Flight Safety Information October 3, 2016 - No. 194 In This Issue 40 years of safer aviation through reporting Naval aviation trying to fix flawed safety culture Canadian pilots no longer have to fly real aircraft to keep valid licences Birds Are Giving Researchers A Crash Course In Flight Safety Mitsubishi Aircraft May Delay Delivery of First Jet to ANA Full sized battery-powered helicopter takes flight GRADUATE RESEARCH SURVEY 40 years of safer aviation through reporting The U.S. has an incredibly safe aviation system - it's unparalleled when compared to other modes of transportation. The basis for this historic safety record is that we identify and correct safety concerns before they become real problems. NASA's Aviation Safety Reporting System (ASRS) is one of the tools used to make the system as safe as it is. Celebrating its 40th anniversary this year, NASA's confidential ASRS is widely used by pilots and other airline employees to identify potential hazards. This information is one of 185 data and information sources across government and industry used by the FAA and the aviation community to detect, mitigate and monitor risk. People working on the front lines of aviation submit their safety concerns to ASRS in the form of incident reports. The system analyzes these cases and responds by distributing vital information from its conclusions to the aviation community. The reports, always handled confidentially, are also used to identify deficiencies and discrepancies in the National Airspace System that need to be remedied. "Voluntary reporting programs have significantly contributed to the nation's impressive commercial aviation safety record," said FAA Associate Administrator for Aviation Safety Peggy Gilligan. "In addition to reporting programs that are investigated and verified, ASRS gives aviation workers another way to report potential safety issues." Making the nation's airways safer "Since the implementation of the Aviation Safety Reporting System, approximately 1.4 million reports have been submitted by pilots, dispatchers, mechanics, air traffic controllers, flight attendants, ground personnel, and others," said Linda Connell, director of the NASA ASRS, which is located at NASA's Ames Research Center, Moffett Field, Calif. "Many of those reports have had a direct influence on making the nation's airways safer, and we are extremely proud of these contributions to safety." Over the past 40 years, the ASRS has issued more than 6,200 safety alerts to the FAA and other decision makers in the aviation community who are in a position to correct unsafe conditions. Recent alerts have addressed a wide range of safety issues, including air traffic departure procedures, aircraft equipment problems, airport signage and marking issues, confusion among similar-sounding navigation fixes, or positions, and aeronautical chart deficiencies. Many of these issues involve significant human factors and performance contributions. One example of a safety alert issued by ASRS emerged from reports of intense sunlight reflecting off a large concentrated solar power plant in the southwestern United States, temporarily blinding pilots in the cockpit. The pilots reported the safety hazard to ASRS, which then issued an ASRS Alert Message. Ultimately, this process led to the formal marking of the solar plant obstruction on charts, so that pilots could avoid flying over the area. ASRS information was also instrumental in the revision of solar plant operations to help reduce the adverse effects of certain mirror array configurations. Other significant ASRS accomplishments include identification of fire hazards associated with the packaging of lithium ion batteries for shipment in aircraft, health hazards associated with the use of certain de-icing fluids, and the susceptibility of certain pressure-sensitive aircraft systems to icing from super- cooled water droplets. A research repository for aviation safety "The ASRS is the largest repository of aviation human factors incidents in the world," Connell noted, "and it has conducted more than 7,200 database searches for government agencies, industry groups, research organizations, aircraft manufacturers, aviation students, and a wide variety of other organizations." Since 2006, all reports are logged and processed with full anonymity and that de-identified data has been accessible to the public. In the last 10 years, the ASRS Database has had more than 189,000 queries. Like safety alerts and database searches, ASRS research findings have also been influential. ASRS data findings on the content and formatting of aviation checklists and manuals for flight crews were incorporated in a FAA Advisory Circular. An ASRS Alert concerning an aircraft wing oscillation issue contributed to the FAA Aircraft Certification Service taking action to mitigate the problem. Through its website, the ASRS provides access to a range of safety products, including publications, database reports, program overview materials, and ASRS reporting forms for four categories within the aviation community, divided up broadly as pilots and dispatchers; air traffic controllers; maintenance technicians and ground crew; and cabin crew. A model for safety reporting systems everywhere ASRS has become a model for safety reporting systems worldwide. It has become a charter member of the International Confidential Aviation Safety Systems, a group of 13 nations that operate ASRS-like voluntary, confidential, non-punitive aviation safety reporting systems. The ASRS has also been recognized for its safety contributions by other industries, including rail operations in which NASA ASRS collaborated with the Federal Railroad Administration to create and operate the Confidential Close Call Reporting System. http://phys.org/news/2016-09-years-safer-aviation.html Back to Top Naval aviation trying to fix flawed safety culture: 1-star Aviation safety protocols are, the saying goes, written in blood. That's why every time a helicopter nearly topples on deck, a cable fails to stop a landing plane, or a pilot runs low on breathing oxygen in flight, witnesses are trusted to report it. In addition to these critical incident reports, squadrons are routinely assessed for aviation safety to prevent the next mishap. But all too often these squadron leaders weren't fixing safety issues over the last three decades, according to the leader of the organization charged with investigating Navy and Marine Corps mishaps, who said some commanding officers stashed the surveys rather than fix the problems. The Navy only got serious about fixing this flawed culture two years ago, he said. "It was an organization basically frozen in time for about 30 years," Rear Adm. Chris Murray said Sept. 10, referring to the state of things when he took over the Naval Safety Center in 2014. "Great at investigating things, but not doing a whole lot to prevent mishaps." That was most apparent in the aviation community, he said, where squadrons members are anonymously surveyed on safety. "We've been doing surveys in squadrons forever," Murray told the audience of aviators at the annual Tailhook reunion near Reno, Nevada. "Frankly, it was a great one-on-one with our guys and the squadron's CO, but it never really got any further than that." "If we found something that was pretty troubling, that kind of went in the CO's desk," said Murray, a career naval flight officer who has commanded a carrier air wing. "And frankly, some of our COs went, 'Yeah, my [projected rotation date] is in two or three months, so maybe I'm just going to keep that in my desk and let my [executive officer] deal with it.' " The safety boss said the culture has been revamped so that these squadron surveys are get more scrutiny from higher ups and that officials are using more mishap data to assess the causes of mishaps. A spokeswoman for the Naval Safety Center said Murray's example was intended to show the gravity of the problem and he didn't intend to suggest this was typical. "Rear Adm. Murray did not intend to suggest that COs shoving safety reports in their desks was ever the norm," said his spokeswoman, Margaret Menzies. "This was more of a metaphor used to gain the audience's attention and reinforce how valuable the information contained in a safety report can be -- and in fact, it should not be shoved in a desk." Naval aviation has faced questions about whether it has been doing enough mitigate known dangers. Indeed, officials are trying to fix oxygen problems in F/A-18 Hornets that some aviators say they've been reporting for years to no avail. And a 2015 Navy Times investigation found that the NSC and Naval Air Systems Command had ignored years of reports that helicopters landing on destroyers and frigates were vulnerable to waves that could wash them overboard -- changes only came in the wake of a 2013 helicopter crash. The Navy Times report was based on 13 official hazard reports in the years before a helicopter tragedy; more sailors came forward after this report to say they had seen waves strike their helicopters. "These surveys are very in-depth and provided me with a different perspective on what is going well and not so well," retired Capt. Sean Butcher, an HH-60H pilot, told Navy Times. "Sometimes the squadron leadership tells the CO what they think he wants to hear, not what he needs to hear and these surveys help ensure we are on the right track or if we need to change direction a bit. " Butcher said he always took action to remedy any problems they brought up, adding he wasn't aware of any fellow COs who swept them under the rug. Still, there is some debate about how widespread the survey problems were and the severity of the issues that were not reported or fixed. Making changes has largely been left up to the squadron's skipper, according to a retired Navy and Marine Corps mishap investigator. "Yeah, it's not mandatory. It's a CO's mirror, so to speak, on the culture and the command climate," Matt Robinson told Navy Times in a Sept. 19 phone interview. "It's up to them whether they want to address the issues if there are any or not." Still, in most cases he saw, COs took the results and made necessary changes. "I may have seen it a couple of times where the squadron climate was caustic, but it is very rare," he said. "The survey, from what I have seen, works -- and every single survey that I have heard about, been a part of, the CO has taken the comments to heart and has implemented change to make it better." Making changes The year Murray came on board was also one of the worst for naval aviation deaths in years. Marine Corps Times Marine aviation deaths hit 5-year high The old safety survey system has been phased out, according to Murray. Now, after a visit from the safety center, the results are briefed up the chain of command to helicopter squadron commodores and air group commanders for another set of eyes. That could complicate things, though, Butcher said. "The survey was only briefed to the COs of the squadron because of concern that sharing potentially derogatory information about the CO and the command to the wing commodore could have a negative impact on the command," he said. "The fear that the commodore's perception of the squadron and ranking of his squadron commanders could be influenced by information from these surveys is a very real concern." The revamped safety center has also done a deep dive into its mishap data, mining the causes of accidents in the MH-60 Seahawk and Hornet communities, the two places hardest hit. The compiled reports include unit assessments, hazard reports filed, Aviation Safety Awareness Program filings and causal factors of past mishaps, to widen the investigations beyond Class A mishaps and include data on near-misses and other identified dangers. The so-called hazard maps shed new light on the causes of mishaps as well as any particular geographic problem for VFA squadrons. Despite his previous assumption that most mishaps caused by human error could be blamed on pilots, due to procedural mistakes, communication errors or just lack of experience, the data show something different, Murray said. It turns out that the Navy has 160 percent more mishaps because of maintenance errors than anything pilots do. They also found that in the VFA community, squadrons based at Naval Air Station Lemoore, California, are much more likely to have maintenance problems than their East Coast counterparts at NAS Oceana, Virginia. "Anyone that's been a [commander, air group] out in Lemoore and a CO at Oceana, like I have been, can tell you that you have maintenance master chiefs waiting like cordwood to be your maintenance master chief at Oceana. That does not exist out in Lemoore," Murray said. He attributed that to Oceana being a more favorable duty station, which can siphon off some more experienced E-9s. That concern has been forwarded to the air boss, Vice Adm. Mike Shoemaker, in hopes of persuading more experienced Hornet maintainers to go to California, Murray said. With two more weeks to go in fiscal year 2016, naval aviation has seen 14 mishaps this year, including four within three weeks this summer, all Marine Corps Hornet crashes and deaths. Marine Corps Times Marine aviation is plagued with problems and it needs serious attention now Still, that's down from 19 in the previous year, and a vast improvement in the long term, Murray said. "When I started flying in '84, naval aviation averaged 40 class A mishaps a year. Almost all totally lost airplanes," he said, adding that the numbers have been cut in half in each successive decade. https://www.navytimes.com/articles/mcpons-confession-sailors-react-to-profile-of-navys-new-top-enlisted Back to Top Canadian pilots no longer have to fly real aircraft to keep valid licences Canadian pilots are no longer obligated to fly an aircraft or helicopter in order to maintain a valid licence after Ottawa changed the rules to require only flight-simulator testing, a move aviation experts say threatens public safety. The sweeping rule change puts Canada at odds with the United States and European Union, which still compel pilots to meet stringent standards to keep their licences valid, including a requirement to actually fly a plane. Until now, Canadian airline pilots could not legally fly an aircraft unless they acted as a captain or co-pilot within the previous five years or completed a flight review with an instructor and met other licensing standards. Private pilots also had to meet similar requirements including takeoff and landings within a set period. The Canadian Federal Pilots Association, which represents all federal aviation inspectors, called the rule change "reckless." The association said it will dilute pilot-training skills and put the flying public at risk. "It affects all pilots and assures all pilots can maintain pilot currency and never fly an airplane or helicopter again," said Greg McConnell, CFPA national chair. "If you had a heart issue, would you go and see a heart surgeon that hadn't operated in five years? There are real safety concerns here." Mr. McConnell said flight-simulator tests are part of the licensing requirement for pilots but should not be the only qualifier to keep their licences valid and current. "I have flown many simulators. I never felt I was going to die in a simulator, but in a real airplane, you know that is a possibility," he said. "There is so much stuff that gets missed when you are not actually manipulating the controls of an airplane. ... There is a whole host of skills you don't exercise in a simulator." Transport Minister Marc Garneau did not appear to know about the rule change, signed off on by Transport Canada on Aug. 23, when approached by The Globe on Friday, but said he was confident his department would not do anything to jeopardize air safety. "I am sure it has been done based on a serious look at what is important for our pilots to do," he said. Transport Canada issued a statement to The Globe saying the move will make pilot training more "cost effective and efficient" and will "also reduce greenhouse gas emissions." It argued public safety was not at risk. "Simulators offer pilots a realistic environment that accurately replicates the cockpit and electronic equipment and provides flight and ground-handling capabilities identical to those in an aircraft," the statement said. Mr. McConnell said Transport Canada made the rule change with "zero consultation" from the industry, largely to save money and protect the department from violating the rules established to ensure safety in air travel. Many of Transport Canada's aviation inspectors, who are licensed pilots, are not able to keep their licences current because Conservative spending cuts imposed in 2011 curtailed their ability to fly government aircraft. He believes the department changed the rules to ensure federal aviation inspectors maintain the proper credentials. A CFPA survey of licensed aviation inspectors, conducted in April, found that about half have not been assigned flight training for more than a year and one in 10 has not been assigned to flight training for up to 10 years or more. "With the stroke of a pen, Transport Canada has devised a work-around so their own pilots comply with Canadian Aviation Regulations," Mr. McConnell said. "Aviation inspectors who are pilots are becoming like traffic cops without a driver's licence. This situation undermines public safety and inspectors' credibility with the industry they are supposed to oversee." The Transportation Safety Board has raised concerns about aviation inspector training, most recently in its investigation report on the crash of an Ornge medical evacuation helicopter in Northern Ontario. http://www.theglobeandmail.com/news/politics/canadian-pilots-no-longer-have-to-fly-real-aircraft-to- keep-valid-licences/article32204718/ Back to Top Birds Are Giving Researchers A Crash Course In Flight Safety Research at The University of Queensland has revealed the stunningly simple reason why birds never crash mid-flight: they always veer right. The findings from Professor Mandyam Srinivasan's laboratory at the Queensland Brain Institute have enormous potential for automated anti-crash systems on aircraft. Professor Srinivasan said there was much for humans to learn from how bird flight had evolved over 150 million years. As air traffic becomes increasing busy, there is a pressing need for robust automatic systems for manned and unmanned aircraft, so there are real lessons to be learned from nature. "Birds must have been under strong evolutionary pressure to establish basic rules and strategies to minimise the risk of collision in advance," Professor Srinivasan said. "But no previous studies have ever examined what happens when two birds fly towards each other". The modelling shows that birds always veer right - and sometimes they change their altitude as well, according to some pre-set preference. In a series of experiments Professor Srinivasan's team released pairs of budgerigars from the opposite ends of a tunnel, and filmed them with high-speed video cameras to observe their strategies. The team recorded 10 birds on 102 flights - and not a single collision was observed. "Another finding was that birds would rarely fly at the same height, and this raises the question of whether individual birds have a specific preference for flying higher or lower," Professor Srinivasan said. "It might be that their position in the group hierarchy determines their flight height. This is a question for further research". "While we can't say how birds solve the problem of switching to different altitudes, we can propose some simple strategies for autopilot systems and unmanned aerials vehicles to prevent head-on collisions," he said. http://www.gizmodo.com.au/2016/09/birds-are-giving-researchers-a-crash-course-in-flight-safety/ Back to Top Mitsubishi Aircraft May Delay Delivery of First Jet to ANA The aircraft-maker informed ANA of delay possibility ANA Holdings is the first customer for the regional jet Mitsubishi Aircraft Corp. may delay the delivery of Japan's first domestically made passenger plane to the first customer ANA Holdings Inc. because of possible technical modifications to the aircraft. The builder of the Mitsubishi Regional Jet, set for delivery in mid-2018, is conducting a close study on whether there may be a delay in development with involved parties, Miho Takahashi, a spokeswoman for Mitsubishi Aircraft, said by telephone Monday. The company informed ANA of the possible holdup in late September, and the carrier will decide on a response only if a delay is confirmed, said Maho Ito, a spokeswoman at the airline. The Mitsubishi Regional Jet, aimed at challenging the dominance of Brazil's Embraer SA and Canada's Bombardier Inc. in the market for planes with fewer than 100 seats, suffered recent setbacks after two flights to the U.S. were aborted following faulty air-conditioning sensors. Its third attempt was a success, with the plane arriving at Moses Lake, Washington, on Wednesday to start flight testing. While a delay is possible, Mitsubishi Aircraft and its parent Mitsubishi Heavy Industries Ltd. said no decision has been made to change the delivery schedule at present. 'Appropriate Steps' "When issues arise in the development process, we take appropriate steps, including informing and consulting with the authorities and customers," the two companies said in a statement Monday. "If any decisions are made in the future on important items to be made public including development schedule, we will announce them promptly." ANA, the operator of Japan's biggest airline and the launch customer for the Mitsubishi Regional Jet, has ordered 25 MRJs, including options. The jet, which can seat as many as 92 people, made its first flight in November last year and won its first order from a European company in February. Mitsubishi has 427 orders for the aircraft, including options and purchase rights. Japan's last domestically produced commercial aircraft was the YS-11, a turboprop made by Nihon Aircraft Manufacturing Corp., a consortium that included Mitsubishi Heavy, Kawasaki Heavy Industries Ltd. and Fuji Heavy Industries Ltd. Production was stopped in 1974 after 182 of the planes were sold. http://www.bloomberg.com/news/articles/2016-10-03/mitsubishi-aircraft-may-delay-delivery-of-first-jet- to-ana Back to Top Full sized battery-powered helicopter takes flight A full sized battery powered Robinson R44 helicopter A full size helicopter powered by lithium ion batteries has taken off in the US in what the developers believe is the first such flight. The helicopter, a used Robinson R44 modified by Tier 1 Engineering, flew for a five minute cruise flight to 400 feet altitude with a peak speed of 80 knots. "I'm very pleased to achieve this historic breakthrough in aviation," said Glen Dromgoole, President of Tier 1 Engineering. "Never before has a manned helicopter performed a vertical takeoff, cruise and landing solely on battery power, and we are thrilled to have further achieved 400 feet altitude and 80 knots during our first full test flight." The Tier 1 Engineering team designed and integrated all of the helicopter sub-systems, which included eleven 700 V, 100Ah Brammo Lithium Polymer batteries weighing 500 kg, twin electric motors and a control system from Rinehart Motion Systems in a helicopter that weighs 1100kg. The five-minute flight on September 21st drained approximately 20% of the battery energy, giving the prototype a 20 mile (30km) range. "We expect to improve the endurance using higher energy density batteries, a more efficient electrical drive system, and ultimately a more aerodynamic airframe," said Dromgoole. "We removed the Lycoming IO-540 internal combustion engine, installed a custom mount for the electric motors and a reduction gearbox to interface with the existing drivetrain but no changes were made to drive train or flight control system. The engine bay contains the motor controllers and cooling system for the electric drive components and the battery modules are supported by a lightweight composite panel and attached to the landing gear under the belly." There are two three-phase permanent magnet synchronous motors which are stacked together to provide redundancy in the event of a motor failure. The project is funded by Lung Biotechnology to produce an Electrically-Powered Semi-Autonomous Rotorcraft for Organ Delivery (EPSAROD). All flights were accomplished at the Los Alamitos Army Airfield under a special airworthiness certificate in the experimental category. Lung Biotechnology intends to apply the EPSAROD technology to distributing manufactured organs for transplantation to major hospitals with much less noise and carbon footprint than current technology. http://www.power-eetimes.com/news/full-sized-battery-powered-helicopter-takes-flight/page/0/1 Back to Top GRADUATE RESEARCH SURVEY Dear Airline colleagues, I would be very grateful if airline staff among you accept this invite to complete my short online survey on "exploring the influence of emotionally intelligent leadership on airline safety culture". https://www.surveymonkey.com/r/EI-INTEL The survey is an element of my final project which explores how safety leadership who utilize or exhibit emotional intelligence leadership qualities can influence the organisations safety culture. Safety leadership in this context is taken as all management and supervisory staff who act as, or should act as safety leaders in their teams. I am researching to see if the leadership qualities of each individual safety leader can impact safety culture. Emotional intelligence markers are embedded in 10 of the survey questions. The survey contains an introduction and explanatory page, followed by 14 questions and should only take 8 to 10 minutes. If you would like to make any comments on the project, or have any questions, please contact me at Patrick.Morris.1@city.ac.uk. Thank you in advance and best regards. Pat Morris. MSc Student, City University of London. Curt Lewis