South West Airlines Flight WN 1380 17 April 2018.
On 17 April 2018 a South West Airlines Boeing 737-700 experienced an in-flight engine failure on climb-out from New York La Guardia airport which resulted in the death of one passenger who was partially sucked out of a shattered windows during a cabin depressurisation.
The NTSB have confirmed that a fan blade from the left-hand engine (a CFM56-7B) had separated from the engine hub and an initial examination has shown evidence of metal fatigue where the blade became detached.
This accident will be monitored by the ASG because a CFM56-7B engine on another SWA Boeing 737 experienced a very similar blade failure on 27 August 2016 during climb-out from Pensacola Florida. This accident resulted in airworthiness instructions, still current, which require ultrasonic inspection of all affected blades.
On 20 Apr 2018, the FAA issued an Emergency Airworthiness Directive (EAD) which requires an ultrasonic inspection for cracks of the fan blade dovetail within 20 days and removal from service of cracked fan blades, in accordance with a CFM Service Bulletin issued on the same day.
The ASG notes that the EAD is satisfied if CFM Service Bulletins dated 24 March 2017 (as revised on 13 Jun 2017) or 24 Jul 2017 were implemented.
We await further information from the FAA and NTSB.
Nigel is an aviation consultant and flight operations auditor with over 35 years of experience in commercial aviation with both passenger and cargo airlines. He specialises in flight operations support, operational control and supervision. He is the holder of an FAA Part 65 Flight Dispatcher licence and an aviation safety advisor to the PACTS (Parliamentary Council for Transportation Safety) and an independent expert to European Aviation Safety Agency (EASA).
Nigel Johnstone has been involved with civil aviation over 35 years.
“Commercial aviation has an enviable reputation for safety and is frequently held up as an example to aspire to. That reputation has been hard won; coming from the efforts of aviation professionals spending decades learning from incidents and accidents that have befallen the industry.
How Working on the Flight Deck has Changed During the Last 50 Years by Ian Frow - ASG Committee Member
How Working on the Flight Deck has Changed During the Last 50 Years by Ian Frow ASG Committee Member
FLIGHT DECK/FLIGHT CREW CHANGES IN PAST 50 YEARS
A Personal Note
Once I had started to write this blog it turned into something slightly different with a more personal remembered slant. (My personal reminiscences are in italics) For my entire career I was a long-haul pilot although, especially in the early days, we flew a number of short haul type sectors in both Europe and elsewhere in the world. This essay reflects the changes primarily in the BOAC/long haul world but with some BEA/short haul comparisons where applicable.
The memories of technical changes are just that – memories – and need an accuracy health warning. And the comments are simply mine with the perspective of 47 years working in aviation and in my retirement years (up to the present) having a membership of various aviation safety committees.
I joined BOAC in September 1958. At that time young pilots joining ‘The Corporation’ were mortified to find that first; they were to be Flight Navigators. The reason was that the ‘specialist’ navigators were, like the radio operators, being phased out
Following a year’s mini degree ground school, we went off to navigate across the Oceans and Deserts of the world, initially under instruction. In the summer of 1959 I flew on my first flight as a BOAC flight deck crew member. The aircraft was a piston engined Douglas DC7c bound for New York via Boston – a long day’s work before Flight Time Limitations were invented. I was there to observe the navigator navigating but no more than that. It turned into an epic. We did numerous missed approaches at Boston, failed to get in and went on to New York Idlewild where we landed after yet more missed approaches. The total chock to chock time was 14 hours 15 minutes which I only exceeded when I operated a 747 from Hong Kong to London in 1985!
Subsequently I was a ‘pilot navigator’ on Britannia 102s, Comet 4s and Boeing 707s before completing a pilot course on the 707 and then being able to sit in both the right hand seat and at the navigator’s table. In 1972 I converted onto the Boeing 747. Lacking in enthusiasm for many conversion courses, it was an aircraft I flew, in various versions, until my retirement in 2002, thus completing 30 years on the type.
Despite this I was also exposed to many other aircraft operating regimes through my work in the BALPA technical section, and in particular work on the BALPA Concorde Evaluation.
Flight Deck Crew in the Fifties
The DC 7c crew consisted of the captain, first officer, relief first officer, flight engineer, navigator and radio operator. This was typical for most long haul aircraft types at that time. It is worth noting that throughout the following descriptions of flight deck crew members in the fifties all are referred to as ‘he’. There were no women on major airline flight decks until the eighties.
He was frequently a dominant figure who had served in the war and brooked little input from hi
The flight deck of a B707s crew. Crew Resource Management was many years in the future. He could be a petty tyrant an attitude of mind not helped by the fact that he received excessive respect from both his crew and the ground handling staff. He usually stayed alone in a superior hotel to the rest of his crew.
The occupant of the right had seat usually had a respectable level of airline experience and the captain occasionally allowed him to fly the aeroplane. All too often, in his apprenticeship as a commander, he adopted all the worst traits of his captain. He, together with the other flight deck crew members, would stay not only in a separate hotel from the captain but also in an hotel different to that of the cabin crew.
Relief First Officer
He was less experienced (although often with a number of military hours) and he occupied a pilot’s seat whilst one of the other pilots was at rest in the bunk. He was often frustrated since he rarely had the chance to actually handle the aircraft between his routine checks.
He had an encyclopaedic knowledge of the aircraft systems and was capable of getting his hands dirty to fix snags down route. He was also often a very effective pilot monitor because the Flight Engineer’s seat was set back from the pilots’ seats
Engineers working on a Comet 4cand he had a good situational overview. Through the years there were several occasions when a Flight Engineer’s intervention saved the day. As a group they traditionally had a very good instinct for finding a bargain, particularly for breakfast deals. The flight engineer position continued into the 747 era but effectively ceased after ‘9/11’ in 2002 when the three crew 747s were grounded because of cost.
He was often as old as the captain, frequently with distinguished wartime experience. (This could also be the case with the Flight Engineer and Radio Operator). He was the intellectual of the crew, sometimes a demon cards player. The role of the navigator gradually ceased in BOAC as the ‘Pilot Navigators’ took over, ironically initially trained by the ‘specialist navigators’.
He had the tiresome task of conducting all HF (long range radio) transmissions and collecting weather and other information for the captain. HF was often impossible to read and usually a cacophony of noise. Radio operators often had a reputation of being eccentric and odd (due to listening to all that noise?). In the fifties this crew position was being phased out as the pilots took over all radio duties.
Flight Deck Crew in the Twenty First Century
The standard crew of a Captain and First Officer is sometimes augmented in long haul by one or more crew members. Thus on most sectors the tasks of those five fifties crew members are now performed by two. The vast amount of automation
The flight deck of a Finnair A350and automatic information sources has to take the place of those three lost crew. Generally automation copes but sometimes, in unusual emergency situations, the extra hands, heads and eyes may be missed. (The Qantas A380 engine disintegration incident in Singapore would probably been a disaster had it not been for lucky chance that there was a heavily augmented crew on the flight deck).
The advent of Crew Resource Management training has totally revised the power/authority gradient on the flight deck – there are now few captains who believe they have a direct line to the Almighty. However there is an increased tendency for the left hand seat to have relatively few years’ experience. Thus first officers with even more limited experience no longer have the facility of learning by osmosis, watching and learning from the techniques of highly experienced captains.
The removal of an engineering specialist (which happened many years earlier in short haul) has meant that pilots have, one the one hand to rely far more on the ground maintenance engineers and on the other they have be able to do some of the more simple engineering checks and procedures themselves.
Navigation - from the Fifties until the Twenty First Century
In the fifties over land, there were radio beacon aids to navigation (NDBs, VORs). Once on the Ocean or over remote areas, navigation was by use of Loran, Consol (both using long range radio signals) together with astro and, all too often ‘dead reckoning’ (plotting a track based on the forecast winds). In daylight, over remote land areas it was not even unusual to resort to map reading. In the North Atlantic and the Pacific there were a number of stationary ‘Weather Ships’ who would add to their weather reporting role by giving passing aircraft radar fixes.
(In some areas of Europe there were chains of radio stations whose signals produced an approximation of a position on a rolling map on the flight deck. The ‘Decca Navigator’ was allegedly quite good when it worked properly).
Most fixing methods required plotting position lines on a chart which of course took time. Especially at night, astro navigation came into its own; but a ‘three star fix’ involved 10 plus minutes of calculations, followed by three sights using a bubble sextant, each lasting exactly 2 minutes and separated by 2 minutes exactly. (The sextant was deployed through a port in the flight deck roof, which replaced the ‘astrodome’ on previous types). The result of all this effort was a three position line fix – but by the time it was plotted on the chart the position was valid fifteen minutes ago.
Even Loran, Consol and ‘dead reckoning’ would not produce an instantaneous fix. In the later sixties the 707s and VC10s of BOAC were fitted with Doppler which at least gave accurate tracking and groundspeed information. It was not until the Boeing 747 entered service in 1970, with inertial navigation built into its management systems, that a crew could know their instantaneous position. In the eighties, once the ‘glass cockpit’ aircraft types entered service, pilots had the luxury of map displays showing a plethora of instantaneous position and route information. During the nineties additional refinements were made to on board navigation systems incorporating satellite navigation and ground aid inputs being used to refine the INS position to very high accuracy. No longer was the last known position between five and fifteen minutes ago.
The Development of Instrumentation
In the fifties all aircraft instrumentation was ‘electro mechanical’ and the maintenance engineers for this equipment were very closely related to the clockmakers/menders of old. The compass systems were gyro stabilised but also
Concorde flight deckrequired checking (using astro) over long periods of flight. It took a number of ‘Controlled Flight into Terrain’ accidents before the three needle altimeters were replaced by a (still electro mechanical) single needle analogue display showing hundreds of feet with a digital window showing thousands.
All the other flight instruments had an analogue display but with time a digital window was introduced into many of the engine and systems instruments. There are some who feel that the modern glass cockpit digital airspeed displays are inferior to the old analogue format because a needle position can be immediately seen to be correct whilst a digital display requires an extra mental calculation process to assess if the speed is ‘right’.
The attitude displays in the fifties were not especially user friendly and could be subject to acceleration errors. There was a variation between types which meant that some attitude displays showed bank angle at the top whilst others had the indication at the bottom of the dial. This often caused difficulties when converting from one type to another. Through time flight director displays were added to show navigation information when on airways and, eventually, ILS demands on approach. Later information from the INS was available and more recently from the Flight Management System. Some early flight directors were more popular than others but each type had its proponents.
In the fifties and sixties, many airfields had very limited approach aids and for some the only aid was an ADF (Automatic Direction Finder) approach requiring a high degree of skill. Other airfields especially those with military presence also had
Heathrow Radar 1960sthe facility of Surveillance Radar Approach (SRA) where a controller issued directions for maintaining the correct centre line and glide slope. This again required a high degree of skill on both sides and some SRA controllers were better than others. (On that first BOAC flight of mine I believe we were attempting to make approaches using a mixture ADF and a less than perfect radar controller). In the fifties Instrument Landing Systems (ILS) were being introduced although even at major airfields not all runways had the necessary transmitters.
Autopilots in the fifties really only provided height and heading hold facilities, not always very well, and requiring careful monitoring. Later autopilot developments made it possible to ‘couple’ to the ILS signal for approach. Eventually BEA led the field in developing the capacity to make fully automatic landings. It is now possible to make automatic landings in visibility conditions so poor that the next problem after landing is finding the terminal.
Modern autopilots are so accurate and reliable that pilots are encouraged to use them as much as possible. The autopilot may be engaged shortly after take-off and not disengaged until landing at destination. Whilst properly managing the automatic handling and management systems can be intellectually challenging, the lack of pure aircraft handling practice is leading to concerns that pilots may not be able to cope when full automatic control is not available. Several recent accidents have reinforced this concern.
Most crews in the fifties, both long and short haul, would expect to spend a number of nights away from base. In long haul a trip could be scheduled to last up to three weeks, but with disruptions it could last longer than four weeks. Disruption was a way of life. (BOAC had a number of day trips to Europe. Scheduled for a day trip to Frankfurt, I set off with just my briefcase, only to arrive home ten days later having been to Australia – laundry had been a problem!). The plus side was that there many free days in some attractive places (but also in some hell holes).
(Long haul BOAC/BA crews could also be temporarily based away from base in Honolulu, Hong Kong, or Sydney for periods of some months as a means of avoiding fatigue through large time change).
Initially in long haul, a flight deck and cabin crew would stay together for the whole trip, no matter how long. This developed a useful team spirit (plus a few temporary or long term liaisons). Gradually through the years cabin and flight crews tended to follow different itineraries and would only work together for two or three day’s work which affected both the team spirit (and the liaisons).
One of the pleasures of long haul flying was the ability, during periods of low workload, to entertain passengers visiting the flight deck. This meant that during an airline career it was possible to have met a number of the famous, the interesting and, sometimes, the boring.
(I particularly remember being having Nelson Mandela join us on the flight deck for the landing into Johannesburg just months before he became president of South Africa. But there was also an inebriated Judy Garland who insisted on continuously singing ‘Somewhere over the Rainbow’ on a London to Rome sector).
Possibly because it was an unfamiliar environment, it was surprising how many of the famous had quite different personalities on the flight deck from their public profile. Flight deck visits were undoubtedly a most useful PR exercise for the airline. Following 9/11 and the security closure of all flight deck doors this facility was lost. At the same time the co-operation between the flight and cabin crew was compromised particularly in respect of safety. There have been several accidents/incidents where the locked flight deck door compromised safety.
Perhaps the most significant changes in aviation in the past fifty/sixty years have been the introduction of the gas turbine engine, highly accurate worldwide navigating systems, the automation of most aircraft systems and, probably the introduction of female flight deck crew members. Pilots have developed from being highly skilled artisans, able to think and react quickly, to being clear thinking operators and monitors of highly complex automatic systems. At the same time their lifestyle has become much more intense and tiring (caused by degradations in Flight Time Limitation legislation) together with the added concerns over security and terrorist activity (together with the endless security screenings).
Ian Frow 23rd November 2016
This article was originally published in the BALPA Blog 2016
FATIGUE – Tired Aircraft Maintenance Engineers (AME’s) Can Make Mistakes With Disastrous Consequences
IATA has released their 2015 Safety Report a copy of which can be downloaded (gratis) here IATA 2015 Safety Report
Chairman’s Opening Address
STATE OF THE ASG 2017-2018
The following is an extract from the opening address
Our work is as important now as it was when the Group was first formed in 1964 to fight the use of wide cut JP4 fuel in passenger carrying airliners. A ‘globalised’ economy has made our task more complex.
Globalisation is the development of an integrated global economy including greater free trade, free international capital flows, and the availability of inexpensive labour markets in developed and less developed areas. Human societies have gradually integrated over the centuries, but the pace of integration increased dramatically in the late 20th century. Fast aircraft, huge ships, and information technology, especially the Internet, have made the world more interdependent than ever. Companies manufacture products in countries of low labour cost and sell these products across the globe. In the 21st century, money, technology and raw materials can move across national borders quickly and easily. Globalisation has also led to ideas circulating more freely, which has resulted in the creation of international laws and new social movements.
Commercial aviation satisfies the avid and avaricious demands of an integrated global economy. It moves cheap labour around the world on a daily basis and matches the expectations of a low cost mass travel market that expands in double percentage points year on year. The profits are huge. Last year (2017) Ryanair announced profits of €1.32 Bn a rise of 6% on previous figures. Ryanair boasted that:
• Avg. fares fell 13% to €41;
• Traffic grew 13% to 120m customers;
• Load factor rose to an industry leading 94%;
• Unit costs were cut 11% (ex-fuel they declined 5%);
• Over €1bn was returned to shareholders via share buybacks.
But who paid the price for this staggering business success?
In an integrated globalised economy companies have access to overseas companies that offer outsourcing; employment conditions and security have changed for many workers. With lower standards of living, third world companies can offer their services at a greatly reduced rate. This has affected many workers in the developed world as well as other large countries as more companies embrace the outsourcing trend. While it means a greater profit margin for the companies, it can also lead to poorer conditions for employees.
The working environment for western pilots has changed dramatically since the 1970s and 80s and Dickensian working practices have become the norm. Pilots are self-employed; they buy their own uniforms and pay for their own hotel accommodation. They earn no money until the brakes are released or after the chocks are placed around the nose wheels. They must endure pernicious bonus schemes like an attendance bonus of £12,000 pa that forces them not to report sick even when unfit to fly. They must try to rest between flights in rooms unsuited for the purpose and in the case of Colgon Air flight 3407, excessive fatigue endured by the crew led to the deaths of 49 passengers and crew and 1 person on the ground.
But the hunger for greater profits from airline operators and their shareholders knows no end and must be satiated. Regulators like EASA are eager to satisfy a requirement for ever lower FOC’s and DOC’s. Under ORO.FTL.100 pilots work longer with unrealistic opportunities to rest, their workload increases as there are fewer people to support them. Worse still, we are hearing reports of companies who are even subverting the already wholly inadequate EASA FTL schemes. Pilots are also pressured into carrying less fuel than their judgement requires by the publication of league tables which are designed to embarrass and pressure them. EASA will soon reduce fuel requirements when their fuel schemes initiatives become EU law. EASA does not require that anyone involved with the calculation of fuel requirements be qualified to do so and that ground staff involved with the inflight assistance to aircrew flying on just Trip Fuel plus 45 min reserves need not be qualified to do so either. Ignorance is preferred, even for those holding safety critical jobs like flight planners, as they cost less than qualified personnel.
Deregulation, supported by safety management systems and Performance based control of air safety may actually be the anathema of air safety? The collapse of global economies in 2008 was caused by the deregulation of the banking system; the irony of this will not be lost on you.
Through performance based rule making and rule making teams that include operator representation like Ryanair and British Airways and the European Sport Pilot Association, regulators like EASA are eagerly making rules that benefit shareholders and company executives’ interests, but not the safety interests of the mass travelling public. Performance Based Oversight by aviation authorities like the CAA is meant to keep operators in check and thus maintain safety standards, but when operators censure the submission of ASRs and decide when an MOR can and cannot be submitted the philosophy that underpins PBO becomes contaminated and thus the results are skewed in favour of less scrutiny of the operator. It’s not until an accident or serious incident occurs like an attempted landing in a 63KT crosswind, that authorities become aware of errant compliance and low safety standards. So if you are competent safety minded professional pilot can you expect to keep your job if you complain about cost overrides of safety standards?
The workload burden placed on pilots is increasing and they are expected to work for longer and rest less. This can only end in disaster as the James T Reason Swiss Cheese Accident Causation model will predict.
This is where the work of the Air Safety Group is imperative and onerous. There is much to do, some of it urgent. Together we can help to make passenger travel safer and I look forward to a long and flourishing future for the Group.
R Nigel Johnstone
The ASG has become concerned following the promulgation of NOTAM A1294/18 in the early hours of this morning at Gatwick Airport.
Q) EGTT/QSPLC/IV/BO /AE/000/025/5109N00011W014
A) EGKK B) 1804080040 C) 1804080420
DUE SHORT NOTICE SICKNESS ALL GATWICK ATC SERVICES WILL BE SUSPENDED
BETWEEN THE HOURS OF 0100-0200 AND 0330-0400. AS A RESULT A ZERO
FLOW RATE WILL BE APPLIED FROM 0040-0220 AND 0310-0420.)
Enquiries as to why there was no staff sickness cover to maintain operational continuity should be addressed to Gatwick Airport Ltd.
What is a NOTAM :- A notice to airmen (NOTAM) is a notice containing information concerning the establishment, condition or change in any aeronautical facility, service, procedure or hazard, the timely knowledge of which is essential to personnel concerned with flight operations. (ICAO Annex 11: Air Traffic Services) https://www.skybrary.aero/index.php/Notice_To_Airmen_(NOTAM)
It’s Been a Challenging Week for Air Traffic Control.Firstly, on Tuesday we had an issue with the Central Flow Management Unit (CFMU), which coordinates supply and demand in the air traffic network. This lack of ability to coordinate demand across Europe resulted in some substantial delays and severe traffic flow restrictions at a number of major European airports.
Then, on Wednesday the UK National Air Traffic Service (NATS) introduced their new electronic flight strip system to the London terminal area. While it caused a few minor delays this has, so far, passed by largely without incident, by which I mean major delays.
Finally there were two closures of Gatwick Airport on Saturday and Sunday nights because of lack of air traffic controllers, which hints at some structural issues within ATC. The Notice To Airmen (NOTAM) issued about the closure said that Gatwick would be unavailable at certain times during the night because no ATC service would be available due to ‘short notice sickness’. Although the word 'closed' was not used the phrase ‘zero flow rate’ was used, which essentially means Gatwick was closed without actually saying as much.
Around two years ago as part of a cost-saving exercise Gatwick Airport outsourced it’s aerodrome control from NATS, who had provided the service for many years, to Air Navigation Solutions (ANS), which is part of the German Air Traffic Service Provider DFS. NATS staff are well-trained, have solid terms and conditions and a good pension package, but this also makes them relatively expensive. As with many things in life though, it seems that you get what you pay for with ATC. It was planned that NATS staff would remain working alongside ANS at Gatwick until the former personnel transferred back to NATS units in March 2018, which has just happened. Colleagues in the ATC community have told me that during the time NATS and ANS were working in parallel, there were difficulties validating the new controllers so that they were legal and competent to control the airfield independently without being mentored. Equally colleagues in ATC, at Gatwick specifically, reported that the unit was short-staffed and that a combination of voluntary and enforced overtime has been employed to cover the gaps. The effective closure on Saturday and Sunday nights led a Gatwick Airport controller to tweet:
Three ATCOs on a night shift, last night and tonight and two of them happen to be sick at short notice. Remaining one has to have a break at some point.
He also tweeted that:
Resource is tight everywhere, not just at LGW. Already several instances of approach function unavailability over night due to staffing at TC [Terminal Control] this year.
Gatwick Airport and the CAA will no doubt claim that closing the airfield (or applying zero flow rate) was the safest option and in that we agree. They have to meet their legal obligations for controller rest and their duty of care to passengers and staff. The real concern is however, that the UK’s second largest airport, and the busiest single runway airport in the world, has found itself in a situation with so little ATC cover that the airport has been forced to close, albeit at the moment only for short periods at night. This is also not an isolated example. In August last year, and again last month, Stansted Airport was forced to 'close' in a similar way because of lack of staff in air traffic control.
The key questions at this stage seem to be where is the cover for unforeseen events such as sickness? If as asserted, resource is tight everywhere, what is being done to address this shortfall without placing a further burden on the existing controllers? The difficulty with enforced and even voluntary overtime to cover shortfalls is that it covers up the underlying staffing problems while at the same time the probability of fatigue issues increases. While the whole industry is debating the issues surrounding pilot fatigue, controller fatigue is equally dangerous and receives comparatively less attention.
Having redundancy is a key component to maintaining safety in aviation: it’s why transport aeroplanes have two engines, backups for each major system and the main reason we have two pilots. Outsourcing to cheaper air traffic service providers might produce cost savings for the airports, but recent events demonstrate that sufficient depth of redundancy may not be available to guarantee continuity of this safety-critical service through unforeseen events at our major airports.