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Hind ight 12

The ability or opportunity to understand and judge an event or experience after it has occured
EUROCONTROL

Runway excursion

Controllers and pilots teaming up


to prevent runway excursions
by Captain Bill de Groh, IFALPA

Some hidden dangers


of tailwind
by Gerard van Es, NLR-ATSI

The role of ATM in reducing


the risk of runway excursion
by Jim Burin, FSF

* Piste - French: 1. (ski) track, 2. runway Winter 2011


Contents Winter 2011
Hind ight 12
The ability or opportunity to understand and judge an event or experience after it has occured

4 eDItORIAL
4
6
For alligators and stabilised approaches
Language and safety issues
p. 8
8 Before the runway Professor
12 tHe VIeW FROM ABOVe Sidney Dekker
12 Do runway excursion accidents necessarily have precursors
in lesser events?

16 121.5 - SAFetY ALeRtS


16 IFR Aircraft Operations Below RVR Minima
18 Emergency descent in high traffic density situations
20 Abbreviation and Misinterpretation of Type C R/T Call Signs
21 Briefing and Provision of Operational Aeronautical
Information to Air Traffic Controllers
22 Operation of SSR Mode C by General Aviation VFR
Recreational Flights
24 FANS CPDLC Erroneous ATC Log Data Presentation

26 CASe StuDY
26 Her new barbecue sauce
28 Comment No. 1 by by Dragan Milanovski
29
30
Comment No. 2 by Captain Ed Pooley
Comment No. 3 by Alexander Krastev
p. 16
32 LeARNING FROM OtHeRS
Safety Alerts
32 Nearly a Runway Excursion

34 FROM tHe BRIeFING ROOM


34 A slippery business
36 Controllers and pilots teaming up to prevent

39
runway excursions
Runway friction characteristics measurement and aircraft braking
p. 52
42
45
Runway excursions: cleared to land... ready or not!
Understanding cockpit factors
Paule
48
50
Some hidden dangers of tailwind
The role of ATM in reducing the risk of runway excursions (Probably)
Bortargues
see and (possibly) avoid
52 TCAP: an altitude capture enhancement to prevent TCAS RAs
58 AIRPROX - Altimeter System Error - Whats my level?

60 SKYbrary DOWNLOADS
60 Wind velocity reporting

2
p. 34
A slippery
business

eDItORIAL teAM
Editor in Chief: Tzvetomir Blajev
p. 45
Editorial Adviser: Captain Ed Pooley
Graphical Design: Frdrique Fyon Understanding
cockpit factors
CONtACt uS
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Altimeter System
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HindSight 12 Winter 2011 3


EDITORIAL

For alligators and


stabilised approaches
O nce I was being led by a guide through
the Everglades wetlands in southern
Florida. The saw grass prairie and the man-
have been shown to contribute to runway excursions, they
only affect landing overruns. Furthermore, NLR studies have
shown that these only make up about 40% of all runway ex-
grove forests were beautiful but I was stay- cursions. Even in landing overruns, unstabilised approaches
ing alert. Is it true that the alligators will keep are not the most important factor. Slippery runways and
away from you if you use a strong torch or long landings are much more important although long
flashlight? someone from the group asked landings and unstabilised approaches may sometimes be
our guide. A flashlight is fine, but your survival associated. The NLR studies showed that even a 100% rate
generally depends on how far you keep it from for stable approaches would only reduce the total number
the alligators and how fast you carry it it, he re- of runway excursions by up to 10%.
plied.
Like flashlights in the Everglades, good ATM
practice can improve the rate of safe out-
The NLR studies showed comes. So should we promote ATM practices

that even a 100% rate for which avoid making adverse contributions
to the likelihood of a stabilised approach, a
stable approaches would long landing or problems with slippery run-
ways? Adverse contributions include; high-
only reduce the total speed approach clearances, not announc-

number of runway ing the vectoring limits, vectoring too short


onto the final, setting up interception of the
excursions by up to 10%. glide path from above and not providing the
Tzvetomir Blajev latest meteorological and runway state in-
Editor in Chief of Hindsight formation to the crew.
Fellow of the Flight Safety Foundation The question here is should
we have a flashlight or not if Should we also reflect these sup-
the survival is not necessarily portive practices more in our
always determined by this fact? Should we make it compul- procedures? Before we do,
sory, by law and procedures, because we know it may in- perhaps we need to ask
crease our chances, even if there are stronger survival strat- whether ATM procedures
egies like stay away and run fast? Making it compulsory are going to be con-
is potentially opening the litigation window for the pros- sidered as a continu-
ecutors to take the aim at companies which are organis- ation of the legal
ing swamp excursions without equipping the participants framework. Are
with torches. Now put yourself in the shoes of people work- they going to
ing for these companies are you going to encourage the be used as evi-
adoption of such procedures? dence when
apportioning
Now take another risk - runway excursion - and think of the blame and liability, or should
effect ATM can have on the rate of the stabilised approach- they be deliberately ex-
es. Sure, if the stabilised approach criteria are not met at the cluded from legal admis-
mandatory gate set by the Operator, then the crew should sibility?
initiate a go-around. And of course, this is a more reliable
strategy compared to managing the ATM influence on sta- Enjoy reading
bilised approach. But although unstabilised approaches HindSight!

4
Hind ight 12
The ability or opportunity to understand and judge an event or experience after it has occured

HindSight 12 Winter 2011 5


EDITORIAL

Front Line Report:


Language and safety issues
By Bert Ruitenberg
Language is a wonderful phenomenon. Ive attended quite a few
Human Factors events where some of the participants must have felt
quite out of place because essentially they were Human Resources
people. Human Factors, Human Resources, phrases that are apparently
easy to confuse even though I think that linguistically theyre not really
that close at all. At least not as close as the phrases Runway Incursion
and Runway Excursion - now theres a pair of almost identical twins!

A fter targeting Runway Incursions as a safety subject it


would therefore seem logical for the aviation industry to
target Runway Excursions in a subsequent step. Im not go-
of the Threat and Error Management (TEM) framework, a RI
is an Undesired State that can still be managed to influence
the outcome. RIs may involve vehicles or pedestrians. Dif-
ing to argue that Runway Excursions arent a safety issue - far ferences in aerodrome lay-outs, signage and markings are
from it. What I would like to argue however, is cited as factors in RIs. Weather does not seem to be a huge
that from a safety management perspective, factor in RIs, except that more RIs occur in good weather
theres a world of difference between Run- conditions than during low visibility conditions.
way Excursions and Runway Incursions and
that the remedial approach towards one of And here is a list of similar attributes for Runway Excursions
those safety issues is therefore not simply (REs). They happen on the ground but they often have their
transferable to the other issue. origin when the aircraft still is in the air. An RE is always a dan-
gerous situation, because it involves a veer off or overrun off
the runway surface. An RE
I think ATC also has a role to play usually results in some form
Bert when it comes to preventing REs.
of damage (either to the
aircraft or to the aerodrome
Ruitenberg
Just ask yourself this question: infrastructure or both). In
terms of the TEM frame-
recently retired from working
as a TWR/APP controller, supervisor and ATC why do pilots and their aircraft work an RE is an end state
that cannot be managed to
safety ocer at Schiphol Airport, sometimes end up too high and change the outcome. REs
Amsterdam, The Netherlands.
too fast on final approach? exclusively involve aircraft.
Runway length and runway
He was recently appointed as the new surface conditions are cited
IFATCA Safety Coordinator. as factors in REs. Weather is a
huge factor in REs, with heavy precipitation and strong wind
as recurring elements in investigation reports.
Allow me to start by listing a number of attributes of Runway
Incursions (RIs). You see the differences? The lists are not meant to be ex-
haustive, by the way. Now lets take a look at the remedial
They happen on the ground and they have their origin on approaches for RIs versus REs. The European Action Plan for
the ground. A RI does not necessarily have to result in a dan- the Prevention of Runway Incursions (EAPPRI) has led to the
gerous situation, since it may occur on a runway that is not successful establishing of a Runway Safety Team at many
active or on which no aircraft is landing or taking off at the European airports. In those teams, representatives from the
time. A RI does not have to result in any damage. In terms airport authority, the major airlines based or operating at

6
??
EDITORIAL

?? ? ?
?? ?
?

?
the airport, air traffic services, and other par-
ties who perform their daily work on the ma-
noeuvring area, all participate with the aim
to come up with recommendations for local
improvements to prevent RIs.
? ?? ? ?
The recommendations from the Runway Safety
Teams usually focus on items such as signage and
markings, ICAO compatibility, lighting and more. They and to properly execute, a Rejected Takeoff (RTO) and a failure to
may also comprise items such as the airport infrastructure, recognise the need for a go-around and to conduct a go-around
names of taxiways and/or intersections, stopbar availabil- at any time during an approach, flare or touchdown as primary
ity and usage, aeronautical charts (airport maps) and more. factors in runway excursions. The Foundation offers several strat-
Moreover, Runway Safety Teams have organised dedicated egies that pilots can adopt to help avoid the risk of an RE.
campaigns to enhance the awareness of the aerodrome us-
ers on the subject of RIs, including ATC. But I would go further than that: I think ATC also has a role to
play when it comes to preventing REs. Just ask yourself this
All those things are good things (at least in my book) to help question: why do pilots and their aircraft sometimes end up
prevent Runway Incursions, yet very few of them are any too high and too fast on final approach? Did we perhaps put
good at all when it comes to the prevention of Runway Excur- them there, or at least did they maybe keep up the speed in re-
sions. The simplest form of action to prevent an RE after land- sponse to a request from us? In other words, are our ATC proce-
ing is of course to execute a missed approach instead of land- dures and working styles adequate to facilitate airline pilots to
ing. But deciding on that particular action is not as simple for always perform stabilised approaches? And who can provide
a pilot as it may seem. This is where the concept of a stabilised the most up-to-date weather information to pilots?
approach comes in: if certain flight parameters are not met at
a predetermined point during final approach, the pilots are Ill leave you to contemplate those questions and return to
supposed to execute a missed approach. Notice however, what I started this article with: language issues. To assist in over-
that this does not address the issue of an RE during take off. coming language issues the concept of a definition was intro-
duced. I found the following definitions for Runway Excursion
When analysing REs that occurred during take off, the factors on the internet. The first one is attributed to ICAO (although I
that are often cited include; mechanical failure, wind condi- havent been able to trace it back to an ICAO document) and
tions that were different from what the pilots knew or runway reads as follows: a veer off or overrun off the runway surface.
surface conditions that were different from what the pilots Skybrary contains this definition: a runway excursion occurs
knew. Once again it comes down to pilot decision making, when an aircraft fails to confine its take off or landing to the
except of course in case of mechanical failure. designated runway. Wikipedia states that a Runway Excursion
is an incident involving only a single aircraft where it makes an
I am therefore not convinced that local Runway Safety Teams inappropriate exit from the runway.
are the best platform to address Runway Excursions as a safe-
ty issue, as proposed by some. The power of Runway Safety The whole idea of putting a label such as runway incursion or
Teams is the local knowledge of infrastructure and proce- runway excursion on a safety occurrence is to make it easier to
dures that may be improved to prevent RIs. But the issues file the data from the event somewhere and to compare it with
around REs are more universal in nature (no pun intended), similar occurrences. With the definitions above, a take off from a
which to me suggests that a more generic approach may be taxiway would be considered as a Runway Excursion when the
required to successfully address the problem. Skybrary definition is used, but not with the other RE definitions
(and rightly so, I say, better label it a taxiway take off ). More-
In fact, this generic approach is already being taken by organ- over, in the ICAO definition, the B777 undershoot at Heathrow
isations such as the Flight Safety Foundation, which provides would not be a RE, but with the Skybrary definition it would be.
a Runway Excursion Risk Awareness Tool (available online in Dear Safety Managers of the world, there still is a lot of work to
Skybrary). In it they cite a failure to recognise the need for, be done...

HindSight 12 Winter 2011 7


EDITORIAL

Before the runway By Professor Sidney dekker

display with flight information. My airspeed is leaking out of


Editors Note: This time, we decided to invite some the airplane as if the hull has been punctured, slowly deflat-
comments on Professor Dekkers article from subject ing like a pricked balloon. It looks bizarre and scary and the
matter experts. Their responses follow the article. split second seems to last for an eternity. Yet I have taught
myself to act first and question later in situations like this.

W e are at 2,000 feet, on approach to the airport. The big


jet is on autopilot, docile, and responsively follow-
ing the instructions I have put into the various computer
So I act. After all, there is not a whole lot of air between me
and the hard ground. I switch off the autothrottle and shove
the thrust levers forward. From behind, I hear the engines
systems. It follows the heading I gave it, and stays at the screech, shrill and piercing. Airspeed picks up. I switch off
altitude I wanted it at. The weather is alright, but not great. the autopilot for good measure (or good riddance) and fly
Cloud base is around 1000 feet, there is mist, a cold driz- the jet down to the runway. It feels solid in my hands and
zle. We should be on the ground in the next few minutes. docile again. We land. Then everything comes to a sudden
I call for flaps, and the other pilot selects them for me. The standstill. The screens freeze, the world outside stops mov-
jet starts slowing down. Then we come to the top of our ing. We are in a simulator. Nice work says the instructor
approach. The autopilot nudges the nose of the jet down- from his little pedestal behind the two pilot seats. I turn
ward, onto the glideslope towards the runway. around and smile at him, knowing that he knows what I
know.
Then something strange happens. The thrust levers that
control the power to the jets two engines move all At that very moment an accident was still being investi-
the way to the back to their idle stop. This is very little gated on which the scenario was based. A big jet crashed
thrust for the situation we are in, not enough for keep- short of the runway because, in a one-in-a-million chance,
ing the jet aloft much longer. In a split second my eyes the autothrottle was tricked into a wrong mode by some
dart up to the computer display with the various mode rare indication failure of the airplanes altimeter system. The
annunciations, which tells me what mode the various radar altimeter erroneously told the autothrottle that the

People are expert at adapting their readings of


Professor risk so as to make the world look more normal,
Sidney Dekker less hazardous.
is Professor of Human
Factors & Aviation Safety at Lund University
in Sweden. automatic systems are op- jet was on the ground (even though, pertinently, it was not)
erating in. The autopilot is and that it was time to retard the thrust levers and to pull
He gained his Ph.D in Cognitive Systems doing what it is supposed the power.
Engineering at the Ohio State University to be doing; riding the
in the US. glideslope to the runway. However, the autothrottle computer never bothered to tell
the autopilot about its intentions. The autopilot was happi-
His books include The Field Guide to However, the autothrottle ly doing its thing, riding down the glideslope to the runway,
Human Error Investigations and Ten is another story. This is the blissfully unaware that the other computer system had just
Questions about Human Error. His latest computer that helps con- robbed it of the only factor responsible for being able to fly
book is Just Culture: Balancing Safety and trol how much thrust goes at all: airspeed. None of the books available to pilots about
Accountability. out of the engines and it this jet ever revealed this possibility. As far as most pilots
is in a mode that I have were concerned, it was an unknown-unknown.
He flies as a First Ocer on B737NG. never seen in this situation
before; fully retarded. My But no more. Here I was sitting in a simulator for a regular
eyes flutter down onto the four-hour proficiency session to keep my rating valid. The

8
EDITORIAL

scenario that killed a bunch of people


in the same jet but in another part
of the world was being played
through our flight, into our
hands and minds. The official
accident report was not even
out yet, but plenty of pilots
had realised that this could
be really hazardous and de-
cided to do something about it.
For themselves, their colleagues,
everybody. Now that is double-loop
learning.

Yet the accident revealed both the strengths


and the weaknesses of how we learn in aviation.
There had been trouble with radar altimeters on this kind
of jet before. It turned out that some pilots in the same
airline, as well as in other airlines, had sometimes experi-
enced funny things with the radar altimeter. For example,
spurious warnings about proximity to the ground would
be triggered. In some cases, even the autothrottle would nised. Hey, they landed without incident, right? No harm,
go into the wrong mode. But the failures would never re- no incident. At best, as a pilot you sit in the crew bus after
peat themselves on the next leg of the trip. They were im- the flight and say, Boy, that final was a little tight today,
possible to recreate on the ground. wasnt it? But if there is no close call, there is no report
from anyone.
Also, on the accident flight, the jet was turned onto the
localizer less then five miles before the runway and kept at This is one of the biggest challenges for learning in avia-
2000 feet, so it got stuck above the glideslope. When final- tion: how do we decide what counts as bad news? Learn-
ly given clearance to descend with the ILS (which by then ing after nine people are dead is one thing, but what is
needed to be captured from above), the autothrottle re- near enough to a bad outcome to count as a close call,
tard made the airplane do exactly what the crew wanted: as something that should be reported? People are expert
go down and slow down (which, in this jet, is really hard at adapting their readings of risk so as to make the world
to do at the same time, by the way). The jets behaviour look more normal, less hazardous. Norms for what counts
masked the autothrottle retard problem until it was too as risky get renegotiated the whole time, particularly as
late for the crew to recover. operational experience with a procedure accumulates.
Base to a three and a half-mile final for a 747? No problem,
It turned out that at this airport, tight line-ups are very we do it all the time. And if he can do it, a four-mile final
normal. In fact, compared to some approaches even that for a 737 should be a piece of cake. It is called production
very morning, the accident aircraft got a relatively long fi- at this airport. It is, however, the kind of normalisation of
nal. The official rules and guidelines for ILS approaches by deviance (oh, weve seen this before, its OK.) that eventu-
the ANSP had not been followed for more than a decade ally brings an unsuspecting jet with a funky radio altimeter
(deviance was normal). Never mind the 5-mile minimum down before the runway, rather than on it.
line-up. We do it everyday. Its the way we teach it. Its
called a job and pilots appreciate us doing it. All the data from the accident in question here are from the
official published accident report only.
But if an unknown is unknown, or the deviant has become
normal, then the symptoms of trouble may go unrecog- See http://www.skybrary.aero/bookshelf/books/1175.pdf

HindSight 12 Winter 2011 9


EDITORIAL

Responses and comments from experts

[1] A formal response from ATC The Netherlands


by Job Brggen, Safety Manager
to otherwise unexplained events. Although airlines cannot
possibly fully understand what happened: better safe than
sorry.
Sidneys account addresses a well known aspect which is called
drift into failure. By absence of any mishaps the ongoing activi- On the navigation support side, the ANSP is now undertaking
ties are declared as safe and risk barriers can slowly erode. If we renewed research into stabilised approaches and the contrib-
are not constantly and credibly reminded of hazards, we tend to uting role of the ANSP to achieve this. A stabilised approach
think the hazard is non-existent. Sidneys account nicely paints is an important enabler to achieve consistently safe landings.
the picture for this with his bus ride at the airport where the crew Not without reason, this is a crucial requirement within all
decides not to file an ASR about a particular short line-up. The IOSA registered airlines. Efforts are underway to analyze how
accident of a 737-800 that crashed on final approach because of the ANSP can further support this requirement by putting in
lack of airspeed serves as a sad reminder of how many small con- extra safety barriers and make another small step towards
tributions can turn an otherwise normal flight into a tragedy. The even better achievement of stabilised approaches.
full report about this from the Accident Investigation Board (AIB)

[2] Comment from a Pilot perspective


is publicly available .

The flight was a Line Flight Under Supervision with the Captain by Captain Ed Pooley
acting as instructor, the First officer acting under supervision and
a third pilot acting as safety pilot. Whilst the AIB report about the Usually I enjoy reading Professor Dekkers human factors
accident is a long account of what happened, the report does lit- take on flying commercial aircraft. However, following an ad-
tle to help understand the behaviour in the cockpit. The captain vanced opportunity to read his column this time, I offer what
actively calls one thousand, as audible proof that he was indeed I believe is a more realistic examination of the pre-crash se-
monitoring the altitude, yet it is not understood why he does not quence.
command a missed approach as the aircraft is not in a stable ap-
proach. Maybe he thought things would be working out okay? If we forget for a moment the minor initiating malfunction of
Not unlikely: at 1000 ft the autopilot was nicely tracking the glide a radio altimeter, and that it had a long and not too illustrious
slope and localizer, he had set the right speed on the autothrottle history, we are left with a complete failure by any of the three
and although a little fast still, he may have expected the aircraft to flight crew to individually notice that the aircraft was attempt-
settle on this reference speed. But at 500 ft, 33 knots (!) below his ing to stay airborne with idle thrust set. Since none of them
reference speed, with an unusual nose-up attitude, elevator trim noticed as individuals, CRM was not going to be relevant. So
visibly and audibly running to compensate, thrust levers at full re- what did they all apparently not notice over a significant pe-
tard, speed tape flashing, there can be little doubt about being in riod on an undemanding Cat 1 ILS approach being flown to a
a non-stable approach. Thanks to the investigation report, we are non-limiting runway? Well, two things really stand out. Firstly,
made aware of how a technical failure in the aircraft, combined idle N1 (thrust), idle fuel flow and a steadily decreasing indi-
with a lack of awareness by the crew, joins up with an approach cated airspeed must all, yes all, not have been noticed. Sec-
that puts the aircraft above the glide slope, which in turn partly ondly, the most abnormal aircraft attitude which began to
masks the technical failure of the aircraft. But why were these ex- develop as the aircraft tried to stay on the ILS glide slope with
perienced captains and two colleague pilots not responding to only idle thrust and the usual drag items (landing gear, trail-
this (in hindsight) obvious threat? ing edge flaps) deployed, could not have been noticed either.
Despite this drift into failure, the situation was still recover-
This question mark is so enormous that, in absence of any suit- able even when the stick shaker activated, if the response had
able explanations, one may feel compelled to look for other clari- been timely - but unfortunately it wasnt.
fications. Here is where Sidney suggestively redresses the con-
tributing factors in this accident as primary causes and without I will briefly return to the radio altimeter failure. Even without
wanting to downplay the contributing factors of course, it is bet- a history of malfunction on the accident aircraft being un-
ter to refer to the accident report: the principal cause of the crash recorded and improperly dealt with, the radio altimeter has
was lack of airspeed on approach and subsequent stall. always been recognised as an instrument which, if it malfunc-
tions, is probably going to affect other systems too. The fact
Evidently, this aspect has been picked up by some airlines as that the failed system fed the auto throttle should have been
shown by Sidneys simulator ride and put this aspect into their readily within the possibilities reviewed by the crew, even if
training programs. This seems a good and reasonable response they were not specifically alerted to it by reading a specific

10
QRH drill. And besides, a design which normally links the left
hand radio altimeter to the single auto throttle is entirely in-
tuitive, as is the linking of each autopilot to its corresponding
[3] Comment from an ATCO perspective
by Bert Ruitenberg
radio altimeter.
On the plus side, there is nothing in the text that is not ad-
It is also worth observing that this was a line training flight for dressed in the official report (albeit in other words). On the
the First officer and a Safety Pilot was occupying the supernu- minus side, I think Sidney is too easily accepting statements
merary crew seat and this should have lessened the chances of from the report with respect to what is the normal way of
a prolonged failure to recognise that the aircraft energy state working at EHAM.
was not sustainable. Three pairs of eyes, including a pair of
trainees eyes, are usually thought to at least restore the margin The line up given to the accident aircraft was never an inten-
of safety to the normal case of two fully qualified pilots. tional short line up. It just ended up intercepting the LLZ a
mile closer to touchdown than expected - which may be a
Indeed, the short turn on and closure of the ILS glide slope result of the timing of the turn-to-intercept instruction, or of
from above may not be ideal, but it is well within the world of the turn rate applied by the pilots, or a combination of the
reality. Lets not forget that any pilot must be ready to decline two.
any clearance which they believe will lead to an undesirable
safety-related outcome. For a short line up an aircraft at EHAM is normally vectored
for an interception even closer to touchdown (4.5 to 5 NM)
and given descent to 1200ft after passing the CTR boundary.
Lets not forget that any pilot must be Some aircraft were given such an approach that morning, but

ready to decline any clearance which not the accident aircraft. The preceding aircraft was a Heavy,
after which a 5NM minimal separation is required, and that
they believe will lead to an undesirable is not a situation in which a controller will consider a short
line up for the next aircraft in a busy sequence. (And yes, the
safety-related outcome. report confirms that the 5NM wake turbulence separation
minimum was not breached with the accident aircraft.)

None of this interferes with the theme of inevitability which What I accept to be correct in Sidneys text is that at EHAM,
comes across in Professor Dekkers piece which is over-fo- the controllers have drifted into believing that vectoring air-
cused on the role of the initiating radio altimeter malfunction craft to intercept the LLZ close to the GP interception point
(which the crew were aware of) and provides, at best, a rather is normal, rather than giving them a 2NM level flight on the
idiosyncratic view of the descent into disaster and at worst, a LLZ before the GP comes in (as is stated in the procedures).
rather irrational one. I will close by quoting from the Official This modified interception point however is more or less the
Report : position that pilots fly to themselves when they are cleared
for a do it yourself ILS interception. Furthermore, pilots
When the aircraft passed 1000 ft height, the approach was not (when asked) often indicate that a 6NM final is sufficient,
stabilised so the crew should have initiated a go around As the so controllers have adapted their vectoring accordingly over
airspeed continued to drop, the aircrafts pitch attitude kept in- the years. I suppose a psychologist could rightly call this nor-
creasing. The crew failed to recognise the airspeed decay and the malisation of deviance.
pitch increase until the moment the stick shaker was activated.
Subsequently the approach to stall recovery procedure was not In the simulator Sidney quickly detected the anomaly be-
executed properly, causing the aircraft to stall and crash. It was tween the two automated systems, yet in the accident aircraft
also noted that despite the indications in the cockpit, the cock- three pilots sadly did not respond timely to similar clues on
pit crew did not notice the too big decrease in airspeed until the the flight deck. Not reacting to anomalous calls and signals
approach to stall warning. With the cockpit crew - including the from a radar altimeter because it does that all the time is I
safety pilot - working to complete the landing checklist, no one guess another example of normalisation of deviance.
was focusing on the primary task: monitoring the flight path
and the airspeed of the aircraft. It can thus (also) be concluded In my opinion, the real message from Sidneys text is that
that the system based around the presence of a safety pilot on both controllers and pilots need a more comprehensive un-
board.did not function effectively. derstanding of the importance of stabilised approaches.

HindSight 12 Winter 2011 11


THE VIEW FROM ABOVE

Do runway excursion accidents


necessarily have precursors
in lesser events?
By Captain Ed Pooley
It is generally considered that one of the ways to reduce the prospect
of a serious incident or an accident is to ensure that careful attention is
paid to all the lesser events1...

The contributory factors which are But is this always true? I am now go-
identified in these lesser events usu- ing to take a look at one serious run-
Captain Ed Pooley ally involve potential precursors2 of
similar events, including accidents. It
way excursion that happened a couple
of years ago in Denver, USA. Based on
is an experienced airline pilot who for many is also sometimes claimed in reverse what the NTSB investigation3 found
years also held the post of Head of Safety for a that accident investigations will invari- had occurred and what was consid-
large short haul airline operation. ably find that significant elements of ered to have led to it, could this for-
the cause of an accident had visible tunately non-fatal, but nevertheless
He now works as an independent air safety and direct precursors in events with major, runway excursion have been
adviser for a range of clients and is currently less serious outcomes. This model foreseen on the basis of past experi-
acting as Validation Manager for SKYbrary. gives a heavy weight to the identifica- ence of lesser events at either the air-
tion of precursors in lesser events as a line or the airport concerned?
means to accident prevention.
The accident occurred when the pilot
handling the initially uneventful night
take off of a Continental Airlines Boe-
ing 737-500 (the Captain) lost control
near to rotation speed on a take off on
gusty crosswinds. The aircraft left the
runway and careered over 700 me-
tres across mainly flat ground before
coming to a stop. Fortunately, all the
occupants escaped before a fuel fed
fire turned the aircraft into a convinc-
ing hull loss. The result is shown in the
photograph taken from the official ac-
cident report.

1- I define a lesser event as one which excludes a


Serious Incident which ICAO define as one where
an accident nearly occurred and prescribe an
independent investigation under the same Annex
13 procedures as apply to the investigation of actual
accidents.
2- A Precursor is a thing that comes before another
of the same kind (OeD)
3- http://www.skybrary.aero/index.php/B735,
Photograph taken from the ocial accident report _Denver_uSA,_2008_(WX_HF_Re_FIRe)

12
THE VIEW FROM ABOVE

The precise wind


velocity to which an
aircraft was actually
exposed can only be
discovered by referring
to the aircraft flight data
recorder after a flight.
There is no readout of it
on the flight deck.

Although not all aircraft manu- direction (and that in the northern
facturers stipulate a maxi- hemisphere, the instantaneous wind
mum crosswind component direction can be expected to back
permitted during a take off if the speed increases and veer if
There are a couple of interesting things or a landing in a particular type the speed decreases). Most pilots
about Denver (apart from the unusual (Boeing did not do so for any of will be aware that there are
design of the main terminal build- their aircraft types at the time formalised requirements
ing) that some readers may be aware of this accident), to declare the range
of. The first is that it is situated at an such limits
abnormally high altitude for a major are likely
commercial airport of over 5000 ft amsl to be in-
and the second is that it is well known cluded un- of wind directions and
to be subject to mountain wave condi- der Limitations wind speeds either side of
tions as a result of its proximity to the in the applicable Operations` Manual the mean, once either exceeds an officially
Rocky Mountains. Although the first current at the time and the figures for specified threshold of variation. They will
has a significant effect on aircraft take take off and landing may be slightly be grateful for ATC services which pre-empt
off and landing performance, it had no different. The question of whether it is their questions about wind velocity variation,
relevance to the accident we are look- probable that any take off or landing but ready to ask for what has not been of-
ing at the aircraft was about to get can be made without exceeding those fered already and, in the context of what they
airborne about half way down the run- limits is not a matter of measurement. know, is needed to complete the picture.
way. The second, however, is the cause The precise wind velocity to which an
of interesting wind velocity variations aircraft was actually exposed can only What about ATC and the information they
at Denver and has led to the setting be discovered by referring to the air- pass on about the wind? It will not be the
up of one of the most comprehensive craft flight data recorder after a flight. wind velocity where the aircraft actually
integrated systems for the tactical mea- There is no readout of it on the flight is or is soon going to be. Instead, it will
surement of low level wind velocity in deck. So what the pilot normally ex- be a modest selection of the most use-
the world. ATC see summaries of this pects is to receive from ATC, by ATIS ful data which will inform the decision of
and other information as well as hear or directly, the available and relevant whether the imminent landing or take off
any pilot reports and are then faced information about the actual wind ve- should be executed. Most ATC TWR Units
with the decision of how best to give locity which has been recorded in the are good at ensuring that the pilot has
pilots useful information when they are general vicinity of the runway con- the best available information. Some tend
about to make a take off or landing. cerned in the past few minutes. They to respond to requests from the pilot but
will be aware that in gusty conditions, many do not wait to be asked but proac-
Lets look briefly at the matter of main- a change in the spot wind speed can tively offer what they have and keep it up-
taining directional control of an aircraft be expected to be associated with a dated until the actual take off or landing is
in strong and variable crosswinds. simultaneous change in the exact wind in progress.

HindSight 12 Winter 2011 13


THE VIEW FROM ABOVE

Do runway excursion accidents necessarily have precursors in less serious events (contd)

The investigation into the Denver accident found The (unanticipated)


that the probable cause of the accident was: wind velocity conditions
encountered exceeded
The Captains cessation of right rudder
input, which was needed to maintain di-
very rarely. With regard to the perfor-
mance of the flight crew, no precursor
the ability of the pilot
rectional control of the airplane, about 4
seconds before the excursion, when the
from a lesser events was found for this
accident, only that it had occurred in
involved on the day but
airplane encountered a strong and gusty the context of insufficient training for not the capabilities of
crosswind that exceeded the Captains
training and experience.
circumstances which, in detail, were
always going to be rare.
the aircraft.
It also established that: The investigation also wind velocity which they had access
Performance calculations indicated
that the airplanes rudder was capable
noted that: to. Of course if there are procedures
to guide the designation if active
of producing enough aerodynamic (1) Mountain wave conditions were runways, then they must take proper
force to offset the weathervaning ten- present at the time of the accident and account of likely crosswind compo-
dency created by the winds the air- resulted in strong westerly winds and nents. Those at Denver did not. Fur-
plane encountered during the accident very localized, intermittent wind gusts thermore, if there are procedures to
takeoff roll. as high as 45 knots that crossed the air- guide the selection and transmission
planes path during the takeoff ground of observed wind velocities to aircraft
In other words, the (unanticipated) roll. about to land or take off, then these
wind velocity conditions encountered must guide controllers on the opti-
exceeded the ability of the pilot in- (2) The TWR ATCO did not.provide mum selection of wind velocity data
volved on the day but not the capa- information about the most adverse to be given to a pilot. Those at Den-
bilities of the aircraft. Despite the fact crosswind conditions that were dis- ver did not. The recommendations
that the actual (momentary) crosswind played on his ribbon display terminal; provided procedural fixes to both is-
component at the point where control therefore, the pilots were not aware sues but again no specific precursors
was lost was estimated to have been of the high winds that they would en- were identified in any previous lesser
at least 10 knots greater than the ap- counter during the takeoff roll. events.
plicable Operations Manual limitation.
It was observed in the probable cause (3) Other airplanes departed on run- The simple fact is that a take off suc-
statement that the specific training ways 34L and 34R before the accident cessfully accomplished in challenging
and experience of the pilot had not ex- pilots departure; the pilots of those crosswind conditions leaves no trace.
posed him to a comparable challenge departing airplanes did not report any In such an accident, there were never
in the past and that, by implication, crosswind-related issues or difficulties going to be any Aircraft Operator or
this had increased the likelihood of the ATC precursors in lesser events and
handling error which directly led to the (4) Currently, the Denver International so in this example at least, the case is
accident. Airport air traffic control tower runway made. I would suggest that it invites a
selection policy does not clearly ac- deeper review of how we can enhance
The investigation concluded that the count for crosswind components when accident prevention without relying
main way forward regarding flight selecting a runway configuration. so heavily on the database of lesser
crew skills was to use a higher fidel- events to inform risk assessment. But
ity training simulator , so that pilots Although there was no general evi- thats for another timeand it is not
could be exposed during training to dence of especially challenging cross- in any way a general argument for not
the full range of anomalous surface wind conditions at the time, ATC did seeking to collect data on lesser events,
wind velocity conditions which they not pass the accident aircraft all the for which there are many other sound
may possibly experience, even if only potentially useful information on justifications.

14
121.5 - SAFETY ALERTS

RequeSt FOR SuPPORt MeSSAGe

IFR Aircraft Operations


Below RVR Minima
Hello,

My name is Richard Sid Lawrence


and I would like to introduce myself as the new
face of the EUROCONTROL Safety Alert service. Synopsis
Published 15 March 2010

it has been reported that in one European state, aircraft sometimes approach
I joined EUROCONTROL in 2006 having served in the
and land despite the reported RVR at the destination aerodrome being lower
UK Royal Air Force as an air traffic controller at home than the applicable minima for approaches/landing given in EU OPS 1,
and abroad in a career spanning 29 years. Since Appendix 1(Old) to OPS 1.430.
arriving in Brussels, I have worked as a coordinator
for the European Safety Programme for ATM (ESP) The purpose of the Request for Support message was to invite air navigation
covering a wide range of ATM safety-related issues. service providers and aircraft operators to share their experiences and good
As well as my work coordinating EUROCONTROL practices related to the topic.
Safety Alerts, I am also the EUROCONTROL Call Sign
Similarity Project Manager.

Regular readers will know that a selection of the


latest Safety Alerts is featured in this magazine.
Analysis
Im pleased to continue with this convention. The conduct of Low Visibility Operations is detailed in EU Ops 1. The State in ques-
In the pages that follow, my aim is to take you tion had not established and published the lowest aerodrome operating minima
for its aerodromes - EU OPS 1, OPS 1.430 only says that, Such minima shall not be
through the Alerts that are of interest to you.
lower than any that may be established for such aerodromes by the State..
Unlike in the past when the emphasis was on a
faithful reproduction of the Alerts, my intention is Consequently, its air traffic controllers are not aware of such limitations i.e. that
to try and bring new information to the table. for each instrument approach at a particular aerodrome there is a minima which
So this section will feature more in the way of no operator should go below. Furthermore, the controllers do not have in place a
feedback, responses, comment and analysis procedure(s) to act as a safety check when a commander decides to commence an
related to each Alert. approach to land when the reported RVR is less than the specified Minima.

If you would like to know more about the UK CAA/NATS AIC 100/2006 provides details of how the UK applies the concept of
EUROCONTROL Safety Alert service, register as Absolute Minima RVR for certain types of operations.
a subscriber, submit a suggestion or have a
subject that you wish to consider for a Safety
Alert then please contact me at
Assumptions
richard.lawrence@eurocontrol.int.
n Controllers are not permitted to prohibit a pilot from making an instrument
approach other than for traffic reasons. The final decision to commence an
The first Safety alert to be reviewed is a Request for

Support Message - IFR Aircraft Operations Below
RVR Minima...
n
approach in specific weather conditions rests solely with the commander of the
aircraft.

Controllers are not responsible for determining, passing or enforcing com-


manders mandatory aerodrome operating minima.

Alternatively, register your interest through the EUROCONTROL Website - Safety Alerts Board
http://www.eurocontrol.int/safety/public/standard_page/safety_alert_board.html
or go to SKYbrary:
http://www.skybrary.aero/index.php/Portal:EUROCONTROL_Safety_Alerts
to access the Alerts featured here and all previous Alerts.

16
121.5 - SAFETY ALERTS

Support requested dents that the controllers responsi-


bilities vis-a-vis the decision of a pilot
It is important to recognise that an
ATC clearance to land is not an in-
to continue an approach (or take-off )
ANSPs and aircraft operators were struction. As described in PANS ATM
should be limited to providing the RVR
invited to respond to the following 4.5.1., Clearances are issued solely
values and ensuring that the runway sur-
questions: for expediting and separating air
face is clear of obstructions.
traffic and are based on known traf-
What should controllers do when a fic conditions which affect safety in
n A similar understanding is apparent
commander indicates that he/she aircraft operations. In the case of a
from the responses from the ANSPs: i.e
intends to commence an approach landing clearance this means that the
controllers are only obliged to pass the
when the reported RVR is below the controller has taken the necessary
weather information, ensure the runway
lowest minima for that aerodrome/ actions to ensure that the runway is
is clear and then carry on controlling as
approach? clear and that safe separation can be
normal. The view was also shared by two
What are your practices in dealing maintained from other traffic. The pi-
n National Aviation Authorities:
with this issue (can also apply to take- lot is not bound to comply with the
off )? clearance (if for instance the weather
With specific regards to RVR minima
conditions prevent a landing) but
it was also clear to respondents that
Additional Considerations: should inform the controller if they
this is the responsibility for Aircraft
do not intend or cannot execute it.
Operators and pilots and not ATC. Not-
The following considerations could in- withstanding this, one ANSP has intro-
form responses: Moreover, ICAO PANS ATM, 4.5.1.3,
duced a warning to be broadcast on
clearly identifies where the division
ATIS during Low Vis Ops: Attention,
The need for States to establish and of responsibility/accountability is be-
n crews of arriving traffic, check your
publish RVR Minima for all instrument tween ATC and the pilot-in-command
landing minima. Whilst another ANSP
approach procedures at aerodromes. regarding the execution of issued ATC
respondent stated that perhaps ATC
The requirements for controller clearances. [EUROCONTROL emphasis
n should remind pilots to remember
awareness and training regarding in bold and underline text]
[check] your minima.
RVR Minima.
n Controller responsibility/authorisa- Landing Clearances n 4.5.1.3 The issuance of air traf-
tion regarding the issuing of landing fic control clearances by air traffic
clearance when the reported RVR is With regard to the responsibility (and control units constitutes authority
below the RVR Minima. possible liability) of controllers issuing for an aircraft to proceed only in so
n The need for controller procedures landing clearances to aircraft they know far as known air traffic is concerned.
and associated phraseology. (or suspect) are operating below any es- ATC clearances do not constitute
n The requirements for controller re- tablished RVR minima, there were mixed authority to violate any applicable
porting of LVO related occurrences. responses. In some cases it was sug- regulations for promoting the safe-
gested that ATC should offer conditional ty of flight operations or for any oth-
er purpose; neither do clearances
Feedback and or discretionary clearances: e.g. clear to
land at own discretion. relieve a pilot-in-command of

responses
any responsibility whatsoever
Whilst others state that in line with the in connection with a possible
principle that it is ultimately the aircraft violation of applicable rules and
A total of 24 responses were received: commanders responsibility, the control- regulations.
8 from ANSPs, 13 from Aircraft Opera- ler should issue a normal landing clear-
tors/Associations and 3 from National/ ance providing the runway is clear and
Regulatory Aviation Authorities. The re- traffic permits: Thus, there should be no need for con-
sponses also included detailed extracts trollers to issue discretionary type land-
from one national AIPs and one Aircraft ing clearances. Controllers can issue a
Operators operations manual dealing EUROCONTROL notes: normal landing clearance once they
with RVR Minima. have fulfilled their safety and traffic
This theme is taken forward in ICAO responsibilities the decision to exe-
All respondents to the RFS agreed that PANS ATM 7.10.2. which states, An cute that clearance is solely the pilot-in-
the Assumptions in the RFS were correct. aircraft may be cleared to land when commands taking into account, inter
It is clear that the division of responsibili- there is reasonable assurance that the alia, any minima (including RVR) that are
ty between the cockpit and control room separation in 7.10.1, or prescribed applicable.
is well understood. in accordance with 7.11 will exist
when the aircraft crosses the runway The complete Summary of Responses
There was unanimous agreement threshold can be found on the SKYbrary Book-
amongst the aircraft operator respon- shelf.

HindSight 12 Winter 2011 17


121.5 - SAFETY ALERTS

SAFetY WARNING MeSSAGe

Emergency descent in high


traffic density situations
Published 22 July 2010
ICAO Provisions
Purpose According to ICAO PANS ATM, 15.1.4: Upon receipt of advice that an aircraft is
making an emergency descent through other traffic, all possible action shall be
taken immediately to safeguard all aircraft concerned. When deemed necessary,
The Safety Warning Message was raised air traffic control units shall immediately broadcast an emergency message.
to highlight the concerns of European
aviation stakeholders related to emer- PANS ATM, 12.3.2.5 specifies the emergency message phraseology: ATTENTION
gency descent, in particular in high traffic ALL AIRCRAFT IN THE VICINITY OF [or AT] (significant point or location) EMER-
density scenarios. GENCY DESCENT IN PROGRESS FROM (level) (followed as necessary by specific
instructions, clearances, traffic information, etc.)

Synopsis With regard to the actions by the pilots-in-command (PIC), PANS ATM 15.1.4.2
states: It is expected that aircraft receiving such a broadcast will clear the speci-
fied areas and stand by on the appropriate radio frequency for further clearances
Existing iCAO provisions describe what from the air traffic control unit.
is expected from air traffic controllers
and pilots in the event of an emergency In addition, the provision 9.1.1.1 of the European Regional Supplementary Pro-
descent, including the option for ATC to cedures, ICAO Doc. 7030, recommends pilots of the aircraft executing an emer-
gency descent to initiate a turn away from the assigned route or track before
broadcast message regarding the
commencing the emergency descent
emergency descent. However, the

Analysis
provisions may, in some circumstances
specific to high density operations, lead
to potential risks for operations and
several European States have therefore A broadcast of a message associated with emergency descent is optional and-
promulgated different national depends on the best judgement of ATC in a given set of circumstances. However,
procedures to be followed. the pilot community expressed a need to be informed of such events especially
with regard to ACAS TAs/RAs that may be experienced when they are in close
proximity to aircraft conducting an emergency descent.

An emergency message broadcast would also be received by aircraft not nec-


essarily affected by the emergency descent. Therefore, unless the emergency
broadcast is appropriately targeted and contains unambiguous instructions,
there is the possibility of aircraft unexpectedly deviating from their track to clear
the specified area which, in areas of high traffic density, has the potential to cre-
ate additional hazardous situations.

In mitigation, several ATS authorities and ANSPs in the EUR Region have published
in their national AIPs, procedures indicating clearly that an aircraft receiving an
emergency broadcast is not expected to leave the specified area, but is to continue
according to their latest clearance unless threatened by immediate danger, and to
stand by on the appropriate channels for specific clearances and instructions.

18
121.5 - SAFETY ALERTS

Whats up guys??
Whats the emergency???

Emerging considerations
It is considered that effective risk management of the emergency descent case
in controlled airspace requires ATM procedures which are at least regionally,
and preferably internationally, defined to a single standard. As described in the
original SWM the matter is under active review by EUROCONTROL Airspace and
Navigation Team in association with the ATM Section of ICAO. Subsequently,
EUROCONTROL has been invited to:

n Develop, as a short term solution, a proposal to amend the European Regional


Supplementary Procedures (EUR SUPPs) (Doc 7030) so as to provide clear and
concise direction to air traffic services and to aircraft when an emergency de-
scent is in progress.

n Develop, as a long term solution, a proposal to amend the Procedures for Air
Navigation Services Air Traffic Management (PANS-ATM) (Doc 4444) so as to
minimise the chance that aircraft notified of an emergency descent will react
in a manner that could create a hazardous situation.

At the time of writing, it was anticipated that any proposals would be considered
by the EANPG COG at its meeting in November 2010.

In the meantime, it is suggested that air traffic controllers:

n Note the potential pilot actions stemming out of the requirements of PANS-
ATM 15.1.4. 2.

n Where practicable, try to provide specific instructions to those aircraft that


would be in direct conflict with the emergency descent aircraft, when it is
judged necessary to broadcast an emergency message.

n Follow national procedures where these are published.

Further Actions and Considerations for ATC can be found in the SKYbrary article Emergency Descent:
Guidance for Controllers at
http://www.skybrary.aero/index.php/Emergency_Descent:_Guidance_for_Controllers

This article also contains links to other training materials:

n EUROCONTROL Guidelines for Controller Training in the Handling of Emergency/Unusual Situations


n Unexpected Events Training

HindSight 12 Winter 2011 19


121.5 - SAFETY ALERTS

SAFetY ReMINDeR MeSSAGe

Abbreviation and Misinterpretation


of Type C R/T Call Signs
Published 5 August 2010

Synopsis Feedback
and discussion
The EUROCONTROL Call Sign n There is no standard policy amongst the airlines on use of leading zeros.
Management Cell (CSMC) had received a Most, however, try not to use them whereas others are more inclined to
number of reports of call sign confusion utilise them if it helps with their commercial flt number allocation or ATC
caused by the incorrect abbreviation or call sign de-confliction.
misinterpretation of some Type C R/T
call signs whose alphanumeric flight n From the available literature on the subject of avoiding call sign similarity/
identification suffixes start with a zero. confusion these additional points (not exhaustive) are worth bearing in
mind:
- Wherever possible try to use no more than 3 digits in the call sign suffix.
- Start the call sign suffix with higher number, e.g. 6.

ICAO provisions
- In accordance with ICAO Doc 8585, try not to create call sign suffixes
ending with a zero (or a 5) to avoid potential confusions with headings,
flt levels etc.
ICAO Annex 10, Vol II, Chapter 5, 5.2.1.7.2.2
states that there is no abbreviated form n The EUROCONTROL Call Sign Similarity Project launched in 2008 aims to
for Type C call signs (i.e. those that are reduce the risks associated with Call Sign Similarity/Confusion through the
formed by the R/T designator of the air- establishment of centralised and co-ordinated actions based around a CSS
craft operating agency (e.g. Highjet), fol- Tool and Service managed by the EUROCONTROL Central Flow Manage-
lowed by the flight identification suffix ment Unit, Call Sign Management Cell.
(e.g. 123A)).
n For more information on the EUROCONTROL Call Sign Similarity Project

Analysis please go to http://www.eurocontrol.int/safety/public/standard_page/


Callsign_Similarity_project.html

In the occurrences that have been report- n or the Call Sign Similarity Management Cell -
ed, the flight identification suffix of the call http://www.cfmu.eurocontrol.int/cfmu/public/standard_page/cfmu_
sign was alphanumeric and had a leading programmes_css.html
zero, e.g. Highjet 045K. These flight iden-
tifiers have sometimes been incorrectly
abbreviated, e.g. Highjet 45K, or have
Further reading
been misspoken as Highjet 405K, which n ICAO Annex 10, Volume II Chapter 5.
has contributed to some crews becoming n SKYbrary - Air Ground Communication Briefing Note No2
confused about which flight is being ad- www.skybrary.aero/bookshelf/books/110.pdf
dressed by ATC.

20
121.5 - SAFETY ALERTS

RequeSt FOR SuPPORt MeSSAGe

Briefing and Provision of


Operational Aeronautical Infor-
mation to Air Traffic Controllers
ICAO provisions Feedback and
Published 20 August 2010

Purpose discussion
Other than some very generic advice
in ICAO Doc 9426, ATS Planning, there
are no other known specific require- A total of 18 responses were received:
The purpose of this Request for Sup- ments/standards related to the type 14 from ANSPs, 2 from ATC Associations,
port message (RFS) was to gather and format of the aeronautical infor- and 2 from aircraft operators.
good/best practices associated with mation that should be displayed to
the briefing and provision of opera- controllers when they are at their op- As anticipated, it was evident from the re-
tional aeronautical information to air erating positions. plies from ANSPs that a variety of methods
traffic controllers, both before and are used to brief controllers prior to their
after they assume responsibility for a
particular control position. Analysis undertaking operational control tasks.
These include:

Synopsis
The timely and accurate presentation n Verbal briefing by Supervisor/manager.
of operational aeronautical informa- Military ANSP includes aircrew.
tion is clearly safety related. ATCOs n Electronic self-briefing
need access to it to permit them to n Email, internet
A European ANSP has received safety assess situations and adjust their con- n Written documentation (AIP AMDTs,
reports regarding a lack of operation- trolling actions accordingly. The spe- NOTAMs etc)/Checklists/Information
al information (e.g. NOTAM, airspace/ cific briefing actions that should be folders/Staff Notices etc
procedure changes etc) available at taken at each unit and at each oper-
controller working positions (CWP). ating position vary according to local For the provision of operational safety-
The ANSP was conscious that it ANSP needs. related aeronautical information at con-
perhaps could adopt the good/best troller working positions (CWP) there was
practices used by other ANSPs and it again a mixed-bag of responses:
is hoped that the feedback informa-
tion will help them in their quest to Support n Electronic Support Information Retriev-
improve their processes/facilities in
due course. requested n
al type systems
Paper NOTAMs (Note: One ANSP had
recommended that details of certain
Air navigation service providers were activities (e.g. gliding areas) that are de-
asked to provide brief details of how fined by list of coordinates should also
they disseminate operational aero- be made available to controllers at their
nautical information to ATCOs and in CWP in graphical as well as written/text
particular if this is delivered/accessed form.
via electronic self-briefing facilities n Supervisor support.
and/or is presented in electronic for-
mat to controllers at CWP.

HindSight 12 Winter 2011 21


121.5 - SAFETY ALERTS

SAFetY ReMINDeR MeSSAGe

Operation of SSR Mode C


by General Aviation VFR
Recreational Flights
Published 13 October 2010 Guidance on the operation
Synopsis of SSR Mode C
Guidance on the operation of SSR Mode C is covered, inter alia, in:
n ICAO Doc 8168, PANS OPS Vol I, 1.1.3;
A European ANSP requested that pilots n European General Aviation Safety Team (EGAST) Collision Avoidance Safety
of General Aviation (GA) VFR recreational
Promotion Leaflet (GA1);
flights are reminded of the positive safety
n EUROCONTROL Guidance Notes for GA Pilots, No 11, Getting the Most from
effects that the operation of SSR Mode C
Your Transponder;
(when fitted) offers themselves, other
n National AIPs which in some states mandates the operation of Mode C
airspace users and ATC/FiS providers.
(and in some cases Mode S) when flying VFR outside CAS.

Analysis Feedback and Further reading


Notwithstanding any local differences
notified in National AIPs for the car-
discussion n ICAO Doc 8168, PANS OPS Vol I.

riage and operation of transponsders, Although only very limited feedback n EGAST Collision Avoidance Safety
it is generally recognised that, when was received following publication, Promotion Leaflet (GA1) - www.
fitted and operated, the use of Mode there was strong support for this easa.europa.eu/essi/egastEN.html
C (verified or un-verified), provides the message from a range of organisa-
following safety benefits: tions (e.g. IATA and IFATCA) during the n SKYbrary:
pre-release consultation process un- - EUROCONTROL Guidance Notes
n It preserves the full effectiveness of dertaken before the circulation of all for GA Pilots, No 11, Getting the
Safety Nets such as Airborne Colli- Safety Alerts. Most from your Transponder -
sion Avoidance Systems (ACAS) and http://www.skybrary.aero/book-
ground-based ATC Short Term Con- shelf/books/714.pdf
flict Alert (STCA): - Safety Nets - http://www.sky-
brary.aero/index.php/Safety_
n It also helps controllers and Nets
flight information officers
to enhance the level of n Netherlands AIC A01/10 Impor-
service they can provide to tance of Selection of SSR Mode C
all users. Regarding Collision Avoidance. -
http://www.eurocontrol.int/msa/
public/standard_page/modes_
aics_netherlands.html

22
EXPECT THE
UNEXPECTED!

SAFETY ALERTS
Keeping Your Heads Up!
All EUROCONTROL Safety Alerts available on:
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121.5 - SAFETY ALERTS

SAFetY WARNING MeSSAGe

FANS CPDLC Erroneous ATC


Log Data Presentation

Purpose
Published 22 July 2010 Based on the provided traces, no
CPDLC Clearance to Climb was ever re-
ceived on board the A330. In addition,
all CPDLC Climbing Requests had been
The purpose of the Safety Warning Message was to warn about incidents refused by the ATC DUE TO TRAFFIC.
involving potential erroneous presentation of ATC LOG data to flight crew Analysis of the traffic logs show that
while in Oceanic FANS CPdLC operation. neither a jump in the ATC message se-
quence number, nor communications
issues nor any reset of the FANS system

Incident No1 issued by the Oceanic Ground System


and it is purely coincidental that the
clearance came back for FL360. At the
occurred in flight.

There is no known issue of any ghost


A recent incident occurred where a time of publication (June 2010), the messages on the aircraft manufacturers
(data link) message to climb may have airframe producer provided some ini- FANS system. The standard ATC answer
been sent to an aircraft without the tial advice to aircraft operators. How- to a climb request is CLIMB TO & MAIN-
ANSP Oceanic Ground System initiat- ever, following investigations by Air- TAIN FLXXX. No such message was ever
ing it. The crew had requested FL360 bus, this advice has been superseded received on board.
and they were then presented with and new information was posted on
a message giving them clearance to the Safety Alert and advertised via a To avoid any confusion between a clear-
climb to FL360. However, the clearance SKYbrary Highlight in October 2010. ance received and displayed on the dedi-
message was one that had not been This information is provided below. cated screen (DCDU) upon reception and

24
Feedback and
discussion
This is a complex issue involving ANSPs,
aircraft operators and aircraft manufacturers.

Following the investigation of Incident No 1,


the occurrence was discussed by the ICAO
an old clearance (already treated) that that unit and can appear on a later North Atlantic Communications, Navigation
can be consulted on the MCDU (totally flight of that aircraft. Consequently, and Surveillance (NAT CNSG) in September/
different from the DCDU) Message Re- the ANSP was informed by the air- October 2010. The Group noted that the in-
cord page, a training emphasis has been frame producer that it had advised vestigation had not found any evidence to
issued by the aircraft manufacturer (Air- aircraft operators of this potential explain the unauthorised climb. Numerous
bus) to its customers. SOP amendments problem. bench tests and flight tests had been car-
are currently considered in operational ried out to reproduce any undue display of
documentation (FCOM, QRH handbook). We are aware of a problem where wrong clearance.
Further improvements are however being ATC LOG data from a preceding
implemented in future FANS standards to flight has been retained and later re- The Group surmised that such problem re-
avoid any confusion. presented to the crew in the ATC LOG ports should normally be analysed by the
while in FANS CPDLC operation. The NAT Data Link Management Agency (DLMA)
ATC LOG data is normally cleared ten as it possessed the necessary expertise and

Incident No2 (10) minutes after the FMS transi-


tions to the DONE phase. However,
certain conditions can result in mes-
tools in cooperation with the airframe manu-
facturers to analyse such cases.

The circumstances of incident No 1 are sage retention and display in a sub-


similar to those experienced last year sequent flight ATC LOG.
involving the same ANSP and another
major airframe producer. On that occa-
sion, subsequent investigations found
Moreover, the ANSP advised its
controllers to be aware of this po- Further reading
that if FMCs on some aircraft are not tential phenomenon particularly SKYbrary:
powered down fully after the aircraft if questioned by crew in respect
has landed then, on very rare occasions, of unrequested changes of flight n CPDLC
ATC messages have been retained by profile. n Automatic Dependent Surveillance

Remember, you can be One Click from Safety


See all EUROCONTROL Safety Alerts at either SKYbrary
http://www.skybrary.aero/index.php/Portal:EUROCONTROL_Safety_Alerts
or
The EUROCONTROL Website Safety Alerts Board
http://www.eurocontrol.int/safety/public/standard_page/safety_alert_board.html

STOP PRESS!
The Safety Alert section of HindSight 11, featured the Safety Reminder Message, Own Separation
between iFR Flights in VMC and interaction with ACASii Ops. Since then it has emerged that the
State in question is in the process of revising its Rules of Air so that they will comply with iCAO PANS
ATM 5.9 provisions related to the self separation of iFR flights operating in VMC.

HindSight 12 Winter 2011 25


CASE STUDY

Case Study -
Her new barbecue sauce By Bengt Collin, EUROCONTROL

The Air Hostess nearby. Ten minutes later, as quickly as discrete laugh which he loved, and her
it had started raining, it stopped. Per- jokes were brilliant too! After all, why
Welcome to Angels Town, the local haps it was still possible to have a bar- spoil a great joke with the comment
time is ten past two the air hostess becue later, she wanted to test her new that Sweden actually had produced
stopped talking. The announcement recipe for a barbecue sauce; olive oil, a number of good drivers - it did not
was interrupted by a loud and different garlic, soya, black pepper, topped off seem important.
sound; the aircraft began to move in an with a large glass of Baileys. Yum Yum!
unfamiliar way as it finally stopped. She She planned to use the rest of the small He did not really pay attention to the
got out of her seat, nobody said any- bottle as a refresher while barbequing. traffic on his screen. Instead, he started
thing; it was like time had stopped, like After all you did not want to dry out thinking about an article he had read
someone had pressed the pause but- completely, she thought and smiled. somewhere the other day, an article on
ton. Through the window to the right runway excursion. It obviously caused
she could see the terminal building The D-line Captain a number of fatalities each year; he did
far away, suddenly the captains voice not know the magnitude of the prob-
came over the PA system, focused and They had been discussing the roster in- lem, they never discussed it at work.
clear evacuate, unfasten seat belts, tently. Why do I always have to sleep Some pilots obviously could not land.
evacuate, a brief irritating noise fol- away from home on Friday nights? the He had some pilot experience of his
lowed the message and then the pre- first officer complained. own; he did five hours in a Piper Chero-
recorded message repeated what the Someone has to do it the captain kee some ten years ago. Could it be so
captain had just said; they opened the replied. I am always off on Fridays. complicated to land an aircraft safely?
doors and over wing emergency ex- Thank God its Friday is my motto, he He had been sent to a conference the
its laughed, but the first officer did not. other week to gather some information
Have you checked the weather? the on the subject, but it was really disap-
The Tower Controller captain asked. pointing. The subject was Runway
Yep, 270/11 CAVOK +20. Perfect for excursions the way forward, but al-
It had been a lovely summer evening barbecuing the first officer replied. ready in the opening speech the scope
until it started raining. The heavy show- Should we ask for straight in runway was reduced to how to standardise the
er hammered down noisily and all out- 12? measurement of braking action. He
side life looked miserable and very wet. Were a bit high but, OK, why not re- could not understand why, as this was
With the visibility in all directions plied the captain. only one of many minor contributing
reduced, it was like mist. She factors all completely overshadowed
did not really care, no arrivals The Approach Controller by other more significant ones. One
presentation after the other followed,
He was reading the morning paper sometimes briefly interrupted by com-
even though this was not allowed ments from participating pilots. The
Bengt Collin when in position. He did not care, this minutes and summary were probably
works at EUROCONTROL was a widespread habit and no one written before the meeting and every-
complained. To the right of him worked body just had to stick to them. At the
HQ as an Senior Expert
Beate, a smart and good looking con- end of day two, the way forward was
involved in operational
troller with a great sense of humour. decided, on the way home he could not
ATC safety activities.
Do you know why Swedes can never remember what the decision was.
become Formula 1 drivers? she asked.
Bengt has a long background as Tower and Because they return to the pit stop Beate left for a coffee, two aircraft were
Approach controller at Stockholm-Arlanda after each lap and ask for directions inbound, a B-line a long distance away
Airport, Sweden she continued without waiting for his towards the South East, the other one
answer. She laughed - a bubbling but a D-line arriving from the North West.

26
Youve promised me a one day excursion...
NOT A RUNWAY EXCURSION!

Runway 30 was in use with no depar-


The Approach Controller
tures scheduled for the next twenty
minutes. It was difficult to decide who He was just about to turn D-line for a
should be number one, probably the long final runway 12 when one of the
B-line but D-line was faster. He thought pilots asked for an extended routing.
that it was always easier when the traf- Why did they not think about that
fic is more intense to stop thinking and before, now there could be a conflict
act on your instincts instead. Why not between the two flights approach-
offer D-line a straight in Runway 12? ing opposite ends of the runway. He
That should solve the conflict between approved the extra turn, waited and The D-line Captain
them. The standard culture when work- waited before turning D-line back to-
ing on approach control included of- wards final for Runway 12. The aircraft He turned right towards final for Runway 12,
fering short cuts and diversions from turned very slowly, reduced speed they were still well above the glide path, with
standard routes. He was sure the flight so much that it almost stopped. De- gear down and flaps 3 selected. The speed
crews liked it, not that he had talked to scend to 2000 feet and keep the speed was still too high, flaps all the way he request-
anybody about it, he just knew. Is run- up, youre number one. The aircraft ed; and take care of the EGPWS warning he
way 12 available? one of the flight crew would join final inside 6 miles from quickly added in a friendly way. The Approach
at D-line suddenly asked, as if reading touch down but at least it would prob- Controller called, the wind had increased; no
his mind. Stand by he answered and ably not be in conflict with B-line. D- problem he told the first officer, I landed here
started to coordinate with the Tower line did increase the speed. before you were born, the runway is long
Controller. enough. They continued the approach, were
The Tower Controller told to contact the Tower and got visual con-
tact with the runway straight ahead, how he
The Tower Controller She finished her salad and sat down loved coming home to Angels town. Passing
Sure no problem, straight in runway 12 in front of the computer intending 500 feet the aircraft was still not properly sta-
is approved. We have a few Cbs around to write the new weather report. Fol- bilised but he had full control and had been
but they shouldnt interfere with the lowing the heavy rain a few minutes cleared to land with speed OK. Passing the
final. I will fix a new met report soon, ago she noticed that the wind had in- threshold, twenty, ten, the metallic voice was
just so you know, only need to finish creased, it was now almost 20 knots too loud he thought, still not on the ground,
my late lunch first. My colleague just from North West. She started typing they finally touched down almost half way
went down to buy a newspaper, have but stopped. Better inform approach. down the runway, full reverse selected, the
to do everything myself as usual she She pressed the intercom button while auto brakes started working.
laughed. Are you having a barbecue she discretely held back an imminent
tonight by the way? I have used a new and unexpected burp. The Tower Controller
sauce recipe if youre interested. Talk to
you later she finished the conversation The Approach Controller The aircraft almost didnt land; finally it
without waiting for his answer and con- did and started braking. She had observed
tinued with her salad. Turn right heading 090, cleared ap- the same situation before, you think the
proach runway 12. aircraft will not stop before the end of the
The D-line Captain Tower wait I have traffic. The aircraft runway but it always does. She was very
OK perfect, straight in runway 12 will read back and turned towards five surprised when it almost stopped but then
save us a lot of fuel. Were a bit high. miles final. Tower what did you say? continued slowly off the paved surface and
Please ask approach if we could make OK I will give him the new wind. OK, onto the grass area beyond. Perhaps bet-
a delaying turn to lose some height. thanks. ter postpone the trial of my new barbeque
Ill tell the passengers, the cabin crew D-line, the wind has increased, new sauce she though as she pressed the alarm
need to hurry up, your controls. wind 310 degrees 18 knots. button.

HindSight 12 Winter 2011 27


CASE STUDY

Case Study Comment 1


by Dragan Milanovski
Could it be complicated to land an aircraft safely?

Well, we all know that although it might be complicated to land an


aircraft safely, it is achievable with rare exceptions. This case study
describes one of these exceptions, where a landing aircraft failed to
stop before reaching the end of the runway.

One might argue that the approach request, when that might not be abso-
controller was not busy and was not lutely necessary, or at least not neces-

Dragan Milanovski focused on handling the traffic (lovely


colleague with good sense for humour;
sary all the time or at such high speed.
Specifying the speed and the limit is
is ATC training expert at the EUROCONTROL reading a newspaper when in position; usually a better solution. Nevertheless,
Institute of Air Navigation Services in thinking about the conference) and he I think the controller acted according
Luxembourg. had too much time to think about the to the standard culture like every other
two aircraft he was controlling. If the controller on any other day so far.
Most of his operational experience comes from traffic was busy he might have had to
Skopje ACC where he worked for a number of deny the pilots request for straight-in Then the vectoring for approach was
years on different operational posts. approach runway 12. Maybe we will done under pressure to shorten the
Now, his day-to-day work involves ATC training never know. D-Lines track distance and the aircraft
joined final inside 6 miles from touch
design as well as Initial Training delivery for
The captain was aware that the aircraft down. Although this is not recommend-
Maastricht UAC.
was a bit high and that he would need ed, it is also one of these things that hap-
to do something about it and so he pens almost daily and usually they end
asked for delaying turn. However, this safely. The approach controller failed to
was not the approach controllers ex- recognise that there were too many fac-
The D-Line crew was returning to An- pectation; he was trying to get the D- tors working hand-in-hand and maybe
gels Town, which was a familiar place Line out of the way of another aircraft; vectoring inside 6 miles to intercept the
to them, on a lovely summer evening so he decided to put on some extra glide path from above was not a good
where the weather seemed to be per- pressure by asking the D-Line captain idea on this occasion. Bearing in mind
fect for barbecuing. It all started when to keep the speed up. It is important to that they never discussed runway excur-
the captain accepted the first officers mention here that the complexity of hu- sions at work and that he did not know
suggestion to ask for straight-in ap- man relations could also have played a the magnitude of the problem, this is
proach runway 12. If it wasnt for the first significant role. I am guessing that the not a surprise.
officers idea it would have probably captain was probably thinking that the
been suggested by the approach con- controller had done him a favour by ap- In the meantime, the surface wind
troller. Pilots ask for shortcuts / directs proving the straight-in approach and he changed significantly. When the cap-
/ straight-ins on a daily basis. Control- needed to keep the speed up in return. tain was informed about the new wind,
lers standard practice includes offering He did not know exactly what speed he did not react at all; his mind was set
shortcuts and diversions from standard was required to solve the problem nor and committed on landing the aircraft.
routes especially when this helps solv- for how long he needed to maintain it. The first officers call that the wind had
ing conflicts and improves sequencing. In these circumstances, the captain will increased was dismissed relatively easily
Overall, it leads to fuel saving and more probably stretch it to the maximum, by the captain who intimidated the first
efficient utilisation of airspace. I dont hoping not to disappoint the guy who officer (I landed here before you were
think that it was a factor in this case. did not think twice before approving his born). It also looks like the crew was not

28
CASE STUDY

aware of the recent heavy rain and the with standing water (reduced breaking at that point. The D-Line company will
fact that the runway was wet and prob- action). Failing to stop at the end was have to do some work on strict enforce-
ably contaminated with standing water. the likely outcome. ment of stabilised approach criteria.
Although the tower controller was a bit
late with fixing the new met report, the
Why? What made the
information about the wind change did difference this time? RECOMMENdATiON
reach the crew in time. Can we blame It seems that this is another story where
her new barbecue sauce for keeping everybody involved was doing what The ATC establishment in this story
her thoughts elsewhere? No, I do not they usually do. There were several ma- needs to increase the awareness of
think so. It was business as usual I would jor and few minor factors (mentioned runway excursions, as well as aware-
say. It is normal to think of other things above) that were contributing to each ness of control actions which can
when you are sitting in a position with other and all were working in the same contribute to unstabilised approach-
low (or no) traffic. Eating her lunch while direction. There were many chances to es. i recommend a small training
working, well I would not do it. I like to alter the outcome of this event by tak- package comprising of all the main
enjoy my lunches. ing a different course of action, but it did and contributing factors, with a few
not happen. The last and most crucial case studies that illustrate typical
The aircraft touched down almost half took place when the captain decided scenarios alongside the associated
way down the runway (beyond the nor- to continue approach after passing 500 risk mitigation techniques, to be in-
mal touchdown zone) with significant feet above ground level with his aircraft cluded in the refresher training for
tailwind (excessive ground speed) on a still not properly stabilised on approach. air traffic controllers.
wet runway and probably contaminated He should have decided to go around

Case Study Comment 2


by Captain Ed Pooley
The outcome here could have been a lot worse, just a little bit faster off
the end and a few obstacles and you have a potentially fatal accident

What can we learn from it? The scenario bad habits which normally have no ef- crucial importance when it is. We dont
is not unusual all the actors are doing fect, are ready to line up and create a know if this arose from a breach of
what they normally do with a universally potential accident and then help ensure D-Line SOP or whether they had
relaxed approach on a day when all the that it becomes one. failed to specify or train the right
equipment is working normally and the
weather is nothing special. The control- Lets start by commenting on the end-
lers are reading the paper or letting their
minds wander a little and the flight crew
game. The air hostess (with that title,
our author is either betraying his years
Captain Ed Pooley
talking intently about one of the two fa- or watching too many old films!) started is an experienced airline pilot
vourite routine concerns of all flight crew her arrival PA prematurely, before the who for many years also held the post of Head of
rosters (the other is crew meals!). All aircraft has cleared the landing runway. Safety for a large short haul airline operation.
the players were in underload which She switched too early from her primary
can be as risky as the more complained- safety role to her secondary customer He now works as an independent air safety
about overload and experience has service role. Not difficult to do really in- adviser for a range of clients and is currently
shown this. It is just these circumstances sofar as the safety role of cabin crew is acting as Validation Manager for SKYbrary.
where complacency easily creeps in and rarely called for despite often being of

HindSight 12 Winter 2011 29


CASE STUDY

Case Study Comment 2 (contd)

timing of the post-landing change of role cific conditions on the D-Line straight in breached by a captain fully overcon-
emphasis, but either way this needs fixing clearance, the Approach Controller then fident about his skills without even a
for the day when the outcome is less be- acceded to the request for a track miles comment from the monitoring pilot.
nign increase rather than review the initial Of course, such interventions against
straight in clearance. He decided that it the flight deck authority gradient are
Now to the developing accident sce- would probably not be in conflict with never easy - but it is every operators
nario. Flight crew these days are pre- B-Line job to make sure that they can, and
programmed to carefully consider op- do, happen whenever the need arises
portunities to get to their destinations as Of course, pilots are often their own and that critical SOPs, such as stabi-
quickly as possible while also using the worst enemies. By nature and training lised approach gate criteria, are never
least possible fuel. The days of automati- they are can-do people who sometimes breached.
cally maintaining maximum speed are temporarily vacate the middle ground
gone - fuel use considerations must also between the extreme version of can-do
RECOMMENdATiON
be taken into account and there are typi- and the extreme version of overcau-
cally also automatic maximum speeds be- tious. Like ATC, the captain is determined ATC helped set up this accident
low FL 100 even before ATC step in with to keep to the original plan it would be but, as is usually the case in human
specific speed control. Finally, stabilised a shame to add ten minutes to the flight factors scenarios, the flight crew
approach gates must be passed with rec- time when it simply wasnt necessary to caused it. Taken together, the poor
ommended and ultimately fixed aircraft do so. decision making and ineffective
state conditions met in order to continue. teamwork on the flight deck and
So the main thing the crews look for is a Neither ATC nor the captain considered the blatant disregard for stabilised
shortened routing as offered on this occa- in advance the possibility of wind ve- approach criteria are unlikely to be
sion by the helpful approach controller locity variations during the approach, a one-off in d-Line. Either the exist-
even before the captain had asked for it! given the Cbs in the vicinity and a wind ing flight operations manager has
already close to the maximum allow- failed to find ways of keeping them-
The actual scenario a judgement call for able tailwind limitation. And when the selves informed about whats really
ATC about whether it would work if the updated wind was passed on, with the happening on the line, or they were
approaching B-Line and D-Line were suf- aircraft already above the ILS glideslope aware and tacitly condoned it. Ei-
ficiently far apart for them to approach and the prospect of an EGPWS activa- ther way, they are clearly past their
and land using opposite directions of the tion growing, the fact that the tailwind sell by date and should be replaced
same runway. The decision to go for this component was now well outside land- by somebody capable of improving
option was based upon some unverified ing limits was either positively ignored the prevailing flight operations cul-
assumptions about the groundspeed and or just passively overlooked by both pi- ture in d-Line - and who will have a
tracks of the two aircraft. Having decided lots. Finally, the mandatory 500 ft stabi- mandate to do this from the d-Line
that it was unnecessary to place any spe- lised approach criteria were consciously accountable manager.

Case Study Comment 3


by Alexander Krastev
Alexander Krastev
works at EUROCONTROL as an operational
safety expert. He has more than 15 years The factor that played a primary role in
experience as a licensed TWR/ACC controller this RE incident is the decision taken by the
and ATM expert. Alexander is the content
manager of SKYbrary. APP controller to permit opposite direction
approaches...

30
Although not a standard practice, op- the clearance. This way the initial plan not question any of the decisions and
posite direction approaches have for to use opposite runways for landing in actions of the pilot-in- command. This
years been an operational practice order to provide optimum flight paths could be explained by his failure to
at many airports. Such approaches to both arriving flights has quickly follow the SOPs or by organisational
were not an exception during my TWR turned into a fast developing situa- factors, such as lack of or inadequate
controller years. However, the inci- tion beyond the chances for effective CRM, inadequate SOPs or even an or-
dent statistics at our ATC unit clearly control by ATC. Perhaps physiologists ganisational culture which tolerates
showed that opposite direction ap- and human factors experts could tell high risk inducing behaviour.
proaches led more often to incidents us what the chance of recognising a
of more severe consequences. The failed plan at an early stage is, but I will There were a number of other risk con-
development and implementation of not bet my dinner on it. tributing factors that, in my view, did
dedicated procedures did not change not play a role in this particular event,
the level of risk significantly. Oppo- The snowball effect of the flawed deci- but are important precursors which
site direction approaches require very sion should not come as a surprise to should be acted upon by manage-
high precision of planning and acting any experienced controller or pilot: ment and staff responsible for safety
both on the ground (by APP control- in an organisation, notably:
ler) and on board (by pilots). Even a n Stress in the cockpit owing to the
small deviation from the estimates can speed restriction late into the ap- n Distraction displayed by the APP
dramatically complicate the situation. proach and late final joining. These controller who was reading a news-
There is very little time to react and are typical contributors to unstabi- paper at his working position
quite limited options to resolve the lised approach. n Unsafe practices at organisational
dangerous situation. That is exactly n Stress in the APP and TWR caused level tolerating reading newspa-
what happened in this story. The APP by the unexpected increase in wind pers in ops room and single man
controllers plan collapsed when the speed and the uncertainty about operation in the TWR (may be in
D-line pilot asked permission for a de- the outcome of this non-routine breach of the operational proce-
laying turn. situation. dures).

The flight crew contributed to the pri- The captains decision to disregard
mary trigger of this chain of events the EGPWS warning and to continue
RECOMMENdATiON
the decision for opposite direction approach despite the aircraft posi-
approaches - by giving the final push tion in relation to the glide path (well How could such incidents be pre-
to the APP controller. Despite being above) and the high tail wind compo- vented from happening? Oppo-
aware that the aircraft was a bit high nent (perhaps exceeding the limits set site direction approaches should
for a straight-in-approach to RWY 12 in the AOM/SOP) made the situation not be permitted unless the con-
the captain agreed to the FO sugges- worse and the unwanted outcome al- cerned flights are separated by
tion. Moreover, one could argue that most sure. Instead of going round, he a safe time/distance calculated
the APP controller was mislead by the decided to land. The unstabilised ap- on the basis of the difference
crew because at the time the FO asked proach supplemented by inadequate between the estimated times of
the permission, the crew were aware assessment of the situation and cap- landing of the concerned flights.
of the need to extend the approach to tains overdone self-confidence led to
lose height. Such a hypothesis stands a long overshoot on landing and even-
on the fact that the crew asked for the tually runway excursion.
extension immediately after getting
the permission for straight in RWY 12. One should not overlook the contri-
butions of the TWR controller and the
The next important stage where the FO to the incident. The complacency
sequence of events leading to the inci- displayed by the TWR controller who
dent could have been broken was the put lunch higher than the profes-
decision point for the APP controller sional obligations in her priority list
whether or not to clear the D-line for a (I could hardly believe this can hap-
delay turn. Without proper assessment pen in reality) led to late notification
of the situation and the potential con- of the APP controller and the crew of
sequences, the APP controller issued the increased wind speed. The FO did

HindSight 12 Winter 2011 31


LEARNING FROM OTHERS

Nearly a Runway Excursion


In keeping with the name of our publication, we have decided in this issue to begin a new column which
will draw attention to an accident or incident which has shown, through investigation, that there are
lessons to be learned from it. Usually, we will choose a case relate to the theme of the issue.

SKYbrary contains a searchable library of articles on several hundred selected accidents and significant
incidents, most of them investigated independently under the procedures called for under ICAO Annex
13. The original investigation report on each selected event may also be found on the SKYbrary
bookshelf, either as first published if the primary language used by the investigating agency is English,
or in an official English Language translation if not. Here, we will just give a short summary of what
occurred and note the main findings. For more detail, you should refer to SKYbrary!

The Place: St Kitts, Eastern Caribbean


The Date: 26 September 2009
The Weather: Good
The Event: ATC cleared the aircraft to taxi to in- The captain observed that the runway
tersection A and then to backtrack for ahead looked very short and decided
A British Airways Boeing 777-200 oper- a 07 departure. The crew had estab- that a substantial application of thrust
ating a daytime passenger flight from lished that there would be sufficient against the brakes prior to brake re-
St Kitts to Antigua unintentionally be- take off distance from this point with- lease would be sensible. Take off com-
gan and successfully completed take out the need to backtrack. Following menced and V1 was achieved as the
off from a different intermediate po- a departure briefing which had not aircraft reached the opposite direction
sition on the departure runway than included the expected or possible taxi Touch Down Zone markings. Rotation
the one intended and just succeeded routings, the aircraft taxied instead to followed and lift off was achieved just
in becoming airborne before the end Intersection B. After a short wait at B, before the end of the runway
of the paved surface was reached. Red ATC were advised that the aircraft was
faces all round, not only for the aircraft ready for departure and responded The investigation noted that the op-
crew and ATC, but for the Airport Op- with line up and departure clearance. erator did not authorise Intersection
erator and the local CAA too. At least As the aircraft entered the runway and B departures for Boeing 777 takeoffs
there was no damage and no injury, began to turn towards the departure from Runway 07 at St Kitts and that
just another near miss! heading rather than backtrack, ATC the aircraft had taken off with an ac-
inquired slightly hesitantly whether tual take off run of 1220m available,
The route was quite new and operated a backtrack was required and the re- compared to the calculated one from
infrequently. Both flight crew were sponse was, err negativewe are intersection A of 1915 m. It was estab-
visiting St Kitts for the first time on happy to go from position Alpha. lished that there was no
25

the short hop from Antigua. The TWR Take off clearance was then given. taxiway or holding point
was manned by a trainee under super- signage anywhere at St
vision and traffic was, as always at St Kitts.
Kitts, light. The airport layout
is shown below.
Tower C
Read more at:
http://www.skybrary.aero/index.php/
B B772,_St_Kitts_West_Indies,_2009_
Schematic of runway and (HF_RE)
taxiway layout at St Kitts Terminal

A West Ramp
07

32
FROM THE BRIEFING ROOM

A slippery business
By Marcus Blomlf, Supervisor Stockholm Arlanda TWR
It is well known that contamination on the runway may be a
contributing factor to a runway excursion. In Sweden, known for
warm and dry summers, the contamination mostly consists of snow
and ice in the winter...

Stockholm Arlanda airport is situated in the to function even during prolonged group has to be ready to start clear-
far north of Europe where winters are crisp snowfall. How is this done? How do we ing the runway when the final arrival
and cold. The airport normally has winter maintain good braking actions? How touches down. No lingering allowed
conditions at least 4 months a year. Snow do we prevent runway excursions? on the runway, the next arriving air-
clearing and de-icing procedures on runways craft are exactly 12 min away.
and aircraft becomes a routine business - with The big difference in weather condi-
some 2 metres of snow falling last season this tions during the year makes ATC work To clear runway 01L/19R (3301m)
is understandable. With the standard two highly diverse, especially for the tower with a group of 8-10 sweepers takes
runways open, the airport can still continue controllers. Mixing a group of large 10 min. Following the sweepers are 2
sweepers and aircraft makes an inter- friction testers (Two SAAB 9-5, same
esting challenge. During a standard as Chicago OHare) which measure the
winter day, the supervisor in the tower breaking action. It takes an additional
works very close with the person from 2 minutes to measure, calculate and
the airport in charge for the airside publish the friction values, including
snow clearing. This is vital to ensure the contamination.
the best appreciation of the runway
status and assessment of breaking This value is then given to the aircraft
conditions and contamination. using the now snow-free runway. The
breaking action value is accurate at
The airport supervisor for the the time of the measurement. No esti-
snow clearing is responsible for mate of the future value is given, only
the condition of the runways, the value and the time of the measure-
taxiways and aprons. He or she ment. In heavy snow this means that
decides what to do, when to the values may be worse than the lat-
spread de-icing fluid, etc. The est published figures. However, pilot
standard way to remove the reports are also taken into consider-
snow is to use a group of ation. After all, Scandinavian pilots are
sweepers for a circuit around used to winter conditions. However, if
the airport including two of you are the last aircraft using a runway
the runways and associated before the sweepers starts clearing,
taxiways. A typical circuit the values that ATC gives you may be
for the sweeper group relatively old
at Arlanda takes 48 min.
After 48 min, if it is still Of course, to measure the friction the
snowing, they start it all two vehicles have to be on the runway.
over again. Timing is ev- If you want to measure the number of
erything; the sweeper landings more often, departures will
consequently be reduced which may
create delays. Its a thin line between
keeping an adequate and up to date
friction value, while trying to use the
runway to accommodate as many air-

34
The drivers of the trucks,
ploughs, blow sweep-
ers, snow blowers etc.
are typically seasonal
employees, making an
extensive training
program before each SOMe FACtS
winter season necessary. Surface Liquid de-icing
Sand
684.842 Litres
2.850.000 kg
Aircraft de-iced 9468
Number of days with snow clearing 110
craft as possible. Again, here is when
the professionalism and experience of Snow 2009/2010 190 cm
the supervisor for snow clearing is of Largest amount of snow during one day 23 cm
highest importance and value. With Total area to clear of snow 2.946.043 m
their deep knowledge and experience,
their judgment is one of the most im-
portant tool for keeping the runways The system using 2 runways even One challenge for the tower controllers
and taxiways in a good condition; if during a longer snowfall has proved during snowfall is to keep track of all the
needed they make the decision if and very effective. Delays are kept to a vehicles that are busy with the snow re-
when to spread de-icing fluids on the minimum while being able to land moval. Starting from the winter season
runway. For this, a modern type of (en- and depart regularly and indepen- 2010/2011 all vehicles will be equipped
vironmentally friendly) fluid is used, dently of each other. A few days each with a transponder making them securely
which has the ability to reduce the year however, the weather conditions identified via the multilateration system.
freezing point. The Aviform product become extremely severe, making it To further ensure the integrity of the run-
that is used at Arlanda can be spread impossible to operate two runways. way, the use of stop bars is mandatory.
down to -50C, it is mixed with water Typically this is often the case when
(!) to make it as efficient as possible. snowfall is combined with strong To maintain high safety and throughput,
However, spreading de-icing fluids on winds that polish the surface of the the airport and ATC have developed good
the runways is no miracle cure against runway. The polished surface has to coordination procedures and also invest-
runway excursions; it has to be carefully be ground down using blow sweep- ed in training and equipment. The cost of
evaluated. The fluid is always efficient ers and this requires the sweepers keeping 12 sweepers, support vehicles and
but needs to be carefully monitored, to enter the runway more often. The drivers available 24/7 is not to be under-
e.g. followed by sweeping within a cer- circuit takes around 30 min; it may estimated. However, this investment is es-
tain time period to avoid freezing. reduce the operational available run- sential, as we often have winter in Sweden.
way time to 36 min per hour. This will Even with careful preparation and long ex-
The condition of the runways and taxi- normally build up delays but luckily perience, each winter season is a new chal-
ways is always the top priority. This this situation is rare, normally a light lenge, snow has a strange habit of fall-
may, as a spin-off effect, have an im- to moderate snowfall have a surpris- ing when it is least expected.
pact on the apron conditions. Some- ingly low impact on the throughput.
times, pushback trucks are unable to And we do not like runway
get a grip on the icy surface. The so- The drivers of the trucks, ploughs, excursions!
lution to this is to spread warm sand blow sweepers, snow blowers etc. are
in front of the truck, an efficient but typically seasonal employees, making
very time consuming way of dealing an extensive training program before
with poor friction! The breaking value each winter season necessary. It is Marcus
on the apron can stay poor during ex-
tensive periods during the winter, but
important to ensure not only how to
handle the vehicles, but also how to
Blomlf
the snow is always removed (sooner use the radio and how to navigate the is a Swedish ATCO and has been a (the) Supervisor
or later!) allowing the aircraft to enter airport including where clearance is at Stockholm Arlanda Tower since 2008.
and exit the gates. needed and where it is not.

HindSight 12 Winter 2011 35


FROM THE BRIEFING ROOM

Controllers and pilots teaming up


to prevent runway excursions
By Capt. Bill de Groh. These 49 landing events were almost
evenly divided between veer offs and
According to the NLR Air Transport Safety overruns. Obviously, when an aircraft
Institute (ATSI), as of 7 September 2010 leaves the prepared surface on land-
ing, the potential for injury and death
this year there have been 62 runway exists.
excursions of commercial and executive
aircraft worldwide, 49 of these occurred As a current air line pilot and former
aerospace engineer, a discussion of
during landing. landing performance among pilots
comes naturally. Although the aircraft
commander is ultimately responsible
for ensuring a safe landing, commer-
cial air transport is a team effort, so can
air traffic controllers assist the aircraft
commander in this task? I believe the
answer is yes.

First, it will be necessary to understand


how the Airplane Flight Manual (AFM)
landing performance information is
determined by the aircraft manufac-
turer. That background will highlight
the factors that affect landing distance
which will then point to areas where
controllers can assist the pilot.

Certified Versus
Operational Landing
Performance
The actual landing distance deter-
mined during certification testing is
defined as the horizontal distance nec-
essary to land and come to a complete
stop from a point 15 m (50 ft) above
the landing surface, assuming a level,
smooth, dry, hard-surfaced runway.
The distances determined are based
on standard temperature, accounting
for aircraft weight, wind, and altitude.
The aircraft must be in the landing
configuration using a stabilised ap-
proach, crossing the 15 m height at a
specified speed. No credit for thrust
reverse1 is allowed and maximum
manual wheel braking is used. The

36
The regu-
lating authori-
ties recognise that
the landing profile used in
certification testing is not rep-
resentative of real world operations.
Therefore, operational rules stipu-
late a planning margin to account for
these and other factors that are diffi-
cult to quantify at the time of depar-
ture. The Required Landing Distance
(RLD) is the unfactored landing dis-
tance plus the appropriate margins
applied. However, upon arriving at
the destination, the actual conditions
distances thus obtained represent the The unfactored landing distance com- under which this planning was done,
maximum capability of the aircraft, prises two segments; an air distance may have changed. Some operators
sometimes referred to as the certified and a stopping distance. The air dis- provide operational landing distance
or unfactored, landing distance. Lets tance begins at 15 m over the land- information via ACARS, an onboard
see how these requirements relate to ing surface and ends at touchdown. performance computer, or even paper
real-world landings. Aircraft certification authorities have tables. This information may be based
accepted an air distance fixed at 305 on the same assumptions used in the
Notice there is no correction for non- m or a speed dependent value on certification data but including adjust-
standard temperatures. Temperature average of 460 m. For available land- ments for pilot braking action and use
and pressure conspire to increase true ing distances more than 2 400 m, the of thrust reverse, with a minimum total
airspeed for a given altitude, resulting touchdown zone markings extend a margin of 15%. As you can see, landing
in a longer landing distance. Many air- minimum of 900 m. This means land- distances are not as straight forward
ports have sloping runways and land- ing at the far end of the touchdown as they may seem.
ing down slope, of course, increases zone increases actual landing distance
landing distance. The data determined 440 to 595 m. This can happen if the Safe commercial air transport is a team
is only for dry runways. A wet, smooth aircraft has excessive height over the effort involving many disciplines,
surfaced runway definitely will not be- threshold and/or the pilot extends the not least of which is the relation-
have as well as a wet, grooved runway. flare to achieve a soft touchdown. ship between ATM and pilots.
Neither runway is dry but a grooved
runway provides better drainage and The second segment of the landing is
improved braking effectiveness when the stopping distance which, of course,
wet. The unfactored landing distance begins at touchdown. Not including a
does not account for contaminated thrust reverse credit in the unfactored Bill de Groh
runways. This information can be data is conservative, as long as the
currently flies the EMB-145 for
found in advisory data which is gen- aircraft is equipped with an operative
American Eagle Airlines and is a former aero-
erated by conservative calculation, reverse thrust system. Remember the
not through certification testing. Not unfactored data uses maximum man-
space engineer for McDonnell Douglas/Boeing.
all authorities require their operators ual wheel braking, which is something He is currently the Chairman of ALPAs Aircraft
to use this advisory data. few pilots do in normal operations; on Design and Operations Group and Vice Chair
a dry runway the deceleration rate is, Operations for the IFALPA Aircraft Design and
1- this includes use of reverse pitch in indeed, alarming to pilots and passen- Operations Committee.
turboprop aircraft. gers alike.

HindSight 12 Winter 2011 37


FROM THE BRIEFING ROOM

Controllers and pilots teaming up to prevent runway excursions (contd)

So, what can ATM personnel do to


help ensure a runway excursion does
There is one States ATM distance. These delays can happen
due to distractions that occur when
not happen at their airport? organisation for which ATM issues initial taxi instructions
even before the aircrafts nose wheel
Threat Management it is not uncommon for has touched down. We all understand

Two air traffic techniques immediately


a pilot to receive a the pressures placed on us with the
increased tempo of operations, but
come to mind that can have an adverse
effect on landing distance; high-speed
speed assignment of all of us, pilots and controllers alike,
must step back and not let those
approaches and the slam dunk2. One 180 knots, or Ive even pressures cause us to rush.
of the elements upon which landing
distance is based is a stabilised ap- heard of 200 knots, At the end of the day, pilots and con-
proach. When speed assignments to
the marker are issued to expedite traf-
to the marker trollers are part of a vast team that
works very hard to make commercial
fic flow, then the threat of not achiev- flight operations safe and efficient.
ing a stabilised approach is increased. Although pilots may decline a re-
There is one States ATM organisation proximity of the approaching aircraft quest for a high-speed approach or a
for which it is not uncommon for a pi- may lead a crew to cut the corner of a tailwind landing, please understand
lot to receive a speed assignment of taxiway resulting in a veer off, or take that this is not intended to cause ATM
180 knots, or Ive even heard of 200 an exit that is closed due to construc- difficulties but a consideration of all
knots, to the marker. By accepting the tion. Dont be surprised when a flight the elements discussed above. Con-
high-speed approach, a pilot may be crew declines such suggestions, as trollers can do their part to reduce
working against the edges of safety they may do for safety. the risks of runway excursions by
to get the aircraft configured, on considering the effects of high-speed
path, and on speed by the threshold. Maintaining use of a runway with a approach clearances, the slam-dunk,
Similarly, keeping the aircraft high and tailwind component for noise abate- preferential runways, and issuing taxi
close-in to the airport for noise abate- ment or simply to avoid traffic issues instruction on the rollout. As team-
ment, or for moving traffic below, can with nearby airports, especially if the mates, lets help each other out.
make achieving a stabilised approach runway is other than dry, is definitely
a challenge. It can be difficult to go a risk factor. This technique played a
down and slow down, possibly result- role in the Southwest Airlines acci-
ing in excess height and/or speed over dent at Chicagos Midway airport.
the threshold.
Accurate runway surface condition
As far as approach speed assignments reports greatly assist the pilot in de-
are concerned, there are times when termining whether to attempt the
spacing becomes tight between an landing. When the runway is con-
aircraft that has just landed and the taminated, it is also helpful to know
next on short final. The landing pilot where the preceding aircraft exited
may, but generally should not, re- the runway. This information is use-
ceive instructions while rolling out to ful when considering a runway exit
expedite exiting the runway. Given plan, since unused portions of a con-
that instruction and knowledge of the taminated runway are often much
more slippery than the commonly
2- the slam-dunk is a type of basketball shot in which used areas.
the player jumps up near the basket and powers the
ball manually through the basket with one or both
A delay in deployment of thrust re-
hands over the rim. In aviation a slam-dunk occurs
when an aircraft is held high close-in to the airport by verse, spoilers and/or brakes obvi-
AtC and then cleared for a visual approach. ously has an effect on the landing

38
Runway friction
characteristics measurement
and aircraft braking
by Werner Kleine-Beek, Research Project Manager, European
Aviation Safety Agency. In April 2008, aeroplane operational issues
fell under the European Aviation Safety Agency scope. At that time,
the European Commission had clearly indicated that in the future,
aerodrome operations will also be under the responsibility of EASA.
This extension of the Agencys responsibilities was adopted on
7 September 2009.

In April 2008, aeroplane operational is- water patches are contributing factors, The issue of runway friction characteristics
sues fell under the European Aviation have been a constant issue for avia- measurement is a multidisciplinary one,
Safety Agency scope. At that time, the tion. As part of the process of defining mainly between operations and aero-
European Commission had clearly in- runway surface conditions, friction dromes, but also with regard to aircraft
dicated that in the future, aerodrome measurements are commonly made at certification. There was little doubt that
operations will also be under the re- present using various ground friction- the safety of aircraft operations could be
sponsibility of EASA. This extension of measuring devices. These devices differ enhanced if reliable, accurate and con-
the Agencys responsibilities was ad- substantially among each other with sistent methods of both assessing the
opted on 7 September 2009. the result that different readings are braking action available on a con-
obtained from them on the same sur- taminated runway and apply-
Instances of runway overruns and veer- face. This lack of harmonisation poses a ing this assessment to aircraft
offs, where ice, snow, slush or standing potential safety hazard. performance could be devised.

Werner
Kleine-Beek
joined EASA 2007 as Research Project Manager,
being responsible for management of the
Agencys research projects as well as coordi-
nation and interfacing with other research
programmes. He started his carrier as research
engineer for train traffic control systems,
worked after as avionics systems certification
engineer and in Aviation and Space Department
of the German Federal Ministry of Transport
responsible for technical issues in aviation
administration, space activities, and the
Ministrys research programme & research
coordination.

HindSight 12 Winter 2011 39


FROM THE BRIEFING ROOM Examples of Recommendations that EASA
should consider enacting
Runway friction characteristics [1] General issues, such as taxonomies and definitions
measurement and aircraft braking
n The runway state the aviation community is trending towards a three-
(contd) level definition in that a runway is either: (i) dry; (ii) wet; or (iii) contaminated.
The current EASA definitions (in CS-25) employ a three-level definition, and
it is recommended that EASA maintain this.

However, the magnitude and possible n The definition of contaminants EASA CS-25 - provides a list for the pur-
regulatory complexity of the task should poses of aircraft certification. This list is incomplete as other contaminants
not be underestimated. also occur. It is recommended that EASA expand the list in CS-25 as appro-
priate.
The RuFAB project
n Runway coverage producing contaminated conditions EASA CS-25
In 2008 the Agency launched the re- defines the criterion as being 25% coverage of the reported runway length
search project RuFAB Runway Friction and width. ICAO Annex 15 is one exception, and it is recommended that
Characteristics Measurement and Aircraft EASA review this variation.
Braking. Its aim was to help identify pos-
sibilities of harmonising runway friction n Damp it is recommended that a definition for damp be retained.
characteristic measurement technologies
and provide a basis for improving and n It was recognised that there should be harmonisation between the defini-
harmonising the implementation of cur- tions used for defining aircraft performance and those used for describing
rent ICAO Standards and Recommended the runway surface condition. A table of recommendations was produced.
Practices (SARPS) within the EASA Mem-
ber States. This could provide the op- n The most serious gaps in the present set of definitions are considered to be:
portunity for a global standardised ap- Layered contaminants a multitude of cases are possible.
plication, and contribute to the progress Frost suitable definitions are generally not available.
of the ICAO action plan. Finally, it would
prepare prerequisites to the future EASA n Training programs for:
rules for aerodrome safety. Pilots a training program should be developed and implemented for pi-
lots regarding how to use the information provided from runway condition
The recommendation from the report reporting.
and an EASA workshop with the relevant
stakeholders consists of two types of rec- Runway inspectors (RIs) Certification requirements are required for
ommendations: runway inspectors (RIs), and for staff issuing RCRs and/or NOTAMS directly
affecting aircraft operations.
n Recommendations that EASA should
consider enacting, and
n Recommendations of a more gen- [2] Functional friction assessments
eral nature that would require other
groups (than EASA) to action, or that There is a fundamental variation between the objectives for functional and op-
would require a collaborative effort. erational friction measurements. Correlation to aircraft performance is of much
more concern for operational friction measurements.

It is recommended that work related to functional friction measurements focus


on developing standardised procedures, including calibration and harmonisa-
tion, for the devices, with desired correlation to aircraft as a secondary goal.

n A comprehensive set of technical specification should be developed and in-


corporated into civil aviation regulatory standards.

n Every friction measuring device should be tested to ensure compliance with


repeatability and reproducibility requirements.

n The use of the European Friction Index (EFI) or the equivalent IFI
harmonisation model is recommended.

40
[3] Operational friction assessments

There is a divergence of views within the general aviation community regard-


ing the emphasis that should be placed on observations of the runway sur-
face condition versus ground friction measurements.

It is recommended that fundamental decisions be made by EASA regarding:

n Whether to parallel the trend (being exhibited by a large part of the avia-
tion community) towards de-emphasising friction measurements for op-
erational purposes.

n Updating the current runway surface condition assessment.

n A policy decision to be made by EASA to either regulate the closing of run-


ways for maintenance when predetermined contaminant thresholds are
reached, or to recognise that airports responsibilities are limited to accu-
rately reporting conditions with which carriers and pilots will make aircraft
movement decisions.

Recommendations of a more general nature


n EASA should recommend to ICAO that the SNOWTAM form be updated.
This recommendation has already been adopted by ICAO.

n Functional Friction Harmonization Trials and Development of Consistent


Standards A stepwise method for conducting a calibration and harmoni-
sation trial has been developed. A pilot study should be done to evaluate
the proposed approach.

n There is a need for high-level criteria for a friction-measuring device that is


intended for use in operational correlation with aircraft performance.

n A committee should be formed to develop a performance specification for


a device(s) or for technology (technologies) that would meet operational
runway surface condition reporting requirements.

HindSight 12 Winter 2011 41


FROM THE BRIEFING ROOM

Runway excursions:
cleared to land ...ready or not!
By Graham Wadeson and Anne Isaac, External Safety Team, NATS1
Historically there are 30 runway excursion accidents per year, which
cost the industry approximately $ 1 billion.

The reasons aircraft end up in un- However, when you start to analyse
planned areas at airports are many runway safety events in a holistic way,
and various. When a thoroughly it is often difficult to identify where
robust investigation of events at one professional group does not in-
airports is undertaken, it becomes fluence all the others; they represent
clear that all the humans present a complex and highly coupled safety
in the aviation infrastructure can system.
contribute to events from small
mishaps to catastrophic loss of As shown below, in the 11 years from
life accidents. 1996 to 2007, the world-wide aviation
statistics3 indicate that there were 7
Data from a EUROCONTROL pub- Runway Incursion accidents with a loss
lication2 in 2003 reported that of 282 lives and 220 Runway Excursion
runway incursions and excur- accidents with a loss of 458 lives.
sions are reported in terms of:

n ATC operational errors


or deviations,
n Pilot deviations, Incursions 7
n Vehicle/ pedestrian Excursions 220
deviations.

In some countries, notably Aus-


tralia, they also include animal
involvement in runway safety
events.

The study also made the claim


that, unlike many models of
attribution (one party being at Runway excursions can result from
fault), runway incursion events either take off or landing scenarios
were a result of multiple involve- with the aircraft leaving the runway at
ments and the statistics indicated that the side or overrunning the end.
of the overall attributable deviations:

56% were due to pilot deviation, 1- thanks also to Andrew McCarney, Controller,
23% were attributable to the Southampton Airport and Barney Wainwright,
ATM system, Captain, Flybe, for their contribution.
2- Aerodrome Resource Management: Report on Run-
21% were owing to vehicles, way Incursions. Internal Report eurocontrol, 2003
animals or pedestrians 3- Worldwide Statistics on Runway Incursions and
excursions, IAtA, 2009

42
A/C landed on A/C took off
wrong runway 10% wrong runway 9%

A/C landed at wrong A/C vehicle


airport 4% collission 6%

A/C landed long/


everan 14% A/C to A/C
collision 18%

Graham
A/C taxiied onto active
runway 25%
A/C to A/C
near-miss 14%
Wadeson
works for NATSs as an External Safety Specialist,
within the Division of Safety, liaising and
working closely with airlines and other ANSPs.
Recent data from Honeywell indicates the following common Runway A controller by background, initially within
Incursion and Excursion events the military and then area control, Graham
moved into airspace design and centre operations
which lead to a position as Manager Ops and
A leading contributor to overruns is an approaches. But if were honest, from Training at an airfield, before moving on two
inappropriate aircraft energy state on ATC, we know unstable approaches years ago to his present role.
approach caused or contributed by: are an issue but we dont really know
how big an issue they actually are, at
n ATC errors any specific location. Anne Isaac
n poor planning and late let-down leads the Human Performance
by pilots For ATC, the only real indicator as to development work in the
n poor pilot technique the scale of the issue is provided by the pilot/controller interface in
n landing long recorded number of missed approach- NATS, UK. She gained her
n floating on landing flare es, for which the pilot indicated that it
PhD in Cognitive Neuropsychology
n tailwind was due to being unstable. In these
n saving fuel policies occurrences, the pilots have correctly
at Otago University in New Zealand. Her previous
resolved the situation by recognis- work has been in the development of incident
Since it is a collective responsibility to ing and acknowledging the unstable investigation tools and techniques in European
cause or aggravate an adverse safety situation and mitigating it by carrying ATM, the introduction of TRM into the ATC
event, it should also be a collective re- out the missed approach. Pilots can environment and the introduction of Day to
sponsibility to mitigate and manage be under considerable pressure these Day Safety Surveys techniques into NATS.
the consequences of these events. days from various sources to continue
She has written several book chapters,
approaches, such as economic, legal
Although these single issues/errors and commercial, so the fact that the
academic papers and the book Air Trac Control:
are clearly interesting (but not surpris- decision was made to break off the the human performance factors.
ing), they only give an idea of what approach indicates that a good safety
happened, but are not informative culture/CRM exists and the pilots felt
with regard to why these events oc- under no pressure to continue.
curred. ATC errors is hardly a useful Example
category in the aftermath of a serious But even the record of missed ap- Most, if not all airline SOPs, will de-
runway incursion or excursion. It also proaches doesnt tell the whole story termine a gate height (predominantly
leaves the investigation of the chro- as unstable approaches is a big bucket 1000 which equates to just more than
nology, with regard to who and when of reasons into which many causal 3 miles from touchdown) at which
things happened, open to interpreta- factors can be placed; ranging from point, an aircraft is to be in a stabi-
tion. ATC, pilot, procedural, airspace de- lised configuration (this configura-
sign, weather, other aircraft, workload tion criteria is laid down within the
Knowledge with regard to the context (cockpit or RT loading resulting in late airlines SOPs)
which surrounds both incursion and instruction), aircraft cabin issues .
excursion events is vital if we want to If an a/c is not in this stabilised con-
improve mitigations for pilots, control- The risks associated with a runway figuration on reaching the gate, then
lers and vehicles/persons. excursion and the potential conse- the airlines SOPs will dictate that
quences are well documented, but the the flight crew should break off the
As documented by many sources, one difficulty in determining the scale of approach and execute a missed ap-
of the main causal factors associated the issue associated with unstable ap- proach. If not, then the information
with runway excursions are unstable proaches, is in gaining the evidence. is automatically logged by the on-

HindSight 12 Winter 2011 43


FROM THE BRIEFING ROOM

Runway excursions: cleared to land ...ready or not! (contd)

board FDM system and the airline These avenues of work can be roughly at any point, a runway excursion may
operator will have the chance to be broken down into two main areas: be prevented. The information is
aware of it. The pilot can of course out there and it is perhaps a case of
elect at any point of the approach to n Procedural looking at proce- changing attitudes and culture that
discontinue the approach, but it is at dures/airspace designs which may will finally make a difference.
the gate, that the decision to contin- contribute to unstable approaches
ue must ultimately be made. To some degree it is a leap of faith as
n Educational increased under- historically we use event occurrences
So if an a/c reaches 1000 (the gate) standing and awareness about the to measure the frequency. As far as
and the criteria have been met, the subject from both the ATC and air- runway excursions are concerned,
aircraft can (at the discretion of the lines sides, so that each understand even without more information, it
captain) continue to make an ap- what, how and why things are done must be better for all concerned to be-
proach to land. According to the sta- and the implications for the other lieve that things can be changed now
tistics, there has been no problem. side. and not to wait for more occurrences.
Correct?
Like most things in ATM, nothing
Maybe, maybe not! happens in isolation and as already Editorial note
mentioned, these events involve
Although the stability of the ap- people from all sides; ATC, airlines Some Operators do indeed use
proach is only officially measured and pilots. Much good work has al- 1000 ft as a gate height to deter-
(against the criteria) when the aircraft ready been produced and more is mine if a go around must be flown
passes through the gate, an unstable being undertaken by the likes of FSF, but others, including British Air-
approach is usually the result of a se- CANSO, DGAC and IATA. Not all the ways, do not. It is also unfortunately
ries of events involving various causal causal factors involved are efficiently not yet true to say that all airlines
factors (weather, tailwind, fatigue, addressable, but for those that are, have rules of this sort.
pressure, workload, poor planning, pi- if the chain of events can be broken
lot error, ATC interaction, procedures
etc.), which can occur at any stage of
the approach, even as far back as the
cruise phase. From the ground, we are
Some top tips for controllers to help minimise
never aware of the instances where unstable approaches
the pilot has fought throughout the
approach against these factors to fi-
Controllers
nally become stable at 1100, meeting n Brief before a shift with regard to weather, especially unpredictable winds and serviceability
the gate criteria and continuing to of equipment (ILS)
land uneventfully! n If you do not have precise weather radar to refer to, inform the pilots
n Be aware of the different and most frequent aircraft types and their performance
Indeed, it is very difficult from the characteristics, particularly with regard to phase of flight
ground to be aware of whether an n Always be aware that despite a good knowledge of aircraft performance, pilots will and do
aircraft has proceeded in an unstable fly slightly differently
state beyond the gate, going on to n All airline companies have rules regarding final decision heights most will insist on 1000feet,
land. Only the airlines with their FDM but advising them of an inappropriate track or height if they appear to be displaced from final
information will have sometimes a approach. If a pilot still confirms established and remains displaced, break off, establish if they
better view of the picture. are visual, or send the aircraft around
n Provide aircraft with at least two track distance updates from touchdown (downwind and
The only true way of affecting the rate base-leg)-changes in track distances cause the most problems to pilots planning approaches
of occurrence and therefore reducing n Try to maintain a standard square vectoring circuit pattern-if you keep it standard,
the risk, is to work with all the parties pilots are able to plan their descents.
concerned.

44
Understanding cockpit factors
By Captain Rob van Eekeren
Despite statistics, pilots tend to think that a runway excursion will
never happen to them. In many cases, they are correct.
However, some will face an uncontrollable aircraft leading to a
runway excursion; a horrifying experience.
Research shows that many reasons
and factors could lead to a runway
excursion. Basically there are two
scenarios: an aircraft can either over-
run at the end or veer-off at the side
of a runway. Overruns often occur af-
ter a high energy aborted take-off or
landing. Although pilots are trained
to abort a take-off before V1, take-
off overruns do occur. After land-
ing, pilots may find having reduced
braking capability, resulting in less
remaining landing distance than ex-
pected.

The industry wants high performance


at reduced costs; current calcula-
tion technology is accurate but only
as good as the quality of the input
variables. This quality is lacking, thus
leading to a false sense of safety. At
the same time, efforts are being made
towards optimisation of performance,
environmental restrictions, payload,
fuel, maintenance and operational
factors. Without adequate margins to
cover for real world system imperfec-
tions, safety would be directly nega-
tively affected.

Performance input sequent braking efficiency, which are


often unreliable. Wind varies stochas-
variables tically, while runway friction measure- Captain
Lets first focus on the quality of the ments are not always related to the
parameters needed for runway land- behaviour of the specific aircraft type. Rob van Eekeren
ing distance and take off distance cal- A couple of knots more headwind in- flies the Airbus A330 with KLM Royal Dutch
culation. Runway length, slope, QNH, stead of a tailwind could make a differ- Airlines. He has been heavily involved in
weight of the aircraft, fuel load and ence of up to 5000kg in payload which runway safety since 2001 and works with
technical status are in general precise. could lead to an overweight aircraft for
various organisations to enhance runway safety.
Contrary to these though are; wind, the actual conditions. Are such varia-
the factual runway friction, and con- tions in input variables possible and

HindSight 12 Winter 2011 45


FROM THE BRIEFING ROOM

Runway excursions:
cleared to land ... ready or not! (contd)

realistic? Yes. ICAO Annex 3 allows even


for a wind margin of 60 degrees and 9
knots (reporting threshold gusts). The
actual runway condition state poses an
even greater threat with a possible fault
margin of over 100%. Current runway
contamination measurement methods
give an output that is varied along a
runway and not calibrated to relate to
aircraft performance parameters often
derived by aircraft computers which re-
quire and use inputs to the millimetre
of accuracy. Due to the lack of correla-
tion between the runway measurement
output and the aircraft performance,
computation pilots can face an unbal-
anced take-off without being aware of
it. If then faced with an engine failure,
an overrun would occur.
Reverse thrust Rule makers will
Why does this not occur frequently?
Another worrying development is the
restrictions on the use of reverse thrust
have to accept that
Probably because the chance of an for environmental reasons. It does not adequate margins
engine failure at the most critical mo-
ment (V1) is very low and landings on
only take away the most effective brak-
ing system during the initial part of the are essential to cover
critical-length runways in critical con-
ditions are rare. The industry therefore
landing, but it also has a huge effect on
the brake temperatures. Generally hot
for imperfections of
compensates the flaws in the system by brakes do not have the same braking the theoretical system.
luck, if not there, a runway excursion is performance or could be the source
unavoidable. of a wheel well fire. Performance cal-
culations are not based on hot brakes.
Rubber deposits Hot brakes caused by a lack of reverse a too hard landing increases the risk
thrust will not only affect the current of bouncing and structural failures.
Another issue is rubber deposits on the flight, but also the next flight since Although a firm and correct touch-
runway. After landing, the main brak- dense operations require a quick turn- down, especially in wet conditions,
ing forces are reverse thrust and aero- around. Thus a take-off with possible reduces the chance of a long landing,
dynamic drag during the initial high hot brakes as a result of the previous passenger comfort is in normal opera-
speed portion (> 60 knots), and then landing is likely to occur. Hence why tions found to be very important. So,
the brakes are the main retarding force. a high speed aborted take-off could when pilots are in the normal habit
When the runway is covered with rubber very well result in an excursion. of making soft landings, it is unlikely
deposits and when the runway is moist that these habits are changed under
or even wet, there would be virtually no Soft landing difficult or stressful circumstances like
friction left, resulting inevitably in a low adverse weather.
speed overrun The same logic applies Lets get back to the landing. A good
to contaminated or slippery runways. landing will help a good run on the A good landing is made possible by
Rubber deposits are frequently found runway surface and thus prevent an a good flare. A good flare is an art,
at the touchdown point, which could be excursion. However, long landings especially in gusty conditions. This
the end of the (opposite) runway in use. increase the chance of an overrun. requires excellent and regular train-
That is precisely the low speed area after Passengers like a soft landing, but ing or exposure. For pilots based in
landing or an RTO and thus likely to re- this increases the chances of an in- windy airports, the gust exposure can
sult in a slow speed overrun. correct flare followed by floating. But be up to 50%. But pilots flying occa-

46
sionally into these airports could face Wind and vortices Finally, aircraft wake vortices could
their first windy, gusty landing for make a stable approach very difficult
years. Autopilot limitations preclude Another factor is a wind shift during the to achieve. Although ICAO has pro-
autolands in these conditions. More- approach. Wind on the runway might duced guidelines for spacing, these are
over, the different manufacturers indicate a head wind, whilst during the not always sufficient for performing
have produced aircraft with different approach a gradual or sudden (shear) stable approaches. Approach speeds
flying and especially flaring charac- wind shift occurs from tail to head. For could differ up to 60 knots in modern
teristics. This, in combination with example, some airports are known to aircraft. Trying to optimise runway oc-
a lack of exposure and/or training have a 20-30 knot tailwind in the ap- cupancy, ATC often restricts aircraft not
could lead to phenomena known in proach, changing at the very last min- to fly at their ideal approach speed, but
the literature as, pilot induced oscilla- ute to a headwind during landing. This faster or slower (e.g. 160 knots until the
tions, which result in a poor flare and might be a positive slow shear, but it Outer Marker, poses a real challenge
an uncontrolled, hard or long landing. will make a stable approach extremely for aircraft like the A330). These speeds
difficult to achieve. Preferential runway increase the chance of an unstable ap-
Stable approach allocation systems are often based on proach, increase workload in the cock-
strict ground wind limits, but vertical pit and thus will increase the chance of
A stable approach helps perform a shears are rarely taken into account. a runway excursion.
good flare. Being at the correct air-
speed on the correct glidepath at
the extended centreline, with wings
level in the correct angle of attack at Conclusions and recommendations
the right moment describes the best
essence of a stable approach. Since Nowadays, computerised and design optimisation to the millimetre without adequate
flight operations are in a dynamic margins leaves no room for stochastic real world variations. When at an unfortunate
environment, this ideal situation is moment an unexpected situation arises, the chance of a runway excursion is likely.
virtually impossible to achieve. Thus
certain variables have to be within Pilots and air traffic controllers work together in the same aviation environment with
certain limits. The aerodynamics of the same goals: safe and efficient flights. So how can ATCOs and ANSPs help pilots to
modern aircraft, being vectored with reduce the chance of a runway excursion?
high or relatively high airspeed, pose
a real threat to performing a stable First of all, air traffic controllers should understand precisely all elements of a stable
approach. Runway change or late approach. The design of good approach procedures will help pilots perform a stable
runway allocation can also lead to an approach. Good ATC guidance will help the execution of a stable approach.
unstable approach. Glide paths over
3 degrees (due to terrain or noise Secondly, they should understand fully the importance of timely and factual informa-
considerations) increase the risk of tion needed by aircrew for their performance calculations which is in the range of ?.
an unstable approach considerably. The three / four-dimensional wind and runway friction characteristics are the biggies
For example, the approach speed of a here. Controllers should also realise that runway optimisation, while good for through-
fully loaded Boeing 737-900 in gusty put, might have a direct and adverse effect on flight safety.
conditions on a 3 degrees glide path
requires a vertical speed of 900 feet Finally, rule makers will have to accept that adequate margins are essential to cover
per minute. The Ground proximity for imperfections of the theoretical system. Optimisation in figures after the comma,
Warning System gives an alarm with without these margins, might look good on paper, but disrespect the dynamic forces
1000fpm (the stable approach limit); of nature and the human being.
there is little room for corrections.
Even a small tail wind would make a Unless these three recommendations are respected, it is reasonable to conclude that
stable approach impossible. Further- runway excursion accidents will continue to disrupt airport operations and to cause
more, each knot of tail wind repre- casualties. We do not want that; it is therefore imperative that air traffic controllers and
sents one-knot square more energy pilots work closely together to prevent runway excursions.
to lose on the runway.

HindSight 12 Winter 2011 47


FROM THE BRIEFING ROOM

Some hidden dangers


of tailwind
by Gerard van Es, NLR-Air Transport Safety
Institute, Amsterdam, The Netherlands.
While inbound to Southampton (UK), the crew of a
Cessna Citation had been given the weather as
surface wind 040deg/12kt, thunderstorms, the runway
is very wet. Ten minutes later they were advised that
the visibility was deteriorating - now 2,000m in heavy
thunderstorms.

Shortly after this they were advised runway. This message was immedi-
entirely at your discretion you may ately acknowledged by the co-pilot
establish on the ILS localiser for Run- with the words roger, copied, thank
way 20 for visual break-off to land on you. However, the co-pilot made no
Runway 02. The captain accepted this comment to the captain about the
offer. He then asked the co-pilot for tailwind component and did not raise
the surface wind and was told that the question of continuing to land
it was 040deg but that earlier it on Runway 20 with him. The aircraft
had been 020deg/14kt. The touched down normally and within
flight was then cleared for a 5kt of the target speed but, given the
visual approach for Runway tailwind and the wet runway, it was
02. Meanwhile however, not possible to stop it on the remain-
the captain had decided ing runway length and the aircraft
to land on Runway 20 overran the end of the runway. After
and told the co-pilot coming to rest, the aircraft caught fire
this. He later reported and was destroyed.
that he had decided
to land on this runway
because he could see
the weather at the
other end of the run-
way appeared very
black and he had
mentally estimated
that the tailwind Grard van Es
component would be
about 10kt (the oper- works as a senior advisory flight safety
ating Manual gives a and operations for the NLR-Air Transport
maximum tailwind component Safety Institute - Amsterdam,
of 10kt.) The co-pilot then advised the Netherlands.
ATC that they would be landing on He is currently involved in the European
Runway 20. The controller replied working group for the prevention of
youll be landing with a fifteen knot runway excursions.
tailwind component on a very wet

48
Tailwinds are very on a dry runway). In this example, the
runway was wet which normally re-
were different from those advertised
at the surface. It is not currently pos-
welcome to pilots duces the tailwind limit. The controller sible for the controller to have more
also informed the crew about the very accurate wind reading that also apply
when they are wet runway. Nevertheless, the crew aloft.

flying from A to B continued their landing on the unfa-


vourable runway. Should the control-
since it helps shorten ler have been clearer in his message
when he informed the crew about the
EdiTORiAL NOTE:

the flight time. high tailwind and wet runway? It is not More detail on the accident ex-

However, closer to the the controllers job to decide to land


or not. That decision remains with the
ample used above, including the
Official UK AAIB Report of the inves-
runway they can be crew. In this case, the controller gave
adequate warnings which the crew
tigation, may be found at:

anything but welcome. did not react to. http://www.skybrary.aero/


index.php/C550,_Southamp-
Pilots often complain about unexpect- ton_UK,_1993_(RE_HF_WX_FIRE)
ed tailwinds aloft during the approach.
Tailwinds are very welcome to pilots Tailwinds are a contributor to unstable
when they are flying from A to B since approaches or rushed approaches
it helps shorten the flight time. How- which themselves have contributed to
ever, closer to the runway they can many landing overruns in the past. The
be anything but welcome. Even a bit controller obtains the wind readings
of tailwind can be a hazard. Tailwind from anemometers which are posi-
conditions can have adverse effects tioned close to the runway. Given that
on aircraft performance and handling these anemometers are normally posi-
qualities in the critical flight phases tioned on a 10-m tower, the wind mea-
of takeoff, approach and landing. surements derived from them are not
Tailwind, for instance, increases the representative of the conditions aloft.
required runway length to land on or There are normally significant differ-
takeoff from. To the pilot, it is therefore ences between surface winds and the
important to have timely and accurate winds during approach. It is therefore
wind information. Controllers are an no surprise when a pilot complains
important link in this process. How- to the controller that the winds aloft
ever, in the end the pilot remains fully
responsible whether to takeoff or land.
In the above example, the controller
offered a favourable runway regard-
ing tailwind. However, the captain de-
cided to land on another runway. The
controller in this case informed the
crew that they were landing with a 15
knots tailwind on the other runway
(remember most civil aircraft are cer-
tified for 10 knots tailwind which can
sometimes be increased to 15 knots if
the airline asks the manufacturer, both

HindSight 12 Winter 2011 49


FROM THE BRIEFING ROOM

The role of ATM in reducing


the risk of runway excursions
By Jim Burin, Flight Safety Foundation. Runway excursions are
the most common type of accident in commercial aviation.
One in three jet accidents is a runway excursion, and one in four
turboprop accidents is a runway excursion.

The definition of a runway excursion


is when an aircraft on the runway
surface departs the end or the side of
the runway. About one in every five
excursions occurs on takeoff. There
are two types of runway excursions,
veer offs (going off the side of the
runway) and overruns (going off the
end of the runway). All organisations
that are involved in aviation play a
role in reducing the risk of runway
excursions. These include aircraft
manufacturers, operators, airports, Recommended Elements of a Stabilised Approach
regulators, and air traffic manage- All flights must be stabilised by 1,000 feet above airport elevation in instrument meteorologi-
ment (ATM). ATM plays a significant cal conditions (IMC) and by 500 feet above airport elevation in visual meteorological conditions
role in any issue dealing with the run- (VMC). An approach is stabilised when all of the following criteria are met:
way and runway safety. ATM has two
primary roles in reducing the risk of 1. The aircraft is on the correct flight path
landing runway excursions. First, 2. Only small changes in heading/pitch are required to maintain the correct flight path
they need to provide stabi-
3. The aircraft speed is not more than VREF + 20 knots indicated airspeed and not less than VREF
lised approach assistance to
crews. Second, they should 4. The aircraft is in the correct landing configuration
provide aircrews timely and 5. Sink rate is no greater than 1,000 feet per minute. If an approach requires a sink rate greater
than 1,000 feet per minute, a special briefing should be conducted
6. Power setting is appropriate for the aircraft configuration and is not below the minimum
power for approach as defined by the aircraft operating manual

James M. Burin 7. All briefings and checklists have been conducted

has 42 years of aviation experience and 8. Specific types of approaches are stabilised if they also fulfil the following: instrument land-
ing system (ILS) approaches must be flown within one dot of the glideslope and localiser;
34 years of experience in the aviation safety a Category II or Category III ILS approach must be flown within the expanded localizer band;
field. Jim retired from the Navy as a captain during a circling approach, wings should be level on final when the aircraft reaches 300 feet
after 30 years of distinguished service. above airport elevation
He was the Commanding Ocer of an attack 9. Unique approach procedures or abnormal conditions requiring a deviation from the above
squadron and a Carrier Air Wing Commander. elements of a stabilised approach require a special briefing
As the Director of Technical Programs of FSF
An approach that becomes unstabilised below 1,000 feet above airport elevation in IMC or below
his duties include organizing and overseeing
500 feet above airport elevation in VMC requires an immediate go-around.
safety committees and managing safety
Source: Flight Safety Foundation Approach-and-landing Accident Reduction (ALAR) task Force
related conferences and research. (V1.1 November 2000)

50
the most accurate information avail-
able concerning winds, weather con-
Approach and land- lot-controller communication should
involve the pilots and controllers in
ditions, and runway conditions. ing is the highest risk joint meetings and in joint flight/ATC
simulator sessions to promote a mu-
Approach and landing is the highest phase of flight for all tual understanding of each others
risk phase of flight for all categories
of aircraft. Data has shown that sta-
categories of aircraft. working environment. Discussions,
for example, could include problems
bilised approaches are critical to all
aspects of approach and landing
Data has shown that caused by late clearances and last-
minute runway changes. In the end,
accident reduction. A stabilised ap- stabilised approaches these are challenges that effect both
proach is defined by parameters es-
tablished by operators that include are critical to all aspects pilots and controllers, and these
challenges need to be addressed in
the intended flight path, speed, pow-
er setting, aircraft attitude, sink rate,
of approach and landing order to reduce the risk of runway
excursions.
configuration, and crew readiness. accident reduction.
An example of stabilised approach
criteria are the ones recommended Editorial note
by the Flight Safety Foundation.
(ALAR) program. A major US airline A controller will not necessarily
Stabilised approaches are particu- was having an inordinate number know exactly what criteria are be-
larly important in reducing the risk of go-arounds at one of its hub air- ing applied by each aircraft op-
of a landing runway excursion. There ports. After reviewing FOQA data, erator. Perhaps more importantly,
are several reasons why an approach the airline went to the local ATM they will also rarely know at what
may be unstable. These reasons can organization and reviewed the go- height above landing a mandato-
be attributed to the aircrew, the air- arounds with them. The ATM person- ry gate for application of the sta-
craft, ATM, environment conditions, nel were not aware that some of the bilised approach criteria has been
or a combination of these factors. As procedures they were using were set both 500 ft and 1000ft are
every pilot knows, ATM can destabi- causing the go-arounds. After a dis- widely used. It is worth pointing
lise any approach. For example, late cussion of the issue, the procedures out that, although the example
runway changes and slam dunk ap- were changed. Also, a formal pro- quoted makes a distinction be-
proaches are two ways that ATM can gram was started with regular meet- tween whether an aircraft is in IMC
cause an approach to become un- ings between the airline and the lo- or VMC in assigning the height of
stable. The important question is, do cal ATM personnel. ATM personnel the mandatory gate, many op-
the ATM personnel know that these were given simulator sessions with erators do not do that. Also, some
procedures can cause unstable ap- the airlines pilots to become more have found it useful to have two
proaches, and thus increase the risk familiar with the pilots issues during successive gates, the mandatory
during the approach and landing approaches. In addition, the airline or must one and a prior should
phase? Even more basic, do the con- pilots went to the local ATM facil- one, the latter typically set 500 ft
trollers know what a stabilised ap- ity and observed the challenges the higher.
proach is? Although pilots and con- ATM personnel had to deal with. The
trollers constantly work with each result of these actions was the vir-
other, sometimes they dont fully tual elimination of preventable go-
understand each others challenges. arounds at the airport. There are sev-
eral similar pilot-controller programs
An example of this is used in the around the world, designed to im-
Flight Safety Foundations Approach prove pilot-controller coordination
and Landing Accident Reduction and cooperation. Any program on pi-

HindSight 12 Winter 2011 51


FROM THE BRIEFING ROOM

TCAP: an altitude capture


enhancement to prevent TCAS RAs
By Paule Botargues, Airbus SAS, Automatic Flight Systems
Research, Engineering Department.

The Traffic Alert and Collision Avoidance System known as TCAS was introduced in the 90s to
prevent the risk of mid-air collisions. Today, this safety goal has been reached on a global scale.
However, a recurrent side-effect of TCAS introduction can be observed. This side-effect is what we
call the nuisance RAs or the operationally undesired RAs, which occur during 1000ft separation
level-off manoeuvres. A new Safety initiative has been launched by Airbus in response to BEA and
EUROCONTROL recommendations as well as in response to airline requests to solve this issue.

What is an operationally
undesired TCAS RA? Climb! Climb!

Climb! Climb!
What we call an operationally unde- FL110
sired RA is an RA, which occurs during FL100
FL110
1000ft level-off manoeuvres while ev-
FL100
erything is correctly done by the crew
with regards to operations and clear- Adjust VS! Adjust!
ance.
Traffic!Adjust VS! Adjust!
Traffic!
These undesired RAs can be charac-
Traffic! Traffic!
terised by the following two typical
encounter geometries:
1- eMOtION-7:
european n One aircraft (in red on Figure 1) is
Maintenance Of Figure 1 undesired tCAS RAs occurring during a single 1000ft level-o manoeuvre
tCAS II logic ver- intending to level-off at a given
sION 7.0 - Project level while another aircraft (in blue
commissioned by
euROCONtROL to on Figure 1) is already levelled at
provide the Agency the adjacent level (1000ft beyond Traffic! Traffic!
with the adequate
tool and structure
the 1st aircraft intended level)
to minimize any
Adjust! Adjust!Traffic! Traffic!
possible risk associ-
ated with the ACAS
n One aircraft is climbing to level-off Adjust! Adjust!
II implementation at a given level while another air-
in europe (Jan 2000 craft is descending to level-off at
- Dec 2002).
the adjacent level (1000ft beyond FL110
2- ASARP: ACAS the 1st aircraft intended level) as FL100
Safety Analysis FL110
post-RVSM on Figure 2
Project Project
FL100
commissioned by
euROCONtROL to We know from EMOTION-71 and
investigate the ASARP2 European projects that this Adjust VS! Adjust!
safety of ACAS
following the type of operationally undesired RAs
introduction of represent more than 50% of all RAs Traffic!Adjust VS! Adjust!
Traffic!
RVSM in europe
(Oct 2004
triggered by TCAS in Europe, and Traffic! Traffic!
May 2006). even more than 2/3 of RAs for some Figure 2 undesired tCAS RAs occurring during a double level-o manoeuvre

52
major European airlines which use Recommendations to lightly vary depending on who is
to frequently operate very high prevent these RAs expressing the rule. For example, in
density TMAs like Paris or London. PANS-OPS Doc. 8168, ICAO recom-
Several recommendations have been mends adopting a rate less than
Although these RAs do not imply a made to prevent these undesired RAs. 1500ft/min throughout the last
real collision risk (as far as aircraft The first of them directly addresses 1000ft of climb or descent to the
intentions are to level-off ), they the pilots and consists of reducing the assigned altitude when the pilot is
remain very stressful alerts and vertical rate when approaching an as- made aware of another aircraft at or
above all, they impose - by proce- signed altitude or a flight level, when approaching an adjacent altitude.
dure - an avoidance manoeuvre to pilots are aware of traffic converging in
both aircraft, leading to unneces- altitude. Indeed, this preventive action In the Airbus FCOM, we recommend
sary deviations from initial trajec- enables us to limit the vertical conver- that pilots limit the vertical speed to
tories and to traffic perturbations. gence between aircraft and thus to 1500 ft/min during the last 2000ft of
prevent passing TCAS alert triggering a climb or descent, especially when
Lets take the example of an A320 thresholds. they are aware of traffic that is con-
(medium weight/CG, selected verging in altitude and intending to
speed 300kt) climbing to FL130 As shown in Table 1, we can observe level off 1000ft above or below the
with a vertical speed of 2800ft/min, that the preventive rates to apply pilots assigned altitude.
while an A340-600 (light weight /
medium CG, selected speed VMO-
Vz Dist. to level
20kt) is descending to FL140 with
AI FCOM 1500 ft/min 2000 ft
a vertical speed of 2200 ft/min
FAA 500-1500 ft/min 1000-2000 ft
as shown on Figure 3. In such an
ICAO 1500 ft/min 1000 ft
encounter, TCAS system will trig-
DLH 2000 ft/min 2000 ft
ger a TA at FL116 in the A320 and
simultaneously a TA at FL153 in 1000 ft/min 1000 ft
the A340-600 followed by an RA euROCONtROL ACAS and RVSM Programs 1000 ft/min 1000 ft
at FL123 in the A320 and an RA at Swiss regulation 1500 ft/min 1500 ft
FL147 in the A340-600. table 1 Recommendations to prevent undesired tCAS RAs

This last recommendation meets


OWN
FAA one within AC 20-151A (appen-
FL180 dix A section III), which advises to
reduce the vertical velocity to a rate
TA
RA between 500 and 1500ft/min, when
FL160
RA approaching an altitude between
1000 and 2000ft above or below the
FL140 altitude assigned.

FL120 As a matter of fact, those recom-


RA mendations are rarely applied.
RA
Some pilots confess it is difficult to
FL100 TA
apply as it requires a lot of anticipa-
tion. As a result, there is still a sig-
INTRUS
FL80 nificant number of undesired RAs
observed during 1000ft level-off
Figure 3 example of nuisance tCAS alerts occurring during a double level-o manoeuvre manoeuvres.

HindSight 12 Winter 2011 53


FROM THE BRIEFING ROOM

TCAP: an altitude capture enhancement to prevent TCAS RAs (contd)

Another kind of recommendation ity. This triggering condition is associ- For example, with a vertical speed of
more medium-term has been ex- ated to a set of necessary pre-condi- +3000ft/min at FL130, DZavail is around
pressed by BEA following a mid-air in- tions including: 4000ft. This means that in case of a TA,
cident in March 2003, where a wrong TCAP will activate if the aircraft intend
response to an ADJUST V/S RA was n The Auto Pilot and/or the Flight Di- to capture a flight level lower than
observed in the context of a 1000ft rector must be engaged, FL170. TCAP will be inhibited if the
level-off encounter. BEA requested n The aircraft is converging towards aircraft intend to capture a flight level
aircraft manufacturers to study the its selected altitude, greater than FL170.
capability to take into account TCAS n The distance to the selected alti-
alert triggering thresholds into their tude at the time of the TA is lower Upon TCAP activation at TA:
altitude capture laws. than what we called the TCAP avail-
ability threshold DZavail (see below). n If the aircraft is initially in a vertical
This recommendation has been fol- guidance mode other than the al-
lowed by EUROCONTROL within the The concept of a TCAP availability titude capture mode (for example
ACAS Bulletins and by several airlines threshold has been introduced in or- in a climb or a descent mode), the
who requested a modification of the der to limit TCAP activation to the only vertical mode automatically re-
altitude capture control laws with an TAs corresponding to our targeted en- verts to the altitude capture mode
earlier reduction of the vertical rate to counter geometries, i.e. to the 1000ft (ALT* for Airbus HMI) with the new
prevent such recurrent undesired RAs. level-off encounters. TCAP altitude control law active
(ALT*TCAP control law).
The Airbus Solution: To avoid any TCAP activation upon a See figure 5.
TA occurring in other circumstances
TCAP function (e.g. far from selected altitude), TCAP n If the vertical mode is initially the
In response to these requests for im- availability threshold DZavail has been altitude capture mode (ALT* with
provement, Airbus has launched the defined as the upper distance from the conventional altitude capture
feasibility study of a new system called the selected altitude where a TA can control law active), the vertical
TCAS Alert Prevention or TCAP. occur with an intruder capturing the mode remains the altitude capture
same altitude in the opposite sense mode but with the new ALT*TCAP
The objective of this new TCAP fea- (with a conventional altitude capture control law active. The flight mode
ture is twofold: control law). This DZavail value depends annunciator, ALT* remains dis-
both on the aircraft vertical speed at played.
1) To reduce the number of undesired the time of the TA and on its altitude. See figure 6.
TCAS RAs occurring during 1000ft
level-off encounters by introducing
a new altitude capture law which Intruder
soften aircraft arrival to an intended
altitude when traffic is confirmed in
the nearby vicinity.

2) Not to unduly degrade the aircraft


performance, in particular in de-
FL TGT
scent, by a premature and exces-
sive reduction of the vertical speed DZavail
before reaching the altitude target,
when it is not justified. VZTA
TCAP activation logic is based on the
Traffic Advisory (TA) triggered by TCAS TA
Own
system, which clearly confirms the
presence of traffic in the aircraft vicin- Figure 4 tCAP availability threshold DZavail

54
Figure 5 FMA upon tCAP activation
when initially in OP CLB

New TCAP ALTITUDE capture control law (ALT*TCAP)


Figure 6 FMA upon tCAP activation ALT*TCAP control law objective is to ac- ALT*TCAP vertical speed targets (VzTGT)
when initially in ALt* quire and hold one or several consecu- have been defined so as to efficiently
tive vertical speed targets until the prevent undesired RAs while not to
Once activated, the ALT*TCAP control aircraft reaches its intended altitude unbearably increase the altitude cap-
law remains active until the end of the by resuming a classical 0.05g parabola ture phase duration, based on an opti-
capture (with ALT* mode engaged), profile. misation algorithm applied to 100.000
even if the triggering TA ceases. This is encounters.
to avoid triggering a new TA. When in ALT*TCAP control law, a verti-
cal load factor of 0.15g is applied to When TCAP is active, ALT*TCAP vertical
Finally, it is important to note that ensure a rapid reduction of the vertical speed targets are computed in de-
TCAP activation has no impact on the speed, and therefore a more efficient creasing sequence and refreshed as
lateral trajectory and associated lateral prevention of the RAs. It also gives a long as the TA is active, so as to comply
guidance mode as well as no impact reliable sensorial feedback to the crew with the operational requirement to
on Auto-Pilot, Flight Director and Au- to indicate TCAP function activation if kill the triggering TA for pilot confi-
to-Thrust engagement status. ALT* mode was previously engaged. dence in TCAP effect.

TA

FL target
TCAP V2TGT TCAP V2TGT 0.05g
hold (1) hold (2) Parabola

ALT* ALT

Figure 7 tCAP Profile

HindSight 12 Winter 2011 55


FROM THE BRIEFING ROOM

TCAP: an altitude capture enhancement to prevent TCAS RAs (contd)

In the case of a TA occurring farther EXAMPLES


than the last 2000ft from intended alti-
tude (also called early-TA), the prelim-
inary TCAP vertical speed target is the
Early-TA occurring TA occurring during
function both of the current aircraft when the aircraft is an altitude capture
vertical speed at the time of the TA in descent (in ALT*)
(VzTA) and of the distance to the tar-
geted altitude. Its value is comprised The aircraft is descending in OP DES The aircraft is performing an alti-
between 1500ft/min and VzTA (assum- mode when a TA occurs farther than tude capture on the conventional
ing VzTA > 1500 ft/min). When entering the last 2000ft. The ALT* mode imme- 0.05g parabola capture profile
the last 2000ft from targeted altitude, diately engages with ALT*TCAP control (ALT* mode) when a TA occurs. The
the vertical speed target automatically law active: the rate of descent is then ALT*TCAP law automatically activates
becomes 1500ft/min till the final cap- continuously reduced while the TA is to quickly reduce the rate of de-
ture (see Figure 8). active (few seconds) with a vertical scent, shortcutting the parabola
load factor of 0.15g. Once the TA is with a vertical load factor of 0.15g
In the case of a TA occurring within the off, the vertical rate is frozen on cur- (ALT* mode remains engaged).
last 2000ft of an altitude capture, the rent vertical speed target (>1500ft/
TCAP vertical speed target is the func- min) until reaching the last 2000ft The rate of descent is continuously
tion of the distance to the targeted al- where the vertical speed target be- reduced while the TA is active (a
titude at the time of the TA. Its value comes 1500ft/min. few seconds). Once the TA is off, the
is comprised between 1200ft/min and vertical rate is frozen on the current
1500ft/min (see Figure 9). vertical speed target (1300ft/min)
until the end of the capture.
The average impact on the altitude
capture time is an increase of 40 sec-
onds, compared to the conventional
3- INCAS: INteractive Collision Avoidance Simulator:
altitude capture law, remembering
euROCONtROL tool allowing to simulate encounters
that TCAP control law activation is lim- and resulting tCAS alerts (Input = aircraft trajecto-
ited to a TA occurrence. ries / Output = tCAS alerts)

TCAP Own
Own Own
Own
TCAPactivation
activation TCAP
TCAPactivation
activation
can (OP
(OPDES)
DES) (ALT*)
(ALT*)
canbebenoticed
noticed can
canbebenoticed
noticed
through
throughguidance
guidance through
through0.15g
0.15g
mode
modechange
changeandand nose
noseupup
0.15g
TA
TA
0.15gnose
noseupup Intermediate
Intermediate
FLFLtarget
target rate ofof
rate descent
descent FLFLtarget
target TA
TA
+2000ft
+2000ft +2000ft
+2000ft

1510500
ft0/fm
t/in
min 1310300
ft0/fm
t/in
1600ft
1600ft min
FLFLtarget
target FLFLtarget
target

Without
WithoutTCAP:
TCAP: OP
OPDES
DES ALT*
ALT* Without
WithoutTCAP:
TCAP: ALT*
ALT*

With
WithTCAP:
TCAP: OP
OPDES
DES ALT*
ALT* With
WithTCAP:
TCAP: ALT*
ALT*

TCAP
TCAP TCAP
TCAP
Altitude
Altitudecapture
capturephase
phaseduration
durationis islonger
longer Altitude
Altitudecapture
capturephase
phaseduration
durationis islonger
longer
due
duetotoTCAP
TCAPactivation
activation due
duetotoTCAP
TCAPactivation
activation

Figure 8 early-tA occurring when the aircraft is in descent Figure 9 tA occurring during an altitude capture

56
Expected benefits As far as undesired RAs represent
more than 50% of the totality of RAs
A performance assessment has been produced by TCAS system and as far Paule
carried out thanks to EUROCONTROL
INCAS3 tool coupled to Airbus simula-
as we anticipate a huge efficiency of
TCAP on this RA family, we can as-
Botargues
tion tools in order to measure the ben- sume a major effect on the global works in the Engineering Automatic Flight
efits of the new Airbus TCAP solution airspace perspective with signifi- System Department of AIRBUS France.
in terms of prevention of undesired cantly fewer RAs and the following She is in charge of the multi-program
TCAS RAs. associated outcomes: development of the AP/FD TCAS Mode and also
of research activities for the auto flight system.
For that purpose, several hundreds n For the crew:
of encounters, single level-off and less stress due to RA situations,
double level-off ones, at several flight
levels with random initial vertical rate n For ATC: Next steps
conditions, were tested. fewer unnecessary traffic pertur-
bations owing to undue avoid- This new TCAP altitude capture en-
The resulting performance is signifi- ance manoeuvres. hancement will be available on A380,
cant - not to say optimal - with 100% of A350 and on fly-by-wire aircraft fami-
undesired RAs prevented among the Finally, TCAP solution will efficiently lies in the near future. The certification
overall simulated cases. Based on this contribute to alleviating the crew targets are anticipated between end
very exhaustive assessment, Airbus is workload. Pilots will not have to 2011 and mid 2013 depending on the
very confident about TCAP efficiency anticipate the FCOM recommenda- aircraft type.
in the current airspace environment. tion to prevent undesired RAs any
longer, knowing they are flying an
Another very relevant result observed aircraft equipped with the TCAP sys-
is the following: only one aircraft of the tem, they will just have to monitor
encounter needs to be equipped with the Auto Pilot or the Flight Director
TCAP to allow RAs prevention on both adopting the proper strategy in the
aircraft (see Figure 10). event of a TA.

TCAP-equipped
TCAP-equipped
TA TA
RA RA
BeFORe TA TA AFteR
RA RA

RA RA
RA RA
TA TA TA TA

Not equipped
Not equipped
with TCAP
with TCAP

Classical ALT 2 RAs New ALT No more RA


Benefit for the non-equipped a/c also!
Figure 10 tCAP benefits on a double level-o encounter

HindSight 12 Winter 2011 57


FROM THE BRIEFING ROOM

AIRPROX - Altimeter System Error


Whats my level? By Chantal Bonnet - DSNA

What happened before?


The Airprox:
After take-off, in contact with Sky-
In June 2010, Bordeaux ACC experienced a very serious guide, when AC1 was stable at FL100,
airprox. The first aircraft (AC1) involved was a single- the pilot reported a discrepancy be-
engine turboprop (Pilatus PC12) flown by a single pilot. tween the two altimeters fitted on the
The second aircraft (AC2) was an Airbus 318. The two aircraft. The pilot asked ATC to check
aircraft had been following the same route, with AC2 that the aircraft was at FL 100 and this
gradually catching up AC1. AC1 was reported to be at was confirmed by the controller.
and indicated SSR Mode C FL 270 and AC2 was at FL 290.
The traffic load was low. AC1 was then transferred to Marseille
ACC. The pilot did not report any altim-
When AC2 was at the point of over-taking AC1, the pi- eter problems while in contact with
lots of AC2 felt the aircraft bank very slightly from right Marseille ACC.
to left. They had a look on the Primary Flight Display
(PFD), everything seemed normal. On looking outside, AC1 was then transferred to Bordeaux
however, they saw that they were closing rapidly on ACC with SSR Mode C indicating
another aircraft at their level. The crew took avoid- FL270. This was confirmed and verified
ing action to the left and reported a miss distance of on first contact. A few minutes later,
10m, at the same level. the pilot of AC1 reported to ATC that
he had a discrepancy in the displayed
altitude on his two altimeters: one in-

??
dicated FL270 and the other FL290.
He asked ATC if they could check
his altitude if he put his Mode C on
Standby. At that moment, there was

?
no other traffic in the vicinity of AC1,
and so there was no need to effect
any horizontal separation. The control-
ler, aware that military control centres
were equipped with primary height-
finding radar able to evaluate an alti-
tude, decided to check AC1s altitude
with his military colleagues.

This initiated a complex co-ordination


sequence involving 3 intermediaries
about a request to check AC1s altitude
by a source other than that used to de-
rive the Mode C data being displayed to
the Bordeaux controller. During this pe-
riod, AC2 made its first contact with the
Bordeaux controller and was cleared to
FL 290. After approximately another
3 minutes, the Bordeaux controller re-
ceived confirmation from the military

58
n There is no ICAO procedure related What can be done by ATC
to this situation (i.e. when the pilot is
when the pilot confirms
Further Reading: unable to determine his altitude due
the problem?
to discrepancy in altimeter readings),
n iCAO Annex 6 which is completely different from con- n Establish horizontal separation.
Operation of Aircraft trollers verifying Mode C indications. n Ask the pilot to stop Mode C.
n The pilot did not declare any state of n Inform the pilot that it is not pos-
n SKYbrary articles: urgency (the flight had been controlled sible to determine his/her altitude.
- Altimeter System Error with a critical altitude error for more n Inform other sectors/centres.
- Height Monitoring Units than 35 minutes in airspace that is usu- n Depending on the severity of the
- RVSM ally very busy). situation:
- Aircraft Technical Equipment n Some primary height-finding radar can
- EFIS evaluate the altitude of a flight but this - Ask the pilot to select Mode A
- Altitude Alerter information is not accurate enough to 7700.
- EU OPS be used for separation (the error is gen- - Provide flight assistance if prac-
erally more than 2000 ft). ticable arrange an escort aircraft,
n Ground-to-ground communications help the pilot to remain in VMC.
can be complex. Safety-related infor-
mation must be passed on accurately Internally, important efforts have been
that AC1 was at exactly FL 270! However, from one agency to another or from made to learn lessons from this inci-
it later transpired that the source used one sector to another. dent and provide feedback to ATCOs.
for the cross-check was the same as that n Altimeter System Error can negate the
used by the Bordeaux controller (i.e. SSR benefits of safety nets such as STCA and During the period 2009/2010, two oth-
derived Mode C data). Unaware of this ACAS. er occurrences when pilots informed
and believing AC1 to be at FL270, the n ATCOs and pilots can be surprised if ATCOs that they were not sure about
controller still did not consider it neces- they do not maintain an understand- their altitude were reported. However,
sary to build in any horizontal separation ing and/or knowledge of how certain unlike the incident described
between AC1 and AC2 which was by ground and airborne systems work and above, in those particular
then at FL290 and following AC1 on the how they may interact with each other. cases, the displayed alti-
same route. tudes turned out to be
Mitigations and lessons correct.
The airprox occurred ten minutes after
the (false) cross-check. Neither STCA nor
learned:
TCAS was triggered! n ATC relies on the altitude/height infor-
mation provided by the pilot/aircraft
Finally, ten minutes after the event, the systems for the safe provision of ATS. Chantal Bonnet
pilot of AC1 manually selected the sec- However, there is no independent
She is the head of Safety Analysis Unit in
ond altimeter for Mode C and the aircraft means available to determine the ve-
Bordeaux ACC. Previously she was an ATCO in
was displayed at FL290 on the radar racity of the information. When a pilot
screens. asks a controller to confirm his/her alti- Paris ACC then in Bordeaux ACC. In Bordeaux
tude, because there is a discrepancy in ACC she became an ATC Supervisor and also
Analysis: altimeter readings, this should not be FMP manager.
The investigation and analysis of the considered as a routine situation.
incident by BEA (French AIB) and DSNA
identified a number of key points:
EdiTORiAL NOTE
n The altimeter failure was due to a leak
in the static circuit No. 1 (pilots cir- One important point in this account insofar as it has wider implications for us all is the
cuit). This leak was located on a short number of (serviceable) barometric altimeters on the flight deck. Some small aircraft like
plastic connector that links the static the PC12 will often only have two even though they are sometimes flown IFR in Con-
circuit with the cabin differential pres- trolled Airspace, whereas larger aircraft will have three. Having three altimeters means
sure indicator. that, in the event of the malfunction of a single instrument, cross checking will disclose
n There is no set procedure for the PC12 the problem and the majority reading (two out of three the same) will easily determine
to help pilots determine which altim- which one is unreliable and can be ignored, with one of the serviceable ones selected
eter displays the most reliable infor- as the height encoding source. ATC do not need to know.
mation in these circumstances.

HindSight 12 Winter 2011 59


SKYBRARY

SKYbrary downloads
If you need to find out something about aviation safety, we suggest you
go first to www.skybrary.aero. It doesnt matter whether you are a
controller, a pilot or a maintenance engineer, SKYbrary aims to have
either the answer you are looking for or a direct route to it.

Wind velocity reporting


Description
Article Information
If by any chance you cant find what you This article summarises the origin of
want, please remember that SKYbrary is wind velocity measurements made at Category: Runway
a dynamic work-in-progress which needs airports and communicated to aircraft Excursion
continuous user feedback and benefits to assist their safe take off and landing. Content
from user support. Be sure to tell the SKY- It also provides some guidance on how source: SKYbrary
brary Editor about any difficulty you may this information should be applied by
have had making it work for you. If you can flight crew, which concerns aircraft
Content
directly help us by identifying material we performance calculations, operating
source: EUROCONTROL
could use or even fill a gap by writing some within prescribed AFM limits and the
content yourself then please tell us too! tactical handling of the aircraft during EUROCONTROL

take off and landing.


We aim to provide wide coverage through
both original articles and, especially, by What is wind velocity? Wind velocity and
hosting the best of whats already been
written so that a wider audience can ac- Velocity is a vector, which simply aircraft safety
cess it more easily in one place. means that it is defined by two param- Whilst it is probably true to say that the
eters, speed and direction. A specifica- importance of taking appropriate ac-
SKYbrary is also the place where you can tion of wind velocity therefore requires count of wind velocity during the take
access: that both wind direction and wind off and landing of an aircraft is appre-
speed are given. Wind direction is al- ciated by all aviators and air traffic con-
n all the documents of the Flight Safety ways given as a radial measure in de- trollers, problems arise because unless
Foundation Operators Guide to Hu- grees stating the direction from which it is completely calm, it is impossible
man Factors in Aviation the wind is blowing. Wind speed may when near the ground to know the
be given in either knots (nautical miles actual wind velocity of an aircraft at a
n the largest collection of selected official per hour) or metres per second de- given time and location. Using wind
accident & serious incident reports pending upon the procedures of the velocity information is therefore a
from around the world anywhere in one State concerned. matter of:
place online
Caution: Many references to wind n Understanding exactly what
n an expanding facility to search ICAO measurement from non-expert sourc- velocity is being provided
document text. es equate wind velocity with wind n Using the information
speed and therefore typically refer to appropriately
In future, we will be reprinting a SKYbrary wind velocity and direction which is
article in each issue of HINDSIGHT. This time incorrect. The Flight Safety Founda-
we have chosen something which can affect tion Notes listed under Further Read-
us all Wind Velocity Reporting. ing below are examples of this error.

60
SKY
brary
On-board displays instantaneous wind velocity in the The prescribed requirements for the
immediate area around it. The exact reporting of gusting wind speeds and
of wind velocity sites of wind sensors should be indi- for reporting more than a specified
Flight deck displays of instant wind cated on relevant aerodrome chart in amount of variation in wind direction
velocity based on onboard computa- the State AIP. At most airports used for are contained in ICAO Annex 3 and are
tions are now quite accurate when significant commercial or military air reflected in the procedures for METAR
instant variation is not required, es- traffic, there will be a least one sensor observations. However, the variation
pecially away from the ground, but positioned to the side of any runway in wind speed and in wind direction
their usefulness for assisting the ex- at the each end in the vicinity of the are monitored and used independent-
ecution of a safe touchdown, landing touchdown zone (TDZ) and there will ly and from a practical perspective,
roll or take off roll is often very limited, probably also be at lease one other interpreting the potential extreme
both for practical and computational sensor somewhere in the central area wind velocities is therefore likely to
reasons. Updating of on-board read- of the defined airside zone. Depend- be difficult. However, in respect of
outs of wind velocity depends on the ing on where this general sensor is wind speed, it is generally accepted
system which generates them. FMS and on the relative complexity of the that although the gust ratio - the ra-
wind is the most accurate, because it airport layout, there will often be ad- tio of the maximum gust to the mean
is based on changes GPS or DME/DME ditional sensors adjacent to the mid- wind speed - may frequently reach 2,
position, but it may only be re-calcu- point of each runway. only rarely will it exceed 3 even in very
lated every 30 seconds. Wind velocity strong wind conditions.
based upon an INS is often calculated Variation in wind velocity
as much as 10 times per second but METAR wind velocity
the result is less precise. The net effect Unless the wind is completely calm,
is that neither have real value near or wind velocity rarely remains the Wind velocity in a METAR is stated
on the ground. same for very long and the extent solely as the measured or estimated
of the variation in both speed and mean of each component over the
Location of airport direction is likely to be directly pro- 10 minutes prior to the time of issue
portional to the mean wind speed, of the METAR unless there are signifi-
wind sensors because the effect of terrain friction cant variations during this 10 minute
There is usually more than one sen- upon the characteristics of the wind period. For direction, this means 60
sor position but all will measure the blowing across it increases as wind degrees or more of arc but less than
wind velocity at the standard height speed increases. Clearly, this effect 180 degrees provided that the mean
of 10 metres above the surface, which will be greatest at airports situated speed during the previous 10 min-
is the internationally accepted meteo- in areas of uneven terrain or with utes has been more than 3 knots. In
rological definition of surface wind significant obstacles affecting the the case of speed, variations from the
designed to eliminate distortion at- degree of low level mechanical tur- mean wind speed (both above and be-
tributable to very local terrain effects. bulence over particular parts of the low it) are reported when the variation
Any sensor will be sited so as to pro- aerodrome when particular general from the mean speed has exceeded 10
vide a representative indication of the wind directions prevail. knots. Such variations are expressed as

HindSight 12 Winter 2011 61


SKYBRARY

SKYbrary downloads (contd)

Wind velocity reporting


the maximum and minimum speeds more than 30 degrees or the 2 minute Aircraft performance
attained and must also be included if average wind speed changes by more
the maximum wind speed in a 10 min- than 5 knots over a five minute inter-
calculations and reported
ute period has exceeded the 2 minute val. wind velocity
average wind speed at the same lo- Like any other input to aircraft take off
cation in that period. Any gust value ATC wind velocity reports or landing performance calculations,
which has occurred in the most recent wind velocity will be the (average) fig-
two minute period will, of course, also Display of wind velocity information ure available prior to taxi out or top of
be part of the calculation of average to ATC at major airports usually al- descent. This means that while allow-
wind speed lows at least the reporting by RTF of ances are made in performance tables
both the average wind - that over or equivalent computer programmes
Wind direction is recorded in degrees a two minute period updated every for a certain amount of variation in the
true. Whatever runway(s) is (are) in minute - and instant wind - the value inputs, any change in the wind veloc-
use, the wind velocity for the METAR at that exact time. The latter is usually ity data used which may affect the va-
is normally taken from one designated used only where high wind speeds lidity of the calculation for the runway
anemometer. and their associated greater fluctua- case concerned, must lead to a recal-
tions in both speed and direction pre- culation.
ATIS wind velocity vail. ATC may proactively initiate such
wind checks or this action may be Applying wind velocity
ATIS wind velocity is latest two minute requested by a flight crew. Whilst the
average. The wind direction broadcast ATC TWR at most international and
reports to AFM limitations
is given in degrees true the wind mean major domestic airports will nowadays An AFM or Operations Manual will al-
have digital displays of wind velocity ways contain maximum wind speeds
which can be specific to for take off and landing. These will
be stated as wind components and

will cover the crosswind, tailwind and


speed will be supplemented by the sensor site or integrated from several head wind cases. Instant or two min-
value of the highest and lowest gusts sites and can show a selection of trend ute winds given by ATC will need to
within the 10 minutes prior to issue and extremes data, smaller airports be converted into the applicable wind
time if either exceeds the METAR-spec- may still be limited to dual and plot- components by the flight crew and
ified minimum difference increment ted graphical displays for finding out checked against the stated limitations.
away from the mean. both required broadcast information A suitable graphical display can be
and additional ad hoc assistance. ATC used by PM to read the received ATC
Updating of ATIS broadcasts between plain language ad hoc wind directions figures if no automated conversion
any regular change times because of given during final approach or just is available. In all cases, the apparent
wind velocity changes is usually made prior to or during the take off roll, are general situation including any stated
only if the wind direction changes by likely to be given in degrees magnetic. or apparent trend, is the key to using

62
SKY
brary
this information. Flight crew need to Intelligent use of available wind ve- its consequent inertia in respect of
remember that ATC wind velocity in- locity information can be crucial for flight control inputs, and in respect
formation provided during take off or avoiding runway excursions caused of the delayed response to thrust
landing at times of high wind speed by loss of control near to, or on the lever movement on large fan jet en-
has to be intelligently interpreted ground. Points to consider include the gines.
rather than rigidly applied. It is also following:
important to note that maximum wind Related Articles
components in the AFM are invariably n The W/V provided as instant winds
dependent on the dry runway case, by ATC should be from the data dis- n Runway Excursion
with more restrictive figures usually play for the most appropriate sen- n METAR
given for wet runways or those with sor for aircraft position - but a pilot n Low Level Wind Shear
reduced braking action. may not necessarily know where n Terminal Doppler Weather Radar
that is.
Aircraft handling and Further Reading
The instant wind may be exactly
reported wind velocity n
that or may be a mean figure auto- n World Meteorological Organisation
Any wind velocity given to an aircraft is matically generated over a few sec- (WMO) Guide to Meteorological In-
a proxy of some sort for what the wind onds. struments and Methods of Obser-
velocity actually is where the aircraft is vation
at that time. The degree to which it is a n The display from which an instant n ICAO Annex 3 Meteorological Ser-
proxy will always be greater at higher wind is taken may be a digital dis- vices for International Air Naviga-
general wind speeds, but will also be play, with or without an indepen- tion Chapter 4 Meteorological Ob-
dependent upon aerodrome-specific dent display of the short term aver- se rvati ons and Reports .
factors. Well recognised and signifi- age, range and trend in wind speed n FSF ALAR Briefing Note No 8 - Wind
cant local effects should be detailed in and direction, or it may be a pair of Information
the AGA section of the State AIP. simple mechanical dial displays. www.skybrary.aero/bookshelf/
books/870.pdf
n All instant winds are best interpret-
ed in the context of the amount of
short term fluctuation they appear
to indicate.

n Any wind direction given by ATC


to aircraft about to land or take off
should be expressed in degrees
magnetic so as to correspond to the
similar designation of runway align-
ment.

n The significance of rapidly chang-


ing instantaneous wind velocity for
aircraft handling in the absence of
any definite trend may be affected
by the weight of the aircraft and

HindSight 12 Winter 2011 63


If you are interested in downloading the entire HindSight collection:
www.skybrary.aero

N 1
January 2005
N 2
January 2006
N
June 2006
3 N
January 2007
4 N
June 2007
5 N 6
January 2008

COLLISION
Putting Safety First in Air Traffic Management

COMMUNICATION
HINDSIGHT IS A Hindsight
The ability or opportunity to understand and judge AIRSPACE CONFLICT AVOIDANCE
WONDERFUL THING an event or experience after it has occured.

INFRINGEMENT DETECTION THE RUNWAY AND YOU


Hindsight
The ability or opportunity to understand and judge

WORKLOAD
an event or experience after it has occured.
By Tzvetomir Blajev Hindsight Hindsight
Coordinator - Safety Improvement Initiatives, The ability or oportunity to understand and judge The ability or opportunity to understand and judge Hindsight
and Editor in Chief of HindSight. an event or experience after it has occured. an event or experience after it has occured. The ability or opportunity to understand and judge By
By Ian
Ian Wigmore
Wigmore
Win a free trip for two to Paris:
an event or experience after it has occured.
See
See page
page 22
22
With the benefit of hindsight I would
Hindsight
THE APPLICATION OF
IS AIRSPACE PENETRATION
The ability or opportunity to understand and judge
have done it differently.
See page 26 an event or experience after it has occured.
OFFSET TRACKS
How often do we hear responsible people If we learn the right lessons we will stand with your colleagues - think what you AN ATC PROBLEM OR NOT? ANOTHER SUNNY DAY IN SWEDEN
saying these words? Often, it is an attempt a much better chance of reacting correct- would do if you had a similar experience.
See page 3 IN EUROPEAN AIRSPACE
to disguise the fact that they had not
prepared themselves for some unusual
ly when we are faced with new situations
where a quick, correct decision is essen-
We hope that you too will join in this
information sharing experience. Let us
BY BENGT COLLIN WORKLOAD A STRANGE CONCEPT BY ROLAND RAWLINGS
situation. Yet hindsight is a wonderful tial. This magazine is intended for you, the know about any unusual experiences See page 5
thing and can be of great benefit if used controller on the front line, to make you you have had we promise to preserve BY
BY PROFESSOR
PROFESSOR SIDNEY
SIDNEY DEKKER
DEKKER See page 8
intelligently to prepare ourselves for the know of these lessons. It contains many your confidentiality if that is what you See
See page
page 66
unexpected. There is much to be learnt examples of actual incidents which raise wish. Working together with the benefit
from a study of other peoples actions - some interesting questions for discussion. of HindSight we can make a real contribu-
good and bad. Read them carefully - talk about them tion to improved aviation safety. Front Line Report
The Briefing Room
by Bert Ruitenberg
Editorial 121.5 - Safety Alerts
Learning from Experience

Hindsight is a Wonderful Thing 1 Avoiding Action Phraseology 4 Runway Incursion 8

EUROCONTROL Safety New Clearance Related Loss of Separation 11 THE HUMAN FACTOR COLUMN WORKLOAD VERSUS BOREDOM
Enhancement Business Division 2 to Levels 4

About HindSight 3 Aircraft Turn Performance


Controlled Flight Into Terrain 13
LOSS OF SEPARATION BY PROFESSOR SIDNEY DEKKER BY BERT RUITENBERG
Early Turns 5 Unauthorised Penetration
See page 7 See page 7
Acronyms used in This Issue 24
Undetected Simultaneous
of Airspace 15
THE BLIND SPOT
The Editorial Team 26 Transmission 5 Wake Vortex Turbulence 17
See page 15 AIRBUS AP/FD TCAS MODE:
Contact Us

Disclaimer
27

28
Hand-over/Take-over of
Operational Position 6
Runway Excursion

Level Bust
19

21 NEAR COLLISION INVESTIGATING CONTROLLER A NEW STEP TOWARDS


Feedback 22
The Phonological WHAT? RUNWAY INCURSIONS - AT LOS ANGELES BLIND SPOTS SAFETY IMPROVEMENT
See page 25 IT WILL NEVER HAPPEN TO ME ... See
See page
page 20
20 BY
BY DR.
DR. BARRY
BARRY KIRWAN
KIRWAN By Paule Botargues
See page 18 See
See page
page 12
12 See
See page
page 25
25

European Air Traffic Management - EATM

EUROCONTROL DAP/SAF January 2005 EUROCONTROL DAP/SAF January 2006 EUROCONTROL DAP/SAF June 2006 EUROCONTROL DAP/SSH January 2007 EUROCONTROL DAP/SSH June 2007 EUROCONTROL DAP/SSH January 2008

7
8: winteredition09 Hindsight the ability or opportunity to understand and judge an event or

Hind ight 09 Hind ight 10 Hind ight 11


Hind ight
experience after it has occurred.

N
EUROCONTROL
The ability or opportunity to understand and judge an event or experience after it has occured EUROCONTROL EUROCONTROL
The ability or opportunity to understand and judge an event or experience after it has occured The ability or opportunity to understand and judge an event or experience after it has occured

July 2008

WEATHER Are you responsible Level Bust... Airspace Infringement -


Hindsight

Production for safety? or Altitude Deviation? again?!


Pressure
The ability or opportunity to understand and judge
an event or experience after it has occured.

Putting Safety FirstA WEATHER


in Air Traffic Management
GHOST STORY
By Prof. Sidney Dekker Clashing moral values p08
European Organisation for Safety of Air Navigation See page 8
(EUROCONTROL) January 2009. By Professor Sidney Dekker
NEW! CASE STUDY:
This publication has been prepared by the Safety Improve-
ment Sub-Group (SISG) of EUROCONTROL. The authors
acknowledge the assistance given by many sources in the Next please p15
THE FIRST OFFICER IS MY preparation of this publication.
By Anthony F. Seychell
MOTHER-IN-LAW The information contained herein may be copied in whole
or in part, providing that the copyright notice and disclaimer
By
By Bengt
Bengt Collin
Collin are included.
Safety & the cost killers p16
See
See page
page 16
16 To see or not to see
A letter to aviation prosecutors
The information contained in this document may not be
By Jean Paries
modified without prior permission from EUROCONTROL.
50 YEARS AFTER MUNICH
The views expressed in this document are not necessarily
Level Busts: cause or consequence? by Bert Ruitenberg
those of EUROCONTROL. See page 39
The consequences of p23
by Tzvetomir Blajev by Professor Sidney Decker
EUROCONTROL makes no warranty, either implied or ex-
commercial pressure can be fatal
Lets get rid of the bad pilots
pressed, for the information contained in this document; nei-
ther does it assume any legal liability or responsibility for the
accuracy completeness and usefulness of this information. By John Barrass I separate therefore I am safe The Other Level Busts by Professor Sidney Dekker
by Bert Ruitenberg by Philip Marien
R
GET YOU ER
POST
Airbus altitude capture enhancement
SKYbrary re page
See cent
Lesson from (the) Hudson Air Traffic Controllers do it too! to prevent TCAS RAs
CND January 09

by Loukia Loukopoulos by Paule Botargues


by Jean Paries
Winter 2010 Summer 2010
Summer 2009
EUROCONTROL DAP/SSH July 2008

In the next issue of HindSight:


Fatigue

EUROCONTROL

Putting Safety First in Air Traffic Management

European Organisation for Safety of Air Navigation


(EUROCONTROL) January 2011

This publication has been prepared by the Safety Improvement


Sub-Group (SISG) of EUROCONTROL. The Editor in Chief acknowledges Hind ight 12
The ability or opportunity to understand and judge an event or experience after it has occured

the assistance given by many sources in its preparation.


Runway excursion
The information contained herein may be copied in whole or in part,
providing that the Copyright is acknowledged and the disclaimer Controllers and pilots teaming up
to prevent runway excursions
below are included. It may not be modified without prior permission by Captain Bill de Groh, IFALPA

from EUROCONTROL. Some hidden dangers


of tailwind
by Gerard van Es

diSCLAiMER The role of ATM in reducing


The views expressed in this document are not necessarily those of the risk of runway excursion
by Jim Burin

EUROCONTROL which makes no warranty, either implied or expressed,


for the information contained in it and neither does it assume any legal
liability or responsibility for the its accuracy, completeness or Winter 2011

usefulness.
* Piste - French, 1. (ski) track, 2. runway