Today’s Professional Airline Pilot: All the Old Skills — and More · 2019. 8. 19. · Today’s...

1F L I G HT SAFE TY FOUN D A TI O N • F LI G H T S A F E T Y D I G E S T • JUNE 1990

Today’s Professional Airline Pilot:All the Old Skills — and More

Improved cockpit management and coordination can help reducecrew-related accidents caused by a failure to follow

established rules and procedures.

byCapt. Harry W. Orlady, United Airlines (Ret.)

Orlady Associates(Presented at the International Airline Pilot Training Seminar conducted by VIASA Airlines

and the Flight Safety Foundation in Caracas, Venezuela, January 23-25, 1989.)

those statements are worth remembering.

The actual record looks like Figure 1, taken from theBoeing Aircraft Company [now the Boeing CommercialAirplane Group] Statistical Summary of CommercialJet Aircraft Accidents in Worldwide Operations 1959-1987. The solid top bar shows the record from thebeginning of the jet era in 1959 to 1983, and immedi-ately below it the shaded bar represents the 10-yearperiod from 1974 to 1983. There has been virtually nochange over the years.

Despite extraordinary accomplishments in other areas,our industry has simply not been able to do very muchabout the crew-related accident. The late Hugh Gor-don-Berge very eloquently described our continuingfrustration when he reviewed 1973 jet losses as chair-man of the IATA Safety Advisory Committee (SAFAC)and confessed, “When looking at all the approach phaseaccidents, it is really possible to do no more than toremark once again on their seeming inevitability yearafter year; on their almost exact similarity year afteryear; on the airlines’ apparent inability to prevent theirnumbers from increasing, let alone to reduce them; andon the continuing prominence of the human factor inthe causal chain of events. It therefore seems pointlessto go on repeating what has been said before … SAFACat this, its twelfth meeting, can only look again at thevery sorry list and at a deteriorating trend, then give thesubject careful consideration in an attempt to offer pos-sible guidance ... to the Technical Committee in thismost pressing — and depressing — matter.”

You might well protest that, despite our continuingproblems with controlling crew-caused accidents, the

Our worldwide airline industry is just beginning its30th year of turbojet operations. During that period wehave experienced nearly 400 jet airplane accidents. Wehave killed nearly 18,000 of our passengers — an aver-age of 44 passengers per accident. It is difficult to findmuch comfort in that record. It is especially difficultfor a pilot (or a pilot manager) to find comfort in thatrecord because, despite a generally improving safetyrecord through these years, approximately 70 percentof these tragedies had crew-related causes. And whilethere is no question that the pilot is the “last line ofdefense” in the prevention of an accident, it is a distor-tion and a gross oversimplification to translate crew-related causes to simply “pilot error.”

Knut Hammarskjold, who was then secretary general ofthe International Air Transport Association (IATA), madethis point when he opened IATA’s 20th Technical Con-ference and said in regard to pilot and controller error,“We now know beyond a shadow of a doubt that thesedescriptions of accident causes are at best misleading,and at worst irresponsible.”

Many years before, Benjamin Howard, a long-time aero-nautical engineer who made a study of air carrier acci-dent causes in the early 1950s, had also put the questionof pilot error in perspective when he told a group ofaviation safety experts, “I submit ... we are evadingresponsibility when we charge a crash to pilot errorwhen the pilot is only guilty of doing what other pilotshave already established as something to be expected ofa qualified pilot.”

Today, if we are really going to make progress in betterunderstanding and controlling crew-related accidents,

2 F L I G H T SAFE TY FOUN D A TI O N • F LI G H T S A F E T Y D I G E S T • JUNE 1990

overall safety record continues to show a gradual de-crease in accidents, and certainly is not a deterioratingtrend. And you would be right.

However, Figure 2, which is also taken from the Boeingsummary, shows what Gordon-Berge was concerned within 1973. It also shows a reversal of the deterioratingtrend that concerned him beginning the following year.

Figure 3 shows the probable reason for the reversal ofthe deteriorating trend. It is taken from a paper pre-sented by Loomis and Porter at the 1981 Symposium onAviation Psychology in Columbus, Ohio, U.S., April20-22, 1981. The paper wasentitled, “The Performance ofWarning Systems in AvoidingControlled-Flight-Into-Terrain(CFIT) Accidents.” It showsthe estimated implementationof the required Ground Prox-imity Warning System (GPWS)in the United States, and thealmost immediate decrease of“Controlled-Flight-Into-Terrain”accidents.

Although the GPWS is unde-niably a triumph of modern tech-nology, as a pilot, I find littlesolace in the fact that I appar-ently need an electronic mar-vel to keep me from crashing aperfectly normal airplane intounfriendly terrain.

There is no question that GPWS(and MSAWS, the controllers’ mini-mum safe altitude warning system,was introduced about two years later)have saved many lives. There is alsono question that in many, and probablymost, of these potential accidentsthe warning these systems providedwas preceded by a fairly gross op-erating error by the cockpit crew.Certainly, there is nothing in thedecrease in the accident trend fol-lowing the introduction of GPWSand MSAWS that suggests we havemade much progress from a crew-behavioral standpoint.

I may be unduly optimistic, buttoday we at least believe we arefinally beginning to squarely facethe basic problem of why highly-trained and well-qualified pilotsdo not always perform as expected.

The good news is that we also have some reason to hopethat our additional knowledge and understanding maylead to significant improvements.

Within the U.S. airline community (which consists pri-marily of airlines, manufacturers, pilot organizationsand regulatory authorities), there is a growing consen-sus that current training standards and practices shouldbe reviewed. And that comes despite somewhat surpris-ingly, and until recently largely ignored, significantdifferences in the operating cultures in U.S. airlines.Now there is a pressing and overriding agreement toimprove cockpit management and crew coordination.

Primary factor

Flightcrew

Airplane

Maintenance

Weather

Airport/ATC

Miscellaneous(other)

Total withknown causes

Unknown orawaiting reports

No. ofaccidents

TotalLast 10years

240 82

39 15

5 3

18 7

15 7

11 3

328 117

55 27

383 144Total

10 20 30 40 50 60 70

Percent of total accidents with known causes

11.9%12.8%

1.5%2.6%

5.5%6.0%

4.6%6.0%

3.4%2.6%

*Excludes: • Sabotage • Military action

73.2%70.1%

Legend:1959-1987Last 10 years (1978-1987)

Primary Cause Factors—Hull Loss Accidents*Worldwide Commercial Jet Fleet

Figure 1

60

50

40

30

20

10

0

Annual rates,accidents permilliondepartures

*Excludes:• Sabotage• Military Action• Turbulence injury• Evacuation injury

60 62 64 66 68 70 72 74 76 78 80 82 84 86

Year

All Accidents*All Aircraft - Worldwide Commercial Jet Fleet

Figure 2


A variety of cockpit resource management (CRM) trainingprograms have been developed to meet that demand.However, one of the premises on which most of theseprograms have been based is the assumption that pilotswho are given such training are professional airlinepilots who already have the appropriate skills and knowledgefor their operating responsibilities. Unfortunately, thereis considerable evidence that this has not always been awell-founded assumption. There is no question thatthey have highly developed manual handling skills andbasic aeronautical knowledge, but that is no longer enough.

One of the oldest of our historic problems— and this one has been with us from thedays of the DC-3 — is the failure of pilotsto follow established rules and procedures.It is one of the most common casual fac-tors in air transport accidents — and ithappens year after year after year. Cer-tainly it is still with us in the United States.

This is illustrated by three thought-pro-voking paragraphs from U.S. National Trans-portation Safety Board (NTSB) MemberJohn Lauber’s November 19, 1988 addressto the U.S. Air Transport Association (ATA)Operations Forum:

“On August 16, 1987 a McDonnell Dou-glas MD-80 crashed on takeoff from De-troit, killing all but one small child aboard.Our investigation revealed that the flapsand slats had not been extended for take-off, that electrical power to the configura-tion warning system had been disruptedfor reasons we could not discern, and thatthe flight crew had engaged in extensive,‘non-pertinent’ discussion during their taxito the runway.

“When the basic facts of this accident became known,one of the frequently heard questions from the publicand professionals alike was, ‘What will prevent thisfrom happening again?’ After the standard commentsabout improved procedures, improved training, betterwarning systems, etc., I usually threw in my ‘clincher’— ‘we won’t see another accident like this for severalyears because of increased pilot awareness and the en-hanced vigilance which inevitably follows an accidentsuch as this.’

“I hope I was correct, but the Boeing 727 accident inDallas of this year [1988] should give us pause. Let mestate clearly that I am not prejudging the outcome ofour ongoing investigation of this accident, and have noidea of what our probable cause will be. But the publicdocket opened two weeks ago contains, among otherthings, the following facts: there is physical evidence

that at least the trailing edge devices were up at the timeof impact, an intermittent fault was found in a switchwhich is part of the takeoff configuration warning sys-tem, and that the crew was engaged in extensive “non-pertinent” discussions during their taxi to the runway.”

Unfortunately, the failure to follow established proce-dures seems to have become an increasingly criticalfailure as we have progressed from piston to turbojetoperations. Equally unfortunate, it is a very old andpersistent problem. Therefore, it may be worth discuss-

ing at least some of the reasons we continue to haveproblems with our standard operating procedures [SOPs].

I believe that the role of flight operations managementhas often been overlooked. And it is absolutely crucial.This is because a first requirement is a clear under-standing by flight operations management of the way itwants its flight operations conducted — for example byfully utilizing the “crew concept” if that is its intention.It must then be willing to state this clearly and withoutequivocation. Equally important, its intentions mustthen be communicated effectively to the pilots.

A second management requirement is to ensure thattraining pilots, check airmen, other supervisory pilotsand higher levels of flight operations management fol-low the rules and procedures that have been promul-gated. In the elegant language of academicians, the

5

4

3

2

1

0

5 5

1

4

2

1971 1972 1973 1974 1975 1976 1977 1978 1979 1980

1 1

Period 117 Accidents

Period 22 Accidents

Calendar Year

1971 1972 1973 1974 1975 1976 1977 1978 1979 1980

100%

0100%

0

Estimated Implementationof MSAW Features at63 ARTS-3 Sites

Estimated Implementationof RequiredGPWS Systems

Frequency of Controlled-Flight-Into-Terrain Accidents Before and After GPWS/MSAW Implementation

No

. of

An

nu

al A

ccid

ents

Figure 3


“theory espoused” must also be the “theory practiced”whenever and wherever management is involved. Thissounds relatively simple, but it does not always happen.

Flight manuals, equipment manuals and operational bul-letins are important communications media. They shouldbe useful documents that reflect the character and oper-ating philosophy of the operator. These concepts shouldbe stated clearly and should also be reflected in opera-tional procedures. However, it takes considerably morethan simply the issuance of manuals or directives fromthe top of an “operational Mount Olympus” to commu-nicate these messages effectively to pilots.

Capt. Eric Jackson of Aer Lingus stated a basic prin-ciple of effective communication to pilots when he wrote:

“… there … is an absolute requirement to consult, dis-cuss, justify and defend all procedures, changes andrules where the pilot is professionally and personallyinvolved. This makes constant liaison with workinggroups, association councils and overall grouping nec-essary … with the maximum exchange of information,views and policies absolutely vital.”

This accomplishes two important things. First, it en-sures that pilots understand the reasons for their proce-dures, and second, it almost certainly secures pilot interestand hopefully, it encourages positive involvement intheir utilization.

Yet, the problem of achieving a very high percentage ofcompliance with established procedures is not a simpleone, because we have always had some pilots who rebel.However, regardless of the considerable differences inmotivation, character, life-style, personal goals, per-sonality and ego strength among pilots — regardless ofthe care with which they are selected, monitored andtested — we know that virtually all pilots have at leastone thing in common. Each wants to be considered agood pilot by other pilots. Even more important, eachdoes not want to be considered a “poor pilot” by his orher peers. Pilots, like the members of virtually all othergroups, are sensitive to peer group pressure.

In order to take advantage of peer group pressure, a firstrequirement for a successful effort is to have well-developed and efficient operational procedures — in-cluding the use of checklists and required callouts.Lufthansa’s Capt. Heino Caesar said it clearly: “SOPsmust be realistic, advantageous, easy, and reasonable.”

The message that has to get to flight crew members isthat professional pilots follow established operating pro-cedures for sound reasons they know and understand.It must be made equally clear that this is expected byflight operations management, by pilot representativesand by all flight crew members regardless of their cock-

pit position. Authoritarian pronouncements alone willnot communicate this message effectively. To betterunderstand why, it may be worth exploring some of thereasons for the subset of “willful deviations” from es-tablished policies. If one looks at some of the basicreasons for these deviations, it appears that many of the“willful deviators” can be expected to be particularlysusceptible to peer group pressure. For example, somecommon reasons for willful deviations are:

• Pilot believes the established procedure is sim-ply wrong.

• Pilot believes the established procedures are ap-propriate for the “average” guy but that he or sheis different.

• Pilot believes “his” procedure is either just asgood or better than the established one.

• Pilot believes the procedure is not important ornot necessary — “not worth the bother” eitherjust this once, frequently or always.

• In some instances, the pilot does not really ob-ject to the established procedure but consciouslyor subconsciously just wants to defy “them” (mean-ing management or authority in general). In thiscase, the pilot does not believe safety is jeopar-dized significantly, but even if safety is slightlyjeopardized, that it is worth the risk because heis completely convinced that “it” (an accident)can not happen to him — at least not this time.

There can, of course, be other reasons for willful devia-tions and variations within them. However, with slightmodification, the above reasons are well-recognized asunderlying causes for rule-breaking in other areas. Thesecauses also have at least three things in common, invarying degrees:

• Each one defies authority.

• Each one can mask a degree of insecurity that isfrequently displayed by overcompensating — oftenwith an overly “macho” image.

• Each one reinforces individual egos.

Any solution to the problem of willful deviations shouldat least recognize the needs expressed and, in addition,attempt to sublimate the hostility and, in some cases,the insecurity implicitly suggested in the defiance ofauthority. And although peer group pressure should notbe considered a panacea, it does have elements whichdeal directly with these items.

There has been a significant change in the job of aprofessional airline pilot. It has been an evolutionary


change and it started a long time ago. Without evengetting into some of the issues involving advanced cockpittechnology, today’s pilots must know the technical as-pects of their job (their airplane, procedures, aerody-namics, meteorology, etc.) and it has become increas-ingly important that they also know something abouthuman behavior as it relates to the job of an airlinepilot. At a minimum, they must recognize that boththey and their fellow crew members are human beingswith both human strengths and human limitations. Hu-mans can and do make mistakes. They can and doforget. They can be distracted.

A prime task of today’s truly professional pilots (andprofessional pilot managers) is to take advantage ofhuman strengths to prevent or control human weak-nesses (including outright mistakes) from adversely af-fecting the safety of their flight. I believe that, amongother things, this means pilots must make the “crewconcept” — and the “fail-safe crew” — do justice tothose concepts in practice.

For example, it is implicit in the crew concept that allcrew members must know what is and should be hap-pening with and to the airplane at all times. This is abasic reason for following established procedures andstandard flight profiles. If, for any reason, these aremodified because of a particular situation, it is thecaptain’s professional obligation to be sure that all crewmembers understand the planned deviation. The job of“professional” captains (and to a lesser extent all “pro-fessional” crew members) is to be sure that this is theway their flights are operated. It is not going too far tosay that to do less is being derelict in their duty.

Because there have been some views to the contrary, apoint worth emphasizing here is that the “crew con-cept” does not interfere with the chain of command. Itdoes in fact, reinforce it.

An equally important area that I believe has not re-ceived the attention it deserves is operational monitor-ing, usually by the pilot-not-flying (PNF). It is criti-cally important because, almost invariably, one can saythree things about an air carrier accident:

• First, there was or should have been, a very clearindication in the cockpit at some point duringthe flight that things were not going well.

• Second, there was plenty of time to have savedthe airplane.

• Third, there seems to have been little or no awarenessof the real problem.

One can also say those same things about ground prox-imity and takeoff warnings. There is little question that

a preventive monitoring failure by the PNF precedes asignificant operational anomaly in virtually all cases.This is a particularly important point, for from a systemsafety standpoint, this monitoring failure is as criticalas the failure by the handling pilot. It is really not acredit to our profession that operational monitoring hasnot been given specific status in flight crew training orin checking despite its crucial role in safety.

In still another area, pilot-flying (PF) and PNF dutiesneed to be clearly delineated. It is no longer satisfac-tory to simply state that when the copilot is flying hewill perform the designated captain duties. This ap-proach is fraught with ambiguities. Unfortunately, aweak link in our safety chain seems to be the captainwhen he is performing PNF duties. This is reflectedrather dramatically in the number of accidents that oc-cur when the copilot is flying.

Based upon the preceding considerations, I suggest thefollowing points be addressed:

• Probably one of the most important is that noneof the things I have discussed costs money. Noneof them require “state-of-the-art” simulators orother expensive training aids. They need notinvolve the battle of the training budget. How-ever, they may require considerable self-exami-nation and effort.

• The only foundation upon which a solid operat-ing performance can be built is the consistentutilization of well-developed and efficient oper-ating procedures — including the use of check-lists and required callouts.

• The importance of meaningful operational moni-toring by the PNF and a clear delineation of PFand PNF duties deserves much more attention.

• This final one is taken from an early John Lauberstatement, “The real importance of SOPs lies asmuch in the area of information transfer as itdoes with respect to the issue of the proper wayto fly the airplane. Rigid adherence to SOPshelps to maximize information transfer in muchthe same way that the use of standard phraseol-ogy does.” �

About the Author

Capt. Harry Orlady retired from United Airlines after39 years as a pilot. He flew 10 different types ofaircraft ranging from the Boeing 247 and the DC-3 tothe Boeing 747. He has completed several studies inpilot ground and flight training as well as studies inhuman factors, aviation medicine and aviation safety.


Orlady was awarded several company and industry aviationawards, and has presented more than 80 papers andlectures on aviation operational safety. Since retirementfrom United, he has served as a senior research scientistfor Battelle Laboratories, which operates the U.S. AviationSafety Reporting System (ASRS) for the U.S. NationalAeronautics and Space Administration (NASA) from itsprogram office in Mountain View, California. He hasalso served as a research contractor to the ASRS, as anindependent contractor to NASA/Ames and to privateresearch firms, and as a consultant to the U.S. FederalAviation Administration (FAA).

An elected Fellow of the Aerospace Medical Association,Orlady was a member of the Human Factors StudyGroup of the International Air Transport Association(IATA) and the Medical Study Group of the InternationalCivil Aviation Organization (ICAO). He was also amember of the Steering Committee for IATA’s IstanbulTechnical Conference on Human Factors. Currently,Capt. Orlady is a member of the Human Factors Society,the Association of Aviation Psychologists, the AerospaceMedical Association, and the SAE Human BehavioralTechnology and G-10 Committees.

Some Aviation FrequencyManagement Concerns

Future aviation safety and operational efficiencydepend upon continued access to an electromagnetic spectrumthat is besieged by growing demands for frequency allocations.

byWilliam H. Stine II

Manager, Plans and International Aviation,National Business Aircraft Association (NBAA)

At a recent meeting of the International Business Aviation Council (IBAC) governing board,the author was asked to prepare a paper on the “urgent need to preserve sufficient clear L

Band spectrum and VHF allocations for aviation use…and to send it to all members for theiruse in efforts to insure preservation.” What began life as a few paragraphs on L band andVHF issues quickly grew into a more detailed discussion of the complicated and not well

understood art of radio frequency management.

Admittedly, the arcane art of frequency managementgenerates all the excitement of a paint-drying contest.However, as aviation continues to demand newer, fasterand better communications, the finite amount of electro-magnetic spectrum (EMS) and the irrefutable laws of

physics must be contended with. Solutions to thesetechnical problems will, undoubtedly, result in morecomplicated communication systems in the future.

National and international aviation regulations have dras-


tically increased the required communication betweenthe aircraft and the ground. Presently, the vast majorityof this is carried out in the VHF band from 108 MHz to137 MHz. The types of services allowed in this bandinclude:

• Air Traffic Control (ATC) is presently utilizinga significant portion of the VHF band (118 MHz-136 MHz) for voice communication. There arepresently 40 separate channels per MHz in theaeronautical service — hence 720 channels areavailable in the band.

• Aeronautical Operational Control (AOC) allowsthe operator to maintain contact with its flightsas is required by law for commercial operations.The United States and Canada share 75 channelsbetween 128 MHz and 132 MHz, based on aformula of use and location relative to their mu-tual border. Other regions have similar arrange-ments. Presently AOC is done primarily by voice,but in recent years an increasing amount of traf-fic is being transmitted in the more efficientdigital data form. More than 150 business air-craft in the United States are equipped to dealwith this now.

• Navigation (both VOR and ILS) is provided inthe 108 MHz-118 MHz portion of the band. Al-though voice can be transmitted on these chan-nels, for technical reasons it is not normally usedfor voice transmissions.

Aviation users (both aircrew and passengers) are dis-covering additional needs for communication betweenaircraft and the ground. Not only are there the addi-tional government-mandated requirements, but opera-tors are discovering that having contact with the homeand office via AOC (voice and data) and access to thecommercial land telephone/fax/telex/computer (knownas Aeronautical Public Correspondence [APC] and Aero-nautical Administrative Control [ACC]) has many po-tential benefits. These trends have gained impetus dur-ing the past several years, due in large part to the wide-spread use of pagers and automobile-based cellular tele-phones.

The introduction of data communication links has un-earthed amazing futuristic applications. For instance,with all of a modern aircraft’s operating parametersalready being transmitted in digital data format fromtheir source (engines, fuel system, etc.) via data bussesto the gauges in the cockpit, it is really a simple matterto connect these busses, via a radio communicationslink, to maintenance and engineering at the home basefor almost real-time analysis and record-keeping. Withmost airline operations already maintaining schedulesand dispatch information in computers, it takes little

additional equipment to link such information to theaircraft.

In the very near future such information as weather,airport conditions and clearances (some of this is im-plemented in limited instances) will soon be done rou-tinely by data link. An executive of Japan Airlines hasstated that their future “flight engineer will be on theground.” It is ironic, if not surprising, that air trafficsystem administrators are frequently among the last toseriously consider the implementation of these promis-ing technologies.

All this facile transmission of data is wonderful andcontains the promise of increased safety and efficiency,but not without some technological problems that mustbe addressed. The largest problem, not surprisingly, isthe limitation on the amount of available electromag-netic spectrum. The International TelecommunicationsUnion (ITU-the agency of the United Nations that setsstandards for radios), various state-run postal telephoneand telegraphs (PTT) and other national regulatory bodieshave the responsibility of doling out the available spec-trum to an ever-increasing number of constituents —from broadcasters to telephone companies; from policeto military; from taxi cabs to pizza trucks; and frompleasure boaters to civil aircraft operators.

We in the aviation industry tend to complicate the fre-quency management community’s attempts to make moreefficient use of electromagnetic spectrum. Demandsfrom the various factions of the aviation community foradditional channel designations in the VHF spectrumare not viewed as particularly reasonable when many ofthe channels between 118 MHz and 136 MHz that arepresently available, the so-called quarter channels of.025 MHz spacing (25 KHz), are not being utilized.

The primary reason for this inefficient use of the avail-able spectrum is that aircraft owners, those at the lowerend of the general aviation spectrum, have historicallyresisted equipping their aircraft with 720-channel trans-ceivers, citing the additional cost of equipment. It is areasonable estimate that more than 35 percent of gen-eral aviation aircraft have transceivers with 360 chan-nels (50 KHz spacing) or fewer. This is evident in theUnited States, although one domestic manufacturer alonehas sold more than 150,000 hand-held 720-channel trans-ceivers.

This issue becomes even more acute in light of thestated needs of others. There are more taxicabs inLondon than aircraft based in the United Kingdom andnearly as many pizza trucks in Los Angeles as there areaircraft based in the United States. Additionally thereare approximately 10,000 public broadcast stations inthe United States that provide a public service to theircommunities. Thousands of railroad cars and truck


trailers are presently equipped with Loran C navigationreceivers that transmit the vehicle’s position to theirhome bases via satellite. Within a decade, the carwithout a telephone is apt to be the exception ratherthan the rule.

The aeronautical VHF band lies between 108 MHz and137 MHz. The odd channels from 108 MHz to 112 MHzare presently assigned to the Instrument Landing System(ILS), which is slated to be replaced by the MicrowaveLanding System (MLS). This ILS spectrum is protectedby international agreement only through January 1, 1998,and other potential users (not necessarily aviation) arelining up for this frequency spectrum that they hope willbe vacated or at least no longer protected.

Public broadcasting stations, particularly those using theFM band, are now fairly universally utilizing the spec-trum that lies immediately below the 108 MHz bottom ofthe aeronautical band. The high-power output of thesestations (up to 100,000 watts vs. 15 watts for ILS), theirantenna placement, poorly planned frequency assignmentand, at times, less than ideal line and antenna mainte-nance, can cause a number of phenomena that affect ILSperformance. Occasionally, these high-powered stationsinterrupt VHF communications. The United States has4,000 FM stations, and European authorities, who havejust opened up the top portion of their FM band, havepredicated as many as 25,000 stations in the Europeancommunity. Further, various control signals for powerand cable television companies can, if not properly imple-mented, monitored and maintained, radiate spurious emis-sions into this band.

Very high frequency Omni-directional Range stations(VOR) utilize the even channels between 108 MHz and118 MHz. Because of the problems mentioned previ-ously, primarily FM broadcast interference, by January1, 1998 aircraft must have receivers that meet higher“interference immunity performance” standards.

Beginning January 1, 1989, the 136 MHz to 137 MHzportion of the VHF Aeronautical Band became avail-able exclusively for aeronautical use. This means thatthe industry will have to equip to utilize the additionalspectrum in this band. The U.S. Federal Communica-tions Commission (FCC) issued a notice of proposedrule making (NPRM) on frequency assignments in thisband and the International Civil Aviation Organization(ICAO) sent a notice to member states that urges timelyand coordinated implementation. This, of course, meansthe installation of 760-channel transceivers in aircraft.A quick check of manufacturers in the United Stateshas shown that approximately 14,000 general aviationaircraft are equipped with radios tunable to 25 KHzchannel spacing — a good start, but still less than sevenpercent of the total fleet.

The FCC has also published regulations that are de-signed to implement the agreements reached at the lastMobile World Administrative Radio Conference (MWARC).These regulations require that VHF transmitters havean increased frequency stability tolerance — from 5parts per million to 3 parts per million (.003 percent).Manufacturers in the United States estimate the generalaviation population of equipment manufactured withthe old tolerances to be in excess of 90,000 units. Thereis a move afoot to convince the FCC to allow them tooperate until they die of old age. The problem with thisapproach is that it would further delay the implementa-tion of the 25-Khz channels since these older radios aremore susceptible to interference.

There are other portions of the electromagnetic fre-quency spectrum in which the aviation community hasa vital interest.

For example, L Band for aviation use includes the 1545MHz -1600 MHz (1.5/1.6 Gigahertz-GHz) portion ofthe spectrum. It is in the L Band that the ITU allocatedfrequencies for communication between aircraft andearth stations via satellites. The services allowed onthese frequencies include not only ATC and AOC, butalso “non-safety and regularity of flight” (i.e., adminis-trative control communications).

Initially, communications in this band will be APC andautomatic dependent surveillance (ADS) which will giveATC information on aircraft position, determined byon-board navigation devices, via a satellite link. Theinitial implementation of ADS will most likely be inminimum navigation performance standards (MNPS)airspace over the North Atlantic and the Pacific.

A major problem with domestic regulations governingthe use of the aviation frequencies in the L Band im-plementation is the requirement that the aeronauticalportion of the L Band be shared among all mobileusers, but with priority going to aviation services. Onthe surface, this would seem to be a sound means ofgetting the greatest use of the spectrum. However,there are many technical and institutional hurdles toovercome in order to make this scheme work. Justimagine sharing frequencies with the neighborhoodpizza delivery truck.

The ITU took back four MHz of the still, unused aero-nautical L band from aviation during the last MWARCand for all intents and purposes gave it to land-mobileinterests. This has put the aviation industry in thedifficult position of having to defend spectrum alloca-tion which it is presently not using, but fully intends touse in the future. The U.S. government’s position im-plies that there is more than enough L band spectrum toshare with other mobile users.


Ultimately, international market forces will drive thesolutions to this problem of shared use of the spectrum.If aviation uses all of the available L band spectrum, theproblem will become moot. If it does not, however, itstands to have the same problems (in a somewhat differ-ent form) that VHF is experiencing today. Aviationinterests are not well equipped to defend a spectrumthat sits idle except for occasional peak periods.

Worldwide, more than 23,000 aircraft operate radio al-timeters in the 4,200 MHz-4,400 MHz band. There aresome services that would like to carve pieces out of thisband as well. Safety and economic concerns wouldseem to preclude the reequipping of the aviation fleetwith new radio altimeters, at least in the foreseeablefuture.

New issues will arise in the EMS as needs (real andperceived) continue to develop. It is important to moni-tor national and international regulatory bodies thatmold frequency use and to maintain open lines of com-munication with them to prevent aviation’s communi-cations from being unduly constrained. �

[Reprinted with permission from NBAA’s Business AviationIssues.— Ed.]

About the Author

William H. (Bill) Stine II is the manager, plans andinternational aviation, for the National Business AircraftAssociation (NBAA). He represents NBAA in dealingswith the U.S. Federal Aviation Administration and otherregulatory agencies. Stine is active in the Radio TechnicalCommission for Aeronautics (RTCA), Aeronautical RadioInc. (ARINC) as well as the U.S. Federal CommunicationCommission. He is also the executive officer of theInternational Business Aviation Council (IBAC), overseeingthat organization’s dialogue with the International CivilAviation Organization (ICAO) and editing the IBAC Update.

Previous to his association with NBAA, Stine was chiefpilot of a commercial operation in Colorado where heflew and instructed in both rotorcraft and fixed-wing aircraft.He also was chief pilot for a civil engineering firm, workedon airport and facilities design and was a line pilot in acorporate aviation department. Stine holds an airlinetransport pilot certificate in both fixed-wing aircraft androtorcraft and is a gold seal flight instructor.

A native of Ohio, Stine attended Culver Military Academyand Ripon College, and has a teaching certificate inaeronautical technology.

Reference

Advisory Circular 150/5325-4A, 1/29/90, Runway LengthRequirements for Airport Design. — Washington, DC :U.S. Federal Aviation Administration, Office of AirportSafety and Standards, 1990. xi, 118p.

Key Words1. Airports — Runways — United States.2. Airports — Design — United States.

This Advisory Circular cancels AC 150/5325-3, datedNovember 14, 1967; and AC 150/5325-4, dated Sep-tember 27, 1978.

The AC provides design standards and guidelines fordetermining recommended runway lengths. The stan-

dard and guidelines contained in this advisory circularare recommended by the Federal Aviation Administra-tion for use the design of civil airports. For airportprojects receiving Federal grant-in-aid assistance, theuse of these standards is mandatory.

Contents: Introduction — Runway Length Design Basedon Airplane Groupings — Runway Length Design Basedon Specific Airplanes — Airplane Performance Curves— Airplane Performance Tables — Design Rationale —Figures — Appendices.

Books

Fundamentals of Air Traffic Control / Michael S. Nolan(Purdue University). — Belmont, CA : Wadsworth

Reports Received at FSFJerry Lederer Aviation Library


Publishing Company, 1990. xvi, 560p. : ill. ISBN 0-534-12246-9.1990

Key Words1. Air Traffic Control — History.2. Air Traffic Control — Handbooks, Manuals, etc.3. Air Traffic Control — United States.

Contents: History of Air Traffic Control — NavigationSystems — Air Traffic Control System Structure —Airport Air Traffic Control Communications: Proce-dures and Phraseology — Air Traffic Control Proce-dures and Organization — Control Tower Procedures— Nonradar En Route and Terminal Separation — Theoryand Fundamentals of Radar Operation — Radar Separa-tion — Operation in the National Airspace System —Oceanic and International Air Traffic Control — TheFuture of the National Airspace System — The FederalAviation Administration — Glossary — Common Ab-breviations — References — Index.

Flightdeck Performance: The Human Factor / DavidO’Hare (University of Otago, New Zealand), StanleyRoscoe (ILLIANA Aviation Sciences Limited); withcontributions by Gorden Vette and Michael Young. —1st ed. — Ames, Iowa : Iowa State University Press,1990. 295p. ISBN: 0-8138-0161-3.

Key Words1. Airplanes — Cockpits — Design and Construction

— Human Factors.2. Airplanes — Piloting — Human Factor.3. Air Pilots — Visual Perception.

Contents: The Senses — Vision and Visibility: ThePilot’s Eye View; Orientation: The Spatial Senses /Training and Design — Training Environments: Instructionand Simulation; Human Factors in Cockpit Design /Performance Factors — Navigation and Communica-tion; Stress, Fatigue, and Performance / The SystemApproach — Accidents, Human Abilities, and Pilot Er-rors; Social Psychology in the Cockpit / Conclusion —Perfect Failures / Glossary / Notes / References / Index.

Accidents and causes are viewed from four approaches:the senses, training and design, performance factors,and systems. The visual system, visual acuity, colorvision, and visual tasks (avoiding collisions in midair,flying at night) are explored. The sector whiteout con-dition and the risk factor involved with head-up dis-plays are discussed at length. The authors also coverthe spatial senses: the ear, tolerance of gravity forces,effects of high positive and negative accelerations, dis-orientation, vestibular illusions, and spin recovery. Trainingenvironments, instruction and simulation, predicting pilotperformance, cockpit design, navigation and communi-cation, air traffic control systems, and stress are also

covered. The social setting of crew performance andbreakdowns in communication, cooperation, and coor-dination are analyzed. [overleaf]

Reports

Airline Competition: DOT and Justice Oversight ofEastern Air Lines’ Bankruptcy. Report to the Chairman,Subcommittee on Aviation, Committee on Public Worksand Transportation, House of Representatives. — Wash-ington, D.C. : U.S. General Accounting Office*, Febru-ary, 1990. Report GAO/RCED-90-79, 15p.

Key Words1. Airlines — United States United States.2. Airlines — Finance — United States.3. United States — United States.4. Eastern Air Lines, Inc. — Reorganization.

Actions by DOT and the Justice Department in theEastern bankruptcy case fulfilled the agencies’ respon-sibilities to protect airline competition. Both DOT andJustice have broad responsibilities to protect and pro-mote airline competition which they may exercise dur-ing the course of an airline bankruptcy proceeding;however, neither agency is required to participate in abankruptcy proceeding. Legislation is not needed toclarify or expand either Department’s responsibility toparticipate in airline bankruptcy proceedings. Justicealready represents the United States in the Eastern bank-ruptcy proceeding. However, if Justice was not a party,GAO review of past cases suggests that either Depart-ment would not have difficulty becoming a party be-cause of their regulatory responsibilities to protect andpromote competition.

Report on a Special Investigation into Air Traffic Con-trol Services in Canada / Canadian Aviation SafetyBoard. — Ottawa : Minister of Supply and ServicesCanada, 1990. Report No. 90-SP001, iv, 51, 2p. ISBN0-662-17693-6.

Key Words1 Air Traffic Control — Canada.2. Air Traffic Control — Evaluation — Canada.3 Air Traffic Control — Management — Canada.4. Air Traffic Controllers — Canada.5. Work Environment.

Adopted 02 March 1990.

“The Board found that Canada has a generally safe ATCsystem; the system handles thousands of flights dailyand serious risks of collision are infrequent. However,unsafe conditions do develop and are cause for continu-ing concern. ...


Safety deficiencies were identified in the areas of equipment,staffing and work-load, training, supervision, operatingprocedures, human performance factors, information trans-fer, and management. ... The most serious shortcomingin the ATC system is the shortage of qualified air trafficcontrollers. ... The report contains 48 Safety Recom-mendations [CASB 90-01 - CASB 90-48], addressed tothe Minister of Transport, the Minister of National Healthand Welfare, the Minister of Communications, and thePresident of the Treasury Board.” [Press Release]

Contents: Executive Summary — Introduction — Equip-ment — Staffing — Workload — Training — Supervi-sion — Operating Procedures — Human PerformanceFactors — Information Transfer — Management — Con-clusion — Annexes.

Executive Summaries of the Aviation Accident Study. —Santa Monica, CA : Rand, The Institute for Civil Jus-tice, 1988. Report RAND R-3684-ICJ, vii, 64p. ISBN:0-8330-0921-4. $7.50.

Key Words1. Liability for Aircraft Accidents — United States.2. Aeronautics — Accidents — Liability — United

States.3. Aeronautics — Accidents — Costs — United States.

Contents: Forward — Costs and Compensation Paid inAviation Accident Litigation / J.S. Kakalik et al —Dispute Resolution Following Airplane Crashes / E.M.King and J.P. Smith — Computing Economic Loss inCases of Wrongful Death / E.M. King and J.P. Smith —Economic Loss and Compensation in Aviation Acci-dents / E.M. King and J.P. Smith.

Summary: This volume summarizes the Institute forCivil Justice (ICJ) detailed studies of litigation arisingfrom commercial aviation accidents. Aviation litigationis different from most tort litigation: Aviation accidentsare mass torts that usually involve multiple versus singledefendants and plaintiffs; the dispute between plaintiffsand defendants generally focuses exclusively on the is-sue of the appropriate level of compensation versus whatcaused the injuries and who is liable. The plaintiff’seconomic loss is a new element in the research focusingon the amount of compensation. Previously, there wasan absence of a generally accepted methodology of cal-culating economic loss. Each state has its own laws, andduring the research, the standards being used by thecourts to determine loss were changing. ICJ developedtheir own methodology, “designed to capture the prin-ciples underlying the tort system’s compensation anddeterrence objectives, providing a necessary benchmarkfor comparing levels of loss and compensation acrossaccidents and jurisdictions.”

Air Traffic Control: Status of FAA’s Effort to Modern-ize the System. Fact Sheet for Congressional Request-ers / U.S. General Accounting Office. — Washington,D.C. : U.S. General Accounting Office*, April 1990.Report GAO/RCED-90-146FS, B-239008.1. 30p.

Key Words1. Air Traffic Control — Management — United States.2. Air Traffic Control — Finance — United States.3. United States Federal Aviation Administration.4. National Airspace Systems Plan (NAS).

This fact sheet provides information on the overall sta-tus of the National Airspace Systems Plan in terms ofprojects completed and funds allocated, and the pro-jected cost and schedule of the program’s 12 majorsystem as of January 1990. This report presents thefunding history and schedule changes. GAO found thatmost projects are in production, but few are complete,and most are behind schedule. Information is includedfor the 12 systems: Advanced Automation System (AAS),Air Route Surveillance Radar (ARSR-4), Air Route TrafficControl Center (ARTCC) Modernization, Airport Sur-veillance Radar (ASR-9), Automated Weather Observ-ing System (AWOS), Central Weather Processor (CWP),Flight Service Automation System (FSAS), MicrowaveLanding System (MLS), Mode S, Radio Communica-tion Links (RCL), Terminal Doppler Weather Radar(TDWR), Voice Switching and Control System (VSCS).

Statistical Summary of Commercial Jet Aircraft Acci-dents: Worldwide Operations, 1959-1989. — Seattle,WA : Boeing Commercial Airplanes Product Safety Or-ganization, March, 1990. Boeing Document D6-53810-89. 36p.; charts; ill. Available from: Product SafetyOrganization (B-210B), M/S 69-33, Boeing Commer-cial Airplanes, Seattle, Washington 98124 USA.

Key Words1. Aeronautics — Accidents — Statistics.2. Aeronautics — Accidents — Jet Planes — Statis-

tics.3. Aeronautics, Commercial — Accidents — Jet Planes

— Statistics.

The accident statistics presented in this document areapplicable to worldwide commercial jet operators foraircraft heavier than 60,000 pounds maximum grossweight, but do not include turboprop aircraft. Russian-manufactured or -operated aircraft and military opera-tors of commercial-type aircraft are also excluded. Ac-cidents resulting from sabotage, hijacking, military ac-tion, or experimental test flying, turbulence injury, orevacuation injury are not included. Statistical chartsand tables are arranged according to a generic groupingof the worldwide commercial jet fleet. Charts include


primary cause factors, flight phase, accidents per mil-lion departures, age of the jet fleet, more.

Annual Report 1989. — Ottawa : Canadian AviationSafety Board, [March, 1990]. 58p.; charts; ill. ISBN:0-662-57311-0.

Key Words1. Aeronautics — Accidents — Canada.2. Aeronautics — Statistics — Canada.3. Aeronautics — Safety Measures — Canada.4. Canadian Aviation Safety Board.

Partial Contents: Members of the Board — StatisticalOverview — Activities — Investigations — Applica-tions of Technology in Accident Investigation: AcousticAnalysis, Image Analysis, Document Analysis, RemoteSensing, FDR/CVR Analysis — The Confidential Avia-tion Safety Reporting Program — Human Factors —Communications — Findings — Major Occurrence Re-ports Adopted by the Board in 1989 — Recommenda-tions and Safety Actions — Annexes / Auditor’s Report,Organizational Structure, Historical Statistics.

Text in English and French; French text on inverted pages.

The number of accidents involving Canadian registeredaircraft fell by about 3% to 487 during 1989, comparedwith 1988. It is estimated that there was a 3.5% in-crease in the total number of hours flown, resulting in adrop in the accident rate from 14.5 accidents per 100,000flying to just under 13.6. This rate is slightly below theaverage over the last five years and well below the levelof the 1970s and early 1980s. This annual report maybe the last for the CASB, since a new agency, theCanadian Transportation Accident Investigation and SafetyBoard (CTAI&SB) will come into being in 1990, ex-tending the aviation safety board concept to includemarine, rail and pipeline transportation.

Search Request No. 1786: “Air Carrier Flight CrewFatigue”. — Mountain View, CA : Battelle ASRS Office; Moffett Field, CA : U.S. National Aeronautics &

Space Administration, ASRS; April 30, 1990. 1 volume[approx. 100 pages], spiral bound.

Key Words1. Flight Crews — Fatigue.2. Flight Crews — Duty Time.3. Air Pilots — Fatigue.4. Air Pilots — Workload.5. Airplanes — Piloting — Workload.6. Airplanes — Piloting — Fatigue.7. Aviation Safety Reporting System.

A NASA ASRS search performed for Dr. Len Wojcik,Flight Safety Foundation.

The printout contains 93 reports involving air carrierflight crew fatigue situations related to extended flighthours, submitted to the ASRS database between 1983and 1990. The ASRS database consists of reports vol-untarily submitted; all reports are deidentified. Eachreport, one or two pages long, includes the month andyear of occurrence, person’s functions, flight condi-tions, aircraft type, anomaly, situation report subjects,narrative, other information relevant to the report. All93 reports in this search were submitted by flight crewmembers who either experienced or observed the ef-fects of fatigue on crew performance. Narratives inthese reports report anomalies (altitude deviations, au-topilot problems, excursion from assigned course, equip-ment problem, non-adherence to legal requirements,etc.) which might have led to serious incidents/acci-dents. According to the reporters, the anomalies re-sulted from crew error (lack of attention, confusion,etc.) attributable to crew fatigue, lack of crew rest, dutytime, long flights, etc. �

*U.S. Department of CommerceNational Technical Information Service (NTIS)Springfield, VA 22161 U.S.Telephone: (703) 487-4780.

U.S. General Accounting Office (GAO)Post Office Box 6012Gaithersburg, MD 20877 U.S.Telephone: (202) 275-6241


77% Turbojet

18% Turboprop

4%Piston-Engine

70% Turbojet

17%Turboprop

13%Piston-Engine

49%Turbojet

22%Turboprop

29% Piston-Engine

88% Piston-Engine

8%Turboprop4%

Turbojet

Changes of Worldwide Airline Aircraft Fleet by Aircraft Engine Type 1959-1989

727 and a series of twin-engine jet transports wereintroduced into airline service. In the 1970s, widebodyaircraft with three or four turbojet engines were manu-factured for long-haul operations. As a result of thedemand for fuel efficiency, more efficient turbofan en-gines were developed, and twin-engine air carrier air-craft become more popular.

By the end of the 1970s, twin-engine aircraft accountedfor 57 percent of the total jet transport fleet, comparedwith only 34 percent at the beginning of that decade.The development of highly efficient, ultra-high-bypassturbofan engines has further reduced operating costs.Another important trend is the use of advanced cockpittechnologies to permit operation by only two pilots. Itappears that the twin-engine and two-crew trend willcontinue into the 21st century.

In the last year of the past decade, worldwide airlinesoperating jet transport aircraft (excluding U.S.S.R. makesand models) recorded a total of more than 20 millionflying hours and were involved in 19 fatal accidents. Sev-enteen of the fatal accidents occurred during normal op-erations and two are suspected sabotage events. A total of1,090 persons involved in the accidents were fatally in-jured and 14 jet transport aircraft were totally destroyed.

Worldwide, airline jet transport aircraft annual flyinghours increased from fewer than 200,000 hours in 1959to more 20 million hours in 1989 for a total of morethan 318 million hours over the 30-year period, duringwhich there were 334 fatal accidents. During the sameperiod, the mean fatal accident rate per 100,000 flyinghours decreased from 1.15 to 0.55.

The turbojet transport age began in the early 1950swhen the British Comet entered airline service. Pure-jet air travel expanded significantly in 1959 when theBoeing 707, DC-8 and Caravelle became available forworldwide airline passenger service. By the end of1959, there were approximately 150 turbojets in serv-ice, accounting for about four percent of the total air-line fleet. The higher airspeed of the turbojet cut long-distance travel times by more than half and attractedmore passengers. Airlines throughout the world com-peted vigorously for the passenger market with moreand more turbojets replacing piston-engine or turbo-prop aircraft. In 1969, turbojets accounted for 49 per-cent of the worldwide airline fleet. The proportion ofturbojets in the worldwide airline fleet continuouslyincreased to 70 percent in 1979 and 77 percent in 1989.The four pie-charts in Figure 1 delineate the composi-tion of the worldwide fleet in 1959, 1969, 1979 and1989, and illustrate the changes in aircraft fleet compo-sition by aircraft engine type.

The number of engines per aircraft also changed sig-nificantly during the past 30 years. In the beginning ofthe jet age, most turbojet aircraft, except the French-made twin-engine Caravelle, were equipped with fourengines. In the mid-1960s, the three-engine Boeing

Aviation Statistics

Worldwide Airline Jet Transport AircraftFatal Accidents and Hull Losses

A Review of 31 Years of Operations

Figure 1

1959 1969

19891979


Table 1 - Worldwide Airline Jet TransportAircraft Hours Flown in Thousands(By number of engines, 1959-1989)

Aircraft Annual Aircraft Accumulative TotalIn Service December Hours Flown Hours Flown

Aircraft Type 1980 1989 CY 1989 1959-1989

Two-engine 2,191 4,734 11,690,000 117,373,000Three-engine 2,265 2,283 5,305,000 99,130,000Four-engine 1,576 1,365 3,354,000 102,186,000 Total 6,032 8,382 20,349,000 318,697,000

Two-engine 36.3% 56.5% 57.4% 36.8%Three-engine 37.6% 27.2% 26.1% 31.1%Four-engine 26.1% 16.3% 16.4% 32.1% Total 100.0% 100.0% 100.0% 100.0%

1st generation 1,233 590 588,000 81,158,0002nd generation 3,693 4,620 10,506,000 160,217,000 1/Widebody 1,106 1,603 5,082,000 57,244,000 1/Efficiency 0 1,569 4,173,000 20,078,000 2/ Total 6,032 8,382 20,349,000 318,697,000

1st generation 20.4% 7.1% 2.9% 25.5%2nd generation 61.2% 55.1% 51.6% 50.2%Widebody 18.4% 19.1% 25.0% 18.0%Efficiency 0% 18.7% 20.5% 6.3% Total 100.0% 100.0% 100.0% 100.0%

Two-crew 2,286 4,874 12,000,000 118,617,000Three-crew 3,746 3,508 8,349,000 200,080,000 Total 6,032 8,382 20,349,000 318,697,000

Two-crew 37.9% 58.2% 59.0% 37.2%Three-crew 62.1% 41.8% 41.0% 62.8% Total 100.0% 100.0% 100.0% 100.0%

1/ Readjusted since 1987.2/ Efficiency jet includes Boeing 757, Boeing 767, MD-80, MD-81, A-310, A-320, F-100

Table 1 presents the number of jet trans-port aircraft in service at the end of 1980and at the end of 1989 by three differentgroupings. It is likely that worldwideairlines intent on cutting operating costswill use more fuel efficient twin-engineand two-crew aircraft in the years to come.

The average daily utilization for jet transportaircraft, as shown in Table 2, is aboutseven hours. However, the early jet trans-ports, including Boeing 707/720, DC-8and Trident required more time for main-tenance, so their utilization times are less.The daily utilization of all long-range,

widebody jets, including theBoeing 767 and Airbus 310, av-erages more than nine hours. Insome 30-day periods, the dailyaverage utilization of the Boeing747 has been as high as 15 hours;Airbus-310, Boeing 767, DC-10and L-1011 utilizations have beenas high as 13 hours daily. Notethat except for the widebody jetcategory which increased 0.7hours, the average daily utiliza-tion times of all types of air-craft in 1989 were slightly lowerthan in 1988. This is becausemore new aircraft were deliv-ered to airlines in 1989. As aresult, the airline aircraft fleetincreased from 7,763 in 1988 to8,382 in 1989, an increase ofeight percent, while the totalnumber of flying hours in 1989was only six percent higher thanin 1988.

Table 3 shows the distributionof worldwide airline fatal acci-dents and hull losses by phaseof operation. The overall pat-tern remained fairly constantduring the period from 1959through 1989. The approach/landing phase has accounted forabout 50 percent of all fatal ac-cidents and hull losses through-out the entire period. Table 4shows the distribution of fatalaccidents, hull losses and ratesby aircraft makes and modelsentering into service in differ-ent time periods.

Table 2 - Daily Utilization of Jet Transport Aircraft (ByAircraft Type, 1987-1989)

Aircraft Type Average Daily Utilization (Hours)1987 1988 1989 Change (1988-1989)

Two-engine 6.9 6.7 6.7 —Three-engine 6.8 6.6 6.3 -0.3Four-engine 6.9 6.8 6.7 -0.1

1st generation 3.2 2.9 1.6 -1.32nd generation 6.6 6.4 6.2 -0.2Widebody 8.9 8.0 8.7 +0.7Efficiency 7.9 7.4 7.2 -0.2

Two-crew 7.0 6.8 6.7 -0.1Three-crew 6.8 6.8 6.5 -0.3


Table 3 - Fatal Accidents and Hull Losses(By Phase of Operations, 1959-1989)

Fatal Accidents Hull LossesTakeoff/ Approach Approach/ TakeoffClimb Cruise Landing Ground Year Ground Landing Cruise Climb

14(43.8) 3(9.3) 15(46.9) 0(0.0) 59-64 1(2.4) 22(53.7) 4(9.8) 14(34.1)

14(25.5) 7(12.7) 34(61.8) 0(0.0) 65-69 6(8.1) 41(55.4) 7(9.5) 20(27.0)18(24.0) 16(21.3) 41(54.7) 0(0.0) 70-74 11(11.0) 52(52.0) 12(12.0) 25(25.0)16(28.0) 12(21.4) 27(48.2) 1(1.8) 75-79 6(5.7) 43(51.2) 11(13.1) 24(28.6)

15(27.2) 13(23.6) 25(45.5) 2(3.7) 80-84 7(10.3) 37(54.4) 8(11.8) 16(23.5)

5(45.5) 1(9.0) 5(45.5) 0(0.0) 1985 1(7.7) 6(46.1) 1(7.7) 5(38.5)

2(40.0) 1(20.0) 2(40.0) 0(0.0) 1986 1(11.1) 5(55.5) 1(11.1) 2(22.3)4(30.8) 3(23.1) 6(46.1) 0(5.6) 1987 1(7.7) 5(38.5) 3(23.1) 4(30.7)4(26.7) 4(26.7) 7(46.6) 0(0.0) 1988 0(0.0) 6(46.1) 2(15.4) 5(38.5)

8(42.1) 3(15.8) 7(36.8) 1(5.3) 1989 0(0.0) 7(46.7) 2(13.3) 6(40.0)100(29.8) 63(18.8) 169(50.2) 4(1.2) 59-89 34(7.6) 224(54.0) 51(11.4) 121(27.0)

Table 4 - Worldwide Airline Jet TransportFatal Accidents Hull Losses and Rates

(1959-1989)

Number of Fatal Accidents and Hull-Losses*1st Generation 2nd Generation Widebody Efficiency

Fatal Hull Losses Fatal Hull Losses Fatal Hull Losses Fatal Hull Losses

1959-1964 32 41 — — — — — —1965-1969 34 47 21 27 — — — —1970-1974 41 51(54) 30 37(41) 4(5) 3(5) — —1975-1979 23 35(36) 26 36(37) 7 11 — —1980-1984 12 18 32 40 11 9(10) — —1985 2 1 6 8 3 4 — —1986 0 1 5 7 0 1 — —1987 3 3 6 6 2 2 2 21988 3 3 7 7 1(3) 0(2) 2 11989 4 3 10 8 5 4 0 0Total 154 203 143 176 33 34 4 3

Accidents per 100,000 Flying hours1959-1965 .342 .438 — — — —1965-1969 .115 .159 .197 .252 — —1970-1974 .179 .236 .109 .135 .111 .0821975-1979 .133 .203 .075 .104 .062 .0981980-1984 .157 .235 .072 .090 .051 .0501985 .244 .122 .062 .084 .046 .0631986 — .159 .047 .065 — .0141987 .451 .451 .058 .058 .428 .428 .074 .0741988 .519 .519 .070 .070 .002 — .059 .0291989 .680 .510 .095 .076 .983 .079

1959-1989 .189 .250 .089 .109 .057 .059 .020 .015

*Aircraft destroyed by criminal activity or military force are excluded.


Table 5 - Worldwide Airline Jet Transport Fatal Accidents, Hull Losses and Rates(1959-1989)

Two- Three- Four- Two- Three- All(Hours in thousands) engine engine engine crew crew Aircraft

Fatal CY 1989 9 5 5 9 10 19Accidents Cumulative

as of 1989 117 68 149 106 228 334

Hours per CY 1989 1,299 1,061 670 1,333 835 1,017Fatal CumulativeAccident as of 1989 1,006 1,457 685 1,119 877 954

Hull CY 1989 7 6 2 5 10 15Losses Cumulative

as of 1989 153 77 186 134 282 416

Hours per CY 1989 1,670 844 1,677 2,400 835 1,356Hull Loss Cumulative

as of 1989 767 1,287 549 885 780 766

Table 5 presents the fatal accident and hull loss ratesby aircraft with different numbers of engines and dif-ferent numbers of flight crew members. It is apparentthat the latest aircraft makes and models have a better

Accident/Incident Briefs

This information on accidents and incidents is intendedto provide an awareness of problem areas through whichsuch occurrences may be prevented in the future. Ac-cident/incident briefs are based upon preliminary in-formation from government agencies, aviation organi-zations, press information and other sources. The in-formation may not be accurate.

Air CarrierAir Carrier

It All StartedWith a Delayed Descent

Boeing 747: Minor damage. No injuries.

Because of other traffic, the widebody had been held

high on its visual approach to Manchester, U.K. Airtraffic control then vectored the aircraft through theextended centerline to help the pilot lose the excessaltitude prior to landing. During the approach, thepilots noticed that the captain’s flight director gave nocommands, although ILS raw data indicated one dot leftand one dot high on the glideslope. The flight directorswere turned off for the final stages of the approach thatwas stabilized at an indicated descent rate of 700 fpm.

The captain reported that a firm touchdown was madeon a rise in the runway coincident with a ground prox-imity warning. After the aircraft was parked, a substan-tial quantity of water was observed to be draining fromthe fuselage. Inspection revealed that one of three 110-gallon water tanks had broken away from its mountingsand the contents of all the tanks had emptied into thelower fuselage. The damaged water tank and the asso-ciated plumbing were removed from the aircraft andtemporary piping was installed to provide an operablewater system until permanent repairs could be made. Adiscrepancy notation was made. A heavy landing in-spection was carried out but no other damage was found.After an operational check of the flight directors re-vealed no defects, the aircraft was released for service.

safety record than the ones built earlier. �


Eighteen days later an aircraft inspection revealed thatsome of the vertical support struts for the remainingtwo water tanks had also failed and that rope had beenused to effect a repair. Neither the additional damagenor the fact that rope was used for the repair had beenlogged; further, the original discrepancy report had notbeen followed up and the aircraft had been allowed tooperate in the jury-rigged condition for 38 flight seg-ments. Another heavy landing inspection was made andpermanent water tank repairs effected before the air-craft again was released for service. The failed supportstruts were examined by the aircraft manufacturer andwere found to have failed due to excess loads, with nofatigue or pre-existing defects.

Investigation of the hard landing revealed that the flightdata recorder contained poor data and the rate of de-scent and G forces at touchdown could not be deter-mined; neither could it be established why there was aground proximity system (GPS) warning and why theradio altimeter did not inhibit the GPS below a heightof 50 feet. It was calculated that a vertical accelerationof more than nine Gs would have been required to failthe water tank support struts, but this also would pro-duce other structural damage of which there was noevidence. The aircraft’s maintenance history revealedno previous hard landings.

The incident was discussed in detail with the flightcrew and maintenance personnel. The firm landing wasattributed to the combination of an insufficient flareoutand the touchdown being made where there was anupslope in the runway. In the maintenance area, anumber of serious errors and irregularities involvingboth the repair and the documentation were addressed.

Everybody Up FrontIs Only for Church

Boeing 757: No damage. No injuries.

The aircraft was departing from Belfast, Ireland, on theway to Heathrow, U.K. As the aircraft rotated, the cap-tain found that an abnormally heavy force was requiredto raise the nose. During the initial climb stage, 6.1divisions of nose-up trim was required — the trim hadbeen set at 3.6 divisions according to aircraft loadinginformation during pre-takeoff preparation.

As the aircraft approached its destination, an excessiveamount of nose-up trim again was required, with 11.2divisions being used by the pilot. The landing, however,was accomplished without incident.

Upon checking, it was ascertained that most of the 89passengers had been seated in the forward section ofthe aircraft. The reason for this unbalanced loading

was traced to the fact that free seating selection hadbeen offered to the passengers during boarding at Bel-fast because the check-in computer had been out ofservice. No manual loadsheet had been filled out toreplace the original computed one and there was nocargo in the forward hold.

A reconciliation of the aircraft’s cargo load distribu-tion, as weighed on arrival, revealed an actual trimerror of 4.1 divisions nose-up instead of the 3.6 divi-sions nose-up that had been given to the flight crewprior to takeoff and which would have been withinacceptable limits. The cause of the significant trim dif-ference was attributed to the decision to allow the pas-sengers to sit where they pleased when the computerfailed. The incident was discussed with the involveddispatcher and a notice was published which requiresthat actual passenger seating conforms to the loadingdistribution indicated on the loadsheet.

Careless Paperwork StowageCan Affect Safety

Boeing 737: No damage. No injuries.

As the aircraft was accelerating through 80 knots dur-ing the takeoff from London’s Heathrow Airport, thecaptain’s seat moved rearward on its rails. After thepilot’s two unsuccessful attempts to restore the seat toits proper position, the first officer took control of theaircraft. Later, the seat fore-aft latching was found tooperate properly.

The crew had checked seat position and locking duringtaxi-out. However, after inspecting the seat track area,the aircraft maintenance log was found located betweenthe center pedestal and the seat. Maintenance person-nel found no defect in the seat locking mechanism uponinspection. In an attempt to simulate the incident, amaintenance log was purposely placed between the left-hand seat and the center console; when it was movedrearwards, the log could move the seat fore-aft operat-ing lever, causing the seat to move.

Confusion During Look-See

BAC One Eleven: No damage. No injuries.

The air carrier made a missed approach to London’sGatwick Airport from the decision height of 670 feetbecause of insufficient visual reference. A second ra-dar approach was made at approximately midnight.

During the second approach, good vertical visibilitywas available before decision height was reached. Withthe cloud base at 600 feet, brief visual contact was


made with the airport at decision height. The pilot keptthe aircraft at decision height for a few seconds toevaluate the visibility. He felt the visibility was suffi-cient and descended; all of the airport could be seenwith the visibility stated to be about 2.5 miles.

However, because the glare from the cloud base re-flected the mass of ground lighting, there was someconfusion over which was the landing area because ofthe similar lighting appearance of the runway and ataxiway. After the aircraft had descended to 400 feetand the runway still had not been positively identified,the pilot initiated a missed approach and diverted to hisalternate.

Later discussions over the incident included the possi-bility of adding lead-in runway flashers, and a changewas made to the centerline light intensity of the runwayconcerned. However, procedures still require an imme-diate go-around if visual reference is inadequate at de-cision height.

Flaps Not Set for Takeoff

de Havilland DHC-2 Beaver: Aircraft destroyed. Fatalinjuries to three, serious injuries to one.

The aircraft was departing from a remote airstrip inCanada. A pilot and three passengers were aboard.

The flaps were in the landing position during takeoff.The aircraft lifted off but went out of control during theinitial climb and entered a steep left turn from whichthe pilot was unable to recover.

Distractions Permitted, Checklist Items Omitted

Piper PA-31 Navajo: Substantial damage. No injuries.

The aircraft, with a crew of one and six passengers, wasapproaching its Canadian destination during the lateafternoon in May. The weather was not a factor.

The pilot was interrupted during the landing checklistto respond to questions from a passenger. The aircraftlanded wheels up.

Aiding in the pilot’s downfall was the fact that the gearunsafe warning horn was not operable due to a brokenwire.

Engine Problem After Takeoff

Piper PA-31-350 Chieftain: Aircraft destroyed. Fatalinjuries to six, serious injuries to two.

The aircraft departed the Alaskan airport in the earlymorning of a late December day. Weather included ameasured ceiling of 1,500 feet overcast, visibility sevenmiles in light rain and temperature 5.5 degrees C (33degrees F), four degrees above the dew point. Therewere one pilot and seven passengers aboard.

Slightly more than two minutes after takeoff, the pilotreported to the flight services station (FSS) that he hadlost an engine and was circling to return to the airport.The FSS specialist reported observing the aircraft losingaltitude and descending below a tree line. She alertedthe CFR equipment. The pilot of an aircraft waiting fortakeoff observed the aircraft at about 300 feet as it turnedon a downwind leg west of the airport, apparently eitherdescending or flying away from the airport.

The aircraft descended into trees, becoming invertedjust before impacting a house less than a mile west ofthe airport. Both the aircraft and the house were de-stroyed by the crash and subsequent fire. Two personsevacuated the house with minor injuries but the pilotand five of the aircraft’s passengers were killed. Twopassengers survived and were able to get out of theaircraft and the house before the aircraft exploded.

One survivor reported that it sounded like the left en-gine had exploded at about 300 feet. The other personheard what sounded like a loud backfire shortly afterliftoff, but could not identify which engine it was. Hethought both engines kept running but that one seemedto have more power than the other. During the descent,he heard the stall warning buzzer.

Investigation revealed that neither engine had been featheredand that both were operating at the time of impact.However, the power settings could not be determined.Upon teardown inspection, the right engine was foundto have an extensive cylinder head crack, a partiallydisconnected intake pipe, and was capable of producing55 percent of its rated power; the left engine had sevenseverely worn cam lobes. The rudder trim tab wasfound deflected to the full left position, consistent withcounteracting a left yaw caused by higher power on theright engine. However, it was determined that the pilot

Air Taxi/CommuterAir TaxiCommuter


could have misidentified which engine was backfiringand retarded the left throttle rather than the right one.Since the right engine could deliver only partial power,the pilot was unable to maintain altitude.

The investigation verified that, although the aircraft’sweight was more than the pilot had calculated (becauseaverage passenger weight rather than actual weightswere used during computations) and the center of grav-ity was 3.4 inches further aft than was plotted, theweight and c.g. were within limits. Further, an exami-nation of company checklists revealed that several ver-sions were in use, and that one aircraft had three differ-ent checklists aboard.

The probable cause of the accident was attributed to thefailure of the number three cylinder of the right engineduring a critical phase of flight and the pilot’s mishan-dling of the emergency, during which he allowed theaircraft to descend and impact the terrain.

Into the TreesAnd Back Out Again

Partenavia PN 68: Extensive damage to fuselage, rightwing and right landing gear.

The aircraft was to make a business flight from Stan-sted Airport to West Malling, Kent, U.K. The left-seatpilot, a 350-hour private pilot with an instrument ratingand 58 hours in the aircraft type, was a company direc-tor and owner of the twin-engine corporate aircraft. Theonly passenger was a 14,000-hour professional pilotwith a current U.S. certificate who occupied the right-hand cockpit seat.

The pilot checked weather and filed by telephone, andreceived a weather report from the self-briefing facility,but did not get any terminal forecast because his desti-nation did not provide them. However, he telephonedthe airport and was told that the weather looked allright. Weather at the departure airport was slightly lessthan four miles visibility, rain, 5/8 cloud coverage at1,200 feet and 7/8 at 3,000 feet.

The aircraft departed at 0826 hours on the mid-Decem-ber morning and the pilot was granted a request to stop

Corporate ExecutiveCorporateExecutive

his climb at 2,000 feet to avoid clouds. Twelve minutesinto the flight the pilot experienced a violent yawingand pitching, and disengaged the autopilot. He attrib-uted the incident to clear air turbulence and re-engagedthe autopilot. After another eight minutes the pilot toldthe Thames radar controller that he was at 1,800 feetand three minutes out from West Malling, and wasgranted a frequency change to contact the destinationairport. After disengaging the autopilot, he began adescent intending to level off at 1,000 feet msl prior tomaking a visual landing approach.

The pilot made several unsuccessful attempts to contactthe West Malling control tower, and before he was ableto make visual contact with the airport the aircraft be-came engulfed in clouds and the pilot realized it washitting the tops of trees. The passenger later recalledthat, just prior to the tree contact, the aircraft yawedviolently and that the pilot seemed to have trouble con-trolling the aircraft in the turbulence. Immediately afterhitting the trees, the passenger pushed the propeller andthrottle levers fully forward and helped the pilot controlthe aircraft. Although the aircraft had sustained majorstructural damage and a portion of a treetop was imbed-ded in the leading edge of the right wing, the aircraftmanaged to climb away from the trees that reached to525 feet msl; the airport elevation was 325 feet.

The pilot transmitted a Mayday call to the Thamesradar approach facility stating what had happened andrequesting vectors to the nearest airfield. The aircraft’sairspeed registered zero, the right fuel tank gauge indi-cated zero, the stall warning light illuminated and re-mained on, and there was a distinct smell of burning.Further, unaware to the pilots and the radar controller,the transponder antenna had been torn off during theencounter with the trees.

The controller mistook another aircraft, which was us-ing the same transponder code, for the stricken aircraftwhich was no longer transmitting a transponder signaland was too low to produce a readable primary radarreturn. He directed the Partenavia on a heading thatwould send the other aircraft to nearby Biggin HillAirport; it took the Partenavia toward Gatwick Airport,instead. The pilot of the damaged aircraft recognizedGatwick, however, and reported his position to the Thamescontroller. The latter quickly advised the Gatwick con-troller, who in turn had just given an emergency turn toan air carrier aircraft to avoid collision with an uniden-tified radar return that turned out to be the damagedtwin-engine aircraft proceeding under the direction ofthe Thames controller.

By then, although he had been cleared to land on anyrunway at Gatwick, the pilot of the Partenavia lost sightof the airport in the poor visibility and was advised thathe was one mile from Redhill Airport. Because he


suspected that the collision with the trees may havedamaged the aircraft’s fixed landing gear, the pilot de-cided to land on the grass runway at Redhill. He saw theairport, contacted the tower and did a flyby duringwhich ground observers notified the pilot of the dam-age. After circling the airfield once more the pilotlanded, and the right landing gear collapsed. Rescueservices had been alerted and arrived almost immedi-ately. The occupants evacuated the aircraft without in-jury.

Examination of the aircraft revealed that the right wingleading edge had been penetrated in two places out-board of the engine, and in both locations the structurehad been destroyed back to the main spar — whichitself was slightly buckled at the point of the inboardtree strike. The electrical wiring and fuel lines alsohad been crushed in that area and the vane for the stalldetector had been destroyed. There was some crushingdamage to the right engine cowling and vegetationpartially blocked the oil cooler. The tree impact haddamaged the right main landing gear attachments andweakened them, resulting in the gear collapse duringthe landing. The nose section of the fuselage sustainedsome deformation of the outer skin and the leadingedges of the horizontal stabilizer had some crushingdamage, with the most damage on the right side. Theright-hand cockpit windshield was cracked and a cabinwindow on the right side had been broken, possibly bymaterial thrown by the propeller on that side. Althoughthe right propeller spinner was dented severely, thepropeller showed no signs of damage. The pitot tubehad been completely blocked by vegetation and thetransponder antenna had been scraped off the under-side of the fuselage.

A check of the aircraft’s pitot static system revealed noleaks and no operational or accuracy problems with theright hand altimeter. However, the pilot’s altimeter, whentested in the laboratory, showed a lag in indicated alti-tude of approximately 85 feet during descents below2,000 feet, which was reduced during vibration.

A weather aftercast showed a moist, potentially un-stable warm sector in the area with outbreaks of rain,moderate at times. Visibility varied from slightly morethan one half mile to more than five miles. Cloud coverincluded scattered, occasionally broken stratus at 600feet, stratus possible between 300 and 400 feet wherethere was upslope air motion and broken to overcaststratocumulus with bases at 3,000 feet and tops at 5,000feet. There were overcast layers between 6,500 and12,000 feet with thin layers above. With the potentialinstability in the area, meteorologists stated there couldhave been embedded cumulonimbus in the area be-tween 6,000 and 20,000 feet. Although no thunder-storms were reported, downdrafts of between 20 and 24knots could have occurred in these conditions.

Rocks in the Clouds

Beechcraft Model 200 King Air: Aircraft destroyed.Fatal injuries to one.

The business twin was the first in a flight of two Model200 King Air aircraft for a ferry flight in instrumentmeteorological conditions.

The aircraft climbed in trail formation to 4,500 feet msland headed east through the San Gabriel Mountains inCalifornia. The ceiling was 1,000 feet above their alti-tude when the two aircraft entered the mountains, but itwas lower to the east. The pilot of the lead aircraftreported to the following pilot that he had entered theclouds and was climbing.

That was the last communication received from the leadaircraft. The second King Air climbed through theclouds to visual meteorological conditions and landedat the destination with no incident. The wreckage ofthe first aircraft was found on a mountain two dayslater. It had been destroyed by impact and post-crashfire. The pilot had died immediately.

Check — and Recheck

Piper PA-28R: Substantial damage. No injuries.

The pilot, with two passengers aboard, was returningfrom a cross-country trip. He had flown retractable-gear aircraft only twice previously.

The U.K. control tower had cleared the pilot to enter thetraffic pattern on base leg. Shortly after entering thepattern, however, the pilot was requested to make aspacing circle to allow another aircraft to complete anILS approach. After he completed the orbit, the pilotwas cleared to make a straight-in landing from his pres-ent position.

The aircraft landed gear up.

Punch in the Nose

Piper PA-28: Substantial damage. No injuries.

Other GeneralAviation

OtherGeneralAviation


The pilot was approaching to land on a 1,600-foot-longU.K. runway he had not used previously.

On landing, the aircraft bounced and then porpoisedwith the nose wheel striking the runway. The pilotexecuted a go around and made another approach, thistime using the short-field landing technique. When helowered the nose wheel to the ground, the aircraft re-fused to respond to the pilot’s nosewheel steering input.He used differential braking to maintain directional control.Later inspection revealed that the hard nose-first land-ing from the porpoise had caused substantial damage tothe engine mounting frame and the nose landing gear.

Plastic Fuel Can

Homebuilt: Extensive damage. No injuries.

It was a warm, dry summer evening in England and thepilot had just completed a local flight. He decided torefuel the airplane before putting it in the hangar.

Using a plastic fuel can and a plastic funnel, the pilotstarted pouring the fuel into the airplane’s tank. Therewas a sudden crack as a spark of static electricity oc-curred. The fuel vapor and the fuel quickly burst intoflame and the airplane was extensively damaged by firedespite quick work with extinguishers on hand in thehangar.

Pitch Down Results inHelicopter Put Down

Robinson R-22B: Substantial damage. Minor injuriesto one person.

The lesson for the day was simulated engine failures.The U.S. student pilot had practiced several simulated

power failures with power recoveries. During the lastpower recovery following an autorotation, the studentleveled the aircraft off with the nose pitched forward.The flight instructor tried to raise the nose but theaircraft struck the ground before he was able to arrestthe descent. Both occupants evacuated the aircraft suc-cessfully but the helicopter sustained extensive dam-age. The student pilot was uninjured, but the instructorreceived minor injuries.

Obstruction Observed Too Late

Hughes 269A: Substantial damage. Minor injuries totwo persons.

The rotorcraft was departing for a U.S. sightseeing flighton a warm August day. During the takeoff from ahover, the pilot noticed telephone wires in his flightpath. He tried to accomplish a quick-stop maneuver toavoid the wires, but the helicopter rolled to the left andimpacted the ground.

The aircraft was damaged extensively but there was nofire. The two persons aboard were able to evacuatewith only minor injuries.

Seeing the Sights

Bell 206B: Aircraft substantially damaged. No re-ported injuries.

The aircraft was on a summertime sightseeing flight inthe United States when the pilot pitched the nose downso the passengers could take photographs. However,when the aircraft was put into the nose-low attitude, theengine stopped and the engine-out horn sounded. Thepilot successfully accomplished an autorotation into aplowed field. Upon touchdown, however, the helicop-ter rocked forward abruptly and the main rotor struckthe tail boom, incurring extensive damage. The passen-gers and pilot evacuated the aircraft unhurt.

Checks of the helicopter after the accident revealed thatthere were about nine gallons of fuel aboard and thatthe boost pump was inoperative. �

RotorcraftRotorcraft

Today’s Professional Airline Pilot: All the Old Skills — and More · 2019. 8. 19. · Today’s...

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