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Thoughts on Crew Resource Management (CRM)

by Tori Williams 1. December 2018 18:18
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Crew Resource Management (CRM) is defined by the Federal Aviation Administration as, “the effective use of all available resources: human resources, hardware, and information.” The history of CRM comes from NASA research that took place in the late 1970s. NASA focused its research solely on the human error element involved in aircraft accidents with multiple crews. During this time of research, much of the focus of CRM was on the pilot/copilot relationship. It was discovered that select airline captains thought very little of their first officers. In turn, first officers felt that they could not challenge their captain when they didn’t agree with his or her actions. They felt that it was disrespectful to challenge them as captains were the boss in the cockpit. The purpose of the research at that time was to “gain an environment of equal respect, teamwork and cooperation to safely accomplish the mission of the flight.” The most recent CRM model has evolved into “teaching pilots risk management strategies, focusing on workload management, recognizing hazardous attitudes or patterns, maintaining situational awareness, and communicating effectively to operate efficiently and safely in all aspects of flight.” CRM is an important aspect to any flight training department and is critical for an airline pilot’s career.

CRM covers many different concepts including decision-making and risk management. The decision-making side of CRM covers pilots that are faced with an in-flight decision. Pilots are trained to use the knowledge and technology they have available to them when they are faced to make a decision during flight. CRM includes not only pilots but other crew members, flight attendants, ATC, weather reports, and maintenance workers. Pilots can utilize these people and tools to help them make their in-flight decision. Risk management involves preventing risks and how to manage them appropriately if they do arise. Risks include not only environmental such as weather or operational policies but pilot’s personal risks. Pilots can have personal risks such as fatigue, illness or stress that they are aware of but not always tell their crew members about. Factors such as aircraft weight and runway conditions can also influence risks. Two flight cases below highlight the importance of CRM and why proper training is crucial before the flight crew steps in the cockpit.

Korean Air Cargo Flight 8509 is a perfect case study into what tragedies can happen when there is a breakdown of CRM. The Boeing 747 was flown by a crew of 4 out of London Stansted Airport on December 22, 1999. Maintenance personnel warned the Flight Engineer that the captain’s Attitude Director Indicator (ADI, or artificial horizon) was unreliable during a roll before they boarded the aircraft. It was dark outside at the time of takeoff, so the captain was flying entirely by instruments. The captain began a sharp left turn after takeoff, which was not reflected on his inoperable ADI. The CRM breakdown in this instance was that the co-pilot’s ADI was functioning normally but he remained silent as to not challenge the captain. The Flight Engineer began yelling “Bank!” repeatedly, and an alarm rang out warning of the error, but the pilot continued his sharp turn until the left wing dragged the ground and the plane smacked the ground at high speed and 90 degrees of left bank. All 4 crew onboard perished in the cash.

Southwest Airlines Flight 1248 is another example of where CRM training is crucial. On December 8, 2005 a Boeing 737-7H4 ran off the departure end of runway 31 center just after landing at Chicago Midway Airport. The aircraft rolled through the blast pad fencing and the airport’s perimeter fence where it finally came to a stop after striking a vehicle, which killed a child that was in the vehicle. The cause of the accident was the pilots’ failure to use available reverse thrust in a timely manner to safely slow or stop the airplane after landing. This failure occurred because the pilots’ first experience and lack of familiarity with the airplane’s autobrake system distracted them from thrust reverser during the challenging landing. This case shows that not only were the pilots at fault for the accident but Southwest Airlines as a company. The company failed to train the pilots and assure that they were clear on the operating procedures for the aircraft they were flying.

Between 60-80% of aviation accidents are caused by human error, and a large portion of that are specifically caused by poor Crew Resource Management. Millions of dollars have been invested into CRM training at airlines, flight schools, and other businesses that operate aircraft. Continual CRM training that focuses on teaching pilots and aircraft crew error avoidance, early detection of errors, and minimizing consequences resulting from CRM errors generally has a positive outcome and desired behavioral change. However, it can be difficult to evaluate the impact of CRM training as it is hard to quantify the concept of accidents avoided. Thus, it was determined that more research into the long-term effects of CRM training needs to be conducted in the coming years.

Companies are wanting to dig deeper into how they can better equip and train their employees to use CRM tactics. The FAA has an Advisor Circular (AC) published specifically for crew resource management training. In addition to the certain essential that are universal to CRM, the Advisory Circular also lists effective CRM characteristics which include: CRM is a comprehensive system of applying human factors concepts to improve crew performance, CRM embraces all operational personnel, CRM can be blended in all forms of aircrew training, CRM concentrates on crewmembers’ attitudes and behaviors and their impact on safety, CRM uses the crew as a unit of training, CRM is training that requires the active participation of all crewmembers. It provides an opportunity for individuals and crews to examine their own behavior, and to make decisions on how to improve cockpit teamwork. The number one goal in aviation is safety. Where CRM characteristics are compromised or left out, there’s room for error to slip in which can lead to incidents or accidents that could cause fatalities. Companies in the aviation industry need to ensure that they are taking all of the right steps in training their crews before they are put on the aircraft with souls on board.

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Aircraft Accidents | Aviation History | Aviation Safety

When Is An Aircraft "Destroyed" Versus "Repairable"?

by Greg Reigel 12. November 2018 15:27
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Unfortunately, the terms "destroyed" and "repairable" are not defined anywhere in the regulations. But, as you might expect, the FAA has a policy/opinion about what these terms mean. In fact, the FAA has issued Order 8100.19, Destroyed and Scrapped Aircraft which spells out what these terms mean and how they are to be applied by FAA inspectors. If an aircraft is capable of being repaired and returned to service after it was unserviceable due to wear and tear, damage, or corrosion then it is "repairable." But this means that when the repair is complete the aircraft to returned to service in "its original (or properly altered) condition that conforms to its type design."

The FAA clarifies further that an aircraft is only eligible for repair if it has at least one primary structure around which a repair can be performed. According to the FAA, it "considers an aircraft’s primary structure to be the structure that carries flight, ground, or pressurization loads, and whose failure would reduce the structural integrity of the aircraft." If only some, but not all, of the major structures of an aircraft are replaced, then that would still be considered a repair.

However, if all of an aircraft's primary structures must be replaced then the FAA does not consider the aircraft to be "repairable." Rather, in that situation the aircraft is being "replaced" after being "destroyed." And if the identification plate from the original aircraft was then placed on the "destroyed" aircraft that would violate 14 CFR § 45.13(e) ("No person may install an identification plate removed in accordance with paragraph (d)(2) of this section on any aircraft, aircraft engine, propeller, propeller blade, or propeller hub other than the one from which it was removed.”)

In order to comply with Section 45.13(e), the primary structure must be identifiable and traceable to the particular aircraft and its identification plate. As an example, if a heavily damaged aircraft is repaired by performing many major repairs on its fuselage and replacing all other primary structures that may be destroyed such as the wings and the empennage, that aircraft would not be considered destroyed because the fuselage is repairable. But if the fuselage of that aircraft also needed to be replaced along with the other primary structures, then the aircraft would be considered destroyed.

The Order also provides the following examples for use in determining if an aircraft is destroyed:

  1. All primary structures of an airplane or glider, including the fuselage, all wings, and empennage are beyond repair.

  2. The fuselage and tail boom of a rotorcraft are beyond repair.

  3. Only the aircraft identification plate is reusable.

How is this determination made by FAA inspectors? Well, according to the Order, "FAA accident investigators will apply their specialized knowledge and expertise and follow the guidelines in this order when evaluating aircraft wreckage to determine whether an aircraft is repairable or should be declared destroyed."

Fortunately an aircraft owner can dispute a determination that an aircraft is destroyed by providing the appropriate FAA FSDO or ACO with a repair process that explains how the damaged aircraft can be repaired provided that at least one primary structure of the aircraft is capable of being repaired rather than requiring replacement. If you are faced with a situation where it is unclear whether an aircraft has been "destroyed" or is still "repairable", you will definitely want to consult the Order, as well as the aircaft's maintenance manual.

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Aircraft Accidents | Aviation Safety | Greg Reigel

Runway Incursions: What's the Big Deal?

by Tori Williams 1. November 2018 14:46
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A runway incursion is defined by the FAA as, “Any occurrence at an aerodrome involving the incorrect presence of an aircraft, vehicle or person on the protected area of a surface designated for the landing and takeoff of aircraft." There are four categories of runway incursions, Categories A-D. Category A being the most severe and Category D being the least severe. Category A is classified as an “incident in which separation decreases and participants take extreme action to narrowly avoid a collision.” An accident can be the result of a runway incursion, and therefore exceeds the categories described.

The FAA estimates that approximately three runway incursions happen every day at towered airports in the United States. Thus, the number of unreported incursions at non towered airports must be much larger. Although a runway incursion is by definition a near miss at the worst, they are often a contributing cause in serious aircraft accidents. An accident that perfectly illustrates the dangers of runway incursions is the 1996 collision of United Express flight 5925 and a Beechcraft King Air 90A in Quincy, Illinois. A miscommunication between the landing Beechcraft, the departing King Air, and a third taxing aircraft turned deadly when the King Air failed to look for traffic and the Beechcraft wrongly assumed a radio transmission confirmed they were okay to land. Although the airport was not towered, the presence of both aircraft on intersecting runways was extremely dangerous and lead to a collision at the intersection. A total of 12 people lost their lives in that accident that could have been easily avoided.

Another infamous accident involving a runway incursion is the Russian Aeroflot Flight 3352 that took place in 1984. In short, the ground Air Traffic Controller fell asleep after he authorized several maintenance vehicles to enter the runway. A commercial aircraft carrying 170 passengers came to land at the airport, and the approach controller, oblivious to the maintenance crew on the runway, cleared them to land. To make matters worse, visibility was extremely low and the maintenance trucks did not have their rotating beacons illuminated. The commercial aircraft collided with the vehicles, resulting in 178 fatalities. In this example, the accident investigators placed the majority of the blame on the Air Traffic Controller, but there were mistakes made by all parties involved.

The airport environment is a complex operation with hundreds of moving parts. Pilots, air traffic controllers, and airport designers have to understand the hazards that come with miscommunications and poorly designed airport layouts. It only takes one moment of confusion for a runway incursion to happen, which could be deadly.

The FAA has a record of 1747 total runway incursions happening in the Fiscal Year 2017. There are several reasons that runway incursions occur. One of the most prevalent ones is miscommunication or a total lack of any communication. Many times, pilots and air traffic controllers get “stepped on” or, talked over on the radio frequency. It is highly critical that pilots repeat back their instructions to confirm with the controllers that they heard them correctly and that the directions were for their aircraft and not another. As in the above case study, although there was not a tower at the airport, the landing aircraft assumed that the aircraft announcing they would be holding short was the only one holding short. There was a misunderstanding in this case because one pilot’s radio transmission got covered up by the other aircraft holding short making the pilot of the landing aircraft assume that there was only one aircraft and they were holding short. Other common types of runway incursions include incorrect entry or vacating of an aircraft or vehicle onto the runway protection area, incorrect runway/taxiway crossing, incorrect spacing between departing and arriving aircraft, and landing or taking off without air traffic control clearance.

According the the FAA, approximately 65 percent of all runway incursions are caused by pilots. Detailed investigations of runway incursions over the past 10 years have identified three major areas contributing to these events including failure to comply with air traffic control instructions, lack of airport familiarity, nonconformance with standard operating procedures. Clear, concise, and effective pilot/controller communication is paramount to safe airport surface operations. This is something that is often stressed during initial and recurrent pilot training, but evidently the information does not always stick in the pilots’ minds.

Air traffic control instructions must be fully understood and complied with. Air traffic controllers are in place to assist pilots and want to help when there is confusion but many pilots don’t ask for the help. They are caught up in other tasks such as checklists, taxi directions, and non-essential chatter with the copilot. Pilots are to taxi with their heads-up and eyes outside to ensure they are aware of all aircraft and airport vehicles.

Major factors that increase the risk of runway confusion and can lead to a wrong runway departure include airport complexity, close proximity of runway thresholds, joint use of a runway as a taxiway (FAA, 2017). During the summer construction time, many airports will close runways or taxiways to resurface them or replace them. If a taxiway is closed, this can force aircraft to use runways as a means of getting to another open taxiway. It can also force the aircraft to back taxi on the runway they are departing from.

Thorough planning is essential for safe taxi operations. Aircraft accidents are more likely to happen on the ground than in the air because there are so many moving parts on the airfield. Pilots need to utilize the following services/tools in order to ensure safe airport surface movement: Notices to Airmen (NOTAMS), Automated Terminal Information Service (ATIS), Airport/Facility Directory (A/FD), and recognizing Hot Spots. Although using these pilot tools will not end all runway incursions, they will lower the risks if all pilots are equipped with the proper and current information.

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Aircraft Accidents | Airlines | Aviation Safety | Tori Williams

Why it Took us 3 days to Fly to Oshkosh

by Tori Williams 1. August 2018 18:00
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Only a few days have passed since we returned from the “World’s Greatest Aviation Celebration” at EAA’s AirVenture and I am already having withdrawals! There is nothing quite like sleeping under the wing of an airplane that you flew in and waking up to the sound of aircraft engines whirling to life. As anyone who has been to AirVenture in Oshkosh, Wisconsin knows, the week is completely unforgettable and there is no shortage of things to see and do.

This is the 4th year my husband and I have flown in, and the 2nd time that we’ve flown my father-in-law’s 1931 Waco ASO. This “Straightwing” biplane was restored in the 70’s and has an open cockpit. It is a wonderful aircraft, but definitely not ideal for cross-country flying. It’s extremely windy, and even in the middle of summer the air gets freezing once you’re at altitude. We knew we were in for a long trip before we left, but the series of events that followed were nothing short of unexpected.

Our plan was to leave Saturday morning, have a leisurely trip up, and arrive that evening to set up camp. However, the reality of our trip to Oshkosh was very different. When we got up Saturday morning, it was pouring rain and ceilings were at 800’. We had to wait for that to clear out, so we weren’t able to depart until around 3pm. We had a 20 knot headwind, and ForeFlight indicated our speed across the ground varied between 60-70 mph. We were slow, and the thunderstorms from earlier had broken up but there were still showers we had to avoid.

We made a quick fuel stop in Harvard, Illinois at a gorgeous grass strip called Dacey Airport. After this we were finally in the homestretch to Ripon.

An important side-note: for those who haven’t read the Oshkosh NOTAM, the gist of the arrival procedure is to approach the town of Ripon, southwest of Oshkosh, and visually separate yourself from incoming traffic. Once you have a half mile separation from the plane in front of you, everyone is instructed to fly at 90 knots and 1800 ft in single file to the next town of Fisk. Once directly over Fisk, the Air Traffic Controllers ask you to “rock your wings” for identification purposes and then they assign you a runway and you are passed to another controller who clears you to land. There are often 4 or 5 aircraft on final at any given moment, so accuracy landings “on the dot” and turning off the runway as soon as able are important. The NOTAM states that no talking on the radio is allowed, so usually this approach is actually easier than landing at some other airports.

With the NOTAM in hand and mostly memorized, we approached Ripon with high hopes for a smooth arrival and landing. After all, the 3 other times we have flown in there were never any issues. However, when we were less than 5 miles from Ripon we heard this on the radio: “Attention all traffic – the Oshkosh field is now closed to incoming traffic for the Bonanza mass arrival. Begin holding. This will be a LONG delay so divert to an alternate if you have low fuel.” Partly because we didn’t expect a long delay, and partly because the fuel at Dacey was so expensive, we didn’t fill the tank up. We were far from a fuel emergency, but didn’t have enough to hold for a “LONG delay.” We immediately turned to our alternate, Fon du Lac. As we got near and contacted the temporary control tower, we were out of luck again. Fon du Lac was where the Bonanza mass arrival was departing from, and were again told to divert due to “150 Bonanzas on the runway” (Certainly something you would only hear at AirVenture.)

We began looking for a third alternate, and located untowered Dodge County airport 23 nm away. The annoying thing about this section of our trip was that dozens of other aircraft were forced to do the same thing, and we were all inbound to Dodge County at the same time. One such aircraft had a stuck mic, so he was continually transmitting over everyone else trying to coordinate within the pattern. Eventually we all were able to communicate and land, and I must give props to the staff at Dodge County for the “refueling assembly line” they had created to deal with the sudden influx of frustrated aircraft.

The whole FBO was full of pilots who had to divert. Several were on their phones calling every hotel in town only to find out they didn’t have any rooms available. We asked around for a bit about lodging but it appeared our only option in Dodge County was to set up our tent and camp out. With less than an hour left of daylight, we decided to try going back to Fon du Lac, where my father-in-law had found a hotel with open rooms.

We immediately took off, watching as others began pitching their tents on the airport below us. Thankfully Fon du Lac had cleared out the Bonanzas, and we were able to land there (behind a C-47!) and tie down for the night. We were generously given a ride to the hotel by a T-6 pilot who had the same misfortune as us while trying to enter Oshkosh. His wife had brought a camper up earlier in the week and she drove there to retrieve him. After some late-night pizza delivery, we were exhausted and got some rest before a second attempt to enter Oshkosh on Sunday.

Sunday morning we were awoken to the sound of thunder and heavy rain. The weather had taken a turn for the worse overnight, and it was clearly going to be IFR for several hours. We spent most of the day in the terminal at Fon du Lac, watching The Open Championship on tv and monitoring weather. Finally around 3pm the skies began opening up. Immediately engines could be heard starting and it was “go time” for getting into Oshkosh. We took a few moments to refuel and ready the airplanes, and went on our merry way towards Ripon.

10 miles from Ripon we began monitoring the approach frequency. It already didn’t sound good. The controller urgently repeated the phrases “we are oversaturated! Everyone approaching Fisk turn LEFT and enter a hold! If you are not at Ripon, do not come to Ripon! Enter a hold and come back with a half-mile separation!” We figured this was just a big push of traffic, and it would pass through soon. We were very wrong.

This video was taken by someone else who was in the air the same time as we were. You can hear the hecticness and see the planes that are too close for comfort.

Our approach took several minutes, and the controller hadn’t mentioned a hold in a while so we figured it was safe to go over Ripon and enter the lineup over the railroad tracks to Fisk. However, as soon as we got closer we realized just how many aircraft were trying to do the exact same thing. Dozens of planes could be seen in any direction at different speeds and altitudes, going every which way and being way too close for comfort. It was very reminiscent of a WWI dogfight. We maneuvered around a few such planes but ended up with a Kitfox on top of us, a Navajo flanking us on the right, and a couple small Cessnas flanking our left. Clearly this wasn’t going to work and we would be turned away if we even tried to approach Ripon.

We broke away from that disastrous group and entered a hold around the rather large Green Lake. After a few circles mixed with other traffic, it became clear they were not allowing people to enter Oshkosh any time soon. The controller continued to instruct planes to “turn left and enter a hold,” “restart the approach,” or “stay away from Ripon.” At one point he said “there are 300 of you between Ripon and Fisk, we cannot have that and we need better separation!” I’m not sure of the 300 figure was an exaggeration, but it certainly felt like it was accurate.

We stayed in a hold for a little over 2 hours before we decided to return to Fon du Lac and try again later. During this time several other aircraft began declaring low fuel emergencies and were granted permission to land. We monitored approach for several hours after we landed and it was the same story: people turned away right and left for airport oversaturation or improper compliance with the NOTAM.

We spent another night in Fon du Lac and got up at 5:30am Monday morning. Oshkosh officially opened for arrivals at 7:00am but we were not going to get there late and enter a hold. We departed Fon du Lac at 6:40 and went straight into Oshkosh. This was the arrival we were accustomed to. Peaceful, respectful, professional. We landed on the yellow dot and had an incredibly fun week. I hope that next year they seriously consider a way to handle the record-breaking traffic!

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Aviation Safety | Flying | Airports

Safety Management Systems (SMS) in Aviation

by Tori Williams 1. June 2018 21:37
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There is nothing more important in the aviation industry than safety. Every law, rule, or procedure has its roots in the general objective of increasing safety. Due to the fact that it is always being improved upon and innovated within, the United States’ national airspace system is one of the safest in the world. Today I would like to take a look at one of the newest pieces of regulation regarding safety in aviation, Safety Management Systems (SMS).

Historically, the process for improving safety was purely reactionary. Authorities would wait for an accident, investigate the accident to identify the cause, and then make changes to avoid the same accident in the future. This is ineffective, as it can solve one or two problems at a time but not address the less obvious contributing factors to the accident. Of course, accidents will continue to be investigated and learned from, but there is a new system that takes a more preventative approach.

Safety Management Systems (SMS) is a core concept in the aviation industry and recognized by both FAA and ICAO. This structured and business-like approach to managing and improving safety in all facets of the aviation industry has been explained by the FAA in a series of Advisory Circulars.

Is a SMS mandatory for all aviation operations? Not quite. For example, SMS for all part 139 certificated airports was proposed in the Notice of Proposed Rule Making (NPRM) in October 2010, however, in 2016 the FAA issued a Supplemental Notice of Proposed Rulemaking (SNPRM) which reduced the number of airports that needed an SMS to 265 airports that are certified under Part 139; airports that must have an SMS program include the following:

- classified as a small, medium, or large hub airport in the National Plan of Integrated Airport Systems;

- identified by the U.S. Customs and Border Protection as a port of entry, designated international airport, landing rights airport, or user fee airport; or

- identified as having more than 100,000 total annual operations.

This requirement maximizes safety benefits in the least burdensome manner and is consistent with international standards. Airports that are not required to have an SMS may still use FAA resources and implement selected practices to ensure safety at their airport. A full SMS plan may take months to create, and in some cases require assistance from an outside consulting firm.

The Four Components of SMS

Safety Management Systems has been divided into four distinct components; Safety Policy, Safety Risk Management, Safety Assurance, and Safety Promotion. Each has their own influence on SMS, and they come together to form a complete SMS program. Here is a brief description of each component.

Safety Policy: This is management’s commitment to safety, formally expressed in a statement of the organization's safety policy. A safety policy is written and agreed upon by top management and outlines the exact processes and plans the organization has to achieve desired safety outcomes. This should be the beginning of a positive safety culture that encourages employees to take ownership over their organization’s safety and to ensure they can report safety issues without fear of being reprimanded.

Safety Risk Management (SRM): This component looks at the present and future hazards and risks that the organization faces, then determines if there is an adequate risk control in place to mitigate them. This step often includes a Risk Matrix, or a grid analyzing the likeliness and severity of all possible risk scenarios. This component of SMS is vital for continually analyzing the effectiveness of current risk mitigation methods.

Safety Assurance: Safety Assurance is characterized by self-auditing, external auditing, and safety oversight. This component ensures that the steps taken in safety policy and safety risk management are helping the organization reach their desired safety outcomes. Proper resource allocation and data collecting are vital for this component, as it relies partially on historical information.

Safety Promotion: The human element is at the core of SMS. Having properly trained employees who are passionate about safety will help any organization reach their safety objectives. This component of SMS is all about having a Safety Manager who provides information and training for safety issues relevant to the specific jobs at the airport.

I hope that this brief overview of Safety Management Systems has taught you something new about an effective safety program. The great thing about SMS is that it can be applied to any industry, scenario, and operation. The FAA mandating SMS for certain sectors of aviation is a great move that I believe will eliminate quite a few accidents in the future. What do you think of SMS? Let me know in the comments!

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Aviation Safety



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