t lend itself as well to one alerting system that’s going to solve the accident [problem]…”*

* Michael Snow, human performance specialist, Aviation Safety Group, The Boeing Co., and co-chair of the Airplane State Awareness Joint Safety Analysis Team (JSAT) of the U.S. Commercial Aviation Safety Team (CAST).

While other international specialists have focused on mitigating LOC-I from the standpoint of pilot training for airplane upset prevention, recognition, and recovery, the JSAT concentrated on the loss of flight crew airplane state awareness as a subset of situation awareness. “In the human factors community, we defined situation awareness as awareness of task-relevant information, understanding of that information and then ability to forecast [outcomes], based on that understanding. … Especially task-­relevant information to the task of ‘aviate’ are the basic attitude of the airplane and the energy state of the airplane,” Snow said.

Learning From History

To understand how the loss of airplane state awareness occurred in the 1998–2010 period, the JSAT members selected a preliminary set of 18 non-U.S. accidents, five U.S. accidents, three non-U.S. incidents and four U.S. incidents. The events were selected as the best examples “in which one of the links in the causal chain was the flight crew losing attitude awareness and then not regaining it,” he said.

From these, they analyzed a subset of 18 events (11 non-U.S. accidents, two U.S. accidents, three non-U.S. incidents and two U.S. incidents). Seven analyzed accidents were classified as attitude-awareness events and involved 674 fatalities; six analyzed accidents were classified as energy state–awareness events and involved 596 fatalities.

Table: 12 Airplane State Awareness – ASA themes identified from the most significant problems and contributing factors observed in the ASA event set. Themes present in each event, with yellow boxes marked with an “X.” Source:  Airplane State Awareness Joint Safety Implementation Team Final Report

In the group of six events, the common issue was “the flight crew losing energy state awareness on the low side — so not tracking or solving a developing low-energy state for whatever reason,” Snow said…

One event the JSAT studied was the May 5, 2007, crash of Kenya Airways Flight 507, a Boeing 737-800, after takeoff in a dark night and thunderstorm conditions from Douala, Cameroon (ASW, 8/10, p. 24). “[This is] fairly typical of the unrecovered roll excursions in the set,” Snow said. “They were on the initial climb at 1,000 ft with the autopilot disconnected. Bank angle increased from 20 degrees to 35 degrees over roughly 30 seconds. Importantly, at normal g [one times standard acceleration of gravity] … if you are banking the airplane in level flight, you are also [aerodynamically] loading up the airplane. … At 45 degrees, you’re at 1.4 g; at 60 degrees you’re pulling 2.0 g, etc. So when we see this pattern of increasing bank angle and normal g, we can infer a lack of [pilot] intent. We also know … this roll rate was sub-threshold … [that is,] not something the flight crew felt. In the absence of external visual stimuli, there was no clue, other than the instruments, that the airplane was rolling, and it all happened at normal g, so they didn’t feel the airplane loading up as if it were an intentional bank.”

Photo (C) Bruce Drum (Airliners Gallery) Kenya-Airways 5Y-KYA crashed on May 5, 2007

The team inferred from the official report’s cockpit voice recording that the flight crew was unaware, before the airplane overbank, that the autopilot was not engaged. “So, we inferred a loss of attitude awareness there,” he said. “[This airplane generated an] alert out of the Enhanced Ground Proximity Warning System at 35 degrees [of bank], where the box says ‘bank angle, bank angle’ and the sky pointer turns yellow to indicate a developing overbank situation. … The pilot flying made inputs to the control wheel that went right-left-right, mostly right, over the next few seconds. Bank angle increased past vertical, and vertical speed obviously dropped off … and the airplane crashed. So that’s kind of a basic pattern from the attitude-awareness side [of the airplane-state problem].”

A different LOC-I accident provided a model of what typically occurs when the flight crew’s loss of energy state awareness is a significant “theme” of the causal chain, he said. West Caribbean Airways Flight 708, a Boeing MD-82, crashed near Machiques, Venezuela, on Aug. 16, 2005. Snow said, “Engine anti-ice was turned off. [The flight crew] climbed to Flight Level 330 [approximately 33,000 ft]. Once they had reached that flight level, they re-engaged the engine anti-ice, the actual power being reduced; put the autopilot in hold mode; and then airspeed and Mach decayed very gradually over the next 10 minutes, leading to autopilot disconnect [and] stick-shaker stall warning. In this case, the pilot flying responded with a full-aft column input and nose-up trim.”

Image from the West Caribbean Airways HK 4374X accident final report 

The JSAT concluded from official reports that the captain, the pilot flying, believed something was wrong with the engines. “The first officer was saying, ‘It’s a stall, captain.’ The airplane took … 3 to 3 1/2 minutes to fall out of the sky and crash — so [there was] that signature loss of energy-state awareness,” he said.

From the JSAT’s analyzed events, several other causal themes were identified for exploration of solutions. Snow said, “We’ve gotten really good, really safe, as an industry — and it takes, at least, six of these themes coming together to create an adverse event

• We had lack of external visual references — either IMC [instrument meteorological conditions] or night or both — in all but one of the events
• Flight crew impairment [occurred] in about one-third; that was always fatigue, except in one case where there was alcohol involved.
• Ineffective alerting [occurred] in every single one. …
• We had …inappropriate control action in two-thirds of the events [meaning,] basically, the flight crew acting on the control inceptors to take a developing bad situation and make it worse [such as by] rolling into an overbank rather than out of an overbank [or] pitching down into a nose-down attitude [or] pulling back on the control wheel or the stick to increase angle-of-attack in response to a stall warning.
• Training issues [occurred] in about half — often, [this meant] not having training that would have been helpful, like crew resource management or upset recovery training. Sometimes, [the issue was] not recalling or acting on the training in the appropriate context.
• Airplane maintenance [was] an issue in about one-third. …
• Safety culture [was] an issue in about two-thirds. …
• Systems knowledge [was involved] in about one-third. …
• Automation confusion and awareness [were seen] in roughly two-thirds. …
• Invalid source data [i.e., unreliable flight-critical aero data sent to the flight deck were noted] in five. The data-related events were a failed inertial navigation system; unreliable airspeed or pitot-static issue; frozen angle-of-attack sensor vanes; and a failed radar altimeter.
• What Snow called “a specifically mismanaged distraction” was found to have occurred in every accident/incident selected for analysis. “We could clearly see something — usually in the cockpit voice recorder [data] — that took the flight crew’s attention away from the basic task of ‘aviate’ for some critical interval [that] can be 6 seconds, 10 seconds, sometimes as long as 30 or 40 seconds. … We need to do a slightly better job of minimizing distractions and managing them when they happen,” he said.

CAST Safety Enhancements

The FAA’s Wilborn** told attendees that background for understanding 11 airplane state awareness–relevant safety enhancements (SEs) — SE192 through SE211 — is available at no cost from the CAST website www.cast-safety.org Details of the JSAT’s final conclusions and recommendations — also reflecting CAST members’ consensus-acceptance and commitment of resources for their implementation — are available at no cost on Eurocontrol’s SKYbrary website www.skybrary.aero/index.php/Category:CAST_SE_Plan.

** James Wilborn, aviation safety engineer, Aircraft Certification Service, U.S. Federal Aviation Administration (FAA), and co-chair of the JSAT. 

As examples, four SEs are air carrier actions, targeting

• low-airspeed aural alerting;
• standard operating procedures (SOPs);
• non-standard flight operation; and flight crew training verification and validation. A service bulletin developed by Boeing and Honeywell addresses new methods of low-speed alerting on the flight deck that are being adopted by some U.S. air carriers.

The SOP-related SE describes use of flight data–monitoring programs to identify causes and remediate instances of flight crew non-adherence to SOPs, he said. Non-passenger-carrying/non-revenue flights by air carriers — such as functional check flights or ferry flights — have had “significant safety issues” that are addressed by one SE.

Another SE explains how an operator can verify that a third-party vendor actually provides the pilot training specified by contract, including enhanced upset prevention and recovery training that includes current approach-to-stall recovery procedures; upset-prevention scenarios; stall recoveries after the autopilot has led the aircraft into the stall; unreliable-airspeed scenarios; recovery from spatial disorientation situations, such as the sub-threshold roll noted; safely responding to non-normal situations; and enhanced go-around scenarios.

The last item could include factors such as beginning the go-around maneuver in a very lightweight aircraft from a position other than charted decision height/missed approach point in visual meteorological conditions (VMC), then transitioning to IMC. These improvements will be reinforced by FAA guidance material scheduled for publication in early 2015, he said.

(NOTE from the blogger: This guidance material is included on FAA AC No: 120-109A, published on 11/24/15)

Aircraft manufacturers, represented at CAST — Airbus, Boeing, Bombardier, and Embraer — provided to the JSAT information about their latest available technologies relevant to airplane state awareness. Those deemed most likely to help achieve industrywide objectives theoretically could have eliminated 60 percent of the airplane state awareness problems seen in the analysis, Wilborn said.

The solutions submitted by the manufacturers comprised proprietary systems

• for low-airspeed alerting and protection;
• removing invalid airspeed data from the displays;
• automatic activation of pitot heat;
• multi-sensory alerting of pilots to invalid inertial navigation system data;
• fault-tolerant data sources achieved through multi-voting (or other software logic);
• a ‘­connecting-checklist’ by default — such as electronic checklists or central messaging systems;
• angle-of-attack or stall protection;
• and protecting fly-by-wire airplanes from unsafely low airspeeds by inhibiting automatic nose-up trim.
• The JSAT’s final additions to its recommendations were automated bank angle protection (ideally with multi-sensory pilot alerting of bank angle state, including recovery guidance),
• and synthetic vision systems.

In the latest bank angle protection systems, if the flight crew does not understand, for example, how to respond to a 35-degree “bank angle, bank angle” alert, and then ends up at 45 degrees, “the alert changes to ‘roll right, roll right’ and a red arrow appears on the PFD [primary flight display] to show you which way to go,” Wilborn said. Virtual day-VMC displays — or synthetic vision systems — are useful … to help maintain spatial orientation and energy awareness.

Image: Bank angle alerting with recovery guidance. Source: Airplane State Awareness Joint Safety Implementation Team Final Report

FURTHER READING

1. Flydubai accident Interim Report
2. The Head-Up Illusion: do you remember it?
3. Armavia A320 crash during go-around at night in poor meteorological conditions
4. Tatarstan B735 crash during go-around at night. Learning from the recent past
5. Descent below minimum permitted altitude, final report
6. Going around with all engines operating
7. Speaking of going around
8. Let’s go around

**********************

By Laura Victoria Duque Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter @SafelyWith  Human Factors information almost every day.

_______________________

Going around with all engines operating

A go-around is a challenging procedure because of its rarity and complexity in terms of workload…

I’m just sharing. All credits to the author and the publisher.

Photo (C) Sergei Karpukhin/Reuters

AeroSafety World May 2014 

FLIGHT OPS

What Goes Around 

Study urges improved training to help flight crews to better cope with go-arounds.

BY LINDA WERFELMAN

Most air transport pilots lack adequate training in how to perform the most common go-arounds — those with both engines operating in the high-pressure environment of a missed approach, according to a study by the French Bureau d’Enquêtes et d’Analyses (BEA).

Although a go-around is considered a normal procedure, it nevertheless is challenging because of its “rarity … and complexity in terms of workload,” said the study, begun after fatal accidents in 2009 and 2010 that were associated with “aeroplane state awareness during go-around (ASAGA),” which the agency characterized as “loss of control of the flight path during or at the end of a go-around maneuver.”1

The Study on Aeroplane State Awareness During Go-Around added, “A go-around does not often occur during operations … and is one of the manoeuvres … poorly represented by simulators, in particular due to the absence of a realistic ATC [air traffic control] environment.”

The study’s findings indicated that pilot training typically does not take into account actual go-around accidents and incidents. Accompanying recommendations to the International Civil Aviation Organization (ICAO) and the European Aviation Safety Agency (EASA) included several calling for the development of more realistic training scenarios involving go-arounds with all engines operating.

The multi-phase study began with a statistical examination of go-around accidents and serious incidents, and an in-depth look at selected events.

Researchers searched the ICAO and BEA databases for “ASAGA-type” accidents and serious incidents, ultimately identifying 25 such events, including 15 fatal accidents that were responsible for 954 deaths, and singling out 10 events for further discussion.

Note from the blogger: With a view to identifying common aspects, the BEA selected and studied 10 accidents and serious incidents, in addition to a selection of 6 summaries taken from the various databases searched. These events are summarised below in chronological order. 

Selected accidents and serious incidents

Events obtained from international databases

Source: BEA Study on Aeroplane State Awareness During Go-Around

Among them was the crash of a Gulf Air Airbus A320 into the Arabian Gulf during an attempted go-around in night visual meteorological conditions (VMC) on Aug. 23, 2000. The crash destroyed the airplane and killed all 143 people aboard (Accident Prevention, December 2002). The Bahrain Accident Investigation Board cited several contributing factors, including the captain’s nonadherence to standard operating procedures, the first officer’s failure to draw the captain’s attention to aircraft deviations from standard flight parameters, the flight crew’s “spatial disorientation and information overload,” and their “non-effective response” to ground proximity warnings.

Another example cited was the May 3, 2006,2 crash of an Armavia Airlines A320 during a missed approach to the Sochi (Russia) airport at night with weather conditions that, while VMC, were only slightly better than the airport’s minimums. The accident killed all 113 passengers and crew, and destroyed the airplane (ASW, 10/07, p. 44).

The BEA study said the report by the Russian Air Accident Investigation Commission “suggests that it is possible to hypothesize that the nose-down inputs [by the captain, the pilot flying (PF)] may have been due to somatogravic illusions and/or … the speed approaching VFE [maximum speed with flaps extended].”

The Russian report also “referred to the pilots’ loss of situational awareness in pitch and roll, and inadequate — or even non-existent — CRM [crew resource management] during the go-around phase and until the end of the flight,” the BEA study said. “It also concluded that the captain had engaged the aircraft in an abnormal situation and that, with the exception of his responses to requests, the copilot did not perform his monitoring role adequately. It also highlighted the lack of an appropriate reaction from the flight crew to the GPWS [ground-proximity warning system] warning.”

Shared Themes

The study identified a number of shared themes. For example, all of the events but one involved a twin-engine airplane — relatively light at the end of a flight, with more thrust available than is required for a go-around maneuver. The exception to the twin-engine theme was one event involving a four–engine airplane. In all but one of the events, all engines were operative.

All but two events involved “significant speed and pitch attitude excursions” and, as a result, “excursions in climb speed and altitude,” the report said. In addition, all events involved “a disruption … soon after a higher level of thrust was ordered and generated potentially hazardous maneuvers.” The disruptions often came as a surprise to the crew.

CRM failures “were mentioned” in all of the events, the report said.

Six events occurred during the day in conditions with no apparent visibility problems. Visibility was not specified in one event, and instrument meteorological conditions, “which probably aggravated the situation,” prevailed in nine events, the report said.

In 11 events, the pilot monitoring (PM) performed the tasks specified for beginning a go-around, such as retracting the landing gear and flaps. In four of these 11 events, these actions helped regain control of the airplane; in six others, there was no effect; and in one event, the actions had a negative effect. After these initial actions, insufficient monitoring by the PM was mentioned in reports on nine of the events, the BEA report said.

In 10 events, the airplane’s “strong and quick-acting nose-up pitching moment generated by the engines at low speed placed the pilot in a situation that necessitated a high level of vigilance,” the report said, adding that although causes of the disruptions were “extremely diverse,” they often were made worse by automatic systems.

The most frequently cited “aggravating factor” was the “unexpected or overlooked operation” of the autopilot or the automatic horizontal stabilizer trim or both, the report said. Somatogravic illusions were cited as aggravating factors four times and suspected in two additional events, the report said.

The “intervention of ATC” was cited in six events, and related changes were mentioned in two others.

Pilot Survey

The study’s analysis of 831 survey responses from pilots with 11 French and British airlines showed that 54 percent had performed fewer than nine actual go-arounds at that point in their airline flying careers.

Their answers indicated that the go-arounds were performed for three primary reasons: meteorological conditions, an unstabilized approach or “ATC involvement.” In addition, 30 percent of pilots said they had performed at least one go-around while flying below minimums.

Sixty percent indicated that they had go-around “difficulties” — most often involving vertical flight path management (capturing the go-around altitude) or autoflight system management. Of that 60 percent, half said that they also had difficulties during go-around simulator sessions. When instructors provided responses to the survey, they said those areas were not the only go-around–related problems observed during simulator sessions; in addition, they cited “getting and maintaining pitch angle,” “visual scan management” and decision making.

“The pilots surveyed indicated that, overall, they were sufficiently well trained in [go-arounds] with one engine out (85 percent of the pilots),” the study said. “However, almost half of the pilots indicated that they were not sufficiently well trained in [go-arounds] with all engines in operation. This figure was even higher for the pilots who indicated that they had encountered difficulties in flight.”

Stress and Startle

The study’s human factors analysis of pilot behavior during a go-around concluded that the go-around “introduces a discontinuity in the tasks to be performed and a disruption to their rhythm of execution.

“The diverse nature of the tasks and the speed at which they must be performed generate stress, notably when the startle effect is also included. … Since stress reduces our ability to cope with complex actions, performance levels drop during go-arounds. The sudden onset of new tasks, the need to perform vital, rapid and varied manoeuvres and the rapid changes in the numerous parameters to be managed (controlled) in a limited period of time combine to make it difficult for a crew to perform a go-around that is not controlled right from the start.”

The human factors analysis said that the first challenges associated with a go-around are adapting to a new situation, controlling related stress and managing layers of tasks. The PM is forced to cope with an overload, which often prevents him or her from monitoring the PF, the analysis said.

Suggested Improvements

The study said that the pilots participating in the survey suggested several ways of improving go-around training, including changes in ATC procedures, such as increasing the initial go-around altitudes, which sometimes are too low; limiting pilot-controller communication during portions of a go-around that require crew concentration; and simplifying flight paths.

One pilot elaborated, “Ideally, if there is no terrain restriction, the flight path should go straight ahead in line with the runway and climbing to a height of more than 3,000 ft. The flight paths are all too often complicated, with banks early on in the manoeuvre, and altitudes that are too low.”

Other suggestions called for simplifying operators’ go-around procedures to “indicate the pitch attitude to avoid a CFIT [controlled flight into terrain accident]” and “indicate the thrust needed to move away from the ground and climb steadily.” Procedures also should describe the method of checking automatic systems, clearly state when landing gear and flaps should be retracted and describe the flight path for returning to land, pilots said.

Simulator Sessions

In 11 simulator sessions (six in an A330 simulator and five in a Boeing 777 simulator) designed to bolster other study data, 11 flight crews each flew three go-arounds and participated in post-session interviews. Although all 33 go-arounds were studied, one subset of 11 was the subject of an in-depth analysis that found that at least one pilot in 10 of the 11 participating flight crews reported having difficulty with the go-around session.

Typically, that crewmember was the PM, the study said, noting that within seconds of the start of the go-around, PMs were forced to deal with “multiple and diverse” tasks involving callouts, readbacks of ATC instructions, verification of the pitch attitude, monitoring the PF’s flight control and verification of flight mode annunciator (FMA) modes.

“The crews that experienced difficulties made adaptations to the procedure,” the study said. “Some adaptations had positive effects (approach to interception altitude); others led to deviations from the expected result (flight path, for example).”

The researchers accompanied their evaluation of the simulator sessions with a discussion of simulator fidelity issues, including the inability of a typical full flight simulator to accurately represent a somatogravic illusion — the “powerful perceptual illusion of a nose-up attitude” — that typically occurs during an actual go-around. Although some airlines have suggested training pilots only on fixed-base simulators, “this would appear to be inappropriate for this flight phase,” the study said.

Causal Factors

ASAGA events have always occurred with all engines operating, the study said, noting that, in a typical ASAGA event, the crew begins a go-around with nose-up pitch and the application of full thrust.

“The acceleration due to this rapid and significant increase in thrust can create the feeling of a too-high nose-up pitch,” the study said. “In the absence of external visual references and visual monitoring of instruments, a somatogravic illusion can cause the PF to reduce the aeroplane pitch towards inappropriate values. In practice, these somatogravic illusions are little known to crews, and existing simulators do not make it possible to recreate them so as to train pilots to recognize them.”

Automatic systems add to the problems because their “initial engagement modes [are] different from those expected for the go-around … [and] when they are neither called out nor checked, [this] leads the aeroplane to follow an unwanted flight path,” the study said. “Thus, in addition to reading the FMA, the monitoring of primary parameters — pitch and thrust — is a guarantee for the crew to ensure that the automatic systems put the aeroplane on a climbing flight path during the go-around.”

The study emphasized that ASAGA events result in a “sudden, high workload” for the PM, “higher than that of PF,” with tasks that are difficult to manage. Deficiencies in the performance of the PM’s monitoring tasks “can have catastrophic results,” the study added.

The document also noted that accident reports often mention the absence of CRM while crews cope with an ASAGA event. Nevertheless, the study found that CRM often is in place before the event and again after the crew has regained control of the flight path.

“This ‘lack of CRM’ now seems to be a normal consequence where there is a situation involving startle effect, cognitive overload, time pressure and high stress,” the report said.

The primary challenges in conducting a successful go-around are identifying “ways of giving the crew time to carry it out and also to simplify their actions,” the study said.

Recommendations

The BEA focused its nearly three dozen safety recommendations on flight crew training, calling on EASA — in coordination with airplane manufacturers, operators and non-European civil aviation authorities — to “ensure that go-around training integrates instruction explaining the methodology for monitoring primary flight parameters, in particular pitch, thrust, then speed.”

Related recommendations to EASA and national civil aviation authorities, within Europe and internationally, say these regulators should ensure that recurrent training places greater emphasis on pilots’ monitoring skills.

Because of the difficulties of maintaining CRM during a go-around, EASA should study methods of mitigating CRM’s shortcomings in situations involving heavy workload or other unusual conditions, the BEA said. “Current CRM alone cannot constitute a reliable safety barrier in the case of disruptive elements,” the study added.

Because full-thrust go-arounds can contribute to excessive climb speed, complicate the crew’s efforts to accomplish all actions required by the go-around procedure and contribute to somatogravic illusion, the BEA said manufacturers should install devices to limit thrust during a go-around and “re-evaluate the possibilities of errors linked to the engagement of go-around modes.”

Other recommendations included calls for:

Manufacturers and operators to study pilots’ visual scans as a prelude to improving procedures, especially for go-arounds;

National civil aviation authorities, manufacturers and operators to identify methods of countering the “channelized attention phenomena” in which pilots become so focused on some of their go-around tasks that they neglect others;

EASA and non-European certification authorities to ensure that go-around procedures are evaluated “in a realistic operational environment”;

EASA, national civil aviation authorities and manufacturers to ensure that pilots are familiar with actions required during a go-around “at low speed with pitch trim in an unusual nose-up position”;

ICAO to indicate that, when a missed approach procedure is being designed, a straight-ahead flight path should be given preference, when possible, and the first vertical constraint should be as high as possible; and,

ICAO to define practices so that ATC does not instruct pilots to follow missed approach procedures that contradict published procedures and so that radio transmissions are not made to crews during a missed approach.

In addition, noting the helpful role of cockpit video recordings during the go-around simulator sessions, the BEA recommended that ICAO require image recorders in all full-flight simulators used in training public transport pilots.

“During the study, the use of video was essential to carry out a proper analysis of simulator sessions,” the study said. “The video recordings made it possible to have access to all the information presented to the crew. … Installed in a simulator, it [a video recording system] would be a source of additional information of use during crew debriefing.” 

This article is based on the BEA’s “Study on Aeroplane State Awareness During Go-Around,” originally published in French in August 2013 and subsequently translated into English. The report is available in both languages at <www.bea.aero>. 

Notes

1.  The accidents were:

•  The June 30, 2009, crash of a Yemenia Airways A310 about 6 km (3 nm) off the coast of Comoros during an approach to Moroni­–Prince Said Ibrahim International Airport. The crash killed 152 of the 153 people aboard. The Aviation Safety Network said that the final report by the Comoros L’Agence Nationale de l’Aviation Civile et de la Météorologie cited as the probable cause of the accident inappropriate actions of the flight crew on the flight controls, which resulted in an unrecoverable stall.
•  The April 13, 2010, crash of an AeroUnion A300 B4 near Monterrey, Mexico, that killed all five people in the freighter and two people on the ground. A final report has not been issued.
•  The May 12, 2010, crash of an Afriqiyah Airways A330-200 that killed 103 of the 104 people aboard. The final report by the Libyan Civil Aviation Authority cited the crew’s inappropriate flight control inputs during a go-around as one factor in the accident.

2.  The BEA report, which provides the coordinated universal time (UTC) instead of local time, says the accident occurred May 2, 2006

**********************

FURTHER READING

1. The Head-Up Illusion: do you remember it?
2. Armavia A320 crash during go-around at night in poor meteorological conditions
3. Tatarstan B735 crash during go-around at night. Learning from the recent past
4. Speaking of going around
5. Loss of flight crew airplane state awareness
6. Flydubai accident Interim Report
7. Descent below minimum permitted altitude, final report
8. Let’s go around

**********************

By Laura Victoria Duque Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter@SafelyWith. Human Factors information almost every day 

_______________________

Speaking of going around

When you look at the go-around performance data, doing a go-around is not risk-free…

I’m just sharing. All credits to the author and the publisher.

Photo © Ruí Sousa Madeira planes and stuff

AeroSafety World April 2015

COVER STORY

GO-AROUND RISKS 

Relative-safety factors influence flight crews to perform far fewer missed approaches than predicted by the incidence of unstabilized approaches.

BY WAYNE ROSENKRANS

Presumed-versus-actual practices of airline pilots during unstabilized approaches are receiving close scrutiny in the light of flight data analyses shared by governments and industry. Yet a basic principle still applies, say subject matter experts. “Airlines should emphasize to flight crews the importance of making the proper go-around decision if their landing approach exhibits any element of an unstabilized approach,” said a recent article in Boeing Aero.1

Mitigating risk of the go-around maneuver itself has to be factored into every decision, according to Dave Carbaugh, a captain and chief pilot, flight operations safety, Boeing Test and Evaluation. He sees the unstabilized approach as just one reason among many well-known scenarios for conducting the maneuver, and he wants all pilots to know key lessons learned from incidents and accidents associated with the decision to go around.

In November 2014, he made a presentation to Flight Safety Foundation’s 67th annual International Air Safety Summit (IASS) in Abu Dhabi, United Arab Emirates, elaborating on the same theme as a companion Aero article that he co-authored with Bertrand de Courville.2

Important reasons for airlines and pilots to revisit long-held assumptions about the go-around maneuver include the changing nature of go-arounds compared with the circumstances two or three decades ago, and safety implications of the rarity with which they are conducted, Carbaugh said. Excessive focus on complying with stabilization criteria at specific approach gates defined by standard operating procedures creates a risk of gaps in situational awareness.

Defining approach gates at certain altitudes helps, but they should be considered as one of several phases/segments where the aircraft could become unstabilized. “If there’s a gate at 500 ft, you could end up being OK there but unstable later in the approach,” Carbaugh said. “So an unstabilized approach can occur anywhere in that period of time,” including during the landing up to the point at which the thrust-reverser system is activated.

Flight crews generate some of the conditions necessitating a missed approach. “Sometimes the situation ends up being blatantly unsafe. … [The] reason for doing a go-around is [they’re] just basically not prepared to land,” Carbaugh said. In other words, each flight crew’s real-time assessments must include objectivity about its own performance as well as that of the aircraft and issues in the environment. He cited the specific case of self-awareness of getting “behind the airplane” — that is, unable to anticipate what will occur next because of the level of concentration on present tasks. “You lose your reserve capacity to be able to handle any other activities of concern” in that case, he added.

In recent years, a significant amount of study of pilots’ go-around decision-making processes has occurred. The timing of the decision can be critical to the maneuver’s outcome. “When you look at the go-around performance data … doing a go-around is not without any risk. The lack of decision is the leading risk factor. In other words, if you’d made your decision earlier in the process, you’d probably [have been] able to execute the go-around better than [if] forced into it by having an unstabilized approach, then, at the very last second, deciding [you] have to go around,” Carbaugh said, citing European conference findings in 2013 that about 10 percent of go-arounds reviewed had potentially dangerous outcomes. “In other words, there were airspeed, altitude [or aircraft] ­handling-type problems that could have potentially ended up being a hazardous situation.”3

Carbaugh contrasted the relative lack of complexity of go-around maneuvers 30 years ago with what airline flight crews presently encounter. “We [formerly] had low thrust-to-weight ratios, so the airplane just didn’t climb very quickly. We had less traffic density, so there wasn’t anybody in front of you and … and a lot of times, the go-round was non-complex [such as the air traffic controller saying,] ‘Fly runway heading to 4,000.” It was basically easy. But those days are gone,” he said.

Very complex arrivals and departures create equally complex go-around situations, increasing the workload for the flight crew. There are similarities to the past in the need to monitor attitude, thrust, flight path, aircraft configuration and pitch trim. “In modern days … we have some additional things to do. We have to monitor the autopilot, the flight director and the autothrottle, their modes, and confirm back-and-forth between the pilots that the airplane is doing the right thing,” Carbaugh said.

How well an airline mitigates the current risks partly depends on insights gained from ongoing study of go-around events, such as whether a maneuver possibly endangered a flight in some respect, or whether identified problems recur at a particular airport. “We do that by flight data monitoring and incident reporting. Also, we take a look at the performance of our crews in the simulators and get feedback from our instructors on how they’re doing,” he said.

Go-Around Execution

Problems in performing go-arounds essentially fall into two categories: nose-high situations and nose-low situations, he said. All nose-high situations have common characteristics. “One of them is that they [involve] very high thrust, so things happen quickly. They tend to happen at low speeds, but speed can be an interesting problem because some airplanes have [low relative] approach speeds that are based on the go-around capability … to have controllability when you go around,” Carbaugh said. “The aircraft tend to have, in most of the accidents and incidents, an excessive amount of nose-up trim, and [flight crews] almost always end up in a situation where they are lacking pitch-down elevator control. So you just basically ‘run out’ of elevator control.”

One good example of a nose-high go-around incident in the United Kingdom involved a Boeing 737-300, he said, without further identification except that his examples are not recent. “Similar accidents are happening today, so the issues are still pertinent,” he added. “Sometime during the approach, the autothrottle was disengaged … at a lower-than-needed or normal power setting, which allowed the airplane to slow down near to the stall. The autopilot was still on, so the [autopilot] was still trimming and trying to hold pitch for the lower speed. The captain [pilot flying] noticed the low speed at just about the time they reached minimums and decided to go around. Unfortunately, it was a very exciting situation for them. He grabbed the throttles and pushed them all the way up to the firewall, which — in a 300 — is an overboost-type situation,” Carbaugh said, highlighting the dangerous combination of full power, far more power than required, and a large amount of nose-up trim.

“The airplane pitched up, and they were using elevator-only to recover; they didn’t have enough elevator authority, and the airplane stalled. Fortunately, it fell straight ahead and recovered, and the second time [the nose] started to come up, they used some stabilizer trim and recovered. … We’ve had a number of issues that are similar with the [Airbus] A300-600s and A310s. … Pilots were making the wrong [control] inputs and the trim was compensating for it … basically [cases of] mishandling by the flight crew.”

Part of the threat involved in a nose-high go-around situation is the unlikelihood of the flight crew expecting this to occur or having practiced correct procedures. “They are very rare but they happen every once in a while. The flight crew gets startled,” he said. Correct response can be learned using procedures taught in standardized upset prevention and recovery training (UPRT) courses that incorporate guidance published in the free Airplane Upset Recovery Training Aid,Revision 2 (2008; ASW, 3/15, p. 14).

At IASS, Carbaugh paraphrased the procedure: “Basically, it’s [recognize] the situation. Disengage the autopilot and the autothrottle, as they may be causing some of the problems. Apply full nose-down elevator if you don’t already have it. And then, if you’re holding pressure at full-down elevator, obviously you’re going to need some nose-down stabilizer trim, so use that. … Too much thrust may be causing it, so … why don’t we just pull the thrust back a little bit to prevent the pitch-up. … If all of that doesn’t work to reduce the pitch rate, you can always roll, and that will definitely [make] the pitch come down. Once you get the airplane to [begin to] recover under control, you can [fully] recover, roll the wings level near the horizon and airspeed — and attitude-adjust.”

Nose-Low Situations

The nose-low situations — many occurring when the flight crew is “forced” by air traffic control (ATC) instructions or other factors to perform a low-altitude level-off — also involve some within-category similarity of sequence. “They are characterized by steep climbs followed by steep descents. [The flight crews were] pitching up, but then, all of a sudden, they had to make a change and level off. They’re all at night or in the weather, where they don’t have a discernible horizon. Many times, they started to go around at a not-frequently-trained location … a phase in the approach that they don’t usually see in training,” Carbaugh said.

Initiating a go-around maneuver at higher altitudes adds other challenges — notably a greater risk of spatial disorientation for the pilot flying. “If you’re told to go around at 1,500 ft, partially configured, that could end up a way-different situation and quite startling. To have to go around at that point and to figure out what to do [has] been a cause of some problems,” he said. In addition to the frequently cited A320 accident (ASW, 10/07, p. 44) at Sochi, Russia, he summarized 757 nose-low go-arounds that occurred in Oslo, Norway, and Seychelles.

“[In the low-visibility-weather Oslo event,] they started their go-around at a very high height, relatively — at 1,500 ft AGL [above ground level], and they only had 1,000 ft to climb for their low-altitude level-off. … When they added power, they didn’t climb right away, they just kind of accelerated. They were at flaps 20 at the time,” Carbaugh said. “In the Boeing [automation] system, normally when you select ‘GO AROUND,’ it gives you a 2,000 fpm rate of climb.” If the aircraft does not climb at the programmed rate, however, the software algorithms “presume” that the situation requires more power, he noted.

“So they ended up at full thrust, and then they did a steep climb up to 2,500 [ft], and then a very long, pronounced, pitch-down [occurred] in which they reached minus 40 degrees nose-low. Ground prox [the Enhanced Ground Proximity Warning System] went off — although the pilots said they never heard it — [and] they performed a 3.6-g [3.6 times standard acceleration of gravity] pullout at 400 ft AGL.” The subsequent landing was uneventful, and data from the flight data recorder facilitated incident analysis by Boeing.

The Seychelles example involved night operation over the sea. “They … had a low-altitude level-off, and there was a long pitch-down input which reached 9 degrees nose-low. Anybody would know that if you’re flying level or you’re doing a go-around, 9 degrees nose-low is not a good place to be. … They ended up having a vertical speed of about minus 4,000 fpm [and] recovering at 600 ft AGL,” he said, noting the prevalence in many cases of spatial disorientation, high-workload distraction or an unmitigated physical effect such as somatogravic illusion (that is, the airplane’s sudden acceleration affects the balance organs of the pilot’s inner ear, creating the sensation of being tilted backward and the false perception that the pitch attitude is excessive although it is not [ASW, 7/13, p.12]).

“The pilot [flying] reacted late to an extreme nose-down pitch attitude. So were they not looking at the ADI [attitude direction indicator]? We don’t know. … The only reference they had [for their actual] attitude was the ADI, so you would think they would be looking at it — but apparently not. They were distracted for some reason. [By] then, their control process had broken down. … The only way you’re going to be able to talk yourself into what’s happening in reality [and make appropriate flight control inputs] is to look at the ADI and figure out what’s going on. It’s very difficult.”

T-Shape Scan Pattern

Carbaugh said that among the most effective countermeasures to the nose-low go-around threat scenario is correctly monitoring flight path and energy state at all times. When hand-flying, the basics of attitude instrument flight apply as much as ever — even while scanning the most advanced ADIs, he added.

“Make sure you go back to basic instrument scan, which we learned many years ago is probably best done in a T-shape. Even though we’ve [integrated instruments] into one big display … you still have to do an instrument scan,” he said. “That’s because the [pilot’s] central vision is still needed to read the digital readouts in all of these displays, and also [because of] cognitive performance. Even though pilots will tell you, ‘Oh, I can just take a glance at the ADI or PFD [primary flight display] and see everything all in one glance — they’re not really telling you the truth. They can’t. They think they can, but they can’t. … [The T‑shape scan] takes a little bit of time, and you have to force yourself to do that. … For go-arounds, distraction [from the scan] is something that we have to manage. … At an unknown place [or relatively high altitude, flight crews] tend to rush, and they’re not sure about [airplane] performance.”

A related area of emphasis in training for go-arounds is monitoring proper pitch attitude and power management, fully realizing the possibility that any flight crew’s usual cross-check process could break down under the challenging conditions described, Carbaugh said. “If you’re doing [the maneuver] on autoflight, you definitely have to use good mode awareness. … [If] the pilot flying has [somatogravic illusion], the pilot monitoring needs to [speak up and take action]. If a [pilot’s] in real trouble, [the other’s] got to say, ‘It looks like you’re in trouble,’ and take over. It’s a difficult thing to do — but necessary,” he said. “When I brief an approach [I may say,] ‘If we have a disagreement or we’re not feeling comfortable about what the other person is doing, we need to speak up. … Instead of trying to solve it while we’re finishing the last of the landing, let’s go around. In that case, we can iron out what the problems were in the situation …so that on the next approach, we have a common viewpoint of how it’s going.”

Finally, to make go-around maneuvers safer — regardless of the anticipated recommendations from research undertaken by Flight Safety Foundation committees and other organizations — airlines should continue to encourage and prepare their pilots to be ready and willing to execute a go-around because of unstabilized elements during approach or landing. “Vary some of the go-around initiations [in flight simulators so they occur] at different places that crews aren’t ready for. Monitor the performance of crews in the simulator as well as on the line. Then the airline needs to figure out, ‘Are we taking a close enough look at go-arounds? Are they visible enough?’”

Notes

1.    Coker, Michael. “Why and When to Perform a Go-Around Maneuver,” Boeing Aero, Quarter 2, 2014. Coker is lead safety pilot, Flight Services, for The Boeing Co.

2.    Carbaugh, David; de Courville, Bertrand. “Performing Safe Go-Around Maneuvers,” Aero, Quarter 3, 2014. Carbaugh is identified in the article as a captain and chief pilot, flight operations safety, for The Boeing Co. De Courville is a retired captain of Air France and co-chair of the European Commercial Aviation Safety Team.

3.    The Go-Around Safety Forum was held June 18, 2013, in Brussels. Sponsors were Eurocontrol, the European Regions Airline Association and Flight Safety Foundation, supported by SKYbrary. Presentations are available online at <www.skybrary.aero/index.php/Portal:Go-Around_Safety_Forum_Presentations>

FURTHER READING

1. Flydubai accident Interim Report
2. Let’s go around
3. MyCargo B744 fatal accident at Kyrgyz Republic, Jan 16th, 2017. Preliminary Report
4. Going around with no thrust. Emirates B773 accident at Dubai on August 3rd, 2016, interim report
5. Descent below minimum permitted altitude, final report
6. The Head-Up Illusion: do you remember it?
7. Armavia A320 crash during go-around at night in poor meteorological conditions
8. Tatarstan B735 crash during go-around at night. Learning from the recent past
9. Going around with all engines operating
10. Speaking of going around
11. Loss of flight crew airplane state awareness 

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By Laura Victoria Duque Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter@dralaurita. Human Factors information almost every day 

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The Head-Up Illusion: do you remember it?

The Head-Up Illusion is the feeling of a too high aircraft nose-up pitch, following a sudden forward linear acceleration. The illusion generally occurs in conditions of poor visual cues, such as night operations or instrument meteorological conditions (IMC).

Photo (C) RICK SCHLAMP

I’m not saying this is the cause of the Flydubai flight 981 accident. I am just reviewing the issue because I was reminded of it by the accident scenario: a missed approach and go-around at night with associated poor weather conditions.(See: Flydubai accident Interim Report)

The Head-Up Illusion is the feeling of a too high aircraft nose-up pitch, following a sudden forward linear acceleration. The illusion generally occurs in conditions of poor visual cues, such as night operations or instrument meteorological conditions (IMC).In the absence of external visual references and visual monitoring of instruments, can cause the pilot flying (PF) to push the control column or the side-stick forward to pitch the nose of the aircraft down reducing the aircraft pitch towards inappropriate values. A night take-off from a well-lit airport into a totally dark sky (black hole) can also lead to this illusion, and could result in a crash.

This is a vestibular illusion and belongs to the somatogravic illusions group. The illusion is due to the interaction of unnatural acceleration and its resultant inertia with the otolith organs deep inside our inner ear.

Just let’s remember that two otolith organs, the saccule and utricle, are located in each ear and are set at right angles to each other. The utricle detects changes in linear acceleration in the horizontal plane while the saccule detects gravity changes in the vertical plane. However, the inertial forces resulting from linear accelerations cannot be distinguished from the force of gravity, therefore, they can produce a sensation of change in both horizontal and vertical axes. The combination of these two vectors produces a third resultant vector.

Image modified from Roy DeHart, Fundamentals of Aerospace Medicine, Williams and Wilkins.

The inertial forces resulting from a forward linear acceleration produce a backward displacement of utricle(horizontal)  but also stimulates the saccule (vertical). Therefore, the false sensation is that you are being simultaneously pushed back and down. In the absence of visual references, this produces the illusion that the nose is pitching up.

Another somatogravic illusion that is likely under these conditions is the Inversion Illusion.

Image modified from Roy DeHart, Fundamentals of Aerospace Medicine, Williams and Wilkins.

The Inversion Illusion involves a steep ascent (forward linear acceleration) in a high-performance aircraft, followed by a sudden return to level flight. When the pilot levels off, the aircraft’s speed is relatively higher. This combination of accelerations produces an illusion that the aircraft is in inverted flight. The pilot’s response to this illusion is to lower the nose of the aircraft.

These are some recent major accidents that have been related with somatogravic illusions and spatial disorientation:

• Gulf Air Airbus A320 into the Arabian Gulf during an attempted go-around in night visual meteorological conditions (VMC) on Aug. 23, 2000
• Flash Airlines 737-600 descended into the Red Sea minutes after takeoff on a moonless night from Sharm el Sheikh International Airport in Egypt on January 3, 2004.
• Armavia Airlines A320 during a missed approach to the Sochi (Russia) airport at night with weather conditions that, while VMC on May 3, 2006 (See: Armavia A320 crash during go-around at night in poor meteorological conditions)
• Kenya Airways Boeing 737-800 crashed into a swamp after spatial disorientation and loss of control occurred during climb-out on a dark night on departure from Douala Airport in Cameroon, on May 5, 2007
• Ethiopian Airlines Boeing  737-800 crashed into the Mediterranean Sea shortly after takeoff on a dark and stormy night from Beirut International Airport in Lebanon on January 25, 2010.
• Afriqiyah Airways Airbus A330-202 during a non-precision approach to Tripoli, Libya, on May 12, 2010.
• Tatarstan Airlines Boeing 737-500 during a go-around at Kazan, Russia on  17 November 2013.(See: Tatarstan B735 crash during go-around at night. Learning from the recent past)
• Atlas B763  loss of control on approach at Houston on Feb 23rd 2019

The somatogravic illusions are little known by the flight crews and they can’t be recreated in existing standard simulators so it is difficult to train pilots to recognize it.

 The head-up illusion and other types of spatial disorientation occur when the pilot’s sensory and perceptual capabilities are exceeded which produces the pilot to experiment false sensations about the aircraft’s motion, position or attitude. Spatial disorientation can happen to any pilot at any time, no matter his/her experience, knowledge and expertise. Often is associated with degraded visual conditions, fatigue, stress and startle, distraction, high workload, highly demanding cognitive tasks and some medications secondary effects.

FURTHER READING

1. Flydubai accident Interim Report
2. Armavia A320 crash during go-around at night in poor meteorological conditions
3. Tatarstan B735 crash during go-around at night. Learning from the recent past
4. Descent below minimum permitted altitude, final report
5. Going around with all engines operating
6. Speaking of going around
7. Loss of flight crew airplane state awareness
8. Let’s go around

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By Laura Victoria Duque Arrubla, a medical doctor with postgraduate studies in Aviation Medicine, Human Factors and Aviation Safety. In the aviation field since 1988, Human Factors instructor since 1994. Follow me on facebook Living Safely with Human Error and twitter @SafelyWith. Human Factors information almost every day 

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