New Issue

AeroSafety World July 2010

Checklists and monitoring are designed to counteract the possibility of human error in the cockpit. But while essential, they are not infallible. Benjamin A. Berman and R. Key Dismukes observed line operations during 60 flights to determine whether deviations from SOPs slip through. They do.

They recorded 899 deviations, of which 194 were in checklist use and 314 in operating procedures. In the July cover story, they describe the types of deviations, including both specific causes such as omission of standard callouts and general principles behind the errors.

Also in the July issue, Wayne Rosenkrans looks at factors in the evacuation of the US Airways A320 that ditched in the Hudson River; Mark Lacagnina writes about the spatial disorientation, exacerbated by inadequate CRM and a lack of aircraft handling skills, in the 2008 crash that killed all occupants of a 737-500 at Perm, Russia; plus other feature stories and standard departments. 68 pages. [PDF 4.6M]

Feature articles and departments are now available in text only format as well as Adobe® Portable Document Format (PDF) format.

Cover Story

Designing a Better Error Trap (Text only)

Airlines should examine their SOPs to specifically define the objectives of each procedure and to determine whether it is realistic to assume that pilots can perform the procedure reliably under actual line conditions. Pilots must be aware that in deviating from any procedure, they might be giving up safety margin that is not apparent. [Download PDF 6 pages. 357K]

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Causal Factors

Misgauged Recovery (Text only)

Spatial disorientation was the primary cause of the Sept. 13, 2008, crash of a Boeing 737-500 at Perm, Russia, according to the final report by the Russian Air Accident Investigation Commission. Contributing factors were inadequate crew resource management (CRM), a lack of proficiency in basic aircraft handling and a lack of skills associated with the use of a “Western-type” attitude indicator for recovery from an upset.
[Download PDF 4 pages. 288K]

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Cabin Safety

Survival on the Hudson (Text only)

The lessons learned reflected the importance of leaving as little to chance as possible in preparations to survive an aircraft accident. The investigation revealed that the success of this ditching mostly resulted from a series of fortuitous circumstances, including that the ditching occurred in good visibility conditions on calm water and was executed by a very experienced flight crew. [Download PDF 6 pages. 438K]

Expanded Version of this article

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Flight Ops

Diminishing Skills? (Text only)

With the advent of advanced, highly automated cockpits in current transport category jet aircraft, pilots no longer fly solely by reference to raw data from airplane instruments, and as a result, their basic instrument flying skills may have diminished. [Download PDF 5 pages. 217K]

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Helicopter Safety

Fractured Blade (Text only)

The fatigue fracture of an Aerospatiale AS 350D power turbine blade caused a loss of engine power that led to the May 24, 2008, fatal crash of an Island Express Helicopters air taxi flight on Santa Catalina Island off the coast of California, the U.S. National Transportation Safety Board says. [Download PDF 3 pages. 286K]

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Traffic Control

Virtually Interactive (Text only)

Efforts to computer-generate air traffic control environments inside flight simulation training devices have advanced significantly in step with an emerging consensus about the benefits, several specialists say. The airline industry has spent about six years considering systems and methods that would go far beyond current training of candidates for the multi-crew pilot license in a few countries. [Download PDF 5 pages. 391K]

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Human Factors

Joint Cognitive Systems (Text only)

Cognitive task design today enables innovative solutions to such problems. Crew resource management, one of the most familiar examples of cognitive task design, originated partly from the idea that flight attendants should function as extra eyes and ears for two-pilot flight decks. [Download PDF 4 pages. 258K]

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Executive’s Message

Joining the Team (Text only)

That new face at Flight Safety Foundation is me, Kevin Hiatt, and I’d like to introduce myself. I joined the Foundation in early July. In my role as executive vice president, I have been charged by the Executive Committee of the FSF Board of Governors to oversee the daily operations of the staff, support President and CEO Bill Voss. [Download PDF 1 page. 93K]

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Editorial Page

Surprise Surprise (Text only)

Surprises in aviation are rarely pleasant, and that’s what a couple of Continental Airline pilots got in late 2008 when they taxied for departure from Denver International Airport (DEN) with the tower reporting winds of 11 kt, 70 degrees off the nose. [Download PDF 1 page. 69K]

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Safety Calendar

Industry Events (Text only)

A listing of aviation safety-related conferences, seminars and meetings. [Download PDF 1 page. 74K]

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In Brief

Safety News (Text only)

Maintenance personnel should receive more on-the-job training before they are permitted to perform critical work on aircraft, the U.S. National Transportation Safety Board says. [Download PDF 3 pages. 269K]

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Leaders Log

Professionalism Counts (Text only)

I learned from professionals that you have to work at professionalism, and that takes discipline. The real professionals among us always have time to do things the right way at the right time every time. [Download PDF 2 pages. 123K]

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Data Link

Safety in Numbers (Text only)

The rate of unstable approach events declined 36 percent in 2009 from the previous year among aviation departments participating in Flight Safety Foundation’s corporate flight operational quality assurance program, according to a statistical summary report prepared by Austin Digital, which aggregates and analyzes the data. [Download PDF 4 pages. 397K]

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Info Scan

Night Light (Text only)

The investigation determined that the pilot flying was likely to have been relying on peripheral vision while steering because of the need to concentrate on the forward view; that the rolling takeoff reduced the time available to check position; and that the pilot was misled by “confusing aerodrome markings especially taxiway lead-in lines that directed aircraft onto the runway edge lights, resulting in the misalignment of the aircraft at the beginning of the takeoff roll.” [Download PDF 4 pages. 163K]

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On Record

At the Verge of a Stall (Text only)

The following information provides an awareness of problems in the hope that they can be avoided in the future. The information is based on final reports by official investigative authorities on aircraft accidents and incidents. [Download PDF 8 pages. 284K]

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Smoke Fire Fumes

Selected U.S. Events February–April 2010

Selected Smoke, Fire and Fumes Events in the United States, February–April 2010. [Download PDF 1 page. 67K]

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