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SafetyFocus Africa's aviation safety promotion magazine - vol 6



February - May '17

CONFERENCE REVIEW Highlights of Safety in African Aviation 2016 AIRCRAFT RESCUE Advanced emergency communication - from cockpit to fire crews CAUSAL FACTORS Inadequate experience with engine failures in simulators


Follow-ups to identify maintenance errors AVIASSIST


The safety magazine of

Connecting African professionals to best aviation safety practices - offering business development opportunities for partners

Our focus on your safety Safety is a pre-condition for our daily operations to any destination. KLM is proud to work hand in hand with the AviAssist Foundation as part of that commitment to your safety -




Director's message | A home in Africa


Foundation news | Some recent developments


On record | No weather brief for VFR flight


Conference review | Safety in African Aviation 2016


Read about our journey towards a home in Africa - the ASPCs

On expansion into ground operations & the recent boardmeeting

Of headsets and safety belts

Safety champions gather at the Foundation's annual safety gathering

12 Helicopter safety | Installation error


Inadequate follow-ups failed to identify the maintenance error

14 Lifestyle safety | Get safety in your life & under your skin

Items and ideas to submerge yourself in safety

16 Causal factors | Deadly drift


Verifying fuel quantity & engines failures in the simulator

17 Who's who | Safety champions up close

Some of the safety champions in our work -when will we see you?


Aircraft rescue | Triple play

Three parties having access to first-hand information from the cockpit

26 Safety culture | Quality & safety

Different but complimentary business principles

Our promise to you ......


Every quarter, we aim to bring you the very best update on best safety practices. From aeronautical information services to ground operations safety to safety shopping tips. If you ever feel we can improve, let us know. Do you find the contents interesting or boring? Please send your message - rude or polite - to: After all, it's your magazine.


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Cover photo: Africa sees an increasing use of helicopters for sightseeing. Here ZS-PVA (meanwhile registered in Zambia as 9J-UAZ) from United Air Charter gets ready in Livingstone, Zambia for take-off for a spectacular flight through the Zambezi gorges ŠAviAssist Foundation SafetyFocus Magazine

Edition 22 - 2017 AviassistFoundation AviAssist AviassistFoundation



It was on a trip to North Eastern Rwanda that the idea dawned upon me. I had rented a car to make a trip in the weekend, right after the 2015 edition of our flagship event in Rwanda. The Safety in African Aviation Conference had finished the day before and I had given myself the weekend to see some more of Rwanda, in this case the northeast. Through pure co-incidence, the Headteacher of the primary school that my children attended in rural England, was mentoring a Headteacher in Nyagatare in northeast Rwanda. I was a governor at my kids’ school at that time – perhaps somewhat predictably my portfolio was health and safety. Over the week prior to the Conference, I had contacted the Rwandan Headteacher to see if I could visit him and his school in the weekend after the conference. Meanwhile Constant and I had already met during the conference in Kigali. In the Foundation’s efforts to promote women in aviation, we had offered Nyagatare school a free conference ticket for one of their best math pupils. That way, the girl in question could flavour aviation as a career and experience a professional event. This meant that the pupil and the headteacher came to Kigali for the conference. And so in the weekend I travelled to Nyagatare with Constant. We got talking about his job and my job. Constant told me he was expecting to retire in the next year or two. He was joking that, once he retired, he would happily become the cleaner of the AviAssist office in Rwanda so as to continue a form of permanent employment. Initially, we just had a big laugh about that. I explained that the Foundation had no plans to set up a centre in Rwanda. But in the months following that trip, I started to think that perhaps opening a centre of some sort in Rwanda to build safety promotion capacity in Rwanda and the region might actually be a really good idea.

And so we have ambitious plans for 2017 and beyond. We will start creating East Africa’s leading resource centre for safety promotion. The centre will support technical skills, address human factors and develop organizational & business skills for the current and next generations of aviation professionals. The first AviAssist Safety Promotion Centre (ASPC) will be set up in Rwanda in co-operation with the Rwanda CAA and Rwandair as well as a host of other national and international partners. The AviAssist Safety Promotion Centres take inspiration from our 20+ years of working in Africa but also from other similar institutions around the world such as the Japan Airlines Safety Promotion Centre and the Flight Safety Foundation. We will grow the ASPC into a cornerstone of safety promotion and professional development of aviation (safety) professionals. It will embrace and balance both industry and government interests. An approach in which industry and government interests are balanced in safety improvement efforts has been central to the success of safety initiatives around the world. An intern and trainee program for Rwanda based young professionals will be set up to build African safety promotion & business skills. We will construct the ASPC-Rwanda in phases. Starting with support to (aspiring) Approved Training Organisations with training courses in safety & adjacent domains, we will help build project management capabilities for African safety promotion. Next stages of the ASPC will embrace safety performance measurement, safety data collection and analysis as well as becoming a resource centre for incident & accident investigation and safety research. We will be needing many bricks for our home in Africa but as the Chinese philosopher Lao Tzu said "A journey of a thousand miles begins with a single step".



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Visit to apply online or call +(0)1293 768700 to discuss your requirements. Part of the UK CAA International Directorate

SafetyFocus Magazine

Edition 22 - 2017


SafetyFocus By the AviAssist Foundation



AviAssist is an independent, nonprofit organisation. It serves as a catalyst for safety promotion & promotes professional excellence in African aviation safety. It provides safety promotion services for Africa's aviation industry and business development opportunities in Africa's growing markets for true safety promotion partners. Two decades of experience in Africa has equipped AviAssist well to deal with the technical as well complex political, social and cultural issues that play an important role in improving African aviation safety and in accessing the vast market Africa represents. It strengthens the work of the Safety & Training Committee of the African Business Aviation Association AfBAA

Foundation Board Capt. Auke Dros KLM Royal Dutch Airlines Bert Kraan Deputy Director CAA-NL (rtd.) Hellen Ndichu Safety manager Rwandair

FOUNDATION | NEWS RWANDAIR JOINS FOUNDATION BOARD & HOSTS SIAA 2018 Rwandair has joined the Foundation's Board. RwandAir is constructing a regional Africa network with the aim of establishing its home at Kigali as a hub for the continent. Safety manager Hellen Ndichu will be reinforcing the board and assist in providing strategic guidance to the Foundation. The ties with Rwanda are further strengthened with Rwandair announcing that it will be hosting the next edition of the Safety in African Aviation Conference in 2018. “We are looking forward to bringing SIAA back to Rwanda,” said Foundation director Tom Kok. “Kigali is a remarkable city in an equally remarkable country and it is fitting that Africa’s premier safety event will be hosted by RwandAir, one of Africa’s fastest growing airlines,” he said. “I am delighted and honored that the AviAssist Foundation has chosen Kigali as the venue and RwandAir as the host airline for the 2018 Safety in African Aviation conference,” RwandAir deputy chief executive officer Jean Paul Nyirubutama



Rwandair will be represented by its safety manager - Hellen Ndichu

LEADERSHIP COURSE LAUNCHED The Foundation completed the launch edition of its aviation leadership development course for the Rwanda Civil Aviation Authority (RCAA) in October of last year. The four day course was held for 12 members of staff of the RCAA, ranging from the director of human resources to an airside manager and an air traffic controller. "It was a remarkable course as we extend our support beyond the usual suspects when it comes to safety training," AviAssist Director Tom Kok recaps. "It was outside our comfort zone on technical training but the participants truly enjoyed how the course and the instructor prompted them to make their leadership and followership ambitions explicit. It quickly became clear that the skills transferred during the course will directly contribute to the participants their impact as safety champions."

This new course is one of the first efforts to nurture up-to-date leadership at the middle and top management levels in the aviation industry and transfer those skills from existing leaders to emerging leaders. The course assisted current and emerging leaders to develop two crucial skill sets to complement their technical skills. These skill sets, crucial for their (safety) leadership includes administrative (skills) and interpersonal (behaviour) skills. Currently, very few professional development programs are available to equip (future) leaders and safety champions with the administrative and organisational skills to improve the effective implementation of ICAO SARPs. Leadership remains one of the most critical and relevant aspects of the organizational context. Well-honed leadership skills will help (future) leaders lead the direction of an organisation rather than simply managing existing operations.

Ron Louwerse Managing Director Rotterdam The Hague Airport Schiphol Group Ron Schipper Board member Kenya Airways & Precision Air

said. “RwandAir is going through major growth and wants to ensure it stays a safety leader in our industry. Partnering on this even gives us the opportunity not just to continuously invest in our own safety performance but support the region in doing the same. My RwandAir colleagues and I look forward to welcoming the delegates to our home base of Kigali, gateway to Africa.”

The training got the RCAA participants started on their leadership journey.

Instructor Gwen Dudok van Heel flanked by Bongayi Kizito (Left) and Frank Gatera

The course was so succesful and innovative that the Rwanda Civil Aviation Authority will be hosting a second (and perhaps third) edition in 2017. SafetyFocus Magazine

FOUNDATION | NEWS FOUNDATION COMPLETES 6TH HUMAN FACTORS COURSE commercial aviation accident rate As part of its efforts to bring best practices to Africa through training and support, the Foundation recently completed its 6th Human Factors course. The Foundation's two day course assists operators in implementing methods and tools to help them better manage human error.

Livingstone, Zambia Zambia Airports Corporation staff are engaged in one of the many practical teamwork sessions in the Foundation's human factors course

Human error has been documented as a primary contributor to more than 70 percent of commercial airplane hull-loss accidents. While typically associated with flight operations, human error has also recently become a major concern in maintenance practices and air traffic management. Improving human performance can help the industry reduce the

INTERN JOINS IN RWANDA Rwandan intern Blaise Bazimya joined the Foundation in November. His internship is part of the Foundation’s efforts to build a back office in Africa and work towards more structural presence of the Foundation in Africa.

Blaise is enrolled in a trainee program to strengthen his general business skills as well as his aviation safety skills. He The course provided the participants with is foreseen to play a role in the launch a solid understanding of the role of the of the first AviAssist Safety Promotion human element in the Aviation System. Centre (ASPC) - Rwanda. It gives them ‘tools’ to improve their operational performance and enables them In line with the Foundation’s tradition of to develop new professional safety behav- low cost duty stations, Blaise works from iour, based on the acquired knowledge a home office in Kigali. and understanding. Overall, the Foundation has provided human factors training to over 90 aviation professionals in the past 18 months. The Foundation is foreseeing another four courses in two locations in 2017. Bidding is open for the hosting of the training courses for a maximum of 30 professionals in two courses in one location. More information on bidding on page 21. Intern Blaise Bazimya and Foundation director Kok at the pop-up field office in Kigali

INCIDENT INVESTIGATION COURSE ADDED TO PORTFOLIO The Foundation launched its support to the discipline of incident investigation with a taster training in Livingstone, Zambia in November. The taster course saw participants from 7 African countries coming from airline operators, airports and regulators. "Some incidents and occurrences do not warrant official investigations by States," professional volunteer instructor Jan Smeitink explained. "Nevertheless, those occurrences may be indicative of high risk hazards and could lead to the identification of systemic problems that will not be revealed unless thoroughly investigated. Effective safety management systems largely depend on the quality of the investigation of reported incidents and safety issues." The subjects in the short taster course included data collection to populate investigations, interview & questioning techniques and protocols to safeguard the no-blame approach. The necessity of building accident and SafetyFocus Magazine


incident investigation capacity in Africa continues to be high priority for ICAO and the African states. Safety progress is hampered by a shortage of opportunities to learn from accidents but perhaps even more so from incidents.

The Foundation is now considering bids for hosting events for 2017 and 2018. The events present host organisations and companies with the unique opportunity to host an international course for its staff at cost price.

Due to the success of the taster session, the Foundation is planning a full incident investigation course in 2017. The full course will last 4 days and will deal with a much larger number of topics and include numerous practical sessions. It will be open to participants from across Africa. Course dates will be published by the Foundation in the first quarter of 2017.

"With our courses being so popular while at the same time we can usually not deploy more than one or two editions of a course per year, we want to give all companies & organisations in East and Southern Africa a fair chance to host one of our events," AviAssist Director Tom Kok explained. "Through the bidding process, we can review all applications for a particular course and relate them to the mandate of the Foundation and work towards fair geographical distribution".

One of pillars the Foundation's work are high quality, cost-effective and crucial safety courses that address curricula for which there are currently no feasible commercial alternatives in the countries Instructor Smeitinkg in a role play with students Remmy Sichula (ZACL), or sub-regions where the events are held. Capt. Phil Lemba (Proflight Zambia) and Nicole Kayirangwa (Rwandair) More information on page 21. Edition 22 - 2017



SafetyFocus Africa’s safety magazine Editor & design - Tom Kok Contributors Annette Shaw, Quintin Cairncross, Chris Sorenson EDITORIAL REVIEW BOARD Hans van Dijkhuizen AviAssist Foundation Capt. Vidit Luthra Proflight Zambia Capt. Ed Pooley Flight Safety Foundation European Advisory Committee ADVERTISING SALES Let AviAssist help you organise the African market & support the work of the Foundation while bringing your brand to 42 African countries and beyond. Starting at less than € 11 per country. Contact us: SafetyFocus is distributed for free to 2 professionals per organisation in the aviation industry and government departments involved in or relevant to aviation in 42 African countries. Wider distribution in organisations to mature safety cultures is possible at attractive corporate subscription rates. SUBSCRIPTIONS Stay up-to-date on best practices and subscribe to SafetyFocus. Africa’s quarterly safety magazine right on your doorstep every quarter for a whole year. In this issue, SafetyFocus reproduced articles with kind permission of World Airnews and Aerosafety World of the Flight Safety Foundation.


No weather brief The following information provides an awareness of problems that might be avoided in the future. The information is based on final reports by official investigative authorities on aircraft accidents and incidents.

NO WEATHER BRIEF FOR VFR FLIGHT Helicopters - Bell 430. Destroyed. Four fatalities.


he flight crew did not receive a weather briefing before departing from Hyderabad, India, the morning of Aug. 3, 2008, for a 225-nm (417-km) charter flight to Raipur, with an en route refueling stop in Jagdalpur. Low visibilities and ceilings, and isolated, embedded thunderstorms were forecast for the route. The crew had filed a VFR flight plan with a requested cruising altitude of 3,000 ft direct to Jagdalpur, but shortly after departure, the PIC told ATC that they were descending to 2,500 ft because of weather, said the report by the Indian Directorate General of Civil Aviation. About 27 minutes later, the helicopter was about 60 nm (111 km) northeast of Hyderabad when ATC lost radio communication with the crew. A search was launched three hours after the flight’s estimated time of arrival at Jagdalpur. The helicopter’s emergency locator transmitter failed to activate. On Nov. 13, the wreckage was found on a hill about 140 nm (259 km) northeast of Hyderabad. The aircraft had struck the hill at 2,700 ft, about 80 ft below the top. Local villagers said that there had been heavy rain in the area when the crash occurred.


Jets - Bombardier CRJ200, CRJ700. Substantial damage. No injuries.


ecause there was lightning in the vicinity of North Carolina’s Charlotte-Douglas International Airport the afternoon of June 28, 2008, ground crewmembers were not using headsets for communication. A CRJ200 had been pushed back from a gate, and its flight crew was awaiting taxi clearance when another ground crew began to push a CRJ700, operated by the same airline, from another gate. “A wing walker was stationed at the [CRJ700’s] left wing, in plain sight of the tug driver,” the NTSB report said. “The wing walker was aware of the CRJ200, and when the pushback commenced he believed that the tug driver was only going to push the airplane about 10 ft [3 m], just enough to trigger the aircraft communication addressing and reporting system (ACARS) ‘out’ time.” When the tug driver pushed the CRJ700 beyond 10 ft, the wing walker signaled the driver to stop. The other ground crewmembers saw the wing walker signaling the driver to stop, and one of them ran toward the driver, trying to get his attention. “He stated that the tug driver was focused on the cockpit of the airplane and was directing the starting of the airplane’s no. 2 engine,” the report said. The wing walker “continued to attempt to alert the tug driver; however, the tug driver did not observe the wing walker before the tail section of the CRJ700 struck the tail section of the CRJ200,” the report said. “The empennages of both airplanes

were substantially damaged.” There were no injuries to the 48 people aboard the CRJ200 or to the 64 people aboard the CRJ700.


Piston engines - Beech 58 Baron. Destroyed. No injuries.


hortly after departing from a private airport in Thabazimbi, South Africa, the afternoon of Jan. 17, 2009, the pilot and the five passengers heard a loud banging noise coming from the right side of the aircraft. “The pilot observed the engine indication parameters, and they were normal,” said the report by the South African Civil Aviation Authority. However, as the aircraft continued to climb, the noise became louder. “The pilot then switched off the righthand engine [and feathered the propeller] because he thought it was problematic,” the report said. As the pilot turned back to the airport, he told the passengers to ensure that their restraints were fastened. “One of the passengers, seated on the copilot’s seat, realized that he had not been strapped in [and that] his seat belt and buckle were hanging out of the aircraft and were the source of the noise,” the report said. The pilot attempted unsuccessfully to restart the right engine. “The aircraft started yawing to the right … and became uncontrollable,” the report said. “The aircraft was turning toward the dead engine. The pilot looked for a safe landing area but ran out of time, as the aircraft was descending very quickly.” The Baron was destroyed when it struck terrain, but no one aboard was hurt. SafetyFocus Magazine

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Edition 22 - 2017



From lagging to leading Zambia hosts international safety champions to support maturing of Africa's safety cultures


he African aviation professional society met by the shores of the might Victoria Waterfalls in Zambia on 24 and 25 November. Until mid-last year, Zambia found itself on the EU aviation safety list but the hosting of Africa’s premier aviation safety conference was clear proof of the fact that it aspires to move from a lagging safety promotor to a leading safety promotor. This year, the African aviation society was invited to submit papers for presentation at the 88

conference. The submissions were peer reviewed by the Conference Agenda Development Committee (CADC). Enabling African professionals to submit papers supports the maturing of safety promotion in Africa through improved research and presentation skills. The CADC is made up of distinguished safety experts from across Africa and the globe and reviews the papers for what the conference participants could learn from them and what skills

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will they gain or enhance by attending the presentation and conference. Safety management systems in Africa are now starting to tackle the harder part of maturing safety cultures. Following a period of SMS manual production throughout the continent, numerous organisations and companies are now working hard on maturing safety cultures, addressing human factors, investigating incidents,

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CONFERENCE | REVIEW measuring safety performance and encouraging behavioral changes. MEASURING SAFETY PERFORMANCE Rob Somers from 22 Degrees South Aviation in South Africa spoke about measuring safety performance improvements with a specific focus on helicopter operations. Somers presented on improving the effectiveness of your safety improvement process by changing the way those improvements are measured. Measuring performance improvement is an important part of any management process and forms the basis for continuous improvement. Measuring safety performance is no different and effectively doing so will strengthen the success of an organisation’s improvement efforts. “Finding the perfect measure of safety is a difficult task“, Somers explained. “What you want is to measure both the bottom-line results of safety as well as how well your facility is doing at preventing accidents and incidents. To do this, you will use a combination of lagging and leading indicators of safety performance. Overall, you could say that lagging indicators are typically “output” oriented, easy to measure but hard to improve or influence while leading indicators are typically input oriented, hard to measure and easy to influence”.

© Anton Balazh/

Somers detailed how lagging indicators measure a company’s incidents in the form of past accident statistics. Examples include injury frequency and severity, lost workdays & worker’s compensation costs. “Lagging indicators are the traditional safety metrics used to indicate progress toward compliance with safety rules. They tell you how many people got hurt and how badly. But using only lagging indicators has a major drawback. They tell you how about frequency and severity of incidents, but not how well your company is doing at preventing incidents and accidents. The reactionary nature of lagging indicators makes them a poor gauge of prevention. For example, when managers see a low incident rate, they may become complacent and put safety on the bottom of their to-do list, when in fact, there are numerous risk factors present in the workplace that will contribute to future incidents. “The other option, when it comes to safety performance indicators, is measuring activities carried out to prevent and control injury. Examples include safety training, employee perception surveys & safety audits. You want to SafetyFocus Magazine SafetyFocus Magazine

use leading indicators because they are focused on future safety performance and continuous improvement. These measures are proactive in nature and report what employees are doing on a regular basis to prevent incidents and injuries. Companies dedicated to safety excellence are shifting their focus to using leading indicators to drive continuous improvement. Lagging indicators measure failure; leading indicators measure performance, and that’s what we’re after!” Somers underlined. “It’s important to make sure that leading indicators allow you to see small improvements in performance and measure the positive: what people are doing versus failing to do”. INCIDENT INVESTIGATION Jan Smeitink of Amsterdam Airport Schiphol spoke passionately about improving incident investigation in the region. “Popular TV programs like Air Crash Investigation give a very one-sided look at investigations and focus on major crashes”, Smeitink explained “But the majority of investigations that an aviation operator needs to undertake, look at incidents and safety occurrences. As investigations are often carried out by a single person, the organization should ensure that investigators possess the necessary skills, experience and support to carry out their duties. One of the most striking aspects of many formal accident investigation courses is that the bulk of such courses are not relevant to investigators with aviation operators. Also, courses often are out of the financial reach of smaller operators and those, who it could be argued, may need it most. Yet, at the same time, effective safety management systems largely depend on the quality of the investigation of reported incidents and safety issues.” In his presentation, he gave an overview of the system as it has been laid down in Annex 13 to the Chicago Convention

Edition - 2017 Issue 22 22 - 2017

that forms the basis for the work of the International Civil Aviation Organization ICAO. “It is quite important that investigators get a formal incident investigation course, which will also give them a clear understanding of ICAO Annex 13,” Smeitink underlined. He spoke of the valuable lessons that can be learnt from reports of other incident investigations and of an industrywide underestimation of the importance of well performed incident investigations and quality report writing. “In the ideal case, new investigators will work along an experienced investigator for some time to learn about investigative techniques,” Smeitink suggested. “That way they will see the practical side of recognizing a serious incident, of how to write a report that supports effective recommendations and develop a sense of when risk should be mitigated”. Next to those skills, interpersonal skills are also crucial as the investigator will most likely have to conduct interviews and perhaps even manage a small investigation team. Lastly, I would like to stress the value of investigators involving the aircraft manufacturers as they often take a keen interest in the reputation of their equipment, “ Smeitink concluded. MANAGING CHANGE DURING GROWTH Rwandair shared its experience with managing safety during times of unprecedented growth. “We are implementing major growth plans to strengthen our

ICAO Regional Director Barry Kashambo opened the conference and expressed ICAO's appreciation for the work of the AviAssist Foundation

9 9

CONFERENCE | PREVIEW identify bottlenecks. The action register items would be classified as Green for ‘on track’, Amber (slight delay - monitored as agenda item for next meeting) and Red. Items classified with a red traffic light might actually hamper safe progress and were escalated to weekly executive committee (ExCo) meetings that were spearheaded by the CEO for strategic decision making. Aeroportos de Moçambique's Manuel Vieira passionately sharing ADM's airport wildlife management experience

fleet from 8 to 12 aircraft,” Rwandair’s safety manager Hellen Ndichu explained. “As we meet here for Africa’ safety conference, Rwandair is in the process of introducing two brand new Airbus A330s into our fleet. The expansion represents a 50% increase in available seats. Our growth plans also signify the start of the airline moving from regional to intercontinental operations. We are keen to share with the industry how we uphold safety during such remarkable growth”.

PERFORMANCE BASED NAVIGATION - PBN Aircraft manufacturer ATR spoke about the benefits that performance based navigation or PBN can bring to the region. Though statistically turboprop aircraft appear to be less safe, it became clear that hidden in those statistics is that turboprop aircraft play a key role in opening new routes. Those new routes include lots of destinations for which the national authorities still haven’t designed precision approaches with vertical guidance. “Regional turboprop aircraft play a key role in drawing new destinations into the global web of air connections” ATR’s Regional Flight Safety Director Geraud de Rivals de Mazere explained. “The turboprop statistics

Rwandair's safety manager Hellen Ndichu sharing the balance between change management & safety

Ndichu summarized the three main challenges that they came across as an organization. “Firstly, time constraints to achieve the change per the desired start of operations. A second challenge was getting robust regulatory guidance in a country where no wide body aircraft has been on the register in recent times. Our the third challenge was keeping operations of the airline running versus devoting sufficient resources (human and financial) to project management to manage the implementation of the project” Ndichu stressed that any change, even a change for the better, is always accompanied by hazards and this affects the safety of an organization. “The greatest danger in time of change is not the change – it’s to act with yesterday’s logic,” Ndichu explained. “We needed practical tools to manage our change. These included what we called the RwandAir Change Train for our change management with its three stages. Another instrument we used was the logging of meeting actions in an action register checklist”. Ndichu explained with traffic light indicators that the airline used to make progress visual and easily 10

ATR's Regional Flight Safety Director Geraud de Rivals Mazère presence underlined the importance that manufacturers attach to the conference for client engagement

hide that. To many of those destinations, you wouldn’t be able to operate jet aircraft because of their limitations in flying to such more remote airports. You have to ask yourself what the statistics would look like if you would operate a jet-engined aircraft to those new markets in Africa.” That is why operators such as ATR are keen to work with authorities in supporting the development of Performance Based Navigation procedures into such airports so these authorities can obtain those same safety benefits at those airports. Rivals de Mazere provided an interesting insight into what opportunities such PBN approaches can bring to secondary markets in Africa’s hinterland. FROM KNOWLEDGE TO ATTITUDE CHANGE Human factors expert Frank Klap closed the conference with his observations as a relative newcomer in the African professional culture. Klap has been responsible for human factors training in among others air traffic control organisations for well

over 25 years. Since late 2015, Klap has been running a number of human factors courses for the Foundation in Africa which he combined with some travelling in the margins of those courses. He shared his early experiences in relation to the preparedness to change attitudes. “We work on Knowledge, Understanding & Skills but do we pay enough attention to a change in the Attitudes of trainees? “ Klap wondered. “In a lot of the training that we provide in our industry, we could perhaps pay more attention to that last letter of the KUSA mnemonic- the letter ‘A’”. The mnemonic KUSA relates to the famous Bloom taxonomy of learning that classifies educational learning objectives into those four categories, namely Knowledge, Understanding, Skills & Attitude. ‘The “When speaking of safety, it Foundation is just as important to have the correct attitude as it is to provides this have the correct knowledge platform to and skills,” Klap elaborated. “That is, when I go to work help African on an airport platform full of heavy equipment, I want safety cultures my fellow partners to dis- mature.’ play not only the correct behavior, but to also have an attitude towards safety. My ability to come home in one piece depends upon it! Perhaps the time is there for the African aviation safety community to increase the focus on changes in attitude? After all” an ‘Easy does it’-attitude may not work if you want to perform aviation operations against global safety standards. Tools to effect the required attitude changes do exist and include human factors training, nontechnical skills programs, Crew Resource Management & Team Resource Management training as well as giving formalized feedback to colleagues in an organization. Setting up such programs is not always easy and often need a strong internal champion from someone who knows the organisation's culture”. AFRICA'S HARAMBEE FOR SAFETY With participants and speakers drawn from Mozambique to Ghana to Rwanda and Botswana, the conference once again provided a fantastic update on numerous hot topics in aviation safety. The next edition of the Safety in African Aviation (SiAA) Conference will be hosted by Rwandair on 18 & 19 March 2018 in Kigali, Rwanda. NOTE: All presentations of the 2016 (and the 2015) edition of the conference can be found on under the ‘programs and docs’ tab.

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SafetyFocus Magazine

Edition 22 - 2017



Inadequate follow-ups failed to identify the maintenance error cited in the crash of an AS350 on an EMS positioning flight, the NTSB says. BY L I N DA W E R F E L M A N



n improperly installed part was to blame for the engine failure and subsequent crash of a Eurocopter AS350 B3 during an emergency medical services (EMS) positioning flight in Tucson, Arizona, U.S., on July 28, 2010, the U.S. National Transportation Safety Board (NTSB) says. The pilot and two medical personnel were killed when the helicopter, which had been cruising at 800 ft, entered a rapid descent and struck a 5-ft-high (2-m-high) concrete wall. The wall penetrated the fuselage and the fuel tank. The helicopter, operated by Air Methods as a LifeNet flight, was destroyed by the impact and subsequent fire. In its final report on the accident, the NTSB said the probable causes were that “the repair station technician did not properly install the fuel inlet union1 during reassembly of the [Turbomeca Arriel

2B1] engine, the operator’s maintenance personnel did not adequately inspect the technician’s work, and the pilot who performed the post-maintenance check flight did not follow the helicopter manufacturer’s procedures.” Other causes were the “lack of requirements by the [U.S.] Federal Aviation Administration [FAA], the operator and the repair station for an independent inspection of the work performed by the technician,” the report said. The report also identified as a contributing factor the FAA’s “inadequate oversight of the repair station, … which resulted in the repair station performing recurring maintenance at the operator’s facilities without authorization.” The accident flight originated at 1342 local time at Marana Regional Airport in Tucson, where the helicopter had undergone engine maintenance; the SafetyFocus Magazine

Photos: Jim Kuhn/Wikimedia and © Les Cunliffe/

Installation Error



planned destination was the Air Methods base in Douglas, about a 55-minute flight to the southeast (Figure 1). About six minutes after departure, the helicopter began a rapid descent, which became increasingly vertical as it neared the ground. Witnesses said they heard “whump, whump” sounds and “rapid intermittent popping sounds, which were followed by unusual quietness,” before the impact. Accident investigators said that the helicopter’s descent rates, calculated by examining the last 10 seconds of radar data, “were consistent with an autorotation,” and they theorized that the pilot had tried to conduct an autorotative approach to an open intersection about 300 ft (92 m) beyond the accident site but was stymied by a row of power lines 40 ft (12 m) above the ground; the helicopter’s rotor speed decreased as the pilot maneuvered over the power lines, and the helicopter plunged to the ground.

failure emergency procedures and autorotations,” the report said. “However, because the engine failed suddenly at low altitude over a congested area, more recent training may not have changed the outcome.” The airframe and powerplant technician who worked on the accident helicopter had worked for Helicopter Services of Nevada (HSN) since September 2009 as director of maintenance for Turbomeca engines, supervising the work of four mechanics. He previously worked at Turbomeca for 23 years and completed initial Level 32 Turbomeca training in 1998. Most of the work performed by the HSN technicians was field work — repairs and Level 3 maintenance — through a contract with Turbomeca. Air Methods was founded in 1980 and now conducts helicopter EMS operations in 45 states. It acquired LifeNet in 2002.


The company’s pilot training program says that recurrent training should include four hours of ground training for visual flight rules (VFR) operations and INSPECTIONS another four hours for instrument flight After the engine was reassembled, rules (IFR) ground training, and recomAir Methods maintenance personnel mends at least two hours of VFR flight installed it in the helicopter. The HSN training and four hours of IFR flight technician inspected his own work, as he training. was authorized to do, and Air Methods “However,” the report said, “an personnel inspected the engine after it instructor can recommend a flight test was installed in the helicopter but did not before the completion of the recominspect the HSN technician’s work. mended hours.” Company check airmen told accident investigators that around the time of the This story continues on page 16 accident, each pilot underwent a training flight every six months. A training flight typically Track of Accident Flight included standard commercial maMarana Regional Departure point neuvers, various Airport approaches and landings, engine failures, simulated hydraulic system failures, instrument flight and an instrument approach, and conAccident site cluded with “three to five practice autorotations … [which] terminate Source: U.S. National Transportation Safety Board

The 61-year-old pilot had more than 13,900 flight hours, including 9,465 hours in helicopters, 4,500 hours in single-engine airplanes and 100 hours of instrument time. He had a commercial pilot certificate, with ratings for singleengine land airplane and rotorcraft-helicopter, along with an instrument rating for both airplanes and helicopters. He was hired by Rocky Mountain Helicopters, later acquired by Air Methods, in 2002, after he retired as a pilot for the U.S. Border Patrol. He previously had flown for the U.S. Army. He completed AS350 transition training with Aerospatiale (now Eurocopter) and was qualified as pilot-in-command in 1989. He received training in the AS350 B3 in August 2002. He received satisfactory grades in all portions of his most recent competency/proficiency check, conducted in September 2009. The accident report said that a review of his training records for the previous four years showed 11.3 hours of training and proficiency check flights but no training flights after September 2009 during which he would have practiced autorotation. “The lack of recent autorotation training/practice, although not required, may have negatively impacted the pilot’s ability to maintain proficiency in engine

in a 3- to 5-ft hover power recovery,” the report said.


The accident helicopter was manufactured in 2009 and purchased by Air Methods the same year. When the accident occurred, it had accumulated 352 hours total time. The most recent maintenance was a 20-hour engine inspection performed the day before the accident. The inspection followed work that was done on the helicopter because of fuel coking — a problem involving carbon deposits on the injection manifold3 that does not affect flight performance but can interfere with engine starting, the report said. Replacement of the injection manifold is categorized as Level 3 maintenance, and because Air Methods maintenance personnel were authorized for only Level 1 and Level 2 maintenance, the replacement was performed by the HSN technician. The HSN technician then reassembled the engine, including the fuel inlet union (Figure 2).

Figure 1 SafetyFocus Magazine

Edition 22 - 2017



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Edition 22 - 2017



“In interviews with the Air Methods mechanics and HSN technician, they all reported feeling a sense of pressure to complete the maintenance and return [the accident helicopter and a second Air Methods helicopter with a similar coking problem that required attention at the same time] to service,” the report said. During an initial ground test, a leak from the engine hydromechanical unit was identified, and then repaired. After that, a duty pilot performed a 7.5-minute post-maintenance check flight, which included several flight checks — but not the four post-maintenance checks specified in the AS350 B3 Flight Manual. There were no records from the check flight. The report noted that the American Eurocopter chief pilot said that the four checks specified by the flight manual typically are completed in 30 to 45 minutes. The duty pilot who conducted the check flight said that he had never received training on how to conduct a post-maintenance check flight and that any company pilot who was qualified in the model was permitted to perform check flights.

A duty pilot performed a 7.5-minute postmaintenance check flight.


An examination of the engine at the accident site revealed that the fuel inlet union, on the lower right side of the engine, had separated from the boss on the compressor case but was still attached to the fuel supply line and the hydromechanical unit. During a search of the area, there was no sign of two

Fuel Supply Routing Flange External fuel supply line

Compressor case

Gasket O-rings Fuel union



five-point bolts and self-locking nuts used to mount the union to the compressor case flange, the report said. The accident investigation found no indication of pre-existing airframe failure.


As part of the investigation, a series of engine test runs were performed on another Arriel 2B1 engine at Turbomeca facilities in Bordes, France, under the supervision of the Bureau d’Enquêtes et d’Analyses, to “assess the engine’s operating abilities with the fuel inlet union incorrectly affixed to the engine case flange.” During these test runs, the fuel inlet union was partially attached to the compressor case flange in several configurations, with the attachment nuts and bolts either hand-tightened or, in some cases, omitted; the engine was operated at power levels to simulate engine startup and flight. “The data revealed that, with the [fuel inlet] union installed without its associated mounting nuts and bolts, it was possible to start and run the engine with no observable fuel leak,” the report said. “During the test with the union nuts and bolts tightened by hand, the engine ran for three minutes and 32 seconds before the nuts began to unscrew from the bolts. “The tests further revealed that, with both nuts and bolts removed, the union would ultimately eject … , resulting in an expulsion of about 0.5 L [0.1 gal] of fuel, followed by a subsequent engine shutdown.” The report said it was “likely that the technician did not tighten the bolts and nuts securing the union with a torque wrench and only fingertightened them.”


Any of several procedural requirements might have identified the problem before the accident flight, the NTSB said. Neither the operator nor the repair station had implemented procedures for an independent inspection of the maintenance technician’s work, and no such procedures were required by the FAA. The report noted that requirements are stricter for Federal Aviation Regulations (FARs) Part 135 (“Commuter and On-Demand Operations”) operators with aircraft equipped with at least 10 passenger seats. Regulations say that, for those aircraft, “No person may perform a required inspection if that person

Source: U.S. National Transportation Safety Board

Figure 2 16

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performed the item of work required to be inspected.” If an independent inspection had been conducted, the NTSB said, it “may have detected the improperly installed fuel inlet union.” The report also noted that the FAA’s principal maintenance inspector (PMI) for HSN had revoked the company’s authorization to perform work outside its primary location in 2008.

at locations other than its primary fixed location even though this practice was not authorized.”

“However, the Repair Station Manual was not updated to reflect this change, and the PMI did not follow up on the change, nor did he log the change in the FAA’s tracking system,” the report said. “The PMI was unaware that, in the year before the accident, the repair station had performed work for the operator at locations other than the repair station’s primary fixed location at least 19 times. “The FAA’s inadequate oversight of the repair station allowed the repair station to routinely perform maintenance

“Because the helicopter would not have been operating near its maximum gross weight and the check flight would have been conducted over an open area, the pilot would have had greater opportunities for a successful autorotative landing,” the report added. 


In addition, if — instead of the abbreviated 7.5-minute check flight — a standard full-length post-maintenance check flight had been conducted as specified by the manufacturer’s flight manual, the fuel inlet union probably would have separated then, the report said.

This article is based on NTSB accident report WPR10FA371 and accompanying documents.

1. The report described the fuel inlet union as a “body mounting flange and seal [that] provide the interface” between the tip of the internal fuel line and external fuel supply lines. 2. According to information in the NTSB accident docket, Level 3 maintenance, also known as “deep maintenance,” is defined as requiring “disassembly of a module and/or maintenance intervention.” Level 2 maintenance requires removal of an engine and/ or the separation of engine modules. Level 1 maintenance is performed without removing an engine. 3. An injection manifold is sometimes called a fuel manifold.“In interviews with the Air Methods mechanics and HSN technician, they all reported feeling a sense of pressure to complete the maintenance and return [the accident helicopter and a second Air Methods helicopter with a similar coking problem that required attention at the same time] to service,” the report said.


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Edition - 2017 Issue 22 22 - 2017

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Deadly Drift

The pilots did not realize that an engine on their Brasilia had failed during final approach. BY MA R K L AC AG N I N A



eficiencies in procedures for verifying fuel quantity and the absence in Australia of a flight simulator for emergency procedures training were among the safety issues identified by the investigation of a serious incident in which the flight crew nearly lost control of their Embraer EMB-120ER Brasilia following an engine failure on final approach. The incident occurred the morning of June 26, 2007, during a charter flight from Perth, Western Australia, to Jundee, a gold-mining community about 780 km (421 nm) northeast. The fuel quantity indicators showed that there was 1,190 kg (2,623 lb) of fuel aboard the aircraft when it departed from Perth with 28 passengers and three crewmembers at 0639 local time. “Normal fuel consumption for the flight from Perth to Jundee was in the range of 750–900 kg [1,653–1,984 lb],” said the


report by the Australian Transport Safety Bureau (ATSB). The copilot was the pilot flying. He had 1,618 flight hours, including 1,356 hours in type. The pilot-in-command (PIC) had 3,040 flight hours, including 649 hours in type. Neither pilot had flown turbine aircraft before they began training in the Brasilia. The weather at Jundee was clear with light northerly winds. Jundee Airstrip was privately operated and had a 2,095-m (6,873-ft) gravel runway oriented eastwest. The crew began a straight-in visual approach to the airstrip at about 0800. The Brasilia was in landing configuration and about 400 ft above the ground when the left engine flamed out because of fuel starvation. The aircraft drifted left of the runway centerline, and the copilot applied normal yaw and roll corrections. The drift continued, and the copilot told the PIC that the aircraft was not


responding to his control inputs. The PIC called for a go-around. Neither pilot realized that the left engine had failed. “When the crew advanced the engine power levers to commence the go-around, they were startled when the aircraft yawed and rolled left aggressively in response to the engine power asymmetry,” the report said. ‘SIGNIFICANT DELAY’ The copilot asked the PIC to assist him on the controls. “The crew experienced significant difficulty in controlling the aircraft’s attitude and airspeed,” the report said. The stick shaker activated twice as airspeed decreased from 110 kt to 96 kt. The Brasilia turned 45 degrees left of runway heading, with bank angle increasing to a maximum of 40 degrees. Several enhanced ground-proximity warning system warnings were generated SafetyFocus Magazine

CAUSAL | FACTORS as the aircraft came within 50 ft of the ground. “There was a significant delay before the crew configured the aircraft appropriately for one-engine-inoperative flight,” the report said. Nearly four and a half minutes elapsed between the crew’s initiation of the go-around and their retraction of the flaps and landing gear, and feathering of the propeller. “They reported that there was an immediate and significant improvement in aircraft performance when the left engine condition lever was placed in the feather position,” the report said. After completing the go-around and the engine failure checklist, the crew diverted the flight to Wiluna, about 42 km [23 nm] southwest of Jundee. They landed the aircraft without further incident at 0818. EMPTY TANK Examination of the aircraft revealed that the fuel quantity indicators showed 300 kg (661 lb) remaining in the left tank and 150 kg (331 lb) Paul Morley/ in the right tank. “A physical check revealed that the right tank contained 150 kg of fuel and that the left tank was empty,” the report said. The inaccurate fuel indication was traced to the failure of a capacitance probe in the left outboard tank. The probe had been disabled by an electrical short in wiring that had been abraded from contact with the airframe. No one had noticed that the left fuel quantity indicator was reading high. “There were clear indications that the operator’s fuel quantity measurement procedures and practices were not sufficiently robust to ensure that a quantity indication error was detected,” the report said.1 “There was evidence that flight crews did not have a proper understanding of the reasoning behind the fuel quantity check procedures and the necessity for an independ­ent validation

of the fuel quantity by a totally reliable method.” A “reliable method” existed in the form of dripless measuring sticks, also called dripsticks and magna sticks. They are calibrated fuel quantity measuring devices that can be manually lowered from the wing tanks. There are eight dripsticks in the Brasilia, one for each inboard tank and three for each outboard tank. Pilots must use a table to convert dripstick readings to fuel quantity in kilograms. The report noted that the flight logs for the operator’s six Brasilias showed that the dripsticks had been used to validate fuel quantities only twice — and by the same pilot — in the three months preceding the incident. VAGUE VERIFICATION The operator had established fuel quantity verification procedures based on information contained in Australian Civil Aviation Advisory Publication (CAAP) 234-1(1), Guidelines for Aircraft Fuel Requirements. The report said that the guidelines “lacked clarity” and did not emphasize that one of the major purposes of an independent verification of fuel quantity before flight is to check the accuracy of the aircraft’s gauges. “In broad terms,” the report said, “the CAAP

allowed two options for establishing fuel on board: • “Full tanks or ‘a totally reliable and accurately graduated dipstick, sight gauge, drip gauge or tank tab reading,’ or, • “A cross-check by at least two different methods.” Neither option ensured an accurate verification of fuel quantity “in cases where a gauge was under- or over-reading by a constant amount or when there was a gradually increasing error,” the report said. Commercial aircraft rarely are operated with full tanks, as recommended by the first option, and the use of devices such as dripsticks is “not generally favored” by operators because it is time consuming and requires the aircraft to be on a level surface for accurate measurements, the report said. The operator of the Brasilia used the second option provided by the CAAP. Company pilots told investigators that they generally conducted preflight fuel checks by comparing the fuel-remaining indication on the totalizer — a gauge located on the fuel-management panel — with a calculation based on the fuel-remaining figure recorded in the flight log plus any fuel added since the previous flight.

Embraer EMB-120ER Brasilia


he EMB-120ER is the extended-range version of the Brasilia, the twin-turboprop passenger and cargo aircraft that Empresa Brasileira de Aeronáutica (Embraer) began delivering in 1985. The ER was introduced in 1991 and was the standard version until production ceased in 2000. With accommodations for 30 passengers, the ER’s maximum weights are 11,990 kg (26,433 lb) for takeoff and 11,700 kg (25,794 lb) for landing. Powered by Pratt & Whitney Canada PW118 engines rated at 1,342 kW (1,800 shp), the aircraft’s long-range cruise speed at 25,000 ft is 270 kt, and maximum range is 1,629 nm (3,017 km). Source: Jane’s All the World’s Aircraft

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Edition 22 - 2017


CAUSAL | FACTORS “A discrepancy of 60 kg [132 lb] or more between the indicated total fuel and the calculated total fuel figures required resolution to the satisfaction of the crew,” the report said. “If the discrepancy could not be resolved, then [the dripsticks] were used to confirm the quantity in the tanks.” The operator’s procedures required pilots to record in the flight log the reason for any discrepancy of 60 kg or more. The flight logs for the company’s six Brasilias showed that 68 such discrepancies were recorded during the three months preceding the incident. Pilots attributed 51 of them to “APU burn” — that is, fuel consumed during operation of the auxiliary power unit. No reasons were given for the remainder of the discrepancies. Discovering technical failures such as malfunctions of fuel quantity indicating systems requires procedures for verifying fuel quantity that are “well designed, fully understood and properly conducted by the users,” the report said. “In this occurrence, none of those criteria were present.” The report noted that after the incident, the Australian Civil Aviation Safety Authority (CASA) “initiated a project to amend the guidance [in the CAAP] to provide better clarity and emphasis.”

On. Sept. 23, 2005, a low-fuel warning light for the left tanks in a Fairchild Metro III illuminated during a flight with 16 passengers from Thangool to Brisbane. The crew believed it was a false warning because the gauge showed sufficient fuel, but they diverted the flight to Bundaberg as a precaution. The left engine flamed out as the Metro neared the airport, but an uneventful landing was conducted. Investigators found that the fuel quantity indicating system had not been recalibrated properly during maintenance performed before the incident flight.4 “In each case, the practices used by the flight crew to establish fuel quantity before flight did not detect erroneous fuel quantity indications,” the report said. “The operators involved subsequently amended their procedure to include physical (e.g., dripstick) checks as a mandatory part of the procedures for establishing the quantity of fuel on board the aircraft.” The report said that the incident at Jundee likely would not have occurred if the crew had used the dripsticks to verify fuel quantity before takeoff, or if the Brasilia had been equipped with an independent low-fuel-level warning system, which was not required by certification or operating standards.

SIMILAR INCIDENTS The report discussed three other incidents in which similar fuel-related engine failures occurred recently in Australian-registered commercial aircraft. On Oct. 18, 2007, a Cessna 404’s right engine lost power during a charter flight with three passengers from Beverly to Adelaide. The pilot landed the aircraft at Adelaide without further incident. The ATSB investigation determined that faulty wiring had caused the fuel quantity indicator to over-read.2 On Feb. 5, 2007, the crew of a Boeing 747-300, en route on a positioning flight from Jakarta, Indonesia, to Melbourne shut down the no. 3 engine after noticing that the boost pump low-pressure warning light had illuminated and the fuel quantity indicator for the no. 3 tank was reading zero. The crew continued the flight to Melbourne and landed without further incident. Investigators determined that an electrical problem and/or water contamination had caused the fuel gauge to malfunction.3

‘UNABLE TO FUNCTION’ Neither of the Brasilia pilots had previously experienced a power loss on short final approach. The aircraft’s behavior after power was increased to initiate the go-around at Jundee likely appeared to be “abnormal and without reason,” the report said. “It was likely that the aircraft’s behavior alarmed and focused each crewmember to the extent that they were unable to function effectively as a unit in the areas of decision making and task sharing. There was a delay in the crew’s diagnosis of the situation. The aircraft was at or near the limits of its performance envelope for a significant period after the go-around was initiated.” A flight simulator is the only means of safely training for critical emergencies such as an engine failure on approach, the report said. “Importantly, in addition to being exposed to the full range of emergency situations, pilots are able to practice crew coordination in those situations.”


However, there was no Brasilia flight simulator in the country when the pilots were in training, and CASA did not require simulator training. “At the time of the occurrence, there were 22 EMB-120 aircraft on the Australian civil aircraft register,” the report said. A Brasilia flight simulator was installed in the Ansett Aviation Training facility at Melbourne in March 2009. “Subsequently, under the guidance of CASA, all Australian EMB-120 operators began conducting flight crew endorsement [training] and some recurrent training in the simulator,” the report said.  This article is based on ATSB Transport Safety Report AO-2007-017, “Fuel Starvation, Jundee Airstrip, WA — 26 June 2007, VH-XUE, Empresa Brasileira de Aeronáutica S.A., EMB-120ER.” NOTES 1. Media reports identified the operator as Skippers Aviation. 2. ATSB Report AO-2007-049 (ASW, 6/09, p. 61). 3. ATSB Report BO/200700368 (ASW, 10/08, p. 57). 4. ATSB Report BO/200504768 (ASW, 1/08, p. 60).

The incident likely would have been avoided if the aircraft’s dripsticks had been used to verify fuel gauge readings.

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Edition 22 - 2017 Edition 19 - 2016



In an emergency, pilots should be able to talk directly to ARFF as well as ATC.




n incident involving an Airbus A330 at DĂźsseldorf, Germany, demonstrates the advantages of an advanced emergency communication (ERCOM) system.1 While the aircraft was in flight, the captain declared an emergency because of a fire at door 2 left. The first officer independently called the aircraft rescue and firefighting (ARFF) unit, which also was alerted by air traffic control (ATC) because of the declared emergency. The ARFF unit prepared accordingly. Agreements were made about where the aircraft would stop after it landed and the preparations to be made by the flight crew. After the aircraft landed, the ARFF unit was able to immediately approach the affected door from outside with an infrared 22

camera and report directly to the flight crew that there was no longer a fire. Following the incident, the captain said the information from the ARFF unit contributed to an easing of tension and to his decision not to conduct an evacuation. Also, he recommended that ATC should inform flight crews about the possibility of communicating with ARFF, which a flight crew might overlook because of the stress level. The first officer said that, because of the presence of ARFF personnel and equipment around the aircraft, it would have been necessary to inform ARFF before performing an evacuation, because of the dangers to firefighters from deploying evacuation slides. GERMAN TEST SafetyFocus Magazine

Š Frank Doering/


AIRCRAFT | RESCUE The results of a German test of the introduction of a direct radio communication link between ARFF and flight crews also confirm the advantage of the advanced ERCOM. Five German airports — Frankfurt, Cologne, Düsseldorf, Hamburg and Munich — are participants in the test phase. In the first year of the test, which began in April 2010, 45 contacts were reported between ARFF and flight crews via direct radio communication. The use of an advanced ERCOM proved to be useful in various abnormal situations. In July 2012, the Feuerwehrfrequenz (the German word for emergency communication frequency) finished the first test phase. The frequency is 121.550 MHz. The airports are currently only operating the system in the German language in a field trial with nominated airlines. Communication management is essential in safe air traffic coordination and ARFF operation. The operation, transmission and receiving of information are based on coordinated standard procedures, phraseology and language, which influence the decision-making processes of the participants. This also applies to an emergency on the ground, when an advanced ERCOM enlarges the circle of involved parties. No longer is it just from flight crew to ATC. Now the loop consists of flight crew, ATC and ARFF. In this new and dynamic situation, quick and reliable information is an advantage for all participants and improves safety, preserves equipment and reduces costs.

A test of advanced emergency communication demonstrated its advantages, but procedures need more work.

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TOWARDS INTERNATIONAL STANDARDIZATION? Despite all the safety developments in aviation, there has been no real progress toward widespread adoption of an ERCOM, though several studies and accident reports have recognized its advantages. In 1998, the U.S. National Transportation Safety Board (NTSB) published a safety recommendation that says, “The [U.S.] Federal Aviation Administration (FAA) should establish a designated frequency at all airports certified under [U.S. Federal Aviation Regulations] Part 139 that allows direct communication between ARFF personnel and flight crewmembers.”2 Even within states, the levels of emergency communication facilities differ. For example, in Switzerland, only Zurich airport, which is used by commercial air traffic, offers the possibility of a direct radio communication link between ARFF and a flight crew, and the service is available in German only. This results in different levels of emergency communication standards and procedures, the majority of which are not as efficient as possible. Only two states — the United Kingdom and Australia — were identified as having a countrywide direct communication link between flight crews and ARFF. Both countries use English as their official language, which facilitates the communication. Edition 22 - 2017

The most widely used ERCOM system routes all communication through ATC — a system I call the communication triangle (Figure 1, p. 24). The triangle system fulfills the minimum task of integrating the acting parties. However, the system involves weakness for all participants. The indirect connection between ARFF and flight crew decreases the speed of information flow and increases the possibility of information being misunderstood. Additionally, ATC has to coordinate traffic, besides conveying emergency information. Both tasks take place on the same radio frequency. However, ATC cannot be excluded from the communication triangle, because it is in contact with all resources. As the airport’s traffic coordinator, it needs to be aware of the situation and its development. It has to remain a part of the information exchange without creating additional problems. The principle of direct communication between ARFF and the flight crew is not new, but there exists no standard for the content or requirement for direct communication in an emergency. Based on analysis of incident reports, the German test of this system proved an advanced ERCOM highly effective in the accomplishment of the rescue mission. It allows a more efficient rescue operation through a faster information exchange between ARFF and the flight crew (Figure 1). The system keeps ATC in the communication loop but in a passive position. This means that the ATC frequency and involved personnel gain more communication capacity by transferring the ERCOM voice transmissions to a separate radio frequency. The standard airport traffic frequencies remain unaffected. As a backup, it is still possible to return to the communication triangle via ATC if necessary. Technically, the system is easy to integrate and can be used with existing equipment. The biggest investment in training and radio equipment has to be made by the ARFF unit. Both ARFF and flight crews profit from the improved information exchange, which is more flexible and faster. Both ARFF and flight crews have access to first-hand information about the external and internal condition of the aircraft. This allows them to more quickly get the total picture and coordinate their next steps. Coordinated measures reduce environmental dangers. Running engines and the unexpected activation of evacuation slides with ARFF personnel nearby pose serious risks for ARFF. Coordination also helps to avoid situations where specific aircraft procedures require completing certain steps, such as engine shutdown and setting flaps, before external arrangements are made. 23

AIRCRAFT | RESCUE Similar dangers, involving proximity to ARFF heavy equipment and extinguishing devices, exist for passengers during and after evacuation.3 Those dangers are reduced by an agreement about evacuation speed.

Both ARFF and flight crews have access to first-hand information about the external and internal condition of the aircraft.

REALISING BENEFITS OF CONTROLLED EVACUATION Controlled evacuations, which are conducted less quickly when there is no immediate danger, pose less injury risk than normal evacuations. In the Airport Cooperative Research Program report, Evaluation and Mitigation of Aircraft Slide Evacuation Injuries, ARFF personnel noted that when there is no imminent danger, coordination between the flight crew and ARFF personnel is needed to control the flow and speed of passenger evacuation.4 The analysis of the 45 communication events through DFS, the German air navigation service provider, highlights the advantages identified under actual emergency conditions for the fast establishment of a direct communication link between ARFF and flight crewmembers (Table 1).5 Affected flight crews repeatedly said they welcomed the existence of such a system. A direct information exchange about the situation and the actions taken avoided four evacuations. In two of these cases, a hydraulic failure and a cabin smoke incident, ARFF and flight crews maintained the communication even as an aircraft taxied toward the parking position. Problems that appeared during the test highlight the need for regular inspection of the ARFF radio equipment, the development and publication of standard procedures and the examination of airport radio coverage characteristics. During the test phase, radio equipment failure and the inability to select required frequencies sometimes remained unnoticed, which led to a correction of the daily equipment check procedure. Too much noise in the ARFF vehicle hindered the communication and

even led to missing a flight crewmember’s call. ARFF vehicles were equipped with up to five different radio frequencies, selected by a single switch. As a consequence, a change in the method of activating radio frequencies and a volume control feature are being reviewed. Being unfamiliar with ERCOM standard procedures led to a delay in ARFF alerting, because the flight crew had used only the ERCOM frequency for an initial call. Unclear rules of responsibility caused frequency congestion, as different ARFF units tried to establish contact with the flight crew on the ERCOM frequency. This highlights the need for clear responsibility and a planned, coordinated procedure at bigger airports that have more than one responding ARFF unit. Frequency overlapping was identified as a problem at Hamburg, which hindered communication there.6 During the tests, no language problems were reported. Because the test was conducted in German and involved only German airlines, using the local language posed no difficulties to the participants. In the future, the goal is to make ERCOM available to all airlines and expand it to more airports. A sufficient level of English language knowledge and an understanding of multi-language communication principles will then be necessary. COST BENEFIT ANALYSIS The investment necessary for installation and operation of an advanced ERCOM system is small compared with the benefit. Because the system uses existing radio equipment installed in the cockpit, no investment is necessary for airlines. To comply with International Civil Aviation Organization standards and recommended practices, the necessary technical equipment to record the emergency communication is included in the investment calculation. The

Standard Versus Advanced Emergency Communication

The Communication Triangle

Advanced Emergency Communication System

Source: Florian Grosch

Figure 1 24

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AIRCRAFT | RESCUE recording not only serves as evidence for accident/incident investigations, but also is helpful for ARFF training and analysis. Depending on the equipment already installed as well as technical capabilities, the task of ERCOM recording can be taken over by ATC. ARFF has the highest proportion of the costs. It has to invest in training and equipment. The head of ARFF Stuttgart calculates costs of €15,000–€20,000 (US$19,000–$25,380) for acquisition, installation of radio and a suitable recording system. A further €5,000 (US$6,345) is estimated for English language training of ARFF personnel.7 Although the advantages of an advanced ERCOM system are known and confirmed through accident/incident reports and studies, it must become clear to decision makers that advanced ERCOM, if applied efficiently, can offer greater safety for people, protection for equipment and lower costs.  Florian Grosch is an Airbus captain and a member of the German Pilot Association (Vereinigung Cockpit) Accident Analysis and Prevention

Committee. He has an M.Sc. degree in air safety management from City University, London.

NOTES 1. Incident: Air Berlin, A33‑3 at Düsseldorf, Aug. 15, 2011, fire on board, <avherald. com/h?article=44528d0c&opt=0>.

Advanced ERCOM System Incidents During Test at Five German Airports Number of Incidents

Percentage of Total

Landing gear



Fire/fire report



Smoke in the cockpit



Hydraulic failure



Smoke in the cabin



4. Airport Cooperative Research Program (ACRP), Report 2, Evaluation and Mitigation of Aircraft Slide Evacuation Injuries. Washington, D.C., 2008, p. 19.

Engine failure



Bird strike



Fuel leak



5. DFS, Presentation Feuerwehrfrequenz, May 2011.

Flight control



Rejected takeoff



6. Telephone interview with ARFF Hamburg, June 11, 2011.






2. NTSB, Safety Recommendation A98-4142, June 25, 1998. 3. ARFF Frankfurt, German Commercial Pilot Forum, Frankfurt am Main, Germany, March 28, 2011.

7. Rudloff, A., head of ARFF Stuttgart, via email, June 9, 2011.

Reason for Communication


ERCOM = emergency communication Source: Florian Grosch

Table 1

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Edition 22 - 2017



They are different but complementary business principles.

Quality and Safety BY M A R I O P I E R O B O N


iven the evolution of the aviation safety regulatory framework in the European Union (EU), the United States and other aviation markets, in particular with regard to mandating safety management systems (SMSs), it is important to reflect on the principles of quality and safety, to understand what each has to offer to an aviation operator’s bottom line, and to reflect on the future of aviation management systems. Before beginning, it is best to clarify the terms under consideration. “Quality,” as defined by the International Organization for Standardization (ISO) standard 9000:2005,1 is “the degree to which a set of inherent characteristics fulfils requirements.” “Safety,” as defined in the International Civil Aviation Organization (ICAO) Safety Management Manual,2 is “the state in which the possibility of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and safety risk management.” 26

The first thing that emerges from the definitions is that quality and safety are not the same. Quality refers to meeting requirements, and safety refers to keeping people and property from harm. The two principles are nevertheless related. Customers and regulators require certain safety requirements to be met by an air operator; therefore, a quality product is also necessarily safe. ISO standard 9001:2008 requires the implementation of a quality management system (QMS) oriented to meeting customer requirements, thus improving customer satisfaction. The scope of a QMS as required by ISO goes well beyond the compliance of an air operator with regulatory safety requirements. Many areas related to the customer experience that have little if anything to do with safety fall under the competence of a QMS as required by ISO. The European Joint Aviation Authorities (JAA), through its Joint Aviation Requirements, first promoted the compulsory introduction of quality management in airline operations in the European Union.3 Several other countries (for example, in the Gulf regions) have followed SafetyFocus Magazine

© Flashon Studio /


SAFETY | CULTURE the JAA’s regulatory efforts with regard to quality management, in many cases adopting the same regulations by simply changing their names. This is a path, however, that many important aviation markets, most notably the United States, have not followed. The European regulation that currently establishes a mandatory QMS is EU Regulation on Air Operations (EU OPS) 1.035, but it prescribes only basic quality requirements, “to monitor compliance with, and adequacy of, procedures required to ensure safe operational practices and airworthy aeroplanes.”4 In airline operations, QMSs are mandatory with only safety in mind and with no consideration for other, more strategic, business areas. SMS QUALITY PRINCIPLES In the past decade, ICAO has developed the ICAO Safety Management Manual (now ICAO Annex 19), which accounts for a key innovation: the promotion of SMSs and the provision of guidance on how to implement them. According to ICAO,2 an SMS shares many commonalities with a QMS, and specific SMS processes are nurtured by quality principles. QMSs and SMSs both need to be planned and managed; both depend on measurement and monitoring; both involve every function, process and person in the organization; and both strive for continuous improvement.2 In the safety assurance component of an SMS, the application of quality assurance principles helps to ensure that the requisite systemwide safety measures have been taken to support the organization in achieving its safety objectives.2 Although QMSs and SMSs share many common features, the peculiarities of SMSs should not be

Quality assurance is proactive — the “part of quality management focused on providing confidence that quality requirements will be fulfilled.”1 Just as the scope of QMS goes well beyond monitoring compliance with safety requirements, its inclusion in SMSs extends the scope of safety management beyond ensuring the conformance of working practices with safety requirements toward thoroughly identifying hazards, some of which are organization-specific. An SMS is therefore considerably more proactive than a QMS; furthermore, the theory that supports SMS has been developed with only safety in mind, while the theory supporting QMS has been developed with customer satisfaction in mind. Quality and safety are both fundamental for an organization to attain its corporate goals. Air operators have disparate goals, but they almost all attempt to transport passengers and/or cargo by air at a profit. The fundamental importance of safety in allowing an air operator to operate safely and profitably is unquestionable, because an airline with a poor safety record can be banned from flying to some countries and is not likely to attract many customers. As airlines are increasingly operating in commercially unregulated environments, the ability to meet customer requirements and to improve customer satisfaction is increasingly becoming the determinant of airline profitability. It is to improve its business performance that an air operator can benefit from the implementation of a QMS, without necessarily obtaining a certification. INTEGRATED AVIATION MANAGEMENT SYSTEMS Some countries (e.g., Australia and Canada) led the way to make SMSs mandatory and others followed or will follow (such as the United States and the EU). Since air operators are or will be mandated to implement another system — the SMS — it would be more efficient to implement an SMS with the intention of adopting also a more comprehensive integrated aviation management system (IAMS). An IAMS is the result of the integration of all management systems within an airline, and “describes the relationship and operational responsibility of each supporting management system within the overall enterprise.”5Air operators are complex businesses: they require multiple management systems (including several trans-organizational systems), have dispersed operations, have many technical functions requiring skilled employees, and are highly regulated and characterized by overlapping state jurisdictions.5 Within this operational complexity, inefficiencies can arise from the overlapping of different

© Chris Sorensen Photography

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underestimated. SMSs promote the achievement of high safety standards by encouraging a safety culture that considers the human dimension organizationwide and by promoting a hazard identification/risk management–based approach to safety management. In a QMS, two parts can be identified: quality control and quality assurance. Quality control is reactive — that “part of quality management focused on fulfilling requirements.”1

Edition 22 - 2017


SAFETY | CULTURE systems. If, with the appropriate approach and the appropriate culture, the numerous management systems are integrated, airlines will benefit not only from the contribution each system brings but from a smoother functioning of each system — because of the higher efficiencies generated by the integration. The systems will support one another in optimally achieving the air operator’s business objectives. TOTAL QUALITY MANAGEMENT - TQM Although air operators around the world have succeeded in offering a quality product that is highly safe and usually affordable (meeting another customer requirement: low fares), the air operators have not been rewarded for the quality of their services. The airline industry is notorious for never having paid returns to its shareholders in the aggregate. The problem of the profitability of the industry needs to be urgently targeted. For efficiency and profitability, airlines can benefit from an advanced form of quality management, total quality management (TQM). This tool goes well beyond satisfying the customer or offering quality products as required by ISO 9000.3 TQM is a management approach in which

all members of an organization participate in improving processes, products, services and the culture in which they work. 3 Airlines can benefit from TQM because it is widely agreed that the industry needs cost reduction and control, without losing the focus on product safety. TQM emphasizes, among other things, eradicating defects and waste from operations, reducing development cycle times, reducing product and service costs, and challenging quantified goals and benchmarking. 3 In implementing TQM, airlines could follow the European Foundation for Quality Management model or the U.S. Malcolm Baldrige model. The latter provides a framework for business excellence that stresses the importance of financial and marketplace performance.  Mario Pierobon is a safety management consultant and content producer. He works as an aviation safety regulations expert. His specialties include the delivering of training on safety management systems and on the European aviation safety regulations. He has worked at the International Air Transport Association in Montreal, holds a master of science degree in air transport management from City

University London and currently pursues at PhD on airside safety at Cranfield University. NOTES 1. ISO. ISO 9000:2005 Quality Management Systems — Fundamentals and Vocabulary, 2005. 2. ICAO. Safety Management Manual (SMM), Doc 9859, AN/474, second edition, 2009. 3. Buono, G. Course Book of Quality Management in Airline Operations. City University London, 2010. 4. EU Regulation No 1899/2006 of the European Parliament and of the Council of 12 December 2006. Published in Official Journal of the European Union, Dec. 12, 2006. 5. Lonsbury, S.“Integrated Aviation Management Systems (IAMS).” Presentation at City University London, May 28, 2010. Sandra Lonsbury is senior vice president aviation and aerospace practice, Aviation Risk Advisory Solutions at Marsh.


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