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O N C O M M E R C I A L A V I A T I O N S A F E T Y

ISSUE 63 THE OFFICIAL PUBLICATION OF THEUNITED KINGDOM FLIGHT SAFETY COMMITTEE ISSN 1355-1523

SUMMER 2006

The Official Publication ofTHE UNITED KINGDOM FLIGHT SAFETY COMMITTEE

ISSN: 1355-1523 SUMMER 2006 ON COMMERCIAL AVIATION SAFETY

contentsFOCUS is a quarterly subscription journaldevoted to the promotion of best practises inaviation safety. It includes articles, eitheroriginal or reprinted from other sources, relatedto safety issues throughout all areas of airtransport operations. Besides providinginformation on safety related matters, FOCUSaims to promote debate and improvenetworking within the industry. It must beemphasised that FOCUS is not intended as asubstitute for regulatory information or companypublications and procedures.

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FOCUS is produced solely for the purpose ofimproving flight safety and, unless copyright isindicated, articles may be reproduced providingthat the source of material is acknowledged.

Opinions expressed by individual authors or inadvertisements appearing in FOCUS are thoseof the author or advertiser and do notnecessarily reflect the views and endorsementsof this journal, the editor or the UK Flight SafetyCommittee.

While every effort is made to ensure theaccuracy of the information contained herein,FOCUS accepts no responsibility for anyerrors or omissions in the information, or itsconsequences. Specialist advice shouldalways be sought in relation to any particularcircumstances.

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Editorial 2

Chairman’s Column 3

No.45 (Reserve) Squadron and 4RAF Multi-Engine Pilot Training

The ICAO English Language Competency Requirements 6

Fumes, Smoke and Fire in Transport Aircraft 9

UKFSC Members List 12

Working together to tackle level busts 14Richard Schofield, Operational Safety Division of Safety, NATS

EU Blacklist for Air Carriers 16Sue Barham, BLG

Communication Error, an Industry Campaign to 17Improve StandardsKaren Skinner, Supervisor, London Terminal Control

Automatic Radio Altimeter Call Outs 18An Underutilized resource?by Alex Fisher, GAPAN

National Initiative Targeting Disruptive Passengers 19

It Couldn’t Happen to ME 20Lt Dan Denham Royal Navyex 801 Naval Air Squadron Operations Officer

UKFSC Seminar 24

Front Cover Picture: 4 RAF King Airs in box formation over-fly another 45(R)Squadron King Air in special 90th Anniversary liveryat RAF Cranwell in Lincolnshire.

Editorial

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UK FLIGHT SAFETY COMMITTEE OBJECTIVESUK FLIGHT SAFETY COMMITTEE OBJECTIVES

■ To pursue the highest standards of aviation safety.

■ To constitute a body of experienced aviation flight safety personnel available for consultation.

■ To facilitate the free exchange of aviation safety data.

■ To maintain an appropriate liaison with other bodies concerned with aviation safety.

■ To provide assistance to operators establishing and maintaining a flight safety organisation.

Language Proficiency Requirements

In 1998 following the CFIT accident inCali, Colombia and the 1996 mid aircollision near Delhi, India called on theInternational Civil Aviation Organisation(ICAO) Assembly to take action to ensurethat pilots and air traffic controllers were“proficient in conducting andcomprehending radiotelephonycommunications in the English language”.

In 2005 ICAO set the date of March 2008as the deadline for the initial testing ofEnglish language proficiency to becompleted. As yet it has not been clarifiedjust how this is to be done.

Perhaps this will make regulators andaviators around the world sit up, takenotice and more importantly take action.

In the United Kingdom the National AirTraffic Service (NATS) identified thatcommunication was not up to standardand contributed to two of the high priorityareas of risk in Air Traffic Control, levelbusts and runway incursions. For the pastyear and a half they have been trying toraise the awareness of the need forimproved communication by both pilotsand ATC controllers.

Air Traffic Controllers who work for NATS aresubject to regular but random monitoring oftheir R/T procedures and use of the correctaviation phraseology. If they do not meet thestandard, retraining is provided in order toencourage a higher level of performance.This regular monitoring ensures that a highstandard is maintained.

Regrettably no such regular monitoring ofthe pilot community exists, and as a result,the standard of aviation English andphraseology heard over the R/T is notparticularly good. Some operatorsendeavour to monitor R/T during simulatortraining sessions. Unfortunately this is notnecessarily the best time to do this as creware concentrating on the task at hand andthere is a high concentration on procedures.Nevertheless an effort is being made.

It is of interest to note that pilots sit aninitial examination for their R/T licence.There is no requirement for renewaltesting for the rest of their career. Nowonder that their proficiency deterioratesover a period of time. We all know thatrevision or retraining improvesperformance and that lack of any realmonitoring leads to complacency.

Whilst on the subject of aviation English,we, in the United Kingdom, should not besmug about it not affecting us. There aremany foreign and indigenous pilots flyingfor UK operators who would not pass anAviation English proficiency test.

Proficiency does not occur overnight andseveral hundred hours of training will berequired to bring a non-English speakingstudent up to the required standard. It ispossible that these new requirementscould make or break the careers of somepilots and Air Traffic Control Officersinvolved in international operations.

The economic effects on many airlinesand ATC service providers could besignificant if pilots and controllers aredenied a licence to operate internationallybecause of the non-compliance with theICAO requirements. Hopefully the trainingprogrammes will be good enough toproduce the required result.

It is therefore time for us all toenthusiastically embrace the need forproficiency testing to bring us up to therequired international standard, with aview to reducing any risk to safeoperations that poor R/T may cause. It isimportant that those whose first languageis English should set an example to therest of the aviation community.

Perhaps in the interests of safety theregulators will consider introducing an R/Trenewal every 5 years which includes aproficiency test. We know fromexperience that the present system isnot ideal.

Chairman’s Column

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This is my first column as Chairman ofthe Committee. I would like to thank thePast Chairman and Chief Executive, formaking the smooth transition into the ‘hotseat’ and I very much look forward to thenext 12 months.

The other day I was reading a book aboutthe pioneering flights to Australia. Theaircraft that are today museum pieces,offered the crew and passengers anoutside chance of reaching theirdestination.

Whilst page turning, I reached a passagewhere the crew were discussing in anopen cockpit the dangers of flying over amountain range, in adverse weatherconditions with concerns about engineperformance.

As we all know in those early days flyingwas full of challenges, if not out and outdanger. Things could hardly be moredifferent from the experiences of flight inthe 21st century.

Now, in our air conditioned, pressurisedenvironments, we all take flight forgranted, and in a way rightly so. Therehave been some tremendousdevelopments in the aviation industry withadvanced systems and extremely reliableengines.

However, we should be mindful that in2005 there was an increase in the numberof fatal accidents, with over 900 fatalitieswhen compared with the “safe years”(2001 – 2004), where in 2004 there wereapproximately 350 fatalities.

Many of these accidents were low profilelosses in remote locations involvingaircraft that were either old, or with a lownumber of passengers, or a combinationof both.

With air travel for most of us becomingsafer, perhaps there is a tendency to relaxour guard and become complacent,handing over control to systems that areoften not fully understood.

From the human factors point of view wecould say that sophisticated systems, in away, encourage complacency. Perhapswe need to return to the ‘What if’ culture.

The introduction of new information maynot be helpful for all. Some of our moreexperienced folk are resistant to changewhereas the newer recruits are less so.

To make the process more interesting wecould mix talk and chalk with CBT.

To discourage complacency I believe weneed to develop training procedures thatpromote imagination; the ‘what if’ ratherthan the “need to know” culture throughprogrammes to develop professionalism,competency and commitment. In otherwords is it a job you have in aviation or acareer?

Our Seminar theme for October 2006 willfocus on training. Please make everyeffort to attend.

The more experienced pilots andengineers often talk about airmanshipand apprenticeships. I’m not suggestinga return to the old days but, reviewing thepast often helps us plan for the future,recalling that there are no new accidents,only new people.

My messages are therefore, encouragecontinual professional development, donot rely on statistics, review your nearaccidents, improve system knowledgeand adapt your policies and proceduresto reflect the true changing nature ofaircraft operations.

Safety is a precious commodity whichdeserves our constant attention. We oweit to our passengers, aircraft and ourindustry.

The Risk of Complacencyby Ian Crowe, Willis Ltd

Based at Royal Air Force Cranwell inLincolnshire, No 45(Reserve) Squadron isresponsible for the RAF’s multi-enginepilot training. Although superficially similarto the commercial equivalent, militarymulti-engine pilot training is fundamentallydifferent in many respects. A military pilotis expected to operate in austereconditions, with minimal support, andmust independently balance thesometimes conflicting demands ofmission success and flight safety. Aboveall, in addition to a high level of technicalskill, they must both display and instil inothers that fighting spirit vital tooperational success. The demandsplaced upon the RAF’s multi-engineaircraft pilots are very high: they canexpect to operate in hostile combatenvironments with as little as 300 hoursflying experience, where flexibility ofthought in an ever changing tacticalsituation is essential. An effective,operationally-focussed training system iscritical if they are to go in harm’s way withminimum risk.

The Air Force achieves its goal of trainingits multi-engine pilots by introducing themto the necessary concepts as early aspossible. Potential pilots will commencetraining at 45(R) Squadron having flownapproximately 75 hours during ElementaryFlying Training (EFT) on the RAF Grob115E Tutor. EFT provides the essentialflying skills and disciplines required toproceed to streaming, where students areselected to continue either multi-engine,fast-jet or rotary-wing training.

Those undertaking multi-engine trainingwill proceed to fly approximately 30 hoursduring Multi-Engine Lead IN Training,(MELIN), on the Slingsby Firefly providedvia civilian contract with Babcock DefenceServices. MELIN is embedded within45(R) Squadron and acts as a bridgingcourse between EFT and operating a truemulti-engined trainer. It introduces theessential concepts of a 2-crew cockpitand Crew Resource Management (CRM)on an easily managed platform, and startsto instil in student pilots the required ethosand spirit that is required of a combatpilot. An understanding of the humanfactors of a multi-crew cockpit is a crucialrequisite to successfully carrying out thehuge range of missions asked of today’smilitary pilot.

Student pilots will continue their trainingon the King Air B200 provided under aprivate finance initiative with SercoDefence and Aerospace. In service in

large numbers in the civil aviationcommunity worldwide, this aircraft hasproved itself to be a successful, modernand reliable military trainer, asdemonstrated by its selection by, amongothers, the RAF and the US Navy.Although considered an interim solutionwhilst the RAF’s proposed Military FlyingTraining System (MFTS) is introduced, theKing Air contract is valid until 2011. TheKing Air has provided a significantimprovement in aircraft availability, at noadditional cost compared with itspredecessor, the Jetstream 200, (the pre-production model). Additionally, with itsadvanced avionics and systems, the KingAir provides greater training benefit andprovides an additional flight safety edge.In particular, the introduction of TrafficCollision and Avoidance System (TCAS)has been of great value, not only in thefamiliar procedural environment, but alsoas an aid to situational awareness whenoperating on a see-and-avoid basis inClass G airspace and in the low flyingsystem. The King Air’s speed ofintroduction into service has been, bymilitary standards, meteoric; the contractfor service was approved in June 2003,and 45(R) Squadron was utilising theaircraft to their full potential conductingflying training by April 2004. Thesetimescales are unprecedented and theresult of a successful partnership withindustry underpinned by a determinationto provide a highly capable pilot to thefrontline.

The King Air course is split into twodistinct phases – basic and advanced.The basic phase focuses on generalhandling of the aircraft, basic instrumentflying including radio aids navigation andintroduces the student to operations atnight. It also provides essential training inasymmetric flight, whilst continuouslydeveloping the student pilot’s CRM andability to operate within a multi-crewenvironment. To ensure that they developa sound foundation in the basics ofairmanship and situational awareness,

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No.45 (Reserve) Squadron and RAF Multi-Engine Pilot Training

students are only allowed use of the basicmodes of the Collins EFIS 84 avionics andflight system during this phase.

Once the students can fly the aircraft, theymust learn to operate it as a militaryplatform. The King Air advanced phaseintroduces more complex sortie profiles,making full use of the aircraft’s advancedsystems. In addition to operations in thecivilian procedural environment, in the UKand abroad, students are taught low levelflying, formation flying, and demandingmulti-discipline simulated combatmissions. All these elements are intendedto advance both the student’s skill-set,and also to continue to develop theirairmanship, CRM, systems managementand captaincy.

Throughout the King Air syllabus, full useis made of synthetic training via 2 FrascaFlight Training Devices. Training in thesimulator and in the aircraft is consideredcomplimentary and indivisible, and allowsa continuum from part-task trainer to liveflying. This holistic approach to flyingtraining and effective use of the availablesynthetic trainer allows 45(R) Squadron tomaximise the impact of each hour spent inthe air. At successful completion of thecourse, after flying approximately 110hours, both real and simulated, the pilotsare presented their ‘Wings’. Now theymust proceed to their OperationalConversion Unit (OCU) for a further 120-150 hours flying specific to type.

One of the challenges facing the multi-engine training system is the diversity ofaircraft it must prepare the student pilot tooperate. Aircraft types include older,legacy aircraft such as the VC10 andTristar through to state of the art, modernplatforms such as the C-17 GlobemasterII. The ability of 45(R) Squadron toproduce an individual fully prepared toadvance to any multi-engine OCU isdemonstrative of the training system’scontinual and successful evolution. Thissuccess is underpinned by the excellence

of its QFIs, all of whom are militarycaptains from diverse operationalbackgrounds, and by an excellent workingrelationship with industry partners.

Military multi-engine pilots are expected tooperate in all roles, in all theatres, andmust be prepared for operations in thetactical, low-level and night environments.Crews must operate a plethora of aircraftand role-specific systems, oftensimultaneously with other aircraft, whilstalso ensuring their own safety utilisingdefensive, tactical, and for the future,offensive aids. It is 45(R) Squadron’sproud boast that it does not producetransport pilots. Instead it graduatescombat pilots who operate large aircraft.

A P ROGERSONFlight Lieutenant

Footnote:

45(R) Squadron will be enjoying its 90Anniversary this year and it is intended tocelebrate the occasion with an Association

dinner on Friday 29 September 2006. Theevents continue with a Squadron tour anda plethora of fun tournaments on theSaturday, and conclude with a ChurchService on Sunday 1 October 2006. Anyindividuals with links to the Squadron, pastor present, and are interested in joiningthese celebrations are invited to contactthe 45(R) Squadron Association Secretary,Flight Lieutenant Duncan Wright at RAFCranwell, 01400 267769, or in writing atthe address below.

Flight Lieutenant Duncan Wright45(R) SquadronRAF CranwellSleafordLincolnshireNG34 8HB

Email: crn45sqn-qfi04@cranwell.raf.mod.uk

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The ICAO English Language Competency Requirements

Introduction

Back in 1998 the ICAO Assembly,following observations that lack of abilityto speak and/or understand English wasa contributory factor in a number ofaccidents, decided to formulate AssemblyResolution A32-16 where the ICAOCouncil was urged to direct the AirNavigation Commission (ANC) tostrengthen the provisions of Annexes 1(Personnel Licensing) and 10(Aeronautical Communications) toameliorate the problem.

Subsequently, the ANC established theProficiency Requirements in CommonEnglish Study Group (PRICESG) to assistthe Secretariat in carrying out acomprehensive review of the existingprovisions. The committee met over anumber of years until 2001, including thesetting up of a linguistic expert sub-group,before a submission was made leading tothe ANC which, in 2003, adoptedamendments to Annexes 1, 6 (operationof Aircraft), 10 and 11 (Air Traffic Services)as well as PANS-ATM Doc 4444.

The International Federation of Air TrafficController’s Associations (IFATCA)nominated a representative to PRICE SG, asdid its pilot counterpart IFALPA, with the UKCAA SRG Air Traffic Services Departmentand Eurocontrol making up the majororganisations from Europe within what wasa world-wide group representing bothaviation and language training industries.

I took on the IFATCA responsibility from aCanadian, until the committee waseffectively disbanded on successfulcompletion of its work, and I attendedsubsequent seminars and workshops. Atthese later meetings, it became obviousthat although ICAO had introduced thenew requirements - leaving the method ofintroduction and approval of a scheme(possibly utilising outside organisations)for training and testing to the individualState Regulator - there were manyconcerns outstanding. ICAO had neitherthe resources nor remit to carry out any

further work on oversight or accreditingany testing organisations without theContracting States requiring this input,although agreement was reached tosupply a guidance and implementationmanual (published as DOC 9835) toassist Regulators and other organisationswho would need to design packages fortesting and training purposes.

Earlier this year, it was accepted that theinitial ethos was insufficient for the greatmajority of countries and the Manual onthe Implementation of ICAO LanguageProficiency Requirements was in need offurther development. The PRICESGmembers were therefore asked toreconvene so as to provide further input tothe ICAO Secretariat, and this took placeduring April 2006, hopefully to finalise thework bearing in mind the short timescalesyou will see in the next section of thisarticle. The work included such things asdefining qualifications appropriate forthose who will design and/or carry out thetests, guidance for Regulators on how tochoose external organisations who offer tocarry out training and testing for thoseStates who do not have either resourcesor expertise to do things themselves, andlaying down the structure for testprocedures themselves, although it has tobe recognised that the work producedguidance material only.

Overview

The 2003 Annexe changes simplisticallymean that Pilots, Controllers, FlightNavigators (who use RTF) and GroundRadio Station Operators who are involved inInternational Services must be qualified toat least ICAO Level 4 English LanguageCompetency standards, and to the samelevel where the native language is notEnglish. The ICAO Rating Scale for EnglishLanguage is divided into 6 levels, withNative Speakers or ‘Experts’ being Level sixand each sub-set being specified in termsof the six specific areas of ability covering:-Pronunciation, Structure, Vocabulary,Fluency, Comprehension and Interaction

and all these words have specificmeanings to the linguistic community, ascan be seen below.

From the date of implementation of thechanges late in 2003, for any licenceapplication from a pilot after March 2004or for any Air Traffic Control Officer afterNovember 2003, he/she had to satisfy theLicensing Authority of compliance with theneed to speak and understand thelanguage for radiotelephonycommunications. However, until March2008 when the new rules also apply tothose already holding a licence, Statesare permitted to establish thiscompetency in any way they wish.

Tests to satisfy the requirements fromMarch 2008, however, have to be byspecific reference to the new ICAO RatingScale applied by the relevant StateRegulator and using what are known asHolistic Descriptors.

An example of this is the detail below thatis for the ICAO minimum Level 4(although again, some of the wording isspecific to the language industry).

Pronunciation: - Pronunciation, stress,rhythm and intonation are influenced bythe first language or regional variationand frequently interfere with ease ofunderstanding.

Structure: - Basic grammatical structuresand sentence patterns are consistentlywell controlled. Complex structures areattempted but with errors whichsometimes interfere with meaning.

Vocabulary: - Vocabulary range andaccuracy are usually sufficient tocommunicate effectively on common,concrete and work-related topics. Canoften paraphrase successfully whenlacking vocabulary in unusual orunexpected circumstances.

Fluency: - Produces stretches oflanguage at an appropriate tempo. Theremay be occasional loss of fluency on

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transition from rehearsed or formulaicspeech to spontaneous interaction. Canmake limited use of discourse markers orconnectors. Fillers are not distracting.

Comprehension: - Comprehension ismostly accurate on common, concreteand work related topics when the accentor variety used is sufficiently intelligible foran international community of users.When the speaker is confronted with alinguistic or situational complication or anunexpected turn of events,comprehension may be slower or requireclarification strategies.

Interactions: - Responses are usuallyimmediate, appropriate and informative.Initiates and maintains exchanges evenwhen dealing with an unexpected turn ofevents. Deals adequately with apparentmisunderstandings by checking,confirming or clarifying.

Effects on UK Aircrew and ATCOs

There are a number of areas that areparticularly germane to us, even thoughthe great majority will invariably beassessed as Level 6 or ‘experts’, but fromthe above it can be seen that any testingneeds highly qualified examiners.

Firstly, however fluent you are, for the UKto comply with the Annexe changes,arrangements will have to be made by youremployer to satisfy SRG in whatevermethod is finally approved – probably anexternal company accredited to do this testshould you not be initially assessed as anative English speaker. The latter process,however, does not have to be made by alanguage expert and may be undertaken(for example) as part of initial training andexamination for aircrew/ATC licences (by anappropriately qualified assessor).

‘Native speakers’ will not have toundertake a further assessment or testafter this has been established, but therewill be ongoing requirements for thosewho are assessed as Level 4 (maximum

every 3 years) or Level 5 (maximum 6years), and a need for training/re-testingfor those below this competency.

Discussions are taking place within theEuropean Commission to mandate Level5 for ATCOs at some designated ‘highdensity‘ units, and the UK is waiting forinput from EASA and JAA as well ascomment from industry before decidingon the way ahead for this country. Itseems likely, for example, that Level 4 willbe a requirement for all JAR/FCL and UKPPL holders as potentially they have theentitlement to fly overseas, and overallrequirements may eventually be higherthan those of ICAO.

It is important to realise that the ICAOrequirements are applicable to‘Language’ and not just English, althoughthe latter is a pre-requisite where its use ismandated in accordance with theAnnexes. Furthermore, the sole use ofEnglish for RTF is not mandated, so thenew requirements are applicable to themajority of pilots, controllers, andaeronautical station operators no matterwhich country they are working in.

Testing

The rationale is to test plain language inan aviation environment, which meansthat although it is not feasible tocompletely separate standardphraseology from ordinary use, it is notthe aim to actually test the use of anyelements of the ICAO Radio TelephonyManual (DOC 9432) - which forms thebasis of the UK CAP413 document. Theoperational aspects will invariably becovered in the relevant environment bycompetency or recency examiners.

However, what phraseology is used in thetest package will be those appearing in theinternational sphere rather than the UKdocument - although I suspect that this willnot be of a major significance. CommercialUK pilot licence RTF tests already use theICAO standards, although the PPL written

and practical examinations are based onthe national document.

The six elements all need to be confirmedas competent (with the lowest scoredetermining the attainment level), so it islikely that there will be a number ofsections making up the complete test. Tocomply with ICAO Personnel LicensingAnnexe 1, once the assessment has beencompleted - necessary by 5th March2008 - an additional endorsement will beadded to the licence.

The testing organisation will have to beapproved by SRG, so unlike theunregulated English language trainingindustry, the examination side will bestrictly regulated - although in practicehow prescriptive this will be in other areasof the world may depend on the expertise(or lack of) and resources available withinthe Regulator or contracted organisationto provide this.

ICAO will be publishing an updatedManual of Implementation that willrecommend guidance for training andexperience necessary for all theindividuals involved in the testing, startingwith the Test Design Team and going rightthrough to those assisting with theadministration and ‘feed’ individuals,along with suggested procedures for thetest itself and a basis for Regulators forchoosing outside expertise to assistsetting up the scheme. It can be seenthat the whole procedure requires a gooddeal of expertise and experience, and fewregulators will initially be able to do thiswithout high calibre contract staff oroutside individuals/bodies deemed to be‘experts’ in this field.

Training

Following on from the international needsmentioned above, many countries of theworld will be in the market for this, prior toeven contemplating putting staff forwardfor a test. Without doubt there will beorganisations who will claim to be leaders

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in the field without having any aviationexperience, as until recently there havebeen few who have even considered anyinvolvement with there being quite a limitedmarket - but there is now going to be alarge requirement and the opportunities forcommercial gain (although testdevelopment is likely to be expensive).

Linguistic experts suggest that it takesbetween 100 and 200 hours training for acandidate to exhibit any noticeabledifference in ability. Training (and possiblytesting) may be web based, use ComputerBased Techniques, or classroom workstructured for individuals or groups. Thereare some companies who intend to testusing the ordinary telephone, others bycomputer assessment or voicerecognition/assessment techniques, whilstthe majority would appear to prefer acombination of different methods.

Conclusion

Before 5th March 2008, almost every UKCommercial Pilot and ATCO, together witha number of other related licence holders,will be required to undertake either anassessment to confirm NativeEnglish/Expert English Language Level 6status, or for those who do not meet thiscompetency, complete an SRG accreditedtest to satisfy a minimum of ICAO Level 4.

Those who reach Level 6 will retain thisstatus permanently, but those of Level 4will need to re-test within three years,whilst those at Level 5 will be required toundergo another test within six yearsalthough this can be undertakenoperationally providing the tester isspecifically trained for this task.

Pilots and Controllers in other areas of theworld where English is not the nativelanguage, will be required to have anassessment in the language for thelicensing country, and, where involved inInternational Services (when English hasto be available), an English assessmentto at least ICAO Level 4 Rating Scale.

Those who fail to reach Level four may berestricted in their operating sphere orairspace until they are able to satisfy therequirements, as ICAO regulations do notpermit this aspect to be filed as a difference.

Bob TrottGATCO/IFATCA

Anyone who would like further informationcan contact me attrottonrg@ntlworld.com

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Fumes, Smoke and Fire in Transport Aircraft

This is a very much shortened version ofan original paper by Capt John Cox,prepared for FOCUS by Peter G RichardsFRAeS and published in full by the RoyalAeronautical Society.

Summary

From records going back over 200 years,we acknowledge that any kind of airbornemachine, by the nature of its construction,is susceptible to an in-flight fire. We havevery detailed records now and these showthat in-flight smoke and/or fumes potentiallyleading to a fire, causes a diversion at leastonce a week in the USA alone.

Reviewing the statistics from 1987 to2004, the four leading categories leadingto in-flight fatality, out of the 17 available,were Loss of Control, Controlled FlightInto Terrain, Specific Component failure(other than engines) and In-Flight Fire.FAA Advisory Circulars, Manufacturers,International organisations and learnedsociety journals repeatedly draw ourattention to the hazard of in-flight fire andits precursors.

Risk assessment techniques ensure thatsufficient emphasis is placed inequipment design and operationalfamiliarity, but the onset of in-flight smoke,fumes and fire in an aircraft is sotraumatic for all on board that anythingthat can improve things still further isworth consideration and debate.

This paper will demonstrate that, fromwhat we know thus far, where we can wemust improve things, to make survivaland recovery assured. To this end,recommendations in equipment designand airworthiness, protective equipment,maintenance, and pilot procedures aremade .This is a very abbreviated reportand the full 41 page text will becomeavailable via the UKFSC office or theoriginal author.

A Historical Viewpoint

In 1785 we have our first in-flight fire, withJean-Francois Pilâtre de Rozier’shydrogen filled balloon catching fire overthe English Channel and the loss of alllives. When we commenced flyingaircraft, it was not long before thesebecame ‘victims’ of fire also. Somanufacturers began to mitigate againstthe risk by providing improved materials,and regulators and operators addressedthe operational requirements for dealingwith the risk.

Recently, the FAA acknowledged that itmay well nigh be impossible to ‘eradicateall possible sources of ignition’ in fueltanks, despite several years and millionsof research dollars attempting to do so.Their ‘examinations of large transportairplanes … revealed many anomalies inelectrical wiring systems and theircomponents with contamination by dirtand debris’. The FAA has an Notificationof Proposed Rule Making consultationwindow open until October 2006, toaddress this.

From early accidents, we learn of smokerapidly overcoming the ability of the crewto control the aircraft, due toincapacitation, loss of visibility andultimately control. An early NationalTransportation Safety Board report on theloss of a TWA Lockheed Constellation in1946 determined that the architecture ofthe aircraft wiring through the wing root tothe fuselage ‘resulted in intense localheating due to the electrical arcing’igniting the insulation and thus generating‘smoke of such density that sustainedcontrol of the aircraft became impossible’.Contributing to this was the difficulty ingaining access to inspect this location indetail and although this accidenthappened 60 years ago, we still haveincidents and accidents today thatoriginate from poorly maintained andinspected wiring or components.

The Jet Era

We are now in the Jet era and greatstrides have been made in theinvestigation of accidents. In 1973 madean emergency landing just short of Orlyairport near Paris with dense smokethroughout the aircraft. Although all 117passengers survived the landing, all butone succumbed to smoke inducedasphyxiation. The flight crew had openedthe flight deck windows to improvevisibility, but this tactic had failed, assmoke became drawn to the flight deckand thus they elected to land 70 secondsflight time short of the runway.

That same year, another accident to afreighter B707 became uncontrollablewhen the visibility on the flight deckdeteriorated and the crew became sodisorientated that the flight crashed. Crewactions became uncoordinated such thatthe flight engineer, believing the source ofthe smoke was the Essential AC busbars, selected the ‘source switch’ to adead source - external power - and thusde-activated the Yaw damper. This actioncompromised the flying controls and flapsconfiguration.

The lessons are clear. Smoke or fumesand flight deck activity do not mix andmore could be done to provide flightcrews with realistic competencies to dealwith this. Some mitigation was introducedby providing automatic fire extinguishingin aircraft toilet waste receptacles and bybanning smoking in the toilets too. Yet weentered the wide-bodied or ‘Jumbo jet’era with the same cabin airflow modellingas we have always had.

The Next Generation

The advent of wide-bodied and then moreadvanced ‘Electric jets’ has given rise toever more complicated and integratedavionic wiring and control systems.Attempts were made to lighten the weight

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of all this wire and some serious hazardsintroduced by the choice of some kinds ofinsulation. Electrical smoke became thenumber one hazard for crew to deal with,yet both checklist drills, and firesuppression or control lag far behind. Ourmindset seems to remain stagnant interms of choices of wire bundle size,routing, support, insulation and circuitcontrol. We must also remain alert to thefact that it is not just the wiring that cangenerate smoke and fumes. The wholeaircraft needs to be kept in focus,especially during deep maintenance, whenopportunities must be taken to cleanthings out thoroughly. This authorpersonally experienced an in-flight smoke-generating incident from un-cleanedpassenger oxygen generating canisters.Years of dust trapped between thecanisters and their heat shields filled thecabin with dense smoke while the oxygengenerating process was taking place. Notsurprisingly, this precipitated an immediatediversion and successful landing, as therewas no checklist to cater for such an event.

The aviation community has recognisedthat multiple layers of protection areneeded if advancement in fire safety is tooccur. This brief historical perspectiveshows that we need to continually reviewand learn from our mistakes. We enter theera of intense Regulation.

Regulatory Improvements

Our regulators, both the FAA and theCAA/JAA have not been idle aboutaddressing mitigation strategy, both indesign and construction, - drills andequipment too.

Standards have been set for fireextinguishing in cargo holds, toilet wastebins, portable extinguishers in the cabinand engine nacelles. Cabin furnishingshave come under requirements for fireblocking chemical retardant too. Flightand cabin crews now have standards for

their personal protection, but for the flightcrew, these need constant development.Airflow requirements are now made, butthe means of achieving them remainsdecades old. On board equipment, suchas the crash axe, have rarely been utilisedto assist in locating the seat of a fire, norany training given to facilitate this.Knowledge of the need for and use of aSmoke barrier seems all but non-existent.

It can no longer be acceptable for flightcrew to need to put on two devices toprotect themselves from in-flight fumes orsmoke. The required standard must be afull-face mask and goggles as acombined headset, adjustable to any seatincumbent and with sufficient duration ofsupply to enable safe landing. Beyondthis, the training and checking of crewcompetence must surely require thatsmoke drills be practised with ‘suitablysafe’ real smoke. Getting the smoke tostay away from the flight deck would haveimmense benefits, as many accidentstestify. Training crews not to open windowsor ports will help too, but ensuring the air-flow, under all pressurisation conditions,keeps the smoke away will save manylives. Yet five years after the first allembracing regulation to promote this wehave Swissair Flight 111 and later AirTrans Flight 913 that both crashed killingall on board, from uncontained smokeand fire. In neither case did the crewlocate the source of the fire.

It could be comforting to note theharmonisation between the two sides ofthe Atlantic and with both acknowledgingthe significance of ageing jet aircraftfleets world-wide, common standards areset and enforced. But things likeSupplemental Type Certification need veryserious review as it was a clear failure ofthis process that ‘enabled’ the Swissairaccident. An IFE update bypassed theCabin Bus isolation switch such that awiring fire in a non safety-critical circuitprecipitated a fire through much of theaircraft control circuitry.

Recommendations

These recommendations cover allaspects of transport airplane design,manufacture, operation and maintenance.1. Evaluate all aircraft for single point

failures of wiring and potential effecton the aircraft systems.

2. Improve the engineering by choiceand route of wires, so that the routingdoes not endanger any critical systemwiring. Apply the same rigour toSupplementary Type Certification formodifications as is required fororiginal Type Certification.

3. Require Arc Fault Detection circuitinterruption technology to be fitted toall new and existing jet transports.

4. Conduct continuous smoke testing todemonstrate smoke evacuation for atype certificate.

5. Install Fire Access Ports or dedicatedfire detection and suppressionsystems in inaccessible voids ofaircraft.

6. Mark areas of minimal internaldamage for access by emergencyservices.

7. Increase the number and locationscovered for remote sensing to alertflight crew to the onset of smoke andfire, using whichever technology ismost appropriate.

Protective Equipment

1. Implement vision assurancetechnology for flight crew during flightdeck smoke situations.

2. Install full-face oxygen masks andprovide sufficient oxygen for flightcrew to use during any emergencydescent and landing smoke/fumesevent.

3. Supply and increase the size of theHalon fire extinguisher to 5lbs anddevelop suitable replacementchemical extinguishers.

11

Maintenance

1. Include in the Maintenance programmea regular and systematic cleaningprogramme of all the thermal insulationblankets and smoke barriers.

2. Modify maintenance practices tominimise the ingress of dust, debris,swarf and any other contaminants intothe insulation blankets.

3. Improve wiring inspectionprogrammes to utilise new technologythus minimising the need to disturbwiring bundles.

Flight Crew Procedures

1. Implement flight-crew procedures forusing auto-flight systems to reduceworkload. There should, however, be

a manual reversion capability toprovide control where the auto-flightsystem becomes unserviceable or hasto be disabled.

2. Eliminate the need for flight crew toopen windows or ports. Improveairflow routing to remove any smokeor fumes from the flight deckautomatically, with manual reversion.

3. Review and if necessary re-design allSmoke and Fumes removal checkliststo comply more with advancedthinking such as the Flight SafetyFoundation template. This shouldinclude ‘memory’ items, prevention ofchecklist ‘bottlenecks’, font size andtype style, rapid location of correctdrill, both on cards and electronicformat. Length of checklists to be keptto a minimum.

Flight & Cabin Crew Training

1. Assure that all aircrew receiveappropriate training in the use of acrash axe, smoke hoods and all typesof fire extinguisher carried. With thisinclude a demonstrated competenceto deal with smoke, fumes and firechecklists and when these should beabandoned. Apply realisticallysimulated smoke to establish truecompetence, stressing the importanceof crew interaction, maintenance ofany smoke barriers, problems ofcommunication and ways of assistingflight crew from the flight deckfollowing an emergency landing. ForFlight Crew, the need to remain‘Situationally Aware’ even while dealingwith a smoke removal drill.

Conclusions

This has been a very abbreviated précisof Capt John Cox’s paper that I wouldurge all FOCUS readers to obtain to readin full. There will continue to be in-flightfires because it is not possible to entirelyeliminate all the ignition sources andkeep them clear of the numerous

flammable materials on board, especiallyin remote and inaccessible locations.

Effective, multiple layers of mitigation arethe only answer. Continuous review andmodification is needed from the initialdesign of the aircraft, through approval tomanufacture, from regulation to operationand above all in the calibre of peopleinvolved. Only then can we honestly saythat we have done all we can to reducethe risk of in-flight Smoke, Fumes andFire in Transport Aircraft.

General view, looking forward andoutboard, of the aft inboard corner of thegalley chiller unit (blue) in relation to thewiring looms. Crew emergency oxygenbottle is located beneath chiller.

General view of damaged wires afterchiller removal, with partially failed loomnearest the camera. Areas identified A andB exhibit wire damage not directly relatedto the loom failure. Of significance,damage at A is approximateley the sameheight as the failed section of loom.

“Pictures kindly supplied by the UK Air Accident Investigation Branch, from theirinvestigation into the serious incident of an on-board electrical fire and subsequent en-route diversion into the UK of N643UA in 1998. There are several significant lessons thatcan be drawn from the investigation. The lack of conformity to required maintenanceprocesses, while an obvious candidate, should be ‘measured’ against the airworthinessdesign compromise of putting the chiller module so close to electrical looms withoutrobust shielding to protect them. Wiring damaged by poor ‘housekeeping cleanliness’had also occurred, such that drilling swarf from cabin floor activity had been blown bythe chiller fan into the looms, too. The lack of arc tracking or arc fault detecting circuitbreakers, now available but yet to be retro-fitted to all transport aircraft, means that thisincident, or others closely similar, could be repeated at any time.”

12

Full members

ChairmanWillis LtdIan Crowe

Vice-ChairmanBMEDRobin Berry

TreasurerAir ContractorsCapt. Anthony Barrett-Jolley

Non Executive DirectorRAeSPeter Richards

Aegean AirlinesCapt. Dimitris Giannoulatos

Aer ArannCapt. Paddy Callahan

Aer LingusTom Curran

AIG AviationJonathan Woodrow

AirclaimsPaul Clark

Air Atlanta EuropeCapt. Andrew Wood

Air ContractorsCapt. Anthony Barrett-Jolley

Air MauritiusCapt. Francois Marion

Air SeychellesBen L’Esperance

ALAEDave Morrison

Allianz Marine Aviation

Astraeus LtdJohn Denman

BAA plcFrancis Richards

BA ConnectCapt. Ed Pooley

BAE SYSTEMS Reg. A/CAlistair Scott

BALPACarolyn Evans

Belfast Intl. AirportAlan Whiteside

BMEDRobin Berry

bmi regionalPeter Cork

British AirwaysSteve Hull

British InternationalCapt. Terry Green

CAADave Lewis - MRPSSarah Doherty - Safety Data Dept.Ed Bewley - Flight Operations

CargoLux AirlinesMattias Pak

Cathay Pacific AirwaysRick Howell

CHC ScotiaMike Whitcombe

CityJetCapt. Tom Murphy

Cranfield Safety &Accident Investigation CentreGraham Braithwaite

CTC Service Aviation (LAD)John Dunne

DARARichard Allen

DHL AirPeter Naz

Eastern Airways UK LtdCapt. Jacqueline Mills

easyJetCapt. Lance Jordan

Emerald AirwaysFred Holloway

European Air Transport NV/SAVincent Lambotte

European Aviation Air CharterRon Hendrick

EVA AirwaysRichard Lovegrove

Excel AirwaysGraeme Stagg

First Choice AirwaysPatrick Cafferky

FlightLineCapt. Derek Murphy

FlyglobespanCapt. Steve Brown

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13

Flyjet LtdStefan Kondak

GAPANCapt. Alex Fisher

GATCORichard Dawson

GB AirwaysCapt. Rob Alabaster

Goodrich Actuation Systems LtdGary Clinton

Gulf Air CoCapt. Manin Al Said

Hong Kong Dragon Airlines LtdKwok Chan

Independent Pilots AssociationPeter Jackson

Jet2.comTony Stevens

Irish Aviation AuthorityHarry McCrink

LoganairCapt. Stephen Gates

London City AirportGary Hodgetts

Lufthansa Consulting GmbHCapt. Simon Searle

Malaysia AirlinesCapt. Ahmed Zuraidi

Manchester Airport plcSimon Butterworth

Monarch AirlinesCapt. Tony Wride

MyTravelChris King

NATSPaul Jones

Penaville ServisairKeith Gibson

NetJetsCapt. Catherine Thompson

PrivatAirCapt. Patrick Danalet

Qatar AirwaysNorman Tregaskis

Rolls-Royce PlcPhillip O’Dell

RyanairCapt. George Davis

SBACMartyn Graham - SecretariatVic Lockwood - FR Aviation

ScotAirwaysPaul Calder

Shell AircraftGrant Campbell

Singapore AirlinesCapt. Patrick Lee

Smiths AerospaceDr. Marvin Curtiss

SR Technics Ireland LtdFrank Buggie

TAG Aviation (UK) LtdKen New

The Boeing Co.Thor Johansen

Thomas Cook AirlinesCapt. Roger Chandler

Thomsonfly LtdJez Last

Virgin Atlantic AirwaysGavin Staines

Willis LtdIan Crowe

Group members

bmiDavid Barry

bmi Eng.Tom Webster

bmi babyJeremy Purry

Bond Offshore HelicoptersTony Duff

Bond Offshore Helicopters (Maint)John Crowther

Bristow HelicoptersCapt. Derek Whatling

Bristow Helicopters Eng.Andy Evans

EurocypriaCapt. Constantinos Pitsillides

Cyprus AirwaysCapt. Spyros Papouis

flybe.Neil Woollacott

flybe. Aviation ServicesChris Clark

MODDASC Capt. Michael EvansDASC Eng. Wg Cdr Ian Woodhouse

QinetiQFlt. Lt. Jackie Doncaster

QinetiQ Eng.Paul Wright

RAeSPeter Richards

RAeS Eng.Jim Rainbow

Co-opted Advisers

AAIBCapt. Margaret Dean

CHIRPPeter Tait

GASCoJohn Thorpe

Legal AdvisorVanessa LeighBarlow Lyde & Gilbert

Royal Met. SocietyDr John Stewart

14

In the UK, NATS and the CAA define alevel bust as a deviation of 300 feet ormore from the assigned level. Thisdefinition may differ from the definitionused by other states or service providers,aircraft operators may also use adifferent definition. For example, NATSdoes not include events caused by a laterevision by ATC to a clearance which ispassed too late for the crew toaccurately capture the level as a levelbust.

The number of level busts reported byNATS ATCOs has risen since thebeginning of 2004.

2003 2032004 3032005 394

2006 Jan to Apr 30th 172

Reported level busts for the first quarter of2006 are 50% higher than for the sameperiod in 2005 and a 100% over the sameperiod in 2004. Some of the increase inreported level busts in the second half of2005 and in 2006 is partly due toimproved reporting by controllers and byoperators rather than a genuine increasein events.

Some level busts result in a loss ofstandard separation. Standard radarseparation in the UK will usually be 1000feet vertically or 3 or 5 miles horizontally.The number of level busts which haveresulted in a loss of separation hasremained broadly the same in the last 18months which can be attributed toimproved conflict detection and resolutionby ATCOs. Although the improvement inthe losses of separation is positive, levelbusts remain potentially safety significantevents and together we must continue toreduce the rate of level busts and tocontinue to reduce the number of eventswhich lead to a loss of separation.

Whenever possible and practicable, each

level bust reported by NATS staff isinvestigated; the depth of theinvestigation will generally depend on thesignificance of the events. Based on theinvestigation a causal factor will beassigned to the event based on the NATSEvent Factor Description scheme. The topcauses of level bust events since 2004are summarised above;

Within NATS we use the causal factorinformation to target actions and activitiesto eliminate the causes of these events,some of these causes are within the ATCdomain and we have the ability toinfluence them. Some of these activitieshave already included the identificationand elimination of hot spots at units,digging deeper to understand issuessuch as R/T loading and a drive toimprove controller R/T standards acrossall of the NATS units. We have alsoidentified solutions which can bedelivered with an increased use oftechnology; we are sure that theintroduction of Mode S technology at theLondon Terminal Control Centre willimprove conflict detection and resolutionand enhance controller situationalawareness.

Within NATS we recognise that level bustsare not a new phenomenon, that therehave been a number of different initiativesby various groups to address the problemover a prolonged period and that levelbusts are not the only issue for aircraftoperators. However, we believe that levelbusts are a safety issue for the industry

and that we all need to work together totackle level busts. Working together willensure that we understand the realcauses of level busts and will improve thesafety performance of the industry.

In June of 2005 the Chairman of NATSwrote to a number of airlines to expressthe concern of the NATS Board about theincreasing number of level busts in theUK. In the 11months since the letter waswritten there has been a renewed focuson level busts, one of the key benefits ofthis renewed focus is the fact that NATSand aircraft operators are working closertogether to agree the issues and to deliverthe correct actions. Some of the benefitsof this closer relationship have been;

■ Improved notification to operatorsabout level busts in the UK afterincidents and a quarterly update onperformance to approximately 60operators

Working together to tackle level bustsby Richard Schofield, Operational Safety Division of Safety, NATS

Top causes of level busts by year, 2006 to the end of April 2004 2005 2006Correct pilot readback followed by incorrect action 19% 30% 25%Failed to follow cleared SID 9% 13% 12%Audible incorrect readback not detected by ATC 9% 14% 5%Incorrect pilot readback by correct aircraft 7% 10% 6%Pilot readback by incorrect aircraft 6% 10% 6%Failure to follow ATC Instruction 3% 7% 7%Poor Manual Handling 9% 5% 9%Aircraft Technical problem 6% 5% n/aAltimeter Setting error 5% 5% 13%

15

■ The formation of a group of 17 airlinesbased in the UK or Ireland to shareinformation on airline best practice

■ A review of airline SOPs, facilitated byNATS and led by the AAIB, to try todetermine a relationship betweenSOPs and level bust performance

■ The distribution of education andawareness material

■ A drive to improve pilot and controllerR/T standards which included inputinto FODCOM 1-2006

■ The development and sharing ofsafety information

■ Targeting actions at groups with adisproportionate rate of level bustssuch as corporate and privateoperators

We believe that the actions NATS and theindustry have taken, or are planning totake will have a positive affect. Moreoverwe will start to see a genuine reduction inthe rate of occurrence of level busts and

of the associated risks but it will take timeand we may not completely eliminatethem. In order to deliver theimprovements in level bust performanceand in other safety areas that the industryis focussed on we believe that we need tocontinue to work together to fullyunderstand why safety events areoccurring and to ensure that the correctactions are in place.

We accept that we can’t provide all of theanswers or advice and welcome inputfrom the industry; we’d be pleased toreceive your input. For more informationplease visit www.levelbust.com or contactRichard.j.schofield@nats.co.uk

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16

New rules on EU-wide blacklisting ofairlines and on provision of information topassengers on carrier identity came intoeffect in January 2006 via Regulation (EC)No. 2111/2005.

Hitherto, the banning of air carriers forsafety-related reasons has been dealtwith on a piecemeal basis by individualEU member states. The consequence isa lack of uniformity across the EU, withairlines subject to an operating ban insome countries but not in others.

The new EU regulation provides for theestablishment of a “Community list” ofbanned airlines and requires eachMember State to enforce an operatingban within its territory in respect of thosecarriers listed. The initial list waspublished by the Commission in Marchand contains around 100 carriers, thevast majority of whom are African-based.The list has come under attack from theAfrican Airlines Association as implyingthat all African carriers are potentiallyunsafe.

The Regulation provides for the list to beupdated - to add or remove carriers fromthe list - by the Commission, either on itsown initiative or at the request of aMember State. Although the idea is topromote cohesion across the EU as towhich carriers may or may not operate inthe EU, the Regulation does however alsoprovide for individual Member States toimpose or continue a ban in respect of acarrier who does not appear on theCommunity list if there is considered tobe a specific safety issue affecting thatparticular Member State. It would seem,therefore, that there remains scope for alack of uniformity across the EU.

Air carriers are given the opportunity to beheard in relation to any proposal to placethem on the Community list. The impacton a carrier of an EU-wide ban is likely to

be severe and the Regulation expresslyrecognises that such a hearing may haveto be dealt with urgently. Time will tellwhether the mechanism for hearingrepresentations from carriers will be ableto move at the pace necessary toaddress any carrier objectionsexpeditiously and this may be testedshortly if any of those carriers on the initiallist decide to formalise their objections.

The Regulation includes an Annex settingout “common criteria for consideration ofan operating ban for safety reasons atCommunity level”. Consideration ofwhether a carrier should be bannedrequires an assessment of whether thecarrier is meeting safety standards. Thefollowing are some of the matters whichare to be taken into account:

■ Verified evidence of serious safetydeficiencies on the part of the carrier,including persistent failure by thecarrier to address deficienciesidentified by ramp inspections, or anoperating ban of the carrier by a non-EU country because of deficienciesrelated to international standards.

■ Lack of ability and/or willingness of acarrier to address safety deficiencies.

■ Lack of ability and/or willingness bythe authorities responsible forregulation of the carrier to addresssafety deficiencies demonstrated, forexample, by failure on the part of thethird country regulatory authorities toimplement and enforce relevant ICAOsafety standards.

At present, although many countriesmaintain their own blacklist, they do notmake the list available to the generalpublic, one exception being the UK. TheRegulation, however, changes thatposition. The general public will have fullaccess to the up-to-date Community list

through the websites of air carriers,national civil aviation authorities, EASAand perhaps through the displaying of anotice at airports.

The other important aspect of theRegulation concerns the provision ofinformation to passengers as to theidentity of the carrier who will operate theflight for which a passenger holds areservation. This part of the Regulationapplies to “air carriage contractors”, i.e.either the carrier which sells a ticket to apassenger or, if the flight forms part of apackage holiday, the tour operator or, if apackage or seat-only sale is made by anagent, the agent in question. The basicobligation is that the “air carriagecontractor” must, at the time thereservation is made, inform thepassenger of the identity of the operatingair carrier.

An amendment to the Regulation’sprovisions in the drafting stage sought toaddress one of the main objections thepackage travel industry had to theproposed new rule. Tour operators willoften not be in a position to tell theircustomers the definite identity of theairline who will operate the flight elementof the package at the time a holidaybooking is made. Frequently, bookingsare made many months before the touroperator has finalised its charterarrangements with the carriersconcerned. Tour operators wereconcerned that compliance with theRegulation would therefore be impossiblefrom their perspective.

The Regulation now requires that, if theprecise identity is not known at the time ofreservation, the passenger must be toldwho the air carrier is likely to be and mustthen inform the passenger definitively assoon as the identity is known. Althoughthis might ease the concerns of thepackage travel industry, the wording is

EU Blacklist for Air Carriersby Sue Barham, BLG

1917

still opaque and it is not particularlystraightforward for a tour operator toassess precisely what information it mustgive to passengers and at what stage inthe booking process. What does seemlikely is that the new rules will requiresome adjustments in the booking processor in the way communications withpassengers prior to departure are dealtwith to ensure that the informationrequirements of the Regulation are beingmet as far as possible.

The information obligation applies to anyflight which is part of a contract ofcarriage which started in the EU and,broadly, the flight is either departing fromor returning to an EU member state. Totake an example, if the passenger has areturn trip ticket London-New York-London, he must be informed of the

identity of the carrier who will beoperating both sectors of the booking.However, a passenger who books to flyNew York-London-New York has no suchentitlement in respect of either sector ofhis air travel.

A final point to note is the consequencefor a contract of carriage of the intendedcarrier being placed on the Communitylist of banned air carriers, necessitatingcancellation of the flight. In thesecircumstances the Regulation:

■ provides that passengers are entitledto reimbursement or re-routing inaccordance with their rights under ECRegulation 261/2004 on deniedboarding and cancelled or delayedflights; and

■ if the flight is not covered by ECRegulation 261/2004, for examplebecause it was to be operated intothe EU by a non-EU carrier, it imposesan obligation on the air carriagecontractor to provide reimbursementor re-routing.

Bearing in mind that the air carriagecontractor may simply be the travel agentwho sold the air ticket, this latter provisioncould potentially be onerous.

Communication Error, an Industry Campaign to Improve Standards

Have you ever felt frustrated by poorRTF standards?

I guess we have all experienced anoccasion where time has been wastedclarifying what a pilot or controller meantto say when they have used non-standardRTF, or maybe more seriously an incidenthas been caused by a missed orincorrect readback.

NATS is working with industry to reduceincidents of this nature and is focusing onimprovement of RTF standards for bothcontrollers and pilots. As part of thiswork, pilot RTF standards are now beingfocused on and in conjunction with theairline community NATS is working on theproduction of a DVD based trainingmodule for commercial pilots. This DVDwill follow on from the “Top Ten Tips”

leaflet many of you will have received withCHIRP and also a Phraseology bookletwhich is currently being developed.

These three projects, when combined willhelp to standardise RTF whilst alsodrawing attention to what is currently“best practice”.

The strength of the DVD is that it is beingput together by pilots, controllers andregulators with input from airlines wishingto raise safety standards. The finishedproduct will, therefore, be relevant andinteresting to all. A flexible style isanticipated so that whilst the training canmost usefully be carried out in aclassroom/discussion environment,Airlines will also be able to copy anddistribute the DVD as a self-study aid andencourage debate after individuals havecompleted the course.

The final content and format is due forcompletion shortly, so if you haveanything you would like included, egphrases you don’t understand, pet hatesor phrases that you don’t like to hear,then please contact me at:-Karen.skinner@nats.co.uk .

Also if you would like to receive the finalproduct on DVD please register yourinterest at the email address above.

by Karen Skinner, Supervisor, London Terminal Control

18

Accidents continue with monotonousregularity in which pilot altitude awarenessseems to be less than it should be. GPWSand EGPWS have had a great effect onaccident numbers, but there are stillexamples of landing long or short, or mis-setting or mis-reading altimeters, orcontinuing below DH or MDH without visualreference. Radio (or radar) altimeters havebeen part of standard instrumentation formany years; on the face of it knowing theexact height above ground ought to be anenormous safety advantage. It should beimpossible to bump into the ground if youknow it is there. And yet, the Rad Alt is nottypically included in the pilot’s scan, and itis easy to see why. It is hard to extractmuch information from an indication that ischanging quickly in an arbitrary way thatreflects the uneven contour of the groundbelow, and one that is not immediatelyrelated to the profile being flown which isbased on altitude, not height. So if the Radalt is used at all, it is as an altitudeawareness crew call out at somepredetermined figure. The usefulness ofsuch call outs is, however, questionable aswe all know that the first thing that astressed out, rushed, crew does is toforget to make the standard calls; and ifyou are not expecting to be low during aprocedure (and why should you be?), thechances are not high that you will noticethe one indication that you are.

All that has now changed; along withEGPWS, aircraft typically now have aradio altimeter auto call out function. Thislittle gizmo doesn’t add crew workload,and, above all, it isn’t affected by stressand it won’t (often) forget to do its littlejob. But to be effective, the call outs have

to be recognized, thoroughly understoodand firmly associated with a simple fact:

The exact call outs are pin selectable andso may differ from fleet to fleet, the tablebelow represents a typical selection. Sothe modus operandi is not for the crew tocall 500, 100 etc in order to elicit someparrot like response, but to leave theautomatics to do it. When a call is heardthe instinctive reaction to it has to be ‘isthat sensible, and do we satisfy thesimple criteria given above?’ So when youhear 500, you must ask yourself ‘Are weon approach and if this is a non precisionapproach, are we close to MDA(H)?’. At100 if you can’t see the threshold, therecould be many reasons, too low, too highor just insufficient visibility, but all say‘Don’t continue’. Finally, even if you havepassed all the previous tests, when thatdisembodied voice yells 50, if you canstill see the threshold, you are far too low.

These calls are not a substitute forEGPWS, which can give much earlierwarnings based on its frightfully cleverterrain database, but they are a usefuladdition to the pilot’s armoury, and doaddress some things the EGPWS does

not; think of them as an extra slice ofEmmenthal in Prof Reason’s Swiss cheese.

One final thought: if no one ever toucheddown beyond the Touch Done Zonemarkings or lights there would besubstantially fewer over runs. If the end ofthe zone seems to be approaching, andyou aren’t on the ground yet, a go aroundwould seem to be a good option…..If youcan’t remember what the TDZ andThreshold lights and markings look like, avery good time to remind yourself wouldbe before your next flight.

Call Meaning1000 MUST be level or on an

approach (1000ft is typicalminimum obstacle clearancebefore final approach)

500 MUST be on approach,approaching MDH if NonPrecision

100 MUST be in sight of threshold(except Cat 3)

50 MUST NOT be still in sight ofthreshold

ELSE GO AROUND

Automatic Radio Altimeter Call OutsAn under-utilized resource?by Alex Fisher, GAPAN

1919

The UK Airport Police CommandersGroup is behind a national initiativetargeting disruptive passengers. PoliceCommanders at all of the UK’s airportsand the Crown Prosecution Service haveagreed a protocol with UK airlines andairport authorities through the Departmentfor Transport, the UK Flight SafetyCommittee and the British Airline PilotsAssociation.

The protocol lays out the responsibilitiesof the police together with airlines,ground-handling staff and airport licensedpremises when dealing with disruptivetravellers. The protocol encourages theadoption of a zero tolerance approach todisruptive behaviour, both in flight and onthe ground prior to boarding. Theprotocol also clearly sets out theindividual responsibilities of travellersthemselves and the consequences ofpoor conduct.

The following represent some of theactions and sanctions identified within theprotocol:

■ Abusive and aggressive behaviour willnot be tolerated and those personswho commit criminal offences will beprosecuted to the full extent of thelaw.

■ Drunkenness is not acceptable andanyone who shows up for their flightin an unfit state will be denied carriageand may be removed from the airport.

■ Persons denied carriage because oftheir behaviour will have their flighttickets invalidated, withoutcompensation.

■ Should passengers become drunk onboard the aircraft they will be liable toprosecution, which may result in asubstantial fine, or a period ofimprisonment.

■ Where additional expenses have beenincurred by the Airline, such as divertand landing fees, as a consequenceof bad behaviour, the Police will applyfor compensation for that Airline aspart of the prosecution case.

The initiative sets out national minimumstandards and promotes the developmentof bespoke local arrangements.

It is not only the uniformity of the policeand CPS response that is significant butalso the support of many of the highvolume scheduled and major charterairlines, as well as airport authorities andground agents. Additional support fromGovernment and professional bodies alsoadd weight to the project.

The protocol assiststhe industry indeveloping a robustresponse whenconfronted byaggressive andabusive behaviour. Italso sets out inpractical terms howthe industry, togetherwith its partners withinthe controlauthorities, can adopta strategy that dealswith both preventionand enforcement,based on mutualunderstanding andthe exchange ofinformation.

This iniative has beenproduced by the UKAirport PoliceCommanders Groupon behalf of APCO.The CommandersGroup representssome 59 airports in

the UK and Northern Ireland; clearly agood many of these do not have apermanent police presence and areserviced from the local police station.

The Initiative is that of UK PoliceCommanders Group on behalf of ACPOand represents some 59 airports in the UKand Northern Ireland.

For more details contact:Sgt. Crompton-GuardGreater Manchester Police

National Initiative Targeting Disruptive Passengers

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22

Sat on a desk in the instructors’ office at899 Squadron I had just read an article inan old dusty “Cockpit” magazine1. Thearticle in question was in Issue 64, theWinter 98 edition, and described aparticularly nasty instance of Hypoxia. Thepart which stuck in my mind was when hedescribed the lethargy he felt towardschecking the Master Warning light andcancelling the audio signal. Accusing aninstructor of senility whilst on anOperational Flying Training course maynot have been the wisest start to the daybut as you can guess it got worse ...

I was nearing the end of the course; I hadbeen on 899 Naval Air Squadron fornearly a year by now and only had 5flights to go before finishing the courseand going to the front line. Today’s sortiewas reputedly the hardest of the entirecourse; it involved flying as a singletonattacking a pair of enemy fighters(simulated by two other Sea Harriers from899 flown by Air Warfare Instructors) atboth long and short ranges, eventuallyentering a visual fight, targeting bothwithout being seen, and all of this with norestrictions on where the enemy could go.It could have been 250 ft or 40,000 ft orone at each extreme. All of thesevariables promised an extremely taxingsortie. Levelling at 24,000 ft to put myselfin the middle of where I thought theenemy would be I felt remarkably relaxed,confident even. That should have beenthe first warning sign (the same feelingafter a couple of pints of being the bestlooking, funniest and most charming manin the bar). I had a transit of about 10minutes before reaching my Combat AirPatrol (CAP) Station and so checked all ofmy radar and weapons systemsthoroughly before the `fight’s on’.Throughout this period the autopilot wasselected on holding me level at 24,000 ftgiving a cockpit altitude of approximately14,500ft.

The next event was the master warninglight came on with the accompanyingaudio warning. How annoying I thought tomyself. It wasn’t cancelled; I didn’t evencheck which caution had come on. Nothingin my brain said: “Emergency, react now”. Icarried on at 0.7 Mach straight and levelwith the autopilot selected on heading westover North Devon. At this point the othertwo Sea Harriers were positioning about 80miles away over the Dartmoor area. I don’tknow how many seconds the alarm wenton for, but I remember consciously thinkingthat I should probably cancel it, but onlybecause it was beginning to annoy me. SoI did, I reached up pressed in the buttonand the noise went away. Did I checkwhich caption was associated with thealarm? No I didn’t, despite the OXY captionbeing only about two inches from themaster cancel button I had just pressed.

Another few seconds passed and Ithought to myself that I really shouldcheck what it was that set off the MasterWarning. At last after maybe 30 seconds Ilooked at the warning panel situated tothe left of the Head Up Display. OXY inred. So it’s an OXY caption. Oh well Ithought to myself the OXY caption hascome on. Nothing. No immediate actions.No radio call. No pulling the emergencyoxygen. No rapid descent to below10,000ft. No checking the connections.Nothing. Nada. Rien. Blissful, lethargic,intoxicated nothingness!!!

By this stage I remember a radio call fromthe leader of the other section of fightersasking if I was ready to start the exercise.I radioed to him that I `had a minoroxygen snag and to standby’.

So there we are, I knew I had a problem, Ihad seen the warning with my own eyes, Ihad even radioed the nature of myproblem to the leader of the other playersand the listening Fighter Controller. So atlast I raced through the initial actions

declared a PAN and returned home ... ordid I ? You guessed it ... No!

It was at about this stage that I noticedthat my breathing started to becomelaboured. It was harder to draw airthrough the oxygen mask than normal andso finally I decided to get out my FlightReference Cards (FRCs) and run throughthe OXY drill. I knew the immediateactions, I had even practised themrecently in an Emergency Simulation, but Icouldn’t remember them and so as I hadbeen taught on numerous aircraft types Ididn’t make them up - I got out the cardsto run through them. I did at this stageselect 100% oxygen.

This is where my faculties really startedfailing. I couldn’t find my FRCs. Of coursethey were where I always kept themthroughout my entire flying career, in thepocket on my right knee but I hadforgotten that. Eventually I found them. Istarted skimming down the index lookingfor Oxygen failure, but I couldn’t find it. Imust have flipped the cards over 5 timeslooking for it. The reason I couldn’t find itwas because I could no longer read.Then and only then did I realise that I wasnow massively Hypoxic. I couldn’t readthe cards. I looked up and could only justmake out the instruments and the HeadUp Display (HUD) was blurring.

I swore out loud rolled the aircraft on itsback and pulled into a vertical dive. I wasbelow 10,000 ft in a few seconds and allof my faculties quickly returned. I nowobviously declared a PAN and curtailedmy sortie ... No!

I called up the other players, said I hadsorted out the snag and was happy tocontinue the sortie maintaining below10,000ft as my oxygen had run out.

After a couple of attempts to set up thefirst engagement, sanity and a stinking

It Couldn’t Happen to MEby Lt Dan Denham Royal Navyex 801 Naval Air Squadron Operations Officer

21

headache set in and I finally returned toRoyal Naval Air Station, Yeovilton.Obviously having informed them on theground about my near death experience... No!

Having shut down the jet I still feltdistinctly unwell. I informed the AirEngineering Mechanic at the jet that theoxygen had run out and walked in, signedin and informed the engineers that theoxygen bottle needed changing.

I found my authoriser and again told himthat the oxygen had run out and I had felta bit dizzy, but I was fine now. The debriefwas uneventful and I played down theincident, just saying I hadn’t felt wellwhich is why I curtailed the sortie.

I drove home a few hours later still feelingworse for wear and remember sleepingfor about 14 hours that night.

The next day over lunch at the Squadron Itold the whole story to the listeningaudience. Included in this was the AirEngineering Officer who, on hearing thefull, unadulterated version, rang theWatch Chief and pulled the jet off the linefor an oxygen system inspection. It wassubsequently discovered that the oxygensystem did have a leak.

After this incident the entire Squadronwas educated on the effects of Hypoxia

and to always assume that it hasoccurred after a failure or depletion of theoxygen system. My nonchalant statementto the ground crew (whilst still under theeffects) could have caused the aircraft toget airborne later that day with a re-occurrence of the same incident.

This incident raises many issues both inthe air and on the ground:

■ A few more seconds without oxygenand I would have been unconscious.

■ The aircraft would have carried mydead body over the Atlantic where itwould have run out of fuel andcrashed.

■ Having not informed the other playersof the nature of the problem theycould not have known the seriousnessof the incident.

■ What would or could they have doneeven if they had known?

■ Once recovered I should have thengone through the FRCs and returnedto base, having declared a PAN, andbeen met by medical services andgone straight to the medical centre.

■ Tell the whole story to the Engineersor they will assume a routine failurewith a routine cause.

■ Hypoxia affects individuals differently. Iremembered my hypoxic chamber runduring training and not being able toread then, which is the only thing thatsaved my life.

■ The effects of Hypoxia can last forhours if not days and medicalattention should be soughtimmediately after any hypoxiaincident.

■ Your judgement is impaired for a longtime after hypoxia.

■ The entire Squadron needs to beaware of the effects of Hypoxiaincluding the ground crews and itshould always be assumed that it hasoccurred with any instance of Oxygenfailure or depletion.

■ Whilst airborne, if another pilot, or inthe case of two seat jets, member ofthe crew, informs you of a `minoroxygen snag' don't let it lie - questionthem - talk through it with them -annoy them, and if necessary tellthem what to do.

■ If there's any doubt there's no doubt -declare a PAN, return home and, ifnecessary hand to anyone who raisesan eyebrow, or quotes “lost training”at you ... a copy of this article !!

This article is reprinted with kindacknowledgement to The Royal NavyFlight Safety Magazine COCKPIT – Winter2005/6 Issue No.185

(Footnote)1 The Royal Navy’s Flight Safety Magazine

23

24

0800 - 0900 Registration

Session Chairman - Capt. Robin Berry - BMED

0900 - 0915 Welcoming Introduction - Ian Crowe - Chairman – UKFSC

0920 - 0945 Keynote Speech - Capt. Bob Screen - Aviation Consultant

0945 - 1020 Training Deficiencies - What the Accidents Tell Us - Dave King, Chief Inspector of Air

Accidents - AAIB

1020 - 1040 Refreshment Break

1040 - 1115 Training on Automated Systems - Capt. Simon Wood – BSc, BA, MSc

Director, CAA Flight Operations Research Centre of Excellence - Cranfield University

1115 - 1150 Air Traffic Controller Training Coping with Change - Suzie Rudzitis, General Manager Training

&

Operational Resources - NATS

1150 - 1225 Questions

1225 - 1340 Lunch

1340 - 1415 Military Training for the 21st Century - Gp.Capt.Les Garside - Beattie - Head of RAF Training

1415 - 1450 Decision Making in Command - Capt. Chris White FRAeS - Parbrook Aviation

1450 - 1505 Comfort Break

1505 - 1540 Engineering Training - Steve Pennington, Director Maintenance Training and Standards -

Alteon

1540 - 1615 Cabin Crew Training for European-wide Operations - Chris Hewitt - easyJet

1615 - 1645 Questions

1645 - 1700 Closing Speech - Ian Crowe - Chairman - UKFSC

PROGRAMME

2nd October 20062000hrs Seminar Dinner

After Dinner Speaker - Paul Barron - CBE - Chief Executive NATS

3rd October 2006

UK FLIGHT SAFETY COMMITTEE

A RE-EVALUATION OF AVIATION TRAININGAnnual Seminar 2006

2nd/3rd October 2006The Radisson Edwardian Hotel Heathrow

SEMINAR OBJECTIVEThe complex world of modern airline operations demands the highest levels of both competence and commitment. Theoperation of the most advanced aircraft types and their maintenance, ground and air traffic handling, and theprocessing of many hundreds of passengers per flight, requires an ever-changing training commitment. Once again,the UKFSC has brought together a cross-section of experts to re-evaluate the scope of training needs and theresources required. If your company aspires to be among the best, you should attend this Seminar.

25

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