5. addressing business aviations most frequent and

2018NBAARegionalForum|SanJose,CA|September6,2018

AddressingBusinessAviation’sMostFrequentandExpensiveAccidents&Incidents

MarkE.Larsen,CAM,NBAADanRamirez,XOJETHardyS.Bullock,C.M.,Truckee-Tahoe

AirportDistrict

Welcome

• Runway Excursions

• Ground Handling Events

• Resources

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What we’ll discuss today:


RunwayExcursions

DanRamirez,XOJET

UnstableApproach

Background

– Jets:§ Major248§ Substantial361

– Turboprops:§ Major528§ Substantial243

TotalAccidents1,380

AccidentData2002-2014(FlightSafetyFoundationandAirclaimsDatabase)

Type ofEvent Number PercentageTotals%

Incursion 10 0.07%

Confusion 4 0.03%

Excursion 417 30%

RunwayAccidents

AircraftTypes

• Jets:36%

• Turboprop:24%

AccidentData2002-2014(FlightSafetyFoundationandAirclaimsDatabase)

AccidentFactors2004-2014

35%

26%

18%

18% 16%

14%

14%

13% 12%

12% Go-aroundnotconducted

Touchdown:Long

Landinggearmalf

Ineffectivebraking:rwycontam'n

ApproachFast

Touchdown:Fast

Touchdown:Hard

FlightCrew:CRM

Pilotdirectionalcontrol

Non-complianceSOP

DataSource:FlightSafetyFoundation2018

Corp/BizAircraftvs.121Fleet

0%

10%

20%

30%

40%

50%

60%

Corp/Biz

FullFleet

DataSource:FlightSafetyFoundation2018

Observations

• Continuinganunstabilized approachisacausalfactorin60% ofallapproach-and-landingaccidents.

• In75% oftheoff-runwaytouchdown,tailstrikeorrunwayexcursion/overrunaccidents,arearesultofunstableapproach.

CommonFactorsDuringUnstableApproaches

• Fatigue(e.g.,duetodisruptedsleepcycle,personalstress)

• Pressureofflightschedule(i.e.,makingupfortakeoffdelay,lastlegoftheday)

• AcceptingrequestsfromATCforflyinghigherand/orfasterthandesiredresultinflyingtoohighand/ortoofastduringtheinitialorfinalapproach(e.g.,requestformaintaininghighspeeddowntoGScapture)

• Excessivealtitudeand/orexcessiveairspeed(i.e.,inadequateenergymanagement)

• Laterunwaychange(i.e.,lackofATCawarenessofthetimerequiredtoreconfiguretheaircraftsystemsforanewapproach)

• Non-standardtask-sharingresultinginexcessivehead-downwork(e.g.,FMSreprogramming)

• Shortoutboundlegorshortdown-windleg(e.g.,incaseofunidentifiedtrafficinthearea)

• Inadequateuseofautomation:Latetakeoverfromautomation(e.g.,incaseofAPfailingtocapturetheGS,usuallyduetocrewfailuretoarmtheapproachmode)

• PrematureorlatedescentduetoabsenceofpositiveFAFidentification

• Insufficientawarenessofwindconditions(tailwindcomponent,lowaltitudewindshear;localwindgradientandturbulence)


• Incorrectanticipationofaircraftdecelerationcharacteristicsinlevelflightorona3-degreeglideslope

• Failuretorecognizedeviationsortoremembertheexcessive-parameter-deviationcriteria

• ExcessiveconfidencebythePilotMonitoringthatthePilotFlyingwillachieveatimelystabilization;

• PF/PNFoverrelianceoneachothertocallexcessivedeviationsortocallforago-around;

• Visualillusionsduringthevisualsegmentorcontinuedapproachwithoutacquisitionofadequatevisualreferences


UnstableApproach

MitigationStrategies

• SOPsarenumberonemitigationactiontopreventunstableapproaches

• SOPsenhanceflightcrewdecisionmakingprocessduringtimesofheavyworkload

• Operator’smanagementandaircrewsshouldmutuallydevelopandreviewSOPsforeffectives(LOSA,FOQA,Etc.)


Throughouttheflight,gatesshouldbedefinedtostayaheadoftheaircraftatalltimes.

• Gateidentificationshouldbedefinedby:

• Aircraftposition• Aircraftaltitude• Aircraftconfiguration• Speed• Verticalprofile• Powersetting

TypicalGatePointsDataSource:FlightSafetyFoundation/

EmbraerALAR


• TheFinalApproachFix(OuterMarkeroranequivalentfix)shouldbethelastgatetoconfirmthereadinesstoproceed:

• VisibilityorRVR(andceiling,asappropriate)shouldbebetterthanorequaltoapplicableminimums

• Aircraftposition,altitude,configurationandenergyshouldbeunderthestableguidelines

• Allbriefsshouldbecompletedandagreementonapproachconditions

TypicalGatePointsDataSource:FlightSafetyFoundation/

EmbraerALAR


1. Identifyhighriskareas(withoperationaldata,FOQA,SMS,LOSA)

2. Developinterventionstoolstoreducetheriskinthehighestriskareas(SOPs,LOFT,AQP,ScenarioBasedTraining)

3. Non-precisionapproachhas5timestheriskasaPrecisionApproach,thereforeadjustSOPsandcompanypolicyfortheseoperations.

CriticalItemsforDevelopment

• Whenassessingthedaytodayrisktheproperrunwayenvironmentcanmitigatetheeffectsanunstableapproach

• Someoftheitemstolookatwhenlookingatanairportare:

• Safetyarea(RESA)orappropriatesubstitute(e.g.,EMAS)

• Aircraftrescueandfirefighting(ARFF)availableatalltimesduringflightoperations


0% 50% 100% 150% 200% 250% 300% 350% 400%

DRY

WET

CONTAMINATED

ICE

Runwayrequired[%]


0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110% 120% 130%

-10

-5

0

5

10

15

20

25

30

Repo

rted

windspeed[KTS]

Runwayrequired[%]

OPERATIONALPROCEDURESANDLANDINGDISTANCESCriticalItemsforDevelopment

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110% 120% 130% 140% 150%

50

60

70

80

90

100

Thresholdaltitud

ecrossing

[feet]

Runwayrequired[%]


Unstable Approach

Summary

Theperceptionoftherunwayandoutsideenvironmentshouldbekeptconstantbymaintaining:

• Driftcorrection

– Continuetrackingtherunwaycenterline,resistingthetendencytoprematurelyaligntheaircraftwiththerunwaycenterline;

• Aimingpoint(i.e.,thetouchdownzone)

– Remainonthecorrectflightpathuntilflareheight,resistingthetendencytomovetheaimingpointcloserand,thus,descendbelowthedesiredglidepath(i.e.,“duck-under”)

• Finalapproachspeedandgroundspeed

– Tomaintaintheenergylevel.

Summary

FAA(2007)AVR-20OfficePublication8133-8149

Hackworth,H.,Holcomb,K.,Dennis,M.,Goldman,S.,Bates,C.,Schroeder,D.,Johnson,W.(2007).AnInternationalSurveyofMaintenanceHumanFactorsPrograms(ReportNo.07/25).OklahomaCity,OK:FAACivilAerospaceMedicalInstitute.

Hall,S.,Johnson,W.B.andWatson,J.(2001).EvaluationofAviationMaintenanceWorkingEnvironments,Fatigue,andHumanPerformance:PhaseIII.Washington,DC:FederalAviationAdministrationOfficeofAviationMedicine.http://hfskyway.faa.gov

ICAO– Annex6– OperationsofAircraft,PartI– InternationalCommercialAirtransport– Aeroplanes,Appendix2,2.1.25

ICAO– ProceduresforAirnavigationservices– AircraftOperations(PANS-OPS,Doc8168),VolumeI–FlightProcedures(particularly,PartIX- Chapter1- StabilizedApproach– Parameters,ElementsofaStabilizedApproachandGo-aroundPolicy)

U.S.NationalTransportationSafetyBoard(NTSB)– ReportNTSB-AAS-76-5–SpecialStudy:FlightCrewCoordinationProcedureinAirCarrierInstrumentLandingSystemApproachAccidents

References


GroundHandlingEvents

HardyS.Bullock,C.M.,Truckee-TahoeAirportDistrict

Business Aviation Ground Handling Events are 3,800 times more likely than a fatal accident

26

Source: The VanAllen Group, Inc. 2017

27PhotoCreditsTerryYeomans,IS-BAH,ProgramDirector

PhotoCreditsTerryYeomans,IS-BAH,ProgramDirector28

• Removes the aircraft from service

• Unplanned & significant expenses

• Distracts from the core business

• Damages your brand

• Affects your livelihood

• Injury and death

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Why spend valuable time working on this ground handling issue?

For Aviation Claims Over $1,000,000.00 ground handling was the cause 18% of the time, 15% of total cost.Source: Allianz Global Corporate & Specialty Global Claims Review 2014. Data based on accident years 2009-2013

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Losses & Data

Ground Handling Reporting Requirements… U.S. None, EASA mandates for EASA airports

Ground Handling Accident Database… Limited

Ground Handling Insurance/Loss Data… Unavailable

Operators are the responsible the link – Share Info – Prevent Losses

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50%

33%

10% 7%

Sources of Aircraft Ground Ops Damage

HangarRash TowingAccident GroundVehicleCollision Taxiing

The VanAllen Group 2016 & NBAA Survey Responses, 2016

“A total of 48 percent of respondents reported having one to three ground-handling incidents or close calls in

the last three years, while 8 percent reported having four to nine incidents or close calls.”

The National Business Aviation Association (NBAA) Safety Committee Survey 2016

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The Threat

FBO staffing, training & supervision issues

FBO equipment limitations

FBO financial pressures

Activity peak stresses

Inadequate ramp access control

Inadequate operator standards & practices

FBO: “That’s why I have insurance.” Crew: “The FBO did it.”

Behaviors that help reduce loss

• Selection of a facilities

• Communication with the FBO and the Airport (Some airports handle aircraft)

• Understanding of the ramp area, parking, peak period handling and field tempo

• Stand by your Plane. Duty Out vs. supervising service, movement and fueling.

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Behaviors that help reduce loss

• Communication with S&D

• Micro Risk Assessment: Ask questions, have you tugged this?, fueled this?, etc.

• How is the fuel truck parked?• Chocks?• Cones?• Personnel?• Tow equipment?

• Let others work for you! Go where the industry standards are being used.

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ResourcestoMitigateHazards

MarkE.Larsen,CAM,NBAA

NBAA Reducing Business Aviation Runway Excursions

Download at www.nbaa.org/ops/safety/in-flight-safety/runway/runway-excursions/

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Aviation Safety Information Analysis & Sharing

www.asias.aero

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NBAA Airport Audit Tool

Download at www.nbaa.org/ops/safety/airport-audit-tool/

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International Standard for Business Aircraft Handling (IS-BAH)

www.nbaa.org/admin/sms/is-bah

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NBAA Top Safety Focus Areas

Learn more at www.nbaa.org/top-safety-focus-areas/

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Questions?

• DanRamirezDirectorofSafetyXOJET,Inc.5022BaileyLoopMcClellanPark,[email protected]

• MarkE.Larsen,CAMSeniorManager,Safety&FlightOperationsNationalBusinessAviationAssociation1200GStreet,NW,Suite1100Washington,DC20005(202)[email protected]

• HardyS.Bullock,C.M.DirectorofAviation&CommunityServicesTruckeeTahoeAirportDistrict(KTRK)10356TruckeeAirportRd.Truckee,[email protected]

5. addressing business aviations most frequent and

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