FSD Jun95

F L I G H T S A F E T Y F O U N D A T I O N
JUNE 1995
FLIGHT SAFETY
D I G E S T
Comparing Accident Reports:

Looking Beyond Causes to
Identify Recurrent Factors
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FLIGHT SAFETY FOUNDATION
For Everyone Concerned
Flight Safety Digest
With the Safety of Flight Vol. 14 No. 5 June 1995
Officers/Staff
In This Issue
Stuart Matthews
Chairman, President and CEO
Board of Governors
Comparing Accident Reports:
Looking Beyond Causes to Identify
1
Robert Reed Gray, Esq.
General Counsel and Secretary
Recurrent Factors
Board of Governors Individual accident reports show what went
L.E.S. Tuck wrong on a particular occasion. But compar-
Treasurer ing reports can reveal recurrent factors that
Board of Governors
need attention. A review of several accident
ADMINISTRATIVE reports raises questions about crew fatigue,
the “hurry-up” syndrome and crew interaction.
Nancy Richards
Executive Secretary
FINANCIAL
Brigette Adkins
U.S. Commercial Aviation Fatal-accident
Rate Remains Lower Than Worldwide
8
Accountant Rate in 1994
TECHNICAL Long-term trends in Boeing study show higher
Robert H. Vandel fatal-accident rates in early years of service
Director of Technical Projects for new aircraft types.
Millicent J. Singh
Secretary
MEMBERSHIP
FAA Issues Guidance to Air Carriers
For First-aid Training Programs
13
J. Edward Peery
Director of Membership and Development A recently published book describes current
airline training methods, while considering the
Ahlam Wahdan
Administrative Assistant
influence of technology on future training
methods.
PUBLICATIONS
Roger Rozelle
Director of Publications
Girard Steichen
B-737 Descent with Engines at Idle in
Thunderstorm Results in Flameout
18
Assistant Director of Publications
Gust, wet runway result in runway excursion
Rick Darby by Saab turboprop.
Senior Editor
Karen K. Bostick
Production Coodinator
Kathryn Ramage Flight Safety Foundation (FSF) is an international membership
Librarian, Jerry Lederer Aviation Safety Library organization dedicated to the continuous improvement of flight safety.
Nonprofit and independent, FSF was launched in 1945 in response to
the aviation industry’s need for a neutral clearinghouse to disseminate
objective safety information, and for a credible and knowledgeable
Jerome Lederer body that would identify threats to safety, analyze the problems and
President/Emeritus recommend practical solutions to them. Since its beginning, the
Foundation has acted in the public interest to produce positive influence
on aviation safety. Today, the Foundation provides leadership to more
than 660 member organizations in 77 countries.
Comparing Accident Reports: Looking Beyond
Causes to Identify Recurrent Factors
Individual accident reports show what went wrong on a particular occasion.
But comparing reports can reveal recurrent factors that need attention.
A review of several accident reports raises questions about crew fatigue,
the “hurry-up” syndrome and crew interaction.
John A. Pope
Aviation Consultant
From May 1994 to January 1995, Flight Safety Foundation Safety Digest. Finally, some findings and recommendations
published nine issues of Accident Prevention. Each issue from a 1994 NTSB safety study of 37 flight crew–involved
contained a concise article, without editorial comment, about accidents1 are included because they are relevant to the
a U.S. National Transportation Safety Board (NTSB) accident recurrent factors that were identified in this article.
investigation final report on one specific aircraft accident. Read
thoughtfully as a group, eight of the issues presented an Accident Prevention Vol. 51, No. 7 (July 1994) concerns a Cessna
opportunity to determine if causal factors common to two or 402B, operated by Tropic Air, that crashed near San Pedro
more accidents suggested recurrent factors and — more Airport, Ambergris Cay, Belize, on April 1, 1991, while
important — to determine if actions could be taken to prevent maneuvering for another approach after a go-around that had
them from recurring. been caused by congestion on the airport ramp. The accident
report was prepared by the Belize civil aviation department and
Ascertaining the causal factors in any individual accident can stated that while “there is no evidence which permits the
suggest problems that need to be addressed. But studying investigation to determine with certainty the actual cause of the
causal factors that appear as common denominators in multiple accident, it is considered a reasonable deduction that the pilot
accidents helps us to advance one further step — namely, to was unfit for flight due to fatigue, [that] he stalled the aircraft
set priorities when formulating regulations and procedures to while flying a very low downwind with the landing gear down
enhance aviation safety. When themes emerge from the and [that] the aircraft was much too low to recover from the
background, we know better how to concentrate resources. stall.” Accident investigation authorities noted that in the 28 days
before the accident, the pilot had flown more than 41 hours
This article examines the accidents reported in those eight beyond the maximum duty time allowed by law, and had been
issues and the ways that they are similar to each other, to on duty more than 30 hours in the 2.5 days before the accident.
identify any recurrent factors. Moreover, accidents are also
discussed that involved similar factors and were reported in Accident Prevention Vol. 51, No. 10 (October 1994) discusses
earlier issues of Accident Prevention and in two issues of Flight the August 1993 crash of an American International Airways
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995 1

Douglas DC-8-61 freighter while on an approach to the U.S. day of flying and on the last leg when the crew anticipated
Naval Air Station, Guantanamo Bay, Cuba, during daylight in getting home. Further, the accident occurred late in the
visual meteorological conditions (VMC). afternoon when the human body normally reaches a
physiological low level of performance and alertness. The
The NTSB report said: “The probable causes of this accident Safety Board believes that the combined effects of cumulatively
were the impaired judgment, decision-making and flying limited sleep, a demanding day of flying and a time of day
abilities of the captain and flight crew due to the effects of associated with fatigue had an effect on crew performance.”
fatigue; the captain’s failure to properly assess the conditions
for landing and maintaining vigilant situational awareness of The three factors in the accident cited by the NTSB as evidence
the airplane while maneuvering onto final approach; his failure for fatigue — cumulative sleep loss, continuous hours of
to prevent the loss of airspeed and avoid a stall while in [a] wakefulness and time of day — cannot always be counteracted
steep bank turn; and his failure to execute immediate action to by the simple application of flight and duty time restrictions
recover from a stall.” or limitations.
The NTSB cited three background factors that are normally Methods for predicting or measuring fatigue — such as
examined during accident investigations for evidence of calculating hours flown, type of weather, day or night flights,
fatigue: cumulative sleep loss, continuous hours of wakefulness the number of instrument approaches, landings and takeoffs
and time of day. It went on to say, “The Safety Board’s within the hours flown, rest time vs. duty time, etc. — continue
examination of the flight and duty time revealed the captain to provoke discussion. All of these objective factors have a
had been awake for 23.5 hours at the time of the accident, the significant relation to fatigue, but we are less sure about the
first officer for 19 hours and the flight engineer for 21 hours. effects of other, more subjective, factors (such as pilot
The crew had been on duty about 18 hours and had flown psychology or physiology). How stress can affect a person’s
approximately nine hours at the time of the fatigue has always been very difficult to
accident. The accident occurred at 1656, at measure, because each person has a
the end of the afternoon physiological low
period. The crew members had been awake
“ … in this accident … different capacity to withstand stress.
for the preceding two nights and had the flight-crew members Further complicating fatigue assessment is
attempted to sleep during the day, further how a pilot spends rest time between
complicating their circadian sleep disorders. met all three of the scheduled flights, or between unscheduled
Therefore, the evidence in this accident “pop-up” flights. Flying for a U.S.-
shows that the flight-crew members met all
scientific criteria for certificated air carrier is usually performed
three of the scientific criteria for susceptibility to the according to a monthly schedule based on
susceptibility to the debilitating effects of flight-time and duty-time regulations that
fatigue.” debilitating effects of should allow sufficient rest time before the
next flight. What an airline, regulation or
In a DC-10 accident described on page 5,
fatigue.” flight schedule cannot dictate is how the
the NTSB report observed: “Finally, in light pilot spends his rest time. That time, of
of the captain’s improper control during the course, can be spent on any number of
landing roll, the relatively long duration of his overnight flight, nonrestful activities, even though the implied requirement is
and the fact that the captain’s sleep periods were disrupted in that a pilot should report for duty rested and physically fit.
the 48 hours prior to the accident, the Safety Board considered
the possibility that fatigue adversely affected his performance. One circumstance that is frequently overlooked is how a pilot’s
These factors and the captain’s age of 59 years led the Safety duty day may begin. Many pilots must commute some distance
Board to believe that the captain might have been fatigued to to an airport and it is common for a pilot to report one to two
some extent. Even though the circumstances surrounding the hours before departure to prepare for the flight. Assume that the
flight crew’s activities from April 12 through 14 could have first flight of the day is scheduled to depart at 0700 hours. If the
led to a deterioration of his judgment and piloting skills, there plan is to report 1.5 hours before takeoff time, that makes the
is no information available regarding the captain’s ability to reporting time for that flight 0530. Assume that the pilot needs
perform under either long-term or short-term fatigue. at least one hour for the commute to the airport. So, departing
Therefore, a finding that his performance on the accident flight the resting place should be at no later than 0430. That means
was the result of fatigue could not be supported, nor could it that the pilot should leave a wake-up call for 0330 (leaving time
be dismissed.” to shower, breakfast, etc.). The duty day will not officially start
until the pilot reports at the airport, but the pilot has already
In an Embraer accident described on page 7, NTSB begun to accumulate some degree of fatigue. How much high-
investigators found that “for the two nights before the accident, quality rest should the pilot have had to arrive physically fit and
the pilots averaged only about five to 5.5 hours of sleep per ready for the flight? At what point during the duty day does the
night. The accident occurred after a long and relatively difficult pilot reach the fatigue saturation point?
2 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

In all the four accidents previously discussed, the requirements operated by the FAA to inspect navigational facilities. The
of the flights placed the flight crews into situations that would be King Air had departed Winchester Regional Airport,
conducive to fatigue. Crews, although warned that flying when Winchester, Virginia, U.S., after inspecting the localizer
fatigued can degrade judgment and reaction time, are usually approach facility at that airport. In their haste to reach the next
unwilling to decline a mission. Not only would such a declaration destination before their workday expired, the flight departed
seem to undermine the self-confidence that is a necessary part of under visual flight rules (VFR) and attempted to obtain an
pilot psychology, but it might displease the pilot’s employers. instrument flight rules (IFR) clearance from air traffic control
(ATC) once airborne. The NTSB reported that, after contacting
This tendency to avoid recognizing fatigue must change — ATC, the crew was told to maintain VFR and to stand by
and for that to happen, both pilots and operations management because of controller workload. Eleven minutes later, the crew
must learn to look at the subject differently. Pilots should be was advised to change to a different frequency for an IFR
in touch with their own fatigue level. If they determine that clearance. Before the crew could acknowledge the frequency
their alertness is seriously compromised, they should refuse change, the airplane crashed into a ridge line about 15 miles
to fly, or turn control of the aircraft over to a crew member (if south of the airport. Instrument meteorological conditions
one is available) who is in better condition and better able to (IMC) prevailed at the time of the accident.
ensure a safe flight.
“The probable causes of this accident,” said the NTSB,
Management must remind itself every day that the majority of “were the failure of the pilot-in-command to ensure
accidents are caused by human factors, to which fatigue often that the airplane remained in visual meteorological
contributes. Insisting that pilots fly on schedules that are unduly conditions over mountainous terrain, and the
demanding physically and psychologically (resulting in subpar failure of the Federal Aviation Administration executives
performance), or refusing to recognize that pilots may and managers responsible for the FAA flying program to:
occasionally, through no fault of their own, (1) establish effective and accountable
be too fatigued to fly safely is short-sighted leadership and oversight of flying
and irresponsible management. Management must operations; (2) establish minimum
mission and operational performance
One variable considered in the remind itself every day standards; (3) recognize and address
comprehensive 1994 NTSB safety study performance-related problems among the
was crew-member time since awakening
that the majority of organization’s pilots; and (4) remove
(TSA). Flight crews that had been involved accidents are caused by from flight operations duty pilots who
in accidents were classified according to were not performing to standards.”
whether their TSA was above or was below human factors,
the median for their crew position. Some circumstances in this accident are
to which fatigue similar to a Beechjet (Be400) accident that
It was found that there were no significant often contributes. occurred in December 1991, near Rome,
differences between high-TSA crews and Georgia, U.S. (Accident Prevention, Vol.
low-TSA crews in what were classified as 49, No. 10, October 1992).
“errors of commission.” But high-TSA crews made an average
5.5 “errors of omission” vs. an average 2.0 errors for low- In the Beechjet accident, the company-owned aircraft was
TSA crews. “These results,” the report said, “suggest that the transporting corporate executives on a tour of a chain of
decrements in performance by high-TSA crews tended to be supermarkets and related stores. The trip was running slightly
in the form of ineffective decision making, such as ‘failed to behind schedule and, although the captain filed for an IFR
perform a missed approach,’ and procedural slips, such as ‘did departure, the aircraft departed Rome under VFR in marginal
not make altitude-awareness call-outs,’ rather than a VFR weather conditions. When the captain called ATC for an
deterioration of aircraft handling skill.”2 IFR clearance, Atlanta Air Route Traffic Control Center
(Atlanta Center) told the flight to maintain VFR because “we
In that safety study, the NTSB recommended that the FAA have traffic four and five right now southeast of Rome. We
“require air carriers to include, as part of pilot training, a program will have something for you later.” Some three minutes after
similar to the NASA [U.S. National Aeronautics and Space takeoff, the aircraft crashed near the 1,701-foot [519-meter]
Administration]-Ames Fatigue Countermeasures Program, to mean sea level (MSL) summit of Mt. Lavender, about six miles
educate pilots about the detrimental effects of fatigue, and west of the Rome Airport.
strategies for avoiding fatigue and countering its effects.”3
The first similarity is that the King Air and the Beechjet
“Hurry-up Syndrome” a Frequent Killer captains were attempting to save time by departing VFR in
marginal weather conditions, intending to pick up an IFR
Accident Prevention Vol. 51, No. 8 (August 1994) described clearance after becoming airborne. In both instances, the
the October 1993 crash of a Beechcraft Super King Air 300/F, aircraft crashed before the IFR clearance could be obtained.

In these demonstrations of the “hurry-up syndrome,” minutes After noting that the PIC had performed a “below–glide path
may have been saved but all lives were lost. check” in IMC when VMC conditions were required, the NTSB
report added: “Following this (below–glide path) incident, the
In commercial and corporate aviation, the hurry-up syndrome SIC formally complained to the flight operations/scheduling
usually appears when a flight has been delayed and the flight [section] supervisor for management resolution of this matter;
crew feels pressured to make up for lost time. The NTSB safety however, no action was taken.”
study looked for correlations between flight-delay status and
accidents. Of the 31 accident flights in the study for which In the Beechjet accident, the NTSB report noted, “[the captain]
schedule information was available, 17 (55 percent) were had mentioned to a close acquaintance that he believed that
delayed. Of those 17 delayed accident flights, seven (41 the first officer occasionally paid unnecessary attention to
percent) involved weather as a causal or contributing factor to checklists.” The captain reportedly said that he did not believe
the accident; thus, a majority (59 percent) of the delayed flights that it was necessary to read the airplane checklist verbatim
did not involve weather as a factor in the accident. “because he had considerable experience in the airplane.”
Data from the accident flights were compared with a sample The NTSB report noted that several pilots who had flown with
of on-time performance statistics for nonaccident flights the captain had observed him performing what they considered
during each December, 1987 through 1992, which were questionable practices. The NTSB report said, “One pilot noted
compiled by the U.S. Department of Transportation (DOT). that the captain did not conduct departure briefings and, on
“Compared to the sample of nonaccident flights,” the report occasion, would fly through or very close to thunderstorms.
said, “a larger proportion (55 percent) of accident flights were
The captain was also observed to fly below decision height
running late. This held true whether considering nonaccident without having the runway or its associated lights or markings
flights that departed late” (between 17 in sight.” A pilot who had flown as first
percent and 28 percent of the flights) “or officer with the captain believed that the
arrived late” (between 21 percent and 35 … the first officer … captain “did not have a complete
percent). understanding of U.S. Federal Aviation
had complained to … Regulations (FARs). He saw the captain
“Flight delays can be a source of perceived
time pressure for flight crews,” the NTSB
the company “that the cancel his IFR flight clearance and descend
through clouds to locate an airport and, on
safety study said. “The Safety Board notes captain was operating another occasion, he saw the captain
that the difference in flight delay status descend below decision height before
between the 31 accident flights for which the airplane in violation identifying the runway.”
data were available and the nonaccident
sample is not inconsistent with anecdotal
of FARs and in NTSB investigators were told that the first
evidence of a relationship between time disregard of good officer on the Beechcraft accident flight had
pressure and flight-crew errors in the air complained to an executive of the company
carrier environment.”4 operating practices.” “that the captain was operating the airplane
in violation of FARs and in disregard of
Another similarity exists in the attitudes of good operating practices.” When questioned
the captains and their relationships with their first officers or by the NTSB, the executive denied receiving complaints from
second-in-command pilots. the first officer.
The NTSB report on the King Air accident said: “The The captains in the King Air and Beechcraft accidents seem
[captain’s] supervisor … stated that there were significant to have had much in common. Both tended to disregard FARs
objections to his selection for the PIC [pilot-in-command] and good operating practices, and believed that departing under
position. Several of the SICs [second-in-command pilots] VFR in marginal weather conditions on the assumption that
expressed a desire not to fly with him at that time.” ATC would issue an IFR clearance without delay would not
only save time but would be acceptably safe.
The NTSB report continued: “During interviews at the Atlantic
City FIAO [Flight Inspection Area Office], Safety Board Both captains were flying with first officers who disapproved
investigators were told by flight crewmembers that the PIC of their respective captains’ operating practices, and whose
involved in the accident had demonstrated poor judgment on complaints about the captains to management had been
previous flights. It was alleged that he had: continued on a disregarded or denied. That raises the question as to what action
VFR positioning flight into IMC; conducted VFR flight below would be appropriate for a first officer/SIC who finds the safety
clouds at less than 1,000 feet [305 meters] above the ground of his or her flight being compromised by a captain who has
in marginal weather conditions; replied to an ATC query that little regard for or knowledge of the FARs, or has contempt
the flight was in VMC when it was in IMC; [and] disregarded for checklists. Whether it be a government operation, such as
checklist discipline on numerous occasions.” the FAA flight, or a corporate business aircraft operation, how

should management treat a complaint? In the interest of got a plus ten, sinking a thousand.” Thirteen seconds later, the
personal safety, is the first officer’s/SIC’s best option a quietly automated cockpit voice called out “50” (feet [15.2 meters]),
submitted resignation and, if that course is followed, what and the first officer said, “I’m gonna go around.” The captain
repercussions might be anticipated? stated, “No, no, no, I got it.” The first officer responded, “You
got the airplane.” According to the NTSB report, the captain
took control and landed the airplane. The DC-10 touched down
Captain Takes Control Suddenly 4,303 feet (1,312 meters) beyond the runway threshold,
paralleled the runway centerline for approximately 1,700 feet
Accident Prevention, Vol. 51, No. 5 (May 1994) describes (518 meters), then turned gradually to the right until it went
an American Airlines flight from Honolulu, Hawaii, U.S., to off the runway, coming to rest upright about 2,607 feet (795
Dallas/Fort Worth, Texas (DFW), that departed the right side of meters) from the departure end and 250 feet (76 meters) from
Runway 17L following landing on April 14, 1993. There were the right edge of the runway.
injuries to passengers and crew members during the evacuation.
Damage to the airplane was estimated at US$35 million and The NTSB report said, “The first officer said that after the
because of the repair costs, the hull was considered destroyed. captain took control of the airplane, the airplane seemed to
‘float,’ and that he was not sure where the touchdown was
The NTSB determined that the probable cause of the accident made. The CVR [cockpit voice recorder] data showed that the
was “the failure of the captain to use proper directional control first officer made call-outs expected of the nonflying pilot.
techniques to maintain the airplane on the runway.” After the landing, he did not hold forward pressure on the
control yoke after the nosewheel touchdown. He said it was
Weather was of serious concern as the DC-10 made its not normal procedure to do so unless he was previously briefed.
approach to DFW. After being handed off When asked his opinion regarding the
from the ARTCC to DFW approach control, captain continuing the approach to landing
the flight engineer briefed the captain on “ … prior to the after the first officer judged the need to
the current automatic terminal information initiate a missed approach, the first officer
service (ATIS) as follows: “Echo, 1,400 feet beginning of the replied, “I’ve got to trust him.’”
[427 meters], overcast, 2.5 miles [four
kilometers] visibility, winds 220 at six, airplane’s approach to NTSB investigators found that “prior to the
altimeter 29.49 inches (998 millibars), DFW, no briefings on beginning of the airplane’s approach to
lightning cloud-to-cloud, cloud-to-ground, DFW, no briefings on approach, landing or
thunderstorms moving northeast and approach, landing or go-around procedures, emergency or
pressure falling rapidly.”
go-around procedures, otherwise, were conducted. Without an
approach briefing, the flight crew must fall
The NTSB report said that the first officer emergency or otherwise, back upon standardized operational
was flying the airplane but did not state training.”
whether this was because it was a monitored were conducted.”
approach (in which the first officer is the The NTSB report went into considerable
pilot flying and the captain monitors the detail about the airline’s operational
instruments until the runway environment is in sight, at which procedures and operating techniques.
point the captain takes control and lands the airplane) or
whether it was, as part of a normal routine, the first officer’s The NTSB report concluded that the captain was “well within
leg to fly to a full-stop landing. his authority to take the airplane from the first officer after
the first officer had announced, without prior warning, that
After the DC-10 was cleared for the approach, “the first he was going around. The fact that the captain was able to
officer,” said the NTSB report, “requested that the captain and land the airplane on centerline provides evidence that he was
flight engineer be alert for any indication of wind shear. The in control of the airplane through the touchdown. No clear
captain encouraged him to carry 10 to 15 knots of extra airspeed evidence exists that there was any fault in the captain’s
and the first officer assured him that he would do so.” About decision-making throughout the initiation or continuation of
three minutes later, “the captain reported a 10- to 15-knot gain the approach to [Runway] 17L, or in his decision to take
in airspeed … .” control of the airplane from the first officer and land on the
intended runway. The departure from the runway resulted
The DFW tower controller cleared the flight to land and from the captain’s failure to maintain directional control of
informed the flight crew that winds were calm. The airplane the airplane after touchdown rather than from events or
was in a 10-degree right crab to compensate for a right decisions made prior to touchdown.”
crosswind. The flight engineer reported descending through
500 feet [152.5 meters] and the captain reported the runway The question of who should be flying the aircraft in weather-
lights in sight. About 30 seconds later, the captain said, “I’ve induced or other marginal safety conditions was discussed by

the author in Flight Safety Digest, Vol. 7, No. 8 (August 1988). nonsupervised takeoff in line operational status in conditions
Four accidents (a Boeing 737 in January 1982, at National that included darkness, low ceiling and a wet runway that was
Airport, Washington, D.C., U.S.; a Boeing 727 in July 1982, at also relatively short with no appreciable overrun, with water
New Orleans, Louisiana, U.S.; a Lockheed Martin L-1011 in at its end. These factors, the NTSB said, should have
August 1985, at DFW; and a McDonnell Douglas DC-9 in categorized the takeoff as nonroutine and should have prompted
November 1987, at Denver, Colorado, U.S.) have occurred in the captain to review emergency procedures.
marginal weather when the first officer was the pilot flying.
Since that publication, two additional accidents that have Good airmanship, the NTSB added, should have dictated such
occurred in which the first officer was the pilot flying are notable. a discussion and the captain might even have made the takeoff
himself.
Flight Safety Digest, Vol. 10, No. 2 (February 1991) describes
an accident that occurred on Sept. 20, 1989. A USAir Boeing Accident Prevention, Vol. 50, No. 8 (August 1993) describes a
737-400 was taking off in IMC from LaGuardia Airport, New July 30, 1992, accident. The first officer was making a takeoff
York, New York, U.S., with the first officer flying. As the takeofffrom John F. Kennedy International Airport, New York, New
began, the airplane drifted to the left because of a mis-trimmed York, U.S., in a fully loaded (within 1,300 pounds [590
rudder. Later in the takeoff run, the flight crew heard a “bang” kilograms] of the maximum allowable takeoff weight) TWA
and a rumbling noise, which the NTSB report said probably [Trans World Airlines] Lockheed Martin L-1011 during
resulted from the captain’s continuing attempt to steer the daylight VMC. Barely one second after rotation, the first officer
aircraft during takeoff using the nosewheel tiller. The “bang” decided that the aircraft was not going to fly and told the
was probably caused by the left nosewheel tire suddenly captain, “You got it.” The captain, faced with a split-second
coming off the rim, allowing air to escape violently. The captain decision, chose to reject the takeoff. The flight data recorder
then took over control from the first officer and rejected the (FDR) showed that the airplane was airborne for about six
takeoff but was unable to prevent an overrun. There were seconds. The aircraft touched back down on the runway but
fatalities and injuries and the aircraft was destroyed. Among the left main landing gear departed the left side about 11,350
the 18 NTSB conclusions, as numbered in feet (3,462 meters) from the runway
the report, were: threshold and the right main landing gear
… only seconds were departed the left side of the runway about
“6. Both pilots were relatively 13,250 feet (4,041 meters) from the
inexperienced in their respective positions. allowed for the captain threshold.
The captain had about 140 hours as a
Boeing 737 captain. The first officer was
to make the decision to The NTSB determined that the probable
conducting his first nonsupervised line take control of the causes of this accident were “design
takeoff in a Boeing 737 and his first takeoff deficiencies in the stall warning system that
after a 39-day nonflying period. airplane. permitted a defect to go undetected, the
failure of TWA’s maintenance program to
[“In the 29 accidents for which data were correct a repetitive malfunction of the stall
available,” the 1994 NTSB safety study reported, “the median warning system, and inadequate crew coordination between
number of flight hours accumulated by first officers in the the captain and first officer that resulted in their inappropriate
accident-involved crew position and aircraft type, while response to a false stall warning.”
employed by the air carrier, was 419 hours. In the 32 accidents
for which data were available, 53 percent of the first officers Although the LaGuardia and Kennedy accidents occurred during
were in their initial year as a first officer for that air carrier.”5] takeoff, both aircraft were being flown by the first officer and a
situation resulted whereby only seconds were allowed for the
“9. Because of poor communication between the pilots, both captain to make the decision to take control of the airplane.
attempted to maintain directional control initially and neither
was fully is control later in the takeoff, compounding In the DC-10 approach-and-landing accident at DFW, the captain
directional control difficulties.” also had to make a rapid decision to accept the first officer’s
decision or to take control of the airplane and continue the
“10. Neither pilot was monitoring indicated airspeed and no landing. The NTSB report indicated that it was at about 0659:13
standard airspeed callouts occurred.” that the first officer said, “I’m gonna go around.” After the captain
took control of the landing, “a sound of a thump, similar to
The NTSB also concluded that the captain’s briefing on aircraft touchdown was recorded at 0659:29 on the CVR. The
departure and emergency procedures was not adequate for the second thump was recorded at about two seconds later.”
circumstances of this takeoff. At LaGuardia, the NTSB said,
the captain should have been even more aware that the first The timing would indicate that the captain had about 13
officer needed a discussion of emergency procedures, such as seconds from the time he took control until the aircraft
rejected takeoffs. This was to be the first officer’s first touched down. In view of previous accidents where shifting

control from the pilot flying to the pilot not flying is reduced inappropriate actions to recover from the loss of control. Also
to a matter of seconds, was 13 seconds sufficient for the contributing to the accident was fatigue induced by the flight
captain to make a decision to take control of the airplane and crew’s failure to properly manage provided rest periods.”
transition from a monitoring role to flying the airplane to a
touchdown? Accident Prevention, Vol. 51, No. 1 (January 1995) describes
the crash of a British Aerospace Jetstream J-4101, operated
Weather factors may have categorized the DC-10 approach as by Atlantic Coast Airlines Inc. (ACA), at Columbus, Ohio,
nonroutine and that, coupled with the first officer’s relatively U.S., Jan. 7, 1994.
low time (4,454 flight hours of which 376 were as a first officer
in the DC-10), prompts a reconsideration of the NTSB’s The NTSB said that the probable causes of the accident
statement in the Boeing 737 accident — “Good airmanship were:
should have dictated such a discussion [a review of emergency
procedures] and the captain might even have made the takeoff “(1) An aerodynamic stall that occurred when the flight crew
himself.” Substituting “landing” for “takeoff” shows the allowed the airspeed to decay to stall speed following a very
similarity. poorly planned and executed approach characterized by an
absence of procedural discipline;
As in the DC-10 accident, the NTSB raised training,
procedural, technical and record-keeping issues in the L-1011 “(2) Improper pilot response to the stall warning, including
and B-737 accidents. failure to advance the power levers to maximum, and
inappropriately raising the flaps;
Accident Prevention, Vol. 51, No. 9 (September 1994) describes
the crash of a British Aerospace Jetstream “(3) Flight crew inexperience in glass-
BA-3100, operated by Express II Airlines cockpit automated aircraft, aircraft type and
Inc., at Hibbing, Minnesota, U.S., on Dec. A pattern emerges of a in seat position, a situation exacerbated by
1, 1993. a side letter of agreement between the
common problem with company and its pilots;
The NTSB report said, “The probable
causes of this accident were the captain’s
crew discipline and “(4) The company’s failure to provide
actions that led to a breakdown in crew coordination, and a lack adequate established approach criteria, and
coordination and the loss of altitude the FAA’s failure to require such criteria;
awareness by the flight crew during an of crew resource
unstabilized approach in night instrument “(5) The company’s failure to provide
meteorological conditions. Contributing to
management (CRM) adequate crew resource management
the accident were: the failure of the training by the training, and the FAA’s failure to require
company management to adequately such training; and,
address the previously identified commuter operators.
deficiencies in airmanship and crew “(6) The unavailability of suitable training
resource management of the captain; the simulators that precluded fully effective
failure of the company to identify and correct a widespread, flight-crew training.”
unapproved practice during instrument approach procedures;
and the Federal Aviation Administration’s inadequate These last three accidents were in commuter air carrier
surveillance and oversight of the air carrier.” operations. There are recurrent factors among these (and
several other) accidents, indicative of a pattern.
Accident Prevention, Vol. 51, No. 11 (November 1994)
describes the in-flight loss of control and subsequent forced Such descriptions as “failure to maintain professional cockpit
landing of an Embraer EMB-120 RT Brasilia, operated by discipline,” “poor crew discipline, including flight crew
Continental Express Inc., at Pine Bluff, Arkansas, U.S., on coordination,” “flight crew’s inappropriate actions,” “breakdown
April 29, 1993. in crew coordination,” “failure of the company management to
adequately address the previously identified deficiencies in
The NTSB said that “the probable causes of this accident airmanship and crew resource management of the captain” and
were the captain’s failure to maintain professional cockpit “the company’s failure to provide adequate crew resource
discipline, his consequent inattention to flight instruments management training” are causal factors cited in the three NTSB
and ice accretion, and his selection of an improper autoflight accident reports involving commuters. It appears that the causal
vertical mode, all of which led to an aerodynamic stall, loss factors in those accidents are nearly interchangeable. A pattern
of control and a forced landing. Factors contributing to the emerges of a common problem with crew discipline and
accident were poor crew discipline, including flight crew coordination, and a lack of crew resource management (CRM)
coordination before the stall and the flight crew’s training by the commuter operators.

In the Columbus Jetstream accident, the NTSB report noted: procedures. If a pilot in training has difficulty mastering aircraft
“The events of this accident reflect a total breakdown in crew procedures, that pilot should not be approved for flight
coordination, an essential element of conducting successful operations until proficiency is clearly demonstrated.
instrument approaches. CRM training is not currently required
under [FARs Part] 135; nonetheless ACA did include a one- The fundamental goal for any aviation operation should be
hour class during its J-4101 ground school that included “zero accidents.” Management must establish from the top
previous accidents/incidents, human factor considerations and down a safety culture that recognizes the threats posed by such
the NASA [Aviation Safety Reporting System]. The training factors as those discussed in this article. Management must
did not provide for interaction of the crewmembers or feedback employ qualified personnel who are properly trained to
and continued reinforcement regarding their performance, as maintain and operate properly equipped aircraft. Moreover,
described in [FAA] Advisory Circular (AC) 120-51A, Crew every employee must have the explicit support of management
Resource Management Training.” [AC 120-51A provides at every level to do his or her best to ensure the safety of every
nonregulatory guidance to air carriers regarding the content flight. Anything less sets the stage for an accident.♦
of CRM programs.] To reverse the pattern, one action would
be for Part 135 carriers to institute CRM training. References
[The NTSB safety study identified monitoring/challenging 1. U.S. National Transportation Board (NTSB). Safety Study:
failures in 31 of the 37 accidents studied. “A pattern common A Review of Flightcrew-Involved, Major Accidents of U.S.
to 17 of the 37 accidents,” the study said, “was a tactical Air Carriers, 1978 through 1990. Report No. NTSB/SS-
decision error by the captain (with more than half constituting 94/01. January 1994. Reprinted in Flight Safety Digest
a failure to initiate required action), followed by the first Volume 12 (4) (April 1994).
officer’s failure to challenge the captain’s decision.”
2. Ibid., p. 68.
[The NTSB safety study also said: “The Safety Board is
concerned about the high incidence, in the accident flights, 3. Ibid., p. 73.
of first officer failures to challenge decision errors made by
the captain/flying pilots. The high incidence highlights a need 4. Ibid., p. 20.
for air carrier training programs to devote additional attention
to the monitoring/challenging function of crew members.”6] 5. Ibid., p. 76.
Coupling the lack of crew discipline, coordination and CRM 6. Ibid., p. 75, p. 60.
training with any other poorly judged action — unapproved
practice during instrument approaches, selection of improper About the Author
autoflight vertical mode, flight crew’s inappropriate actions
from loss of control or improper response to a stall warning John A. Pope established John A. Pope & Associates, an
— would almost guarantee the path to an accident. aviation consulting firm located in Arlington, Virginia, U.S.,
after retiring in 1984 as vice president of the U.S. National
There is no excuse for a crew’s use of an unapproved procedure, Business Aircraft Association. He has assisted more than 60
no matter how much that unapproved procedure may appear corporations in developing their operations manuals. He has
to benefit a flight. Those responsible for monitoring crew also conducted more than 20 workshops dedicated to
performance must ensure that crews routinely use approved developing corporate aviation operations manuals.
procedures.
He served as a command pilot in the U.S. Air Force and the
Increased procedural training, preferably in simulators, should Air National Guard. He retired as a colonel from the U.S. Air
aid in preventing accidents caused by incorrectly performed Force Reserve after 33 years of service.

Aviation Statistics
U.S. Commercial Aviation Fatal-accident Rate

Remains Lower Than Worldwide Rate in 1994
Long-term trends in Boeing study show higher fatal-accident rates
in early years of service for new aircraft types.
Editorial Staff
The worldwide fatal-accident rate for commercial jet aircraft was dramatic, but the rate has continued on a plateau —
in 1994 remained within a range that has varied little since the although at a relatively low rate — since the late 1970s.
mid-1970s, according to statistics released by Boeing. 1
Although the fatal-accident rate for U.S. carriers continued to The lower graph in Figure 1 shows the annual numbers of on-
be lower than the fatal-accident rate for non-U.S. carriers, the board fatalities in commercial jet aviation, starting in 1959.
gap narrowed slightly, with an increase in the rate for U.S.
operators and a decrease in the rate for non-U.S. operators. The influence of changes in aircraft types in the worldwide jet
fleet is apparent in Figure 2 (page 11). Airplanes have been
Boeing’s statistics, which covered the years 1959 through 1994, categorized into three groups: “second generation” jet
showed a steep reduction in the overall commercial jet fatal- transports that began to be incorporated into fleets in the early
accident rate since the beginning of the period. Nevertheless, 1960s; the first generation of widebody transports, which
there were clearly defined “spikes” in the fatal-accident rates entered service beginning in the late 1960s; and more recent
for statistical groupings of new types of aircraft in the years types, introduced in the 1980s and 1990s. In each group, the
following their introduction to fleets. accident rate peaks in the early years of introduction to service.
The study defined fatal accidents as those “with on-board Figure 3 (page 12) compares fatal-accident rates for U.S. and
[fatalities] or those where persons other than aircraft occupants non-U.S. operators. A long-term pattern is visible in which the
are fatally injured,” but counted as fatalities only aircraft rate for non-U.S. operators exceeds that of U.S. operators,
occupants. Fatal accidents involving turboprop aircraft were although generally only to a small degree. But the trend lines
excluded from the study. The statistics also ignored accidents for U.S. and non-U.S. carriers parallel one another fairly closely,
stemming from sabotage, hijacking, suicide, military action or especially in the early years of commercial jets.♦
test flying.
Reference
Figure 1 (page 10) shows the overall fatal-accident rate graphed
for the 1959–1994 period according to rates per million 1. Boeing Commercial Airplane Group. Statistical Summary
departures and numbers of fatalities. The decline in the fatal- of Commercial Jet Aircraft Accidents: Worldwide
accident rate during the first decade of commercial jet operation Operations, 1959–1994. March 1995.

10
Worldwide Commercial Jet Fleet Fatal Accidents
20
Excludes
• Sabotage
• Military action
• Suicide
Accidents • Test flying
per million 10
departures
0
15
Fatalities 10 On-board fatalities only

in hundreds
0
60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94
Year
Source: Boeing Commercial Airplane Group
Figure 1
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

Worldwide Commercial Jet Fleet Fatal Accidents, by Generic Group
20
Excludes: Second Wide body New
• Sabotage generation (early) types
• Military action
• Suicide 727 747-100/200/300 MD80
• Test flying Trident DC-10 MD11
VC-10 L-1011 737-300/400/500
15
BAC 111 A300 747-400
DC-9 757
737-100/200 767
F28 A310
Accidents A320/A321
A330
per million
A340
departures 10 BAe146
New Types F100
Second Generation Wide Body (early)

5
0
60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94
Year
Figure 2
11
12
Worldwide Commercial Jet Fleet Fatal Accidents, U.S. and Non-U.S.
30
Excludes:
• Sabotage
• Military action
• Suicide
• Test flying
20
Accidents
per million
departures Non-U.S.
operators
10
U.S.
operators
0
60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94
Year
Figure 3

Publications Received at FSF
Jerry Lederer Aviation Safety Library
FAA Issues Guidance to Air Carriers

For First-aid Training Programs
A recently published book describes current airline training methods,
while considering the influence of technology on future training methods.
Editorial Staff
Advisory Circulars (ACs) controls.” The AC recommends that a visual check be made
during this exchange.
Air Carrier First Aid Program. U.S. Federal Aviation
Announcement of Availability: FAA-S-8081-11, Flight
Administration (FAA) Advisory Circular (AC) No. 120-44A.
Instructor — Lighter-Than-Air (Balloon-Airship) Practical
March 1995. 7 p.; appendix.
Test Standards. U.S. Federal Aviation Administration (FAA)
Advisory Circular (AC) No. 61-116. March 1995. 2 p.
This AC guides air carriers about resources, topics, equipment
and regulations for first-aid training programs. According to
This AC announces the availability of FAA-S-8081-11,
the AC, air carrier crew-member first-aid training programs
practical test standards for the certification of flight instructors
should include first-aid and emergency medical equipment;
for lighter-than-air aircraft (e.g., balloons and airships).
use of emergency and first-aid oxygen; handling of illness and
Instructions for ordering FAA-S-8081-11, pricing and a
injury (including information about protection of crew
Superintendent of Documents publications order form are
members from blood-borne pathogens); assistance from people
included with this announcement.
on board and on the ground; and medical emergency landings.
The appendix discusses blood-borne pathogens.
Positive Exchange of Flight Controls Program. U.S. Federal Reports

Aviation Administration (FAA). Advisory Circular (AC) No.
61-115. March 1995. 2 p. Air Traffic Control: Status of FAA’s Plans to Close and
Contract Out Low-activity Towers. U.S. General Accounting
This AC guides all pilots on the recommended procedure for Office. Report No. GAO/RCED-94-265. September 1994.
pilots’ exchange of flight controls while flying. The AC is 25 p.; appendices. Available through GAO.**
geared to student pilots, flight instructors and pilot examiners.
The AC recommends a three-step process in the exchange of Between fiscal year (FY) 1994 and FY 1997, the U.S. Federal
flight controls between pilots and a preflight briefing that Aviation Administration (FAA) plans to close level 1 (low-
includes the procedure. When the instructor wants the student activity) air traffic control towers that do not meet the FAA’s
to take the controls, he or she says, “You have the flight benefit-cost criteria. The FAA will contract the operations of
controls.” The student takes the controls and acknowledges, all remaining level 1 towers and relocate controllers from the
“I have the flight controls.” The instructor repeats, “You have closed towers to other FAA facilities. This report, to the U.S.
the flight controls.” The same procedure is followed when the House of Representatives Committee on Appropriations,
student returns the controls to the instructor, and the student Subcommittee on Transportation and Related Agencies,
stays on the controls until the instructor says, “I have the flight provides the U.S. General Accounting Office’s (GAO’s)

assessment of the plan and its potential savings (a tower that Validation of the Federal Aviation Administration Air Traffic
is contracted out or closed does not receive federal funding, Control Specialist Pre-Training Screen. Broach, Dana; Brecht-
according to the report); identifies possible obstacles to the Clark, Jan. Report No. DOT/FAA/AM-94/4. February 1994.
FAA’s plan; and identifies ways for the FAA to enhance its 16 p.; illustrations; graphs; bibliographical references.
reassignment strategy for controllers. Available through NTIS.*
International Aviation: Airline Alliances Produce Benefits, But Keywords:

Effect on Competition Is Uncertain. U.S. General Accounting 1. Air Traffic Control Specialist
Office (GAO). Report No. GAO/RCED-95-99. 68 p.; 2. Selection
illustrations; appendices. April 1995. Available through 3. Validation
GAO.** 4. Tests
5. Ability
This report examines the effects that marketing alliances 6. Job Analysis
between U.S. and non-U.S. air carriers have on consumers, 7. Computer Administered Test
traffic flows and revenues, and it identifies issues surrounding
such alliances that need to be addressed by the U.S. Department Two formal validation studies of the Air Traffic Control
of Transportation (DOT). Specialist Pre-Training Screen (ATCS/PTS), a five-day
computer-administered test battery, are described. The ATCS/
The report says that there are not enough data to determine what PTS was designed to replace the nine-week U.S. Federal
effect the alliances have had on fares and whether alliances will Aviation Administration (FAA) Academy ATCS Nonradar
reduce or increase competition in the long term. Nevertheless, Screen program that served as the second major test in the
it says that consumers are benefiting from conveniences allowed ATCS selection system. Review of ATCS job analyses
by the alliances, such as shorter layovers . suggested that predictor tests such as the ATCS/PTS should
assess cognitive constructs such as spatial reasoning and short-
The report says that the DOT has not required U.S. and term memory, and require dynamic, concurrent performance.
non-U.S. airlines to report data sufficient to fully monitor the These studies validated the ATCS/PTS as a predictor.
effects of alliances on competition and the international
competitiveness of U.S. airlines. Also, the DOT has not decided The ATCS/PTS was implemented for actual employment
whether antitrust immunity should be available for other decision making in June 1992. The U.S. controller selection
alliances in markets that allow for significantly increased access system since that time has consisted of the four-hour written
for U.S. airlines. According to the report, the DOT does not ATCS aptitude test battery followed, for applicants earning a
have rules that limit how often a flight can be listed in computer qualifying score and depending on agency manpower
reservation systems; multiple listings of the same flight can requirements, by second-level screening on the ATCS/PTS.
give airlines in an alliance a competitive advantage. Additional research requirements as part of an aviation human-
factors research program are also described.
Aircraft Accident Report: Stall and Loss of Control of Final
Approach, Atlantic Coast Airlines Inc./United Express Flight Denver International Airport. Gryszkowiec, Michael.
6291, Jetstream 4101, N304UE, Columbus, Ohio, January 7, Testimony before the Subcommittee on Aviation, Committee
1994. U.S. National Transportation Safety Board (NTSB). on Transportation and Infrastructure, U. S. House of
Report No. NTSB/AAR-94/07. October 1994. 128 p.; Representatives. Report No. GAO/T-AIMD-95-184. May 11,
appendices. Available through NTIS.* 1995. 17 p.; appendices. Available through GAO.**
This report is the official explanation of the crash of a Jetstream Michael Gryszkowiec, director, Planning and Reporting,
4101 about 1.4 miles (2.25 kilometers) east of Runway 28L at Resources, Community and Economic Development Division,
Port Columbus International Airport, Columbus, Ohio, U.S. U.S. General Accounting Office (GAO) testified before the
The aircraft was operated by Atlantic Coast Airlines, Sterling, U.S. House of Representatives on the current state of Denver
Virginia, U.S., and doing business as United Express Flight International Airport (DIA), addressing in particular three
6291. The NTSB determined that the factors contributing to previously discussed issues: DIA’s development; the automated
or causing the accident were: an aerodynamic stall; improper baggage handling system; and airfield construction.
pilot response to the stall warning; flight crew inexperience in Gryszkowiec pointed out that, in spite of repeated delays in
a “glass-cockpit” aircraft; the failure of the company to provide DIA’s opening date and various construction problems, the
adequate stabilized approach criteria (and the U.S. Federal airport was designed and built in just over five years. The
Aviation Administration’s [FAA’s] failure to require it); testimony concluded with several suggestions as to how future
company failure to provide adequate crew resource airport construction projects can avoid similar difficulties,
management (CRM) training and the FAA’s failure to require including minimalizing changes in design, providing alternate
such training; and the unavailability of suitable training or backup systems for new and untested technology, and
simulators, which precluded effective flight crew training. implementing a vigorous quality control program.

Appendix I provides a graphic, time-line representation of an experiment to determine the effect of an Intelligent Help
DIA’s development. Appendix II is a time-line representation Agent on computer-based training effectiveness are described
of the automated baggage system’s history. Appendix III in Chapter 8. Chapter 9 reports on a joint U.K Civil Aviation
summarizes DIA’s total costs. Appendices IV and V list actual Authority (CAA)/U.S. Federal Aviation Administration
and proposed federal funds for DIA. (FAA) investigation of reliability of aircraft inspection in the
United Kingdom and the United States. Chapter 10 is a
Bird Ingestion into Large Turbofan Engines. Banilower, bibliographic overview of selected issues in computer-based
Howard; Goodall, Colin. Report No. DOT/FAA/CT-93/14. training system design.
February 1995. 127 p.; tables; references; appendices.
Available through NTIS.* Enhancing the Effects of Diversity Awareness Training: A
Review of the Research Literature. Myers, Jennifer G. Report
Keywords: No. DOT/FAA/AM-95/10. March 1995. 25 p.; figures;
1. Aircraft Engine Bird Ingestion references. Available through NTIS.*
2. Aircraft Engine Damage
3. Species of Ingested Birds Keywords:
4. Weights of Ingested Birds 1. Diversity
2. Training
This report contains the findings of a U.S. Federal Aviation 3. Attitudes
Agency (FAA) study that examined 644 large, high-bypass 4. Experiential Learning
turbofan–engine aircraft involved in bird-ingestion incidents
during 1989–1991. Topics include aircraft types and engine Projected changes in the demographic makeup of the workforce
models, ingestion rates, characteristics of the ingested birds, are the primary influence in the spread of diversity awareness
airports and analysis of ingestions that posed potential danger training in both the public and private sectors. This report reviews
to the aircraft. Statistical methods are applied to determine training and experiential learning research literature to identify
the influence of flight phase, bird weight and bird numbers on ways of enhancing diversity awareness training and minimizing
overall engine damage, fan-blade damage, core damage and the potential for backlash. Myers concludes that the effectiveness
other threats to aircraft safety. The appendices provide of training that focuses on altering attitudes to change behavior
summaries of all pertinent data from each ingestion incident. has not been clearly demonstrated. A combination of strategies
before, during and after training, and evaluation and research
Human Factors in Aviation Maintenance — Phase IV Progress programs to identify characteristics of effective training, are
Report. Shepherd, William T.; Galaxy Scientific Corporation. required to enhance the measurable benefits received from
Report No. DOT/FAA/AM-95/14. May 1995. 169 p.; tables; diversity awareness training in the long term.
illustrations; appendices; references. Available through NTIS.*
Aviation Research: Perspective on FAA Efforts to Develop New
Keywords: Technology. Dillingham, Gerald L. Testimony before the
1. Human Factors Subcommittee on Technology, Committee on Science, U. S.
2. Aviation Maintenance House of Representatives. Report No. GAO/T-RCED-95-193.
3. Hypermedia May 16, 1995. 10 p. Available through GAO.**
4. NDI [Nondestructive Inspection] Performance
5. Computer-based Training Gerald L. Dillingham, associate director, Transportation and
6. Ergonomics Telecommunications Issues, Resources, Community and
7. Aircraft Inspection Economic Development Division, General Accounting Office
(GAO) testified before the U.S. House of Representatives on
This 10-chapter report provides an overview of Phase IV the U.S. Federal Aviation Administration’s (FAA’s) recent
research on human factors in aviation maintenance. The field reorganization of the research, engineering and development
evaluation plan for the Performance Enhancement System (RE&D) program. Dillingham’s testimony reviews trends in
(PENS), a computer-based tool designed to aid aviation safety the character of research conducted by the RE&D program,
inspectors in performing oversight duties, is described in other sources of funds for research on problems in developing
Chapter 2. Chapter 3 describes the design of a portable new technology and in reorganization. Dillingham also notes
computer-based work-card system. The development of an that funding for research mandated by the Aviation Safety
ergonomic audit program for visual inspection is discussed Research Act has increased from 8.1 percent of the RE&D
in Chapter 4. Chapter 5 examines a study on ergonomic budget in 1988 to nearly 30 percent in 1995; considerable
factors related to posture and fatigue in the inspection research, however, remains outside the RE&D program.
environment. Chapter 6 reports on the development and
expansion of the Office of Aviation Medicine Hypermedia International Aviation: Better Data on Code-Sharing is Needed
Information System. Chapter 7 describes an investigation of by DoT for Monitoring and Decisionmaking. Mead, Kenneth
individual differences in NDI performance. The results of M. Testimony before the Subcommittee on Aviation,

Committee on Commerce, Science and Transportation, U.S. The appendix lists ATC modernization projects completed
Senate. Report No. GAO/T-RCED-95-170. May 24, 1995. through 1994.
12 p. Available through GAO.**
Developing of Coding Form for Approach Control/Pilot Voice
Kenneth M. Mead, director of Transportation Issues, Communications. Prinzo, O. Veronika; Britton, Thomas W.;
Resources, Community and Economic Development Hendrix, Alfred M. Report No. DOT/FAA/AM-95/15. May
Division, General Accounting Office (GAO) testified before 1995. 34 p.; tables; appendices. Available through NTIS.*
the U.S. Senate on international airline operations and the
competitive impact of code sharing. Mead testified that Keywords:
bilateral agreements often restrict U.S. airlines’ ability in 1. ATC-pilot Communications
foreign markets; however, code sharing is an effective strategy 2. Communication Taxonomy
for airlines to access traffic to and from cities previously 3. Phraseology
unserved, and will play a prominent role in future bilateral
negotiations. To improve U.S. airlines’ access to key foreign This report examines the Aviation Topics Speech Acts
markets, Mead stressed the importance of placing the U.S. Taxonomy (ATSAT), a tool that categorizes pilot/controller
Department of Transportation (DOT) on equal footing with communications according to purpose and codifies
foreign counterparts and noted that data problems must be communication errors. Using ATSAT’s error codes, air traffic
addressed for effective negotiation. controllers’ deviations from U.S. Federal Aviation
Administration (FAA) Air Traffic Control Order 7110.65, and
National Airspace System: Comprehensive FAA Plan for pilots’ deviations from the Airman’s Information Manual, can
Global Positioning System Is Needed. U.S. General Accounting be identified and labelled. Results of a preliminary study to
Office (GAO). Report No. GAO/RCED-95-26. May 1995. measure intercoder agreement reveals that novice coders are
24 p.; figures; appendices. Available through GAO.** more dependent on the surface characteristics of the verbatim
transcripts, but experts rely more on background knowledge
The U.S. Federal Aviation Administration (FAA) is augmenting and experience with ATC phraseology to code ATC
the U.S. Department of Defense’s (DOD) global positioning communications. The authors recommend that any further
system (GPS) to develop its benefits to civil aviation. Once research concerning ATSAT use coders who have received the
fully integrated as a navigational aid in the air traffic control same orientation and instruction before using ATSAT.
system, GPS will be superior to ground-based navigation aids
and will enable civil aircraft to fly more fuel-efficient routes. Aircraft Accident Report: Controlled Collision with Terrain.
This report outlines the FAA plan and projects its development. Transportes Aereos Ejecutivos, S.A. (TAESA) Learjet 25D, XA-
Although the FAA has met all milestones to date, the agency BBA Dulles International Airport, Chantilly, Virginia, June
will face difficulties in maintaining its schedule. The revised 18, 1994. U.S. National Transportation Safety Board (NTSB).
schedule may not give the FAA sufficient time to develop and Report No. NTSB/AAR-95/02. March 7, 1995. 63 p.; tables;
implement its wide-area system for augmenting GPS by the appendices. Available through NTIS.*
current milestone date of 1997.
This report explains the accident involving the TAESA Learjet
Appendix I describes civil air navigation requirements and the 25D that crashed near the threshold of Runway 1R at Dulles
augmentation to GPS. Appendix II lists FAA changes to the International Airport, Chantilly, Virginia, U.S., on June 18,
GPS schedule. 1994. The NTSB determined that the probable causes of the
accident were the poor decision making, poor airmanship and
Air Traffic Control: Status of FAA’s Modernization Program. relative inexperience of the captain in initiating and continuing
U.S. General Accounting Office (GAO). Report No. GAO/ an unstabilized instrument approach, leading to a descent below
RCED-95-175FS. May 1995. 90 p.; appendix. Available the authorized altitude without visual contact with the runway.
through GAO.** Lack of a ground-proximity warning system (GPWS) on the
airplane was cited as a contributory cause.
This is the sixth annual report on the status of the U.S. Federal
Aviation Administration’s (FAA’s) efforts to modernize the U.S. Safety issues discussed in this report include the weather at
air traffic control (ATC) system. This report provides information Dulles International Airport, flight-crew training, qualifications
on the overall status of ATC modernization and includes changes and performance, flight-crew fatigue, operations specifications,
in total modernization costs and the number of completed passenger seating and the GPWS.
projects. Fifteen major modernization projects are discussed in
detail with regard to cost and scheduling estimates. The FAA Appendices A–D provide information on the investigation and
estimates that the total cost of ATC modernization will be hearing; the runway environment; ground track and approach
US$37.3 billion between the initiation of the program in 1982 profiles; and NTSB safety recommendations to the U.S.
and its scheduled conclusion in 2003. Federal Aviation Administration (FAA), respectively.

FAA Air Traffic Control Operations Concepts, Volume VIII: technicians, an anthropometric familiarization for flight
TRACON Controllers (1989) is a technical description of the inspector pilots and technicians participating in the Ops Demo,
duties of a TRACON (terminal radar control area) air traffic an evaluation of aircraft-cabin noise levels and a human factors
control specialist (ATCS). Developed by CTA Inc., it was evaluation of the proposed flight inspection work station design
originally formatted in User Interface Language, but has been for medium-sized, medium-range (MSR) aircraft.
recently restructured into a hierarchical formal sentence
outline. To ensure that no crucial information was lost or altered
during the conversion, the revised document has been reviewed Books
by four subject-matter expert groups, each consisting of six
TRACON controllers and four quality assurance managers. Smallwood, Tony; Fraser, Michael. The Airline Training Pilot.
Brookfield, Vermont, U.S.: Ashgate Publishing. Co., 1995.
This report describes the methods used to effect this revision. 340 p.; illustrations; bibliographic references.
Words, phrases and acronyms not commonly used by
TRACON controllers as well as illogical sequencing of Keywords:
described duties were looked for and appropriate changes 1. Air Pilots — Vocational Guidance
implemented by the subject matter expert groups; 671 changes 2. Aeronautics — Study and Teaching
were made to the document.
This comprehensive guide addresses current airline training
Appendix A provides the definition of verbs used in the methods and considers the future of pilot training in an
TRACON Formal Sentence Outline Job Task Taxonomy. increasingly technologically advanced environment.
Appendix B is the Formal Sentence Outline Job Task Taxonomy. Smallwood and Fraser discuss the techniques and challenges
of preparing the next generation of skilled and safety-conscious
A Human Factors Evaluation of the Operational pilots. The focus is on human factors. The authors examine
Demonstration Flight Inspection Aircraft. Rodgers, Mark D. the psychological aspects of what makes an effective instructor
(editor). Report No. DOT/FAA/AM-95/18. May 1995. 22 p.; and address issues in motivation, student-teacher
tables; figures; references. Available through NTIS.* communication and how information is received and processed.
Chapter headings include “The Basis for Good Instruction,”
Keywords: “Dealing with Difficult Trainees,” “The Process of Learning,”
1. Human Factors “The Brain—Memory,” “Line/Route Training,” “Initial
2. Flight Inspection Command Training,” “Pilot Selection” and “Training Trainers.”
3. Anthropometry Tom Wise’s whimsical cartoons reinforce key points.
4. Acoustics
5. Workstation Design * U.S. Department of Commerce
National Technical Information Service (NTIS)
The four reports in this collection describe the data gathering Springfield, VA 22161 U.S.
and analysis conducted by the U.S. Federal Aviation Telephone: (703) 487-4780
Administration (FAA) Civil Aeromedical Institute’s Human
Factors Research Laboratory to assist the Office of Aviation ** U.S. General Accounting Office (GAO)
System Standards (AVN) in the human factors evaluation of P.O. Box 6015
the Operational Demonstration (Ops Demo) candidate flight Gaithersburg, MD 20884-6015 U.S.
inspection aircraft (FIA). The reports include a survey of (202) 512-6000
aircraft characteristic preferences in flight inspector pilots and (301) 258-4066 (fax)
U.S. Federal Aviation Administration (FAA) Regulations and Reference Materials

Advisory Circulars (ACs)
AC No. Date Title
150/5000-3R 3/13/95 Address List for Regional Airports Divisions and Airports District/Field
Offices (cancels 150/1500-3Q, Address List for Regional Airports Divisions
and Airports District/Field Offices, dated 9/29/93).
150/5360-12A 12/23/94 Airport Signing and Graphics (cancels 150/5360-12, Airport Signing and
Graphics, dated 12/23/85).

Accident/Incident Briefs
B-737 Descent with Engines at Idle in

Thunderstorm Results in Flameout
Gust, wet runway result in runway excursion by Saab turboprop.
Editorial Staff
The following information provides an awareness of problems from previous flights of the departure procedure. The airline
through which such occurrences may be prevented in the fu- recommended that the incident be used in training to emphasize
ture. Accident/incident briefs are based on preliminary infor- the importance of a thorough review of departure procedures
mation from government agencies, aviation organizations, and a departure briefing.
press information and other sources. This information may
not be entirely accurate.
Heavy Rain, Failure to Follow
Procedure Cause Flameout
Boeing 737-300. Minor damage. No injuries.
The aircraft was descending with the throttles in flight idle

when the No. 1 engine failed. The engine flamed out because
of water ingestion after the B-737 penetrated a Level 5
thunderstorm and encountered heavy rain.
The engine suffered over-temperature damage to the turbine

False Memory Results in Wrong Turn section during a subsequent windmilling start. It was
determined that the captain had elected to descend in
Boeing 747-400. No damage. No injuries. precipitation with the engines at idle, despite a warning from
the first officer that an idle descent was contrary to recently
The international flight had departed an airport in Australia published procedures to a maintain a minimum of 45 percent
when the first officer, the pilot flying, initiated a turn to the N1 RPM. The dangers of precipitation-induced flameout have
left. Air traffic control (ATC) had assigned a right turn. caused the U.S. Federal Aviation Administration (FAA),
manufacturers and operators to publish correct procedures.
While the left turn was initiated, the captain was concentrating
on the radios and correcting a mis-set radio frequency. When
he looked up and saw that the airplane was in a left turn, he Fatal Crash Narrowly Averted
told the first officer that the assigned turn was to the right to a After Poor Approach
heading of 170 degrees.
Boeing 737-200. Minor damage. No injuries.
An investigation determined that the captain and the first officer
had not been to that airport in 45 days and that the first officer The aircraft was making a night very high frequency
initiated the wrong turn because of a mistaken recollection omnidirectional radio range (VOR) distance measuring

equipment (DME) approach to a South American airport when Despite flap and power adjustments, the aircraft became
it made slight contact with terrain four nautical miles from the uncontrollable and impacted terrain on final. The pilot received
runway threshold. minor injuries. An investigation determined that another
aircraft had reported wind shear during final approach shortly
After the contact, the captain initiated a go-around and the before the accident.
aircraft completed an uneventful landing. None of the 52
passengers on board were injured. An investigation determined
that the flight crew had ignored published descent procedures,
including decision-height and safety-altitude minimums.
Low Approach Ends on Hilltop

Beech 100 King Air. Aircraft destroyed. Two serious injuries.
Gust Causes Directional Control Loss
The twin-engine turboprop aircraft was making a nondirectional
Saab 340. Minor damage. No injuries. beacon (NDB) approach to an uncontrolled airport at night in
instrument meteorological conditions (IMC) when it crashed.
The twin-engine turboprop Saab was on a daylight instrument
landing system (ILS) approach to a European airport in The airport elevation was 941 feet (287 meters) mean sea level
moderate turbulence and a strong, 20-knot crosswind. On short (MSL) and the NDB was located 1.8 nautical miles (2.5
final, the aircraft encountered a strong gust. kilometers) from the airport. A minimum descent altitude
(MDA) of 1,540 feet (470 meters) was to be maintained until
During the landing roll, directional control was lost and the the runway was in sight. About four miles (6.4 kilometers)
aircraft left the runway laterally before overrunning the runway from the airport, the aircraft struck the top of a hill at 990 feet
end by 164 feet (50 meters). No mechanical defects were found. (302 meters) MSL. The aircraft was destroyed by impact and
The runway was determined to have been damp at the time of a postcrash fire. Weather at the time of the accident was
the overrun. reported as 300 feet (91.5 meters) overcast and one mile (1.6
kilometers) visibility in fog and rain.
Ground Agent Injured by Propeller An investigation determined that the pilots had failed to follow
proper instrument flight rules (IFR) and had failed to maintain
BAe Jetstream 31. Minor damage. One serious injury. a safe altitude on the approach.
The twin-engine turboprop Jetstream was at the ramp at dusk

when a ground agent attempted to retrieve his signal wands Mis-set Fuel Selector Downs
and walked into a rotating propeller. The agent had just finished Twin on Go-around
placing chocks in front of the nose wheel.
Beech 55 Baron. Substantial damage. One serious injury.
An investigation determined that the agent, who was seriously
injured in the accident, lacked ramp experience and that ramp The twin-engine, piston-powered Baron was second for a night
safety procedures had not been followed. visual landing on Runway 03 about 0.5 mile (0.8 kilometer) from
touchdown when air traffic control (ATC) asked for a
go-around to allow the first aircraft to clear the runway.
Wind Shear Whacks Commuter on Final
The pilot initiated the go-around and then reported a dual
Cessna 208 Caravan. Substantial damage. One minor injury. engine malfunction during the climb out. The pilot was then
cleared to land on any runway. As the pilot turned to line up
The single-engine turboprop Caravan was on final approach for Runway 21, the aircraft struck a small grove of trees about
at night during thunderstorm activity when it encountered 1,110 feet (336 meters) left of the extended centerline for
strong turbulence and the airspeed jumped from stall to redline. Runway 21.

A postaccident examination of the aircraft revealed that the
pilot had placed the fuel selector valves in the auxiliary
position. A placard on the fuel selector stated: “Use auxiliary
tanks and crossfeed for level flight only.” Both engines suffered
from fuel starvation. No mechanical problems were found.
Wire Strike During Aerial

Application Kills Pilot
Hiller UH-12E. Aircraft destroyed. One fatality.
Mountain Cuts Short Night Approach The Hiller, engaged in aerial application work, struck a wire
while maneuvering and impacted terrain. The helicopter was
Piper PA-31. Aircraft destroyed. Four fatalities. destroyed and the pilot was killed.
The twin-engine Piper encountered strong winds over the Weather at the time of the daylight flight was reported as visual
mountains during a night flight under visual flight rules (VFR) meteorological conditions (VMC) with 5,000 feet (1,525
and the pilot diverted to a nearby airport to refuel. meters) scattered, 8,000 feet (2,440 meters) broken and nine
miles (14.4 kilometers) visibility.
The pilot contacted air traffic control and reported that he
intended to make an unscheduled fuel stop. The pilot requested,
and was issued, radar vectors to the diversion airport. Although Mechanical Failure Leads to
it was a dark night and the pilot-controlled airport lighting Hard Landing
was never activated, the pilot reported the airport in sight and
was cleared for the visual approach. Radar contact was lost Bell 47G. Substantial damage. No injuries.
about three minutes later.
The helicopter was flying at 50 feet (15.3 meters) above ground
The aircraft wreckage was found the following morning on a level (AGL) and was in the initial phase of a turnaround
mountainside east of the airport. Impact had occurred at 9,100 maneuver when the engine failed. The aircraft landed hard
feet (2,776 meters) about six miles (9.7 kilometers) east of the and the main rotor blades severed the tail boom.
5,622-foot (1,715-meter) elevation airport. Minimum safe
altitude was 12,400 feet (3,782 meters). A subsequent investigation determined that the power loss was
caused by the failure of the oil-pump drive gear in the accessory
case. Weather at the time was reported as visual meteorological
Twin Strikes Truck in conditions (VMC) with clear skies, 10 miles (16 kilometers)
Low-pass Maneuver visibility and winds at three knots.
Britten-Norman Islander. Substantial damage. No injuries.

Check Ride Goes Awry
The twin-engine piston-powered Islander was preparing to land
at a rural Canadian airport when the pilot spotted a co-worker Schweizer 269C. Substantial damage. One minor injury.
leaving the hangar area in a pickup truck. The pilot executed a
low-pass maneuver in an attempt to get the co-worker’s The pilot reported that he was demonstrating touchdown
attention and to obtain a ride into the nearby town. autorotations for his helicopter flight instructor’s practical test
to a U.S. Federal Aviation Administration (FAA) examiner,
During the low pass, the aircraft’s main landing gear struck the when he allowed the main-rotor RPM to decay while turning
rear of the pickup truck’s cab. The pilot maintained control of base.
the aircraft and landed without further incident. Neither the pilot
nor the truck’s driver was injured. The aircraft and the truck The pilot continued the touchdown, but landed hard. The FAA
were substantially damaged. Transport Canada was informed examiner received minor injuries. The pilot was not injured.
and was considering criminal charges against the pilot. The helicopter suffered substantial damage.

Safety is not a cost.
It’s a benefit!
Flight Safety Foundation (FSF) and Transport Canada will conduct at Airshow Canada on Aug. 10,
1995, a Risk Management Seminar that will examine how an aviation safety program can improve
profitability. The important role of company management, which is increasingly being held
responsible for the success of aviation safety programs, will be discussed in detail.
Topics will include well-analyzed problems and their solutions; skillful cost-benefit analysis as the
cornerstone of an effective and efficient safety program; the obligation to establish a safety
program in the same way that a company introduces a new aircraft to the fleet; and the
importance of creating a clear and comprehensive accident/incident response plan. No fee will be
required for admittance to the seminar.
Airshow Canada will be held Aug. 9–11 [industry-only days; public days will be held Aug. 12 & 13.]
in Abbotsford, British Columbia, Canada. Free preregistration is available before July 7 for
industry-only days. In addition to the FSF/Transport Canada seminar, there will be a variety of
other conferences and symposia during the Airshow. The Canadian Business Aircraft Association
will be conducting its annual convention in Vancouver, while its tradeshow exhibits and static
displays will be combined with Airshow Canada at Abbotsford. For more details, contact Airshow
Canada. Telephone: (604) 852-3704 and Fax: (604) 852-4600.
Flight Safety Foundation/Transport Canada

Risk Management Seminar
Airshow Canada
Aug. 10, 1995
Contact Ed Peery, FSF. Telephone: (703) 522-8300 Fax: (703) 525-6047
FLIGHT SAFETY DIGEST

Copyright © 1995 FLIGHT SAFETY FOUNDATION INC. ISSN 1057-5588
Suggestions and opinions expressed in FSF publications belong to the author(s) and are not necessarily endorsed
by Flight Safety Foundation. Content is not intended to take the place of information in company policy handbooks
and equipment manuals, or to supersede government regulations.
Staff: Roger Rozelle, director of publications; Girard Steichen, assistant director of publications; Rick Darby, senior editor;
Karen K. Bostick, production coordinator; and Kathryn Ramage, librarian, Jerry Lederer Aviation Safety Library.
Subscriptions: US$95 (U.S.-Canada-Mexico), US$100 Air Mail (all other countries), twelve issues yearly. • Include old
and new addresses when requesting address change. • Flight Safety Foundation, 2200 Wilson Boulevard, Suite 500,
Arlington, VA 22201-3306 U.S. • Telephone: (703) 522-8300 • Fax: (703) 525-6047
We Encourage Reprints
Articles in this publication may be reprinted in whole or in part, but credit must be given to: Flight Safety Foundation,
Flight Safety Digest, the specific article and the author. Please send two copies of reprinted material to the director of publications.
What’s Your Input?
In keeping with FSF’s independent and nonpartisan mission to disseminate objective safety information, Foundation publications
solicit credible contributions that foster thought-provoking discussion of aviation safety issues. If you have an article proposal, a
completed manuscript or a technical paper that may be appropriate for Flight Safety Digest, please contact the director of
publications. Reasonable care will be taken in handling a manuscript, but Flight Safety Foundation assumes no responsibility for
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F L I G H T S A F E T Y F O U N D A T I O N

Comparing Accident Reports:

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995 1

2 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995 3

4 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995 5

6 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995 7

8 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

U.S. Commercial Aviation Fatal-accident Rate

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995 9

Fatalities 10 On-board fatalities only

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

Second Generation Wide Body (early)

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

FAA Issues Guidance to Air Carriers

Positive Exchange of Flight Controls Program. U.S. Federal Reports

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995 13

International Aviation: Airline Alliances Produce Benefits, But Keywords:

14 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995 15

16 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

U.S. Federal Aviation Administration (FAA) Regulations and Reference Materials

AC No. Date Title

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995 17

B-737 Descent with Engines at Idle in

The aircraft was descending with the throttles in flight idle

The engine suffered over-temperature damage to the turbine

18 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

Low Approach Ends on Hilltop

The twin-engine turboprop Jetstream was at the ramp at dusk

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995 19

Wire Strike During Aerial

Britten-Norman Islander. Substantial damage. No injuries.

20 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 1995

Flight Safety Foundation/Transport Canada

FLIGHT SAFETY DIGEST

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