Organizational Threat Management – Source Skybrary

July 31, 2012 at 11:08 am | Posted in Uncategorized | Leave a comment
Operator’s Guide to Human Factors in Aviation    
Organisation
Organizational Threat Management

Briefing Note

 1   Background and Introduction

Today’s aviation world is characterised by growing integration of all professions involved, including flight, cabin and ground operations, air traffic control (ATC) and maintenance. This coexistence increases the need for a systemic view of safety management. Various types of hazards, precursors or threats contribute to operational risk, which is the product of hazard probability and severity.

The term threat in flight operations is defined as anything external that complicates pilots’ duties and requires attention and management to keep proper margins of safety. The European Working Group on Occurrences Data Analysis developed the following definitions:

  • A hazard is a condition that has the potential for causing damage to people,  property or the environment.
  • A precursor is an occurrence that remained an incident but that might recur in different conditions and become an accident.
  • A threat is a more generic term for a condition likely to cause damage to people, property or the environment, with hazards generated by catalysts or triggering factors.

Investigations often show that events with similar scenarios had occurred. Such incidents can then genuinely be called precursors. Precursors can be detected both statistically and clinically to develop effective countermeasures. Precursors should be sufficiently visible to generate operational defences for pilots and prevent accidents.

The term threat management is increasingly used to describe techniques called countermeasures. These are essential for avoiding and coping with possible internal or external threats to a flight crew, such as regaining control after loss of situational awareness.

The objective of this briefing note is to familiarise the reader with key concepts of threats and their manifestations and to review various ways to focus on threat management.

2   Defining Threats

2.1   Basic definitions

Threats in normal operations are defined as external situations, events or errors that occur outside the influence of the flight crew and must be managed. As such, these threats can be considered as expected. Such events increase the operational complexity of the flight and pose a safety risk to the flight at some level if not properly handled.

Threat anticipation is a key ingredient in crew briefings and implies discussing:

  • What have we been doing right?
  • What are our strengths?
  • What are our weaknesses?

In unfamiliar or abnormal operations, a threat can also be considered as a surprising or unexpected combination of events for which the crew is not prepared or even trained. There also are expected threats that the crew is supposed to routinely handle based on their training to face abnormal situations.

But even if a crew is trained to handle certain events, there may be no clear course of action for a combination of events. The outcome might be uncertain, and there could be a lack of established procedures to cope with developments. The crew may need more resources to master the situation safely.

When situational awareness is lost, resources might become insufficient and workload so high that the crew may become unable to monitor the developing situation. From this point of view, threat management is directly linked with loss of situational awareness.

2.2   Data: What threats need to be managed?

Active threats are expected or unexpected but observable ones that are linked with unsafe acts or inadequate defenses and are mediated by interactions with local events. Typical threats include local triggering factors that help release the hazard and local escalation factors that prevent effective control of the threat. Such factors include:

  • Environmental threats such as: adverse weather (e.g., heavy rain, thunderstorms, wind gusts, wind shear and turbulence); air traffic control (ATC) problems such as challenging clearances, runway changes, language difficulties, controller errors, similar call signs, heavy traffic and radio congestion; terrain, including high ground, topography, facilities and lack of references; and airport conditions such as snow, reduced visibility, poor braking action or runway construction.
  • Operational threats such as: airline operational pressure, including crew scheduling problems, delays, time pressures or diversion to an unfamiliar airport; aircraft problems such as loss of control and false warnings; cabin situations such as door security and sick or disruptive passengers; maintenance factors such as incorrect repairs and errors; ground-related events, including deicing, ground crew errors and fuel spills; and dispatch-related errors.

Latent threats are not directly related to a specific threat, as they are usually not seen in actual operations. Their primary origins are the fallible decisions taken by senior and line managers.

These threats are then further transmitted via other intervening precursors to the point where system defenses may be breached in daily situations and activities. For example, the time before duty either at home or on a stopover can be crucial for crew performance in flight.

Latent threats or failures concern aspects of the system that predispose the commission of errors or that can lead to undesired aircraft states. They are usually discovered when analysing aggregate data such as confidential incident reports. Causes include:

  • ATC practices;
  • Air traffic system design;
  • Organisational, national or professional culture;
  • Regulatory practices and oversight;
  • Training philosophy and practices;
  • Qualification standards;
  • Aircraft characteristics;
  • Equipment design issues;
  • Flawed procedures;
  • Preparation for duty;
  • Scheduling and rostering practices; and,
  • Personal unfitness due to stress, preoccupation or illness.

3   Statistical Data on Threat and Error Management

3.1   Line operations safety audits

The idea of identifying threats stems from the military, but one should clearly bear in mind that threat and error management (TEM) is a safety strategy that should not be confused with other initiatives that have generated other lists of safety issues.

The University of Texas (UTX) at Austin developed the TEM model as a conceptual framework to interpret data from observing crewmembers in both normal and abnormal operations.

A crew is expected to manage a threat so it becomes inconsequential. If the crew fails to do so, they may make a mistake. Depending on the crew’s response to that error, even more mistakes may follow that place the aircraft in an undesirable state that compromises safety.

A mismanaged threat is one that is linked with or induces flight crew error. As such, the TEM model helps to point out contributory factors that crews can recognise and manage.

The UTX line operations safety audit (LOSA) and the Airbus line operations assessment system (LOAS) are distinct programs that use expert observers to collect data about crew behaviour and situational factors during normal flights.

3.2   Data from other safety initiatives

Current safety initiatives are based on two distinct and complementary approaches:

  • An historic/reactive process that reviews mishaps from eight focus areas: controlled flight into terrain, approach and landing, loss of control, aircraft design, weather, occupant safety and survivability, runway incursions, and turbulence.
  • A prognostic/proactive process concerned with future hazards in two focus areas: crew reliance on automation and new concepts for airspace management.

The European Strategic Safety Initiative closely cooperates with the Commercial Aviation Safety Team (CAST), which runs a similar program for the U.S. Federal Aviation Administration (FAA) and other interested parties. Both programs learn from each other, and address the historic and prognostic approaches.

CAST’s mission was to develop and implement a data-driven strategy to reduce the accident rate by 80 percent by 2007. The list of standard events was set up by the CAST/International Civil Aviation Organisation (ICAO) Common Taxonomy Team to generate safety-performance indicators that help produce incident rates.

CAST members originally elected to selectively pursue highly leveraged safety intervention strategies that would maximise the safety benefit to the flying public by chartering Joint Safety Analysis Teams (JSATs) in the following six areas: controlled flight into terrain, approach and landing, loss of control, runway incursions, weather, and uncontained engine failure.

JSATs use a problem-statement methodology that CAST recommends for identifying safety problems in any setting and for developing programmes to solve them.

Based on some 300 problem statements, the following 10 groups were identified:

  • Adverse effects of actions by the ATC system;
  • Problems in using automation;
  • Crew failure to follow standard operating procedures (SOPs);
  • Crew failure to practise crew resource management (CRM);
  • Failure of cockpit instruments and warning systems;
  • Crew failure to recognise the aircraft energy state;
  • Crew failure to monitor and interpret flight and systems data;
  • Failure of airlines to provide adequate training; and,
  • Inadequate training for the type of operation being conducted.

JSAT provides to CAST a list of prioritized safety intervention strategies to reduce fatality risks. CAST and JSSI teams recommend safety intervention strategies and also produce contributing factors grouped and prioritized in a set of standard problem statements. If these high-leverage problems and contributing factors could be eliminated, the risk of death or serious injury would be reduced by an estimated 73 percent.

4   Threat Management Approaches

An operator’s organisation must gear itself to implement prevention strategies through appropriate ab-initio and recurrent training, as well as through operational recommendations to provide pilots with the necessary skills, knowledge and attitudes to help them understand the challenges they face.

TEM can provide a conceptual framework for flight crew training and serve as a crucial component of human factors and CRM training. In particular, it can lead to a template for assessing threats during operations. The following approaches may help.

4.1   Crew-observation techniques

Situational factors in environmental, organisational and technical fields contribute to create threats that occur out of the cockpit but have to be managed by the flight crew. LOSA is predicated on the UTX threat and error safety model, which is based on these five error categories:

  • Intentional noncompliance error;
  • Procedural error;
  • Communication error;
  • Proficiency error; and,
  • Operational decision error.

With three possible responses to these error types:

  • Trap actively after detection and manage to an inconsequential outcome.
  • Exacerbate and cause an additional error or undesirable aircraft state.
  • Fail to respond because the error was ignored or undetected.

With three possible responses to an undesirable aircraft state:

  • Mitigate actively by returning to safe flight.
  • Exacerbate and induce an additional error or further degraded state.
  • Fail to respond because the error was ignored or undetected.

TEM places in context system factors, organizational characteristics and pilot culture.

4.2   Integrated threat analysis

The International Air Transport Association (IATA) Human Factors Working Group launched integrated threat analysis. The goal of this approach is to establish a correlation between threats, errors and undesirable aircraft states in normal operations, incidents and accidents to determine some scenarios in which safety can be compromised and to develop crew prevention strategies to properly manage these situations. The first integrated threat analysis focused on runway excursions.

IATA performed parallel analyses of UTX’s “Archie” database (normal operations), IATA safety trend evaluation analysis and data exchange system (STEADES) incident narratives, and the ICAO’s accident/incident reporting (ADREP) database.

A link was established between long and off-center landings. Weather (e.g., heavy rain, thunderstorms, wind gusts, tailwinds), aircraft malfunctions, rejected takeoffs, night operations, and proficiency issues remain important threats in incident and accident analysis.

Experience shows that ATC, operational pressures and procedural issues are less well-documented threats with risks that need to be managed both organisationally by the airlines and tactically by flight crews.

These three strands of safety-data management complement each other. They show  that we can learn from well-managed threats as well as from mismanaged ones.

4.3   Airline data collection

Incidents and accidents are daunting events that can be prevented by setting up defences. Operational situations potentially lead to systemic weaknesses, breakdowns or failures that correspond to threat events — precursory, isolated occurrences that might recur in different conditions and then become an accident.

  • Precursory operational situations have failing defences (not necessarily precursory) with preventive practices in operational contexts that must be clearly identified.
  • A practice is a way to work adopted by the crew or by an organisation such as maintenance or ATC that is characterised by the way an action, error or procedural deviation or latent condition is performed.
  • The operational context takes into account several elements both in the environment and pilots’ workload and stress.
  • Failures in defences will manifest themselves in the execution of practices and in specific contexts.

The visibility of precursors may be poor and the cross-working of several safety sensors may help reveal various elements that characterise a precursor — its frequency, characteristics and criticality. This suggests that sources other than LOSA are necessary.

LOSA will hence not be able to catch latent conditions, which can only be grasped through precursors, incidents and  accidents. And the identification of countermeasures is possible only if the three specific aspects of an operational situation — defences, practices and context — are clearly identified.

4.4   Safety data management

Airbus performs safety data management (SDM) to support its product safety process. SDM collates operational incident and precursor data from a variety of sources and codifies these events by means of operational and human factors markers through its operational events analysis process (OEAP). The OEAP studies produce data for design, training and operations.

This process attempts to codify threats as:

  • Anticipated (briefed);
  • Avoided (prevented);
  • Managed (recovered);
  • Identified, assessed and managed late;
  • Outcome mitigated;
  • Not identified; and,
  • Outcome inconsequential.

This activity is performed in conjunction with a review and codification of:

  • Situation recognition and diagnosis — alerts, cockpit-cabin interaction, crew diagnosis;
  • Crew actions — flight guidance; systems use; excessive control inputs; untimely,  inadvertent or delayed action; no action despite repeated alerts; late takeover;
  • Procedures — type, access, contents;
  • Crew performance — procedure execution, actions, error management, threat management, aircraft attitude and flight path control, coordination; and,
  • Environment and circumstances — operational, weather conditions, aircraft design,  organisational factors, crew factors.

The Occurrence Data Analysis Working Group of the JSSI drafted an Analysis Capability Specifications document to recommend guidelines for precursor detection. Precursors, or forerunners, are events that come before something similar that leads to or influences its development. There are two methods for precursor detection: scenario-based and hazard-based.

Scenario-based precursor detection consists of diagnosing incidents related to specific threats and identifying various human, procedural, technical and environmental factors, including warnings and alarms. This identification consists of:

  • Verifying the scenario’s efficiency, which is confirmed if it prevents the incident from occurring or degenerating into an accident.
  • Verifying its reliability, which is confirmed when an incident reoccurs in exactly the same conditions.
  • Verifying its universality, which is confirmed if the incident reoccurs in slightly different conditions — another airline, airport or aircraft type.

Hazard-based precursor detection involves either a statistical approach by tracking the list of hazards in the CAST and JSSI initiatives, or a proactive approach during design and certification based on JSSI and CAST data. This analysis can be done in two steps:

  • Upon receipt of a report, the analyst identifies which hazard might be involved.
  • The analyst then either flags it in the database for later retrieval or stipulates where all the occurrences related to each hazard should be reprocessed.

Occurrence retrieval for any given hazard involves categorising events and making a synthesis to validate the hypotheses of the safety model, maintain risk awareness and identify needs for safety actions. This analysis is based on the expertise and judgment of a dedicated expert team since there is no exact guidance.

5   Key Points

Technical information is not the best way to prepare pilots to master expected and unexpected threats while flying. It is nevertheless necessary to feed back information on actual experiences to the authors of such technical information.

It is one thing to develop organisational schemes based on safety data from well-documented events. Yet, it is quite another to learn to master such events in a cockpit environment with a real situation unraveling in the face of incomplete awareness or surprise.

Risk management aims to make events visible by creating proper attitudes for TEM, not by mobilising resources out of context but by prompting crewmembers’ situational awareness when needed. An example is when a traffic alert and collision avoidance system (TCAS) generates a traffic advisory ahead of a resolution advisory to get the pilots’ attention and prompt a timely and appropriate response.

It would be in vain to require optimal performance at all times to be able to deal with ongoing threats. What is necessary instead is to have sufficient built-in risk tolerance and the proper attitudes to face any threats. This is achieved with a pragmatic approach to training and operational strategies.

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Dana MD-83 – Nigeria

July 19, 2012 at 1:40 pm | Posted in Uncategorized | Leave a comment
Dana MD-83 lost power to both engines before crashing says preliminary report. Source IFALPA
 The   Nigerian Accident Investigation Bureau has published its preliminary report in to last month’s accident involving a Dana Air MD-83.

The aircraft was completing a scheduled   flight from Abuja to Lagos when, said the report, it “suffered a total loss of power in both engines”,  and crashed in a residential area nine  kilometres north of Muhammed Murtala Airport, with the loss of all 153 passengers  and crew together with another 10 people on the ground.

The report confirmed that the aircraft had  enough fuel on board and that the preliminary analysis of fuel samples taken from the refuelling truck and the supply tank at Abuja did not reveal any trace of contamination.

The Bureau added that further “investigative activities will include, but is not limited to, the detailed examination of the engines, further testing of fuel samples, continued factual gathering of relevant historical, operational, maintenance and performance information of the accident airplane in addition to other similar airplane models, further development of the background of the flight  crew, further analysis of the CVR audio recording and review of pertinent issues associated with regulatory oversight”.

Crash: Dana MD83 at Lagos on Jun 3rd 2012, following Mayday call collided with power line on approach

June 4, 2012 at 12:20 pm | Posted in Aircraft Accidents | Leave a comment

Crash: Dana MD83 at Lagos on Jun 3rd 2012, following Mayday call collided with power line on approach

By Simon Hradecky, created Sunday, Jun 3rd 2012 16:25Z, last   updated Sunday, Jun 3rd 2012 21:02ZImageImageA Dana Air McDonnell Douglas MD-83,   registration 5N-RAM performing flight 9J-992 from Abuja to Lagos (Nigeria)   with 147 passengers and 6 crew, was on approach to Lagos about 11nm from LAG   VOR when the crew declared emergency reporting engine problems. At about   15:00L (14:00Z) the aircraft collided with a power line, crashed into a built   up area about 1nm abeam threshold runway 18L at Oluwatoyin Street (not intersection   of Toyin Street and Olowu Street as originally reported) and burst into   flames. A number of residential houses around the crash site were on flames,   too, a large smoke plume was visible above the city. All occupants of the   aircraft perished in the crash, there is no information yet about victims on   the ground.Nigeria’s Civil Aviation Authority initially reported the aircraft crashed   shortly after takeoff for Abuja, but corrected to say the aircraft arrived   from Abuja, then turned back reporting the aircraft was departing Lagos and   returned. There are no survivors. Late evening the CAA reported as their   final word, that the aircraft was flying from Abuja to Lagos.

The airline confirmed one of their planes crashed in the outskirts of Lagos.

A number of Nigerian companies report, their staff travelling from Abuja to   Lagos has gone missing.

Sources within Dana Air say the aircraft was flying from Abuja to Lagos   confirming some of the passengers reported missing by their companies were on   board of the aircraft. The aircraft was on approach to Lagos about 11nm from   the Lagos VOR LAG, when the crew declared emergency. The aircraft crashed   shortly after.

Listeners on frequency said the crew reported engine trouble.

LAG VOR is located about 7nm north of the threshold of runway 18L at position   N6.7086 E3.3275.

A photographer reported the crash site was at Oluwatoyin Street, which in the   end turned out to be located 5nm north of threshold runway 18R. Map resources   did not know that street but resolved the name to show the intersection of   Toyin Street and Olowu Street 1nm east of the airport.

Metars:
DNMM 031600Z 19006KT 150V240 9999 BKN013 29/24 Q1012 NOSIG
DNMM 031500Z 19007KT 140V230 9999 SCT014 30/23 Q1013 NOSIG
DNMM 031400Z 20006KT 150V250 9999 SCT014 31/23 Q1013 NOSIG
DNMM 031300Z 19004KT 150V260 9999 SCT014 31/22 Q1014 NOSIG
DNMM 031200Z 17005KT 130V220 9999 SCT013 31/23 Q1015 NOSIG
DNMM 031100Z 14004KT 060V220 9999 SCT013 30/23 Q1015 NOSIG

The tail of the aircraft burning in the streets of Lagos:

Detail Map (Graphics: AVH/Google Earth):

Map (Graphics: AVH/Google Earth):

 

A McDonnell Douglas MD-83 of Dana Air was destroyed when it crashed into a residential are of Lagos, Nigeria

Source: Aviation Safety Network

03/06/2012

Status: Preliminary
Date: 03 JUN 2012
Time: ca 16:45
Type: McDonnell Douglas MD-83
Operator: Dana Air
Registration: 5N-RAM
C/n / msn: 53019/1783
First flight: 1990
Engines: 2 Pratt & Whitney JT8D-219
Crew: Fatalities: 6 / Occupants: 6
Passengers: Fatalities: 147 / Occupants: 147
Total: Fatalities: 153 / Occupants: 153
Airplane damage: Destroyed
Airplane fate: Written off (damaged beyond repair)
Location: ca 4 km from Lagos-Murtala Muhammed International Airport (LOS) (Nigeria)
Phase: Initial climb (ICL)
Nature: Domestic Scheduled Passenger
Departure airport:Lagos-Murtala Muhammed International Airport (LOS) (LOS/DNMM), Nigeria
Destination airport: Abuja International Airport (ABV) (ABV/DNAA), Nigeria
Flightnumber: 997
Narrative:
A McDonnell Douglas MD-83 passenger plane was destroyed when it crashed into a residential are of Lagos, Nigeria. Nigerian Civil Aviation Authority head Harold Demuren was quoted saying that he did not believe that any of the 153 people on board had survived.
Dana Air Fligh 9J-997 took off from Lagos-Murtala Muhammed International Airport (LOS) on a domestic flight to Abuja (ABV).
Shortly after takeoff the plane clipped a power line and crashed into a two-story building in the Iju/Ishaga area of Lagos. The Iju Ishaga Road runs north of the airport on the runway 36R extended centreline. The Ishaga neighbourhood however lies south of the airport, about the extended centreline of runway 18R.L
Local aviation sources indicate the the plane involved was 5N-MAR, presumably meaning 5N-RAM since 5N-MAR is not in the Dana Air fleet list.
Weather reported about 45 minutes prior to the accident:
DNMM 031500Z 19007KT 140V230 9999 SCT014 30/23 Q1013 NOSIG
Wind 190 degrees at 7 knots; winds varying between 140 and 230 degrees; Visibility 10+ km; Scatter clouds at 1400 feet; Temperature 30°C, Dew point 23°C; pressure 1013 mb.

New Pilots’ Association website is airborne:

May 29, 2012 at 7:39 am | Posted in Uncategorized | 1 Comment

New Pilots’ Association website is airborne:    

The Air Line Pilots’ Association (ALPA-SA) has launched a new-look website, reflecting the organisation’s track-record of service to the aviation industry, its growth and ongoing value as a representative body for pilots and flight deck crew.

ALPA-SA (www.alpa.co.za) is a membership-driven organisation that has no commercial interest in aviation and strives to serve as the ‘national voice of pilots’.

Its service mandate includes striving for a safer system of air transportation and the application of professional standards throughout the industry, representation of members at all relevant national and international forums, as well as the exchange of pertinent technical, industrial and professional information.

The development of a new website falls in line with the organisation’s service as a portal to accurate, up-to-date information to the industry says Fanie Coetzee, President of ALPA-SA.

“Online presence is a critical component of our information distribution strategy. We operate within an information-driven industry that relies upon clear, concise and relevant detail. Our website has to reflect our standing within the industry, our links to affiliate programmes and bodies, and news that affects our members,” Coetzee explains.

Aside from providing pertinent information about the industry, Coetzee adds that in revamping the website, ALPA-SA wanted to demonstrate its maturity as a representative body and its experience in dealing with issues.

“Like any other industry operating within the current economic environment, we do face challenges of cost, of standards implementation, of available infrastructure and resources and of labour concerns. We believe it is our role to assist those who form part of the larger aviation industry in helping to address these challenges through open discussion and effective action,” he continues.

Executive leadership at ALPA-SA believe the website certainly communicates the development of the organisation and the strength it embodies in being able to keep up with- and embrace change to improve service delivery.

SAA introduces flights: Johannesburg – Cotonou, Benin

May 22, 2012 at 9:24 am | Posted in Uncategorized | Leave a comment

SAA introduces flights: Johannesburg – Cotonou, Benin:

Source:  Bizcommunity.com - Daily Tourism, Travel & Hospitality news

21 May 2012 07:20
South African Airways has launched another new route from its Johannesburg hub to an African destination, this time to Cotonou in Benin.
The new route is a further step as the airline implements its Africa strategy in support of South Africa’s business, tourism, and development imperatives. The strategy is designed to ensure ongoing expansion of SAA’s continental network in the service of travellers to, from, and in Africa.
Cotonou is the fifth new African destination SAA has introduced since October last year. The airline now operates to 24 African cities from Johannesburg. Among the most recent routes added are Ndola on the Zambian copper belt, the Rwandan and Burundian capitals Kigali and Bujumbura and the oil hub of Pointe Noire in the Republic of Congo.
Part of SAA’s growth strategy:
“This new route to Cotonou forms part of SAA’s Africa growth strategy and demonstrates our commitment to being the premier airline linking Africa to the world and the world to Africa. We are increasingly providing business and leisure travellers with a very convenient and relevant array of destinations. Through our Johannesburg hub, SAA offers the most convenient connections between Africa and South America, the Far East and Asia Pacific,” says Theunis Potgieter, SAA’s general manager commercial.
SAA will initially serve the Johannesburg – Cotonou route twice weekly with one of its very modern and comfortable Airbus A319 aircraft. The flights will operate from Johannesburg to Pointe Noire and onwards to Cotonou, returning from Cotonou via Pointe Noire.
Cotonou is the economic capital of Benin and the seat of many government departments and embassies. It is the country’s largest city.
Schedule Johannesburg – Point Noire – Cotonou (Benin)

 
All times are local at departure/destination points.

FAA Steps Up Enforcement of Laser Penalties

May 17, 2012 at 7:11 am | Posted in Lasers | Leave a comment

FAA Steps Up Enforcement of Laser Penalties

Source: US FAA

16/05/2012

The Federal Aviation Administration (FAA) has directed its investigators and staff to pursue stiffer penalties for individuals who purposefully point laser devices at aircraft.

“Shining a laser at an airplane is not a laughing matter. It’s dangerous for both pilots and passengers, and we will not tolerate it,” said U.S. Transportation Secretary Ray LaHood. “We will pursue the toughest penalties against anyone caught putting the safety of the flying public at risk.”

The number of reported laser incidents nationwide rose from 2,836 in 2010, to 3,592 in 2011. Laser incident reports have increased steadily since the FAA created a formal reporting system in 2005 to collect information from pilots.
The FAA supports the Department of Justice in its efforts to seek stern punishment for anyone who intentionally points a laser device into the cockpit of an aircraft.

“We will continue to fine people who do this, and we applaud our colleagues at the Justice Department who have aggressively prosecuted laser incidents under a new law that makes this a specific federal crime,” said FAA Acting Administrator Michael Huerta.

The FAA has initiated enforcement action against 28 people charged with aiming a laser device at an aircraft since June 2011, and this week the agency directed FAA investigators and attorneys to pursue the stiffest possible sanctions for deliberate violations. The FAA has opened investigations in dozens of additional cases.

The FAA announced last June it would begin to impose civil penalties against individuals who point a laser device at an aircraft. The maximum penalty for one laser strike is $11,000, and the FAA has proposed civil penalties against individuals for multiple laser incidents, with $30,800 the highest penalty proposed to date. In many of these cases, pilots have reported temporary blindness or had to take evasive measures to avoid the intense laser light.

The guidance for FAA investigators and attorneys indicates laser violations should not be addressed through warning notices or counseling. It also directs moderately high civil penalties for inadvertent violations, but maximum penalties for deliberate violations. Violators who are pilots or mechanics face revocation of their FAA certificates, as well as civil penalties.

Local, state and federal prosecutors also have sentenced laser violators to jail time, community service, probation and additional financial penalties for court costs and restitution.

Crash: Sukhoi SU95

May 10, 2012 at 12:22 pm | Posted in Aircraft Accidents | Leave a comment

The Aviation Herald

Crash: Sukhoi SU95 over Indonesia on May 9th 2012, aircraft impacted mountain

  Crash site (Photo: Lystseva Marina):

Source: By Simon Hradecky, created Wednesday, May 9th 2012 10:31Z, last updated Thursday, May 10th 2012 08:10Z

A Sukhoi Sukhoi Superjet 100-95, registration RA-97004 performing a demonstration flight from Jakarta Halim Perdanakusuma Airport to Jakarta Halim Perdanakusuma Airport (Indonesia) with 37 passengers, 6 crew and 2 Sukhoi officials, was enroute near Mount Salak and Bogor about 36nm south of Jakarta about 30 minutes into the flight when the radio contact with the aircraft was lost. The aircraft did not turn up at Jakarta or any other airport in the area. The aircraft wreckage was found by a helicopter the following morning (May 10th) at about 09:15L (02:15Z) on the slopes of Mount Salak at an elevation of about 5300 feet MSL.

Rescue and Recovery teams are currently on their way to the crash site.
The coordinator of the rescue operation said, that the aircraft appeared relatively intact from the air however has received substantial damage after leaving a trail away from the crater down the slope, there was no sign of survivors from the air. Rescue teams are currently on the ground about 1km from the crash site, the terrain being difficult to reach the wreckage.

The Air Force said the aircraft impacted the edge of a cliff (top of the cliff at 6250 feet MSL) about 1.7 nm from Cijeruk. Approximate final position of the aircraft is S6.7045 E106.7373

Indonesian Authorities reported the aircraft was enroute at 10,000 feet near Mount Salak when at about 15:30L (08:30Z) the crew requested and was cleared to descend to 6,000 feet. This proved to be the last radio transmission. Radar contact was lost when the aircraft was in a right hand turn descending through 6,200 feet between Mount Salak and Mount Gede at approximate position S6.72 E106.72. The aircraft was flying clockwise around Mount Salak at that time. A search operation has been initiated and is mounting, first search flights on May 9th did not yet found any trace of the aircraft. Search on the ground is under way, a first team has departed for Mount Salak in the evening, a second ground team is expected to depart on May 10th early morning, more than 600 ground personnel have been deployed by sunrise May 10th.

Sukhoi reported the aircraft registration RA-97004 (MSN 95004) was piloted by a very experienced crew that also flew the first prototype of the aircraft, the commander had more than 10,000 hours total. The crew did not report any anomaly and did not issue a distress call prior to the aircraft disappearing. The aircraft had already concluded another demonstration flight earlier the day. The accident aircraft had accumulated 800 flight hours in more than 500 cycles, there had been no serious technical problems since its first flight in 2009.

Mount Salak is 2,211 meters/7254 feet high, nearby Mount Gede is 2,958 meters/9,705 feet high.

At 15:30L the local weatherstation in Bogor reported visibility at 9000 meters (increasing to 10000 meters in the next reading), temperature at 31 degrees C, dew point at 25 degrees C, humidity 70% and winds arund 5 knots from northeast, no precipitation. In the morning the weatherstation had reported low visibility around about 2000 meters.

Royal Aeronautical Society Conference

May 8, 2012 at 8:26 am | Posted in Conferences | Leave a comment

Royal Aeronautical Society Conference
“The Aircraft Commander in the 21st Century”
London
(Source: Forwarded to the AAP Chairman by Gen Des Barker)

Command lessons from QF32

Airlines are now adapting their pilot training for aircraft captains in the light of recent aviation incidents involving highly automated airliners. Herewith a report of some of the key issues at the recent RAeS ‘The Aircraft Commander in the 21st Century’ conference:                 

What skills will the aircraft commander of the future need? (Lufthansa)

On 20-21 March the Royal Aeronautical Society held its first ‘The Aircraft Commander in the 21st Century’ conference. Organised by the RAeS Flight Operations Group, the conference sought to explore the changing role of the aircraft commander, particularly as civil airliners get ever more automated and complex.

This issue has recently been thrown into sharp focus, as incidents like Qantas QF32 and Air France AF447 have demonstrated differing responses from pilots to ever more complex aircraft.

In particular, the industry now is reassessing the training given to pilots. A major theme that emerged from the conference was that, in the past 20 years, pilots have been taught to ‘Follow the ECAM (Electronic Centralised Aircraft Monitor)’ – the computerised glass display that in Airbus (and Boeing as the EICAS Engine Indicating and Crew Alerting System) which shows critical engine and systems information. While this ECAM display makes life easy in many respects, following it blindly can lead to disaster. Previous training, said one speaker, relied on following the ECAM procedure step-by-step and pilots ‘never considered not doing the procedure’.

‘Use the force, Bruce’

Conference keynote speaker, Captain David Evans.

This issue of displays showing spurious information was highlighted graphically by the keynote speaker at the conference Captain David Evans who, as a Qantas A380 Training and Check Captain, was one of the five flightdeck pilots who successfully resolved the QF32 incident in November 2010 after the No2 Trent engine suffered an uncontained failure. With the ECAM ‘information overload’ deluging the crew with a barrage of error messages the experienced captains had to sort through and examine what these meant for the aircraft. In particular, the ECAM recommended that the crew shift the fuel balance from one wing to another, as an error message said ‘wings not balanced’ as the imbalance limit had been exceeded. However, the reason why the aircraft was becoming unbalanced was that there was a serious fuel leak caused by the exploding engine – a situation that was obvious to anyone looking out of the window and seeing the damaged left hand wing leaking fuel.

Yet, had the crew followed procedure to the letter instead of ‘using the force’ and disregarding the computer, they would have ended up pumping fuel into a leaking fuel tank with unknown consequences. At the very least this would have dramatically shortened the available time for the crew to think through and solve the problem.

Reliance and dependence that the computer always knows best can be dangerous. As Captain Evans notes: “What needs to be brought back into the skies is a ‘healthy skepticism’ about technology”. This view was echoed in a later presentation by Captain Scott Martin, an experimental test pilot at Gulfstream, who said the correct approach was to treat the cockpit automation ‘like a third pilot’ but to be prepared to question it if it was not making sense. In the final analysis, says Evans – ‘airmanship’ or ‘does this seem sensible?’ should trump any automated ECAM/EICAS messages.

Yet this natural suspicion of technology runs counter to the future generations of pilots who will be drawn from today’s ‘Generation Y and Z’ now at college or school. As Evans and others point out, these future captains born in the 1980s and 90s, while being able to grasp new technology and systems far quicker than their predecessors as well as absorb new information, will also, growing up with computers, iPads and smart phones, instinctively trust technology more.

The problem is not only one of younger pilots relying on technology too much but also of older pilots who may be losing touch with basic flying skills after years of relying on the autopilot. Though aircraft accidents remain rare – a noteworthy statistic from the conference showed that while the most common incident was a runway incursion/penetration – the most lethal in terms of lives lost is now loss of control in flight (LOC-I). The RAeS is in the forefront of work with both national and international regulators in addressing this problem and introducing loss of control awareness and recovery training.

So what else can be done? As well at efforts from regulators to address the issue, the conference also highlighted how individual airlines are addressing these commands issues themselves, with more realistic dynamic flight simulation scenarios, a back-to-basics approach and even mentoring and recurrent leadership training for older experienced captains.

Qantas adapting training

A380 ECAM displays on the actual QF32 flight. (via David Evans)

Lessons from QF32 are already making their way into Qantas’ training. At the conference Captain Evans explained how Qantas has started to introduce simulator scenarios based on real (but rare) scenarios to expose pilots to difficult command decisions.

One example chosen for a recent simulator LOFT (Line oriented flight training) exercise was the scenario of flying an A380 through a volcano ash cloud, which could simultaneously set off fire alarms on the flightdeck and elsewhere (thanks to smoke detectors) as well as flame out the engines. In the simulator exercise, pitot tubes would also be blocked by ash.

So what happened? With smoke warnings, engines flamed out, the airspeed went blank and the aircraft went into direct law with no autopilot. In particular, Evans noted, the ECAM logic prioritised the multiple (spurious) fire warnings over the engine flame out warning. However for the pilots, understanding that the ash had caused the smoke detectors to trip, the priority should be to restart the engines.

This simulator exercise clearly demonstrates to pilots how a highly automated aircraft could revert to a challenging manual flying task for the pilots – whilst simultaneously presenting them with information overload in the form of ECAM messages. However, doing this in the sim allows them to hone their command and decision making skills in a safe environment.

Lufthansa – recurrent command training for captains

Lufthansa are introducing a concept of ongoing command training for pilots. (Lufthansa).

Captain Benard Kruse, VP Crew Training Lufthansa, explained how the German flag carrier is implementing a form of ongoing training for its commanders. The idea is that pilots continue to develop leadership competencies over their whole career. Thus, after moving up into a command position, regular training in ‘soft skills’, such as decision making, situational awareness and CRM would continue along the career of a pilot – no matter how experienced he or she is. In small groups of their peers, captains will be able to dedicate time to discussing and learning from each other on command issues. In a sense, this lifelong learning might be thought of as ‘recurrent training’ for non-technical command skills, much as the ‘sim check’ provides a demonstration of a pilot’s continuing technical proficiency in operating an aircraft.

The training, called Captain’s Competence Enhancement (CCE) by Lufthansa would see tailored training for the individual captain over the course of their entire career. Lufthansa’s concept is that captains would attend this two-day classroom seminar course every four years. The first day would see a refresher using a diagnostic personal skills assessment tool (KOBE) while, on the second day, the captains would be able to pick a module such as ‘conflict’, ‘leadership’ or ‘stress’ to concentrate on.

Emirates goes back to basics:

Emirates are expanding fast, but are not satisfied with ‘minimum regulatory standards’.

Emirates Airlines is also adapting its approach to training in the light of recent events and is aiming at the highest standards, a point well made by Captain Martin Mahoney, SVP Flight Training at Emirates. The fast growing Gulf carrier is recruiting and training a huge amount of pilots – with some 624 new recruits training in the last financial year and 322 new command slots created in the same period. In Emirates a pilot can expect to spend 3-5 years in the right-hand seat before being put forward for a command slot.

Despite the airline only recruiting experienced pilots (First Officers with a minimum of 2,500 hours on aircraft over 30 tonnes) Emirates believes it needs to supplement the skills (especially human factors/soft skills) that candidates already have and refresh ones that may have gone stale.

To that end, the carrier has introduced a ‘basic aerodynamics’ course to refresh new entrants about the fundamentals of flight. Intriguingly, it has also reversed the trend for distance learning in favour of a return to ‘chalk and blackboard’ classroom learning. Why? Captain Mahoney contends that not only do pilots learn better by being in the presence of other pilots (as well as reinforcing the pilot culture – an important factor in multicultural airline like Emirates) – but also in that the instructor can watch the students’ eyes to see if the lessons have really understood. In addition, Emirates is also boosting its pilots’ skills with two manual handling simulator sessions every year for new commanders.

The airline has also introduced personality profiles for command upgrade candidates which are pilot’s eyes only (management does not see them) and which provides potential captains with individual, practical feedback on their leadership style as well as strengths and weaknesses.

However, Captain Mahoney had harsh words for ICAO’s Level 4 English standards – arguing that they are “not worth the paper they are written on”. In fact, he revealed that recent simulator tests of pilots from an unnamed defunct European charter carrier saw a 50% failure rate due to their English not being up to the standard needed by Emirates.

These training methods, especially classroom-based learning, are not cheap but are significant in the airline’s efforts to make sure its standards are the highest it can possibly achieve. In fact, Captain Mahoney noted during his presentation that Emirates had even banned the phrase ‘minimum regulatory standards’ from its in-company lexicon – arguing that it has no place in the airline’s culture.

Lessons from the operating theatre:

Professor Rhona Flin, from University of Aberdeen.

But it is not just airlines themselves that are adapting their training of current and potential commanders. There is also fresh input from outside the profession. Though the flightdeck is regarded as the gold standard for CRM (crew resource management), there may be lessons from the medical sector, especially from surgeons, who have a similar high-skilled job with large responsibilities and operate in teams.

Indeed, Professor Rhona Flin, an industrial psychology expert at the University of Aberdeen observed that that in order to access and fully exploit the ‘working memory’ (analytical, which experts now believe can hold up to four ‘chunks’ at the same time), it may be a case of the ‘slower the better’.

She noted that one surgeon had once been given advice “Don’t just do something, stand there”, indicating that slowing down rather than rushing into action may contribute to better decision making in medical operations. Though this may not be possible in some circumstances (Captain Sullenberger’s Hudson ditching and the BA 777 Heathrow landing short of the runway needing fast reactions), taking a step back from the flashing displays and warnings may actually improve critical thinking. Was it perhaps due to the extra critical thinking time brought to the QF32 incident by five experienced captains that resolved the problem successfully?

Conversely, when thinking time is limited –decision-making relies on long-term memory containing models of the world that we use, together with procedures and experience. These might be characterised by ‘the gut feeling’ or ‘we’ve always done it this way’. This may work in some instances but, in more novel or unexpected situations, may make pilots (or surgeons) make the wrong choices or continue down an incorrect path – even when it is obvious in hindsight that the decision was the wrong one.

Seniority:

Any discussion of the selection, training and roles of aircraft commanders is incomplete without the issue of seniority raising its head and that too was debated at the conference. Depending on your viewpoint and your stage in your flying career, seniority can either be viewed as older mediocre captains blocking career advancement for younger skilled pilots, or a necessary way in which the most experienced, highest hour pilots are given the most responsibility. Though some in the airline industry recognise the inconsistency of an industry aiming for the highest standards yet at the same time promoting the longest-served on a ‘it’s your turn’ basis, it is clear that completely dismantling this system would be a major undertaking.

Conclusion:

That aircraft (and crews) are now safer than ever is not in doubt and the statistics bear this out. However, the aviation industry is always striving for perfection. Furthermore, there is a growing unease that the previous ways of learning (and command) need adapting to new and future generations of automated aircraft. Ex-military pilots with ‘nerves of steel’, experience of flying at the edges of the envelope yet unwilling to talk to juniors has given way to systems managers and team players. However, these new pilots, fluent in the latest crew management skills, may also be lacking some basic ‘stick and rudder’ skills and be too willing to trust the computer.

The highly automated aircraft also provides fresh challenges. The issue is not the technology itself but the gulf between normal and non-normal (i.e. emergency) operations. In normal operations a highly automated airliner is easier to fly than previous generations of aircraft but, in a non-normal situation, it is comparatively harder.

It is this gulf between normal and non-normal which is the issue and is so difficult to train for because of the extreme rarity of non-normal emergencies. As one speaker pointed out, in the old days he had flown as a third pilot observing the crew routine and watching them deal with multiple engine failures as part of his apprenticeship to command. Today, a trainee captain riding a jump seat as an observer would be extremely unlikely to witness an in-flight emergency to ‘learn’ from the more experienced crews.

In short, some forward-thinking airlines are already adapting their approach to training and command issues in making sure that the aircraft commander of the future has the correct mix of technical and non-technical skills and, more importantly, knows when to ignore, question or override the computers. As Captain David Evans observes, the commander must: “work out the solutions with the help of technology, not depend on technology for the solution”.

IFALPA News

May 2, 2012 at 1:47 pm | Posted in IFALPA News articles | Leave a comment
Delta buys own refinery:

Delta Air Lines, through its subsidiary   Monroe Energy, has reached agreement with Phillips 66 to buy the Trainer   refinery situated south of Philadelphia for $150 million. Monroe will then   spend $100 million to convert the existing infrastructure “to maximise jet   fuel production”. BP will supply the crude oil to the refinery and the   resultant jet fuel will provide 80 per cent of Delta’s requirements in the   U.S.

“Acquiring the Trainer refinery is an   innovative approach to managing our largest expense,” said Delta’s CEO,   Richard Anderson, “This modest investment, the equivalent of the list price   of a new widebody aircraft, will allow Delta to reduce its fuel expense by   $300 million annually and ensure jet fuel availability in the Northeast. This   strategy is aligned with the moves we have made to build a stronger airline   for our shareholders, employees and customers.”
Delta explained in a statement that Monroe expects to close on the   acquisition “in the first half of 2012”. Completion of the changes to the   plant infrastructure and start of production is expected to begin during the   following three months, “resulting in expected 2012 fuel savings of more than   $100 million”.

ALC buys eight Dreamliners, could be   negotiating for $6 billion 737 MAX order:
        The   Air Lease Corporation (ALC) has announced that it has purchased eight Boeing   787-9s for lease to Vietnam Airlines. Deliveries, which  are scheduled   for 2017 and 2018, mark the lessor’s longest lead time for a placement in its   history.

Separately, it is rumoured that ALC is among   one of the unidentified customers on Boeing’s order book for the 737   MAX,  possibly for as many as 60 of the aircraft. If the order is   confirmed, it would be worth approximately $6 billion. Neither ALC or Boeing   has made any comment but experts believe that an announcement could be made   at July’s Farnborough Air Show.

Bhoja Airlines Boeing 737-236

May 2, 2012 at 1:19 pm | Posted in Aircraft Accidents | Leave a comment

Bhoja Airlines Boeing 737-236

20 April 2012

Pakistan

127 d

[Source: Aviation Safety Network]

(Photos: AFP/Aamir Qureshi):

Status: Preliminary
Date: 20 APR 2012
Time: ca 18:40
Type: Boeing 737-236
Operator: Bhoja Airlines
Registration: AP-BKC
C/n / msn: 23167/1074
First flight: 1984-12-13 (27 years 5 months)
Engines: 2 Pratt & Whitney JT8D-15A
Crew: Fatalities: 6 / Occupants: 6
Passengers: Fatalities: 121 / Occupants: 121
Total: Fatalities: 127 / Occupants: 127
Airplane damage: Written off
Airplane fate: Written off (damaged beyond repair)
Location: Islamabad (Pakistan)
Phase: Approach (APR)
Nature: Domestic Scheduled Passenger
Departure airport: Karachi-Jinnah International Airport (KHI) (KHI/OPKC), Pakistan
Destination airport: Islamabad-Benazir Bhutto International Airport (ISB) (ISB/OPRN), Pakistan
Flightnumber: 213
Narrative:  A Boeing 737 passenger plane was destroyed in an accident near Islamabad, Pakistan. Initial reports indicate that all 121 passengers and six crew members were killed. Bhorja flight B4 213 departed Karachi (KHI) on a domestic flight to Islamabad (ISB). This was Bhorja’s inaugural flight on that route. The airplane crashed, broke up and burned in a rural area near Chaklala Air Base and close to the Islamabad Express Highway. Based on the accident location, it seems likely that the airplane was approaching runway 30 at Islamabad at the time of the accident.  Weather reported about the time of the accident (18:40 LT/13:40 UTC) was poor with limited visibility, thunderstorm and rain:
OPRN 201400Z 23020KT 3000 TSRA FEW025CB SCT030 BKN100 20/16 Q1011.0/29.85
OPRN 201300Z 23020KT 4000 TS FEW025CB SCT030 BKN100 25/15 Q1009.3/29.80

FOX NEWS [Published April 21, 2012]

[Associated Press]

“Pakistan probes jet crash amid criticism”

ISLAMABAD – Pakistan on Saturday barred the head of the airline whose jet crashed near the capital from leaving the country, vowing to investigate a tragedy that has revived fears about the safety of aviation in a country saddled by massive economic problems. The Bhoja Air passenger jet crashed Friday evening as it tried to land in a thunderstorm at Islamabad’s main airport, killing all 127 people on board. The second major air disaster close to the capital in less than two years, the crash triggered fresh criticism of an already embattled government, which faced questions over why it gave a license to the tiny airline just last month.

Sobbing relatives of those who died flocked to a hospital in Islamabad to collect the remains of their loved ones. “We had no idea they would be called for eternal rest,” said Sardar Aftaz Khan, who was trying to secure the release of the bodies of her mother, an aunt and a nephew. Speaking after visiting the scene of the crash, Interior Minister Rehman Malik said that Farooq Bhoja, the head of Bhoja Air, had been put on the “exit control list,” which bars him from leaving Pakistan. Such a ban is often put on someone suspected or implicated in a criminal case. Malik said Bhoja had been ordered into protective custody and a criminal investigation launched into the crash, presumably running alongside the one being carried out by aviation authorities. Prime Minister Yousuf Raza Gilani also ordered a third probe, known as a judicial commission, into the accident.

Nadeem Yousufzai, the head of the Civil Aviation Authority, urged people not to speculate on the cause of the crash before all the evidence had been collected. He said he had listened to a recording of the conversation between the pilot and the control tower and said the pilot was in a “happy” mood. He said the weather was bad, but noted that another plane landed safely at the airport five minutes after the crash. He denied there was any “political pressure” in the awarding of the license to Bhoja Air, one of just three private airlines in Pakistan. The airline only recently received a permit and began flying last month after it lost its license in 2001 because of financial difficulties.

A representative for Bhoja Air, Jahanzeb Khan, declined comment on the travel ban against Farooq Bhoja and said the airline would discuss the case after the investigation was complete. Malik, the interior minister, appeared to back up theories aired by some in the media that the age of the aircraft may have been a factor, saying the airline “seems to be at fault as it had acquired a very old aircraft.” “If the airline management doesn’t have enough money it doesn’t mean you go and buy a 30-year-old or more aircraft as if it were a rickshaw and start an airline,” he said. According to the Web site http://www.airfleets.net, the Bhoja jet was 32 years old and first saw service with British Airways in South Africa. Thirty-two years is not especially old for an aircraft, and age by itself is rarely an important factor in crashes, said Nasim Ahmed, a former crash investigator.

Malik’s comments — and the three official investigations — appeared to be part of a government effort to move quickly and deflect some of the criticism that it is likely to find itself under in coming days because of the crash. Such is distrust of the state in Pakistan, few believe the government — which lurches from crisis to crisis, clinging to power in the face of a mostly hostile media, opposition and judiciary — has the will to hold politically connected people accountable or carry out credible investigations. The violent storm that was lashing Islamabad when the accident took place has led some experts to speculate that “wind shear,” sudden changes in wind that can lift or smash an aircraft into the ground during landing, may have been a factor. It may even have been a dangerous localized form of the phenomena, called a microburst. That can cause planes to lose airspeed suddenly or lift abruptly if a headwind suddenly changes to a tail wind during takeoff or landing. Soldiers and emergency workers at first light began the grim task of looking for bodies and body parts among the debris from the Boeing 737-200, which was spread out over a one-kilometer (mile) stretch of wheat farms around five kilometers (three miles) from Benazir Bhutto International Airport.

The plane was flying from the southern city of Karachi to Islamabad when it crashed. One soldier had a plastic bag over his hand and was picking up small bits of flesh. Another was using a stick to get at remains in a tree. “We are collecting these so that the souls are not desecrated,” one of them said. The officers were also picking up personal effects of the passengers, making piles of documents, bank cards, gold and bangles.

The last major plane crash in the country — and Pakistan’s worst — occurred in July 2010 when an Airbus A321 aircraft operated by domestic carrier Airblue crashed into the hills overlooking Islamabad, killing all 152 people aboard. A government investigation blamed the pilot for veering off course amid stormy weather.

Nasim Ahmed, the former investigator, said it appeared at this stage that the age and air worthiness of the plane were unlikely causes. He said that a combination of factors during landing was probably to blame, possibly the weather or some form of unexpected incident that caused the pilot to lose vital awareness of the plane’s location. Ahmed said the accident highlighted long-standing weaknesses in Pakistan’s aviation industry, which he said couldn’t be separated from management problems in the Civil Aviation Authority, poor government oversight and corruption and nepotism in the state-owned Pakistan International Airlines.

In 2007, the European Union banned most PIA flights from its member’s airports for eight months due to safety concerns. “There are problems in the overall handling of the country, and the Civil Aviation Authority is not an isolated pocket of good governance,” Ahmed said.

“After the tragedy, a rush to judgment”

THE ECONOMIST – Monday 30 April 2012:

A BHOJA AIR 737 carrying 127 passengers and crew was coming in for a landing in a thunderstorm near Islamabad on Friday when it suddenly dropped from 2,900ft (883 metres) to 2,000ft (609 metres), appeared to lose control, hit the ground, bounced up from the impact and exploded, according to witness accounts and government statements. There were no survivors. In Pakistan, the rush to judgment has already begun. Farooq Bhoja, the head of the airline, has been barred from leaving the country—a hint that a criminal investigation may be on the way. Rehman Malik, the country’s interior minister, has implied that the age of the aeroplane, which has been in service with various airlines for over three decades, may have been a factor. Bhoja Air “seems to be at fault as it had acquired a very old aircraft,” he told the press. But well-maintained planes can last significantly longer than 30 years, and the age of an aircraft is rarely cited as a factor in a fatal crash.

The Associated Press has an excellent story [refer to the article above!] on the crash that takes an appropriately skeptical tone towards Mr Malik’s statements and the three crash probes that have been launched since Friday:

Malik’s comments—and the three official investigations—appeared to be part of a government effort to move quickly and deflect some of the criticism that it is likely to find itself under in coming days because of the crash. Such is distrust of the state in Pakistan, few believe the government—which lurches from crisis to crisis, clinging to power in the face of a mostly hostile media, opposition and judiciary—has the will to hold politically connected people accountable or carry out credible investigations.

A rush to judgment, irresponsible comments from the government and three separate investigations are not going to do much to restore flyers’ confidence in the Pakistani government’s ability to safely regulate its airlines. Pakistan’s state-owned flag carrier, Pakistan International Airlines, was barred from all EU airports for eight months in 2007, so it’s clear that international air-travel regulators haven’t had the highest opinion of Pakistan’s aviation sector in the past. So far, the chaos following this incident—the second major crash near Islamabad in as many years—is only making the Pakistani government and its Civil Aviation Authority look worse. It is of course possible that Bhoja Air was at fault in Friday’s crash. But other factors could have played a role in this tragedy. Hazardous weather conditions were reported near the airport. Pilot error could have been a factor. It’s impossible for anyone—Mr Malik, the media, or outside experts—to know exactly who or what is at fault for this crash before the plane’s black boxes are examined and a full, professional investigation is completed. Let’s wait for that to happen before we decide who deserves the blame.

My Thoughts:

Usually “the more corrupt the more the speculation,” as it evolves in nothing more than a “blame game!” Here the Government [and the State owned airline] ‘is never wrong,’ thus it concludes to ‘pilot error’ – if no blatant technical malfunction can be proved! The sad case is that, in a State where there is no indication of a “Just Culture,” we can usually expect lies and more lies and more blame, thus any “accident investigation” is flawed from the onset! As such there will be no substantiated causal factors, thus no valid recommendations, thus this type of accident will happen again and again! Note that I have not even mentioned WX / CFIT or any possible [and actual] causal factors, as accidents in States where there is no “Safety Culture” – [thus no Just or Learning Culture], “a full, professional investigation” is hardly possible, and even if s, with the state / airline accept and implement the recommendations? If not, there can be no preventive actions either and the best we as pilots can do is to have sympathy with the families! The Bhoja Airlines accident will then be a case of: Sad to see that so many have died in vain, again!

However, rest assured that ALPA [and IFLPA] will not give up pursuing ‘justice’ for all crews, a JUST- and Learning Culture, anywhere and everywhere!

Cobus Toerien

Chairman – Accident Analysis & Prevention Committee

ALPA

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