accident and incident investigation in soviet practice · accident and incident investigation in...

F L I G HT SAFE TY FOUN D A TI O N • F L I G H T S A F E T Y D I G E S T • JANUARY 1992 1

Accident and Incident InvestigationIn Soviet Practice

A two-pronged safety effort combines the investigationof both accidents and incidents to spread the data base and

increase the potential for preventing future accidents.

Note: This article was prepared for FSF by the State Supervisory Commission for FlightSafety, Council of Ministers, U.S.S.R., (GOSAVIANADZOR) prior to changes that

instituted commonwealth status for Russia and other Soviet republics.

One of the benefits that resulted from perestroikaand glasnost was a relaxation of the government-imposed secrecy that had shrouded details of do-mestic U.S.S.R. aviation information and inhib-ited the benefits of shared safety data. The StateSupervisory Commission for Flight Safety, Coun-cil of Ministers, U.S.S.R. (GOSAVIANADZOR)and Flight Safety Foundation-U.S.S.R. (FSF-USSR)were formed under the new open atmosphere andare sharing the benefits of two-way communica-tion of aviation safety data with other nations.

The new information exchange has been reflectedby the Flight Safety Foundation through publica-tion in the Flight Safety Digest of: “U.S.S.R.Safety Information,” (Statistics - March 1991);“Use of Flight Data Recorders to Prevent Acci-dents in the U.S.S.R.,” (April 1991); and “U.S.S.R.Civil Aviation Flight Safety Analysis for 1990”(Statistics — July 1991). The following articlehighlights how preventive information is acquirednot only from accidents, but from incidents aswell.

Accident Investigation in Civil Aviation

The State Supervisory Commission for FlightSafety under the Council of Ministers of theU.S.S.R. (GOSAVIANADZOR) was establishedby the Council of Ministers in 1987. This inde-pendent government agency is charged withpromoting aviation safety and preventing avia-tion accidents in the U.S.S.R.

GOSAVIANADZOR is authorized to supervise,on the governmental level, strict adherence byall ministries and other bodies, agencies andorganizations of the U.S.S.R.:

• to standards of flying, air traffic con-trol (ATC) operation and maintenance,airport operations, personnel training,accident and incident investigation; and,

• to airworthiness and airport worthinessrequirements.

GOSAVIANADZOR can also supervise the pro-cess of developing and implementing preven-tive measures by ministries, other governmentbodies, agencies and organizations.

F L I G HT SAFE TY FOUN D A TI O N • F L I G H T S A F E T Y D I G E S T • JANUARY 19922

The commission investigates accidents in theU.S.S.R. involving Soviet airplanes with maxi-mum takeoff weight of more than 30 metrictons (66,000 lb.) and helicopters that weighmore than 10 metric tons (22,000 lb.), plus allforeign aircraft that are involved in accidentsin the U.S.S.R. GOSAVIANADZOR partici-pates, in compliance with Annex 13 of the Chi-cago Convention, in the investigation of acci-dents involving Soviet aircraft in the territo-ries of foreign states1. It also supervises, onthe governmental level, the creation and imple-mentation of technical aspects of search andrescue of aircraft, their passengersand crews.

The commission also can issue air-worthiness type certificates andoperational certificates for airportsto meet the operational weatherminimums for International CivilAviation Organization (ICAO) Cat-egories I, II and III landings.

In order to carry out its functions,GOSAVIANADZOR has threestructural divisions.

The first division is the State Avia-tion Register of the U.S.S.R., whichissues airworthiness certificates for aircraft,aerodromes and their equipment. It also su-pervises determination of airworthiness of air-craft and operational acceptability of airports.

Airworthiness standards development in theU.S.S.R. has a history of more than 60 years.Current documentation includes the third editionof airworthiness standards for civil fixed-wingaircraft and the second edition of airworthi-ness standards for helicopters. Standards havealso been established for airports and theirequipment.

The Soviet standards fully correspond to ICAOrequirements and in some cases exceed theirminimum standards and those of U.S. FederalAviation Regulations (FARs) and Joint Airwor-thiness Regulations (JARs).

The U.S.S.R. standards specify:

• classification of hazards;

• quantitative characteristics for assess-ing the probability of such hazards; and,

• requirements for expected operationalconditions.

Standard methods of assessing compliance withregulations are set forth for all sections of theairworthiness regulations.

The second division of GOSAVIANADZORincorporates State Aviation Inspec-tion, a function that supervises strictadherence to flight and operationalprocedures and to ATC and flightsupport standards by all the min-istries and other governmentalbodies that operate civil aircraft.

Functions of investigation of civilaircraft accidents rest with a thirddivision, the Department of Acci-dent Investigation and Prevention,and a scientific research labora-tory that has the means and meth-ods to investigate accidents.

The laboratory participates in ac-cident investigations, carries out independentresearch and tests, and submits its final re-sults to the commission. Using flight datarecorder (FDR) and cockpit voice recorder (CVR)data, the laboratory models the flight charac-teristics of aircraft, analyzes crews’ actions inemergency situations, and works out and imple-ments new methods of flight dynamics analy-sis and corresponding mathematical models.

Accident and incident investigation is regulatedby the Aircraft Accident Investigation Manual,mandatory for every level of investigation. Thelatest edition of the manual was adopted in 1989.

This manual includes:

• general issues, classification and defi-nitions;

• order and organization of accident in-vestigation;

The Sovietstandards fullycorrespond to

ICAOrequirementsand in somecases exceed

their minimumstandards … .


• order and organization of incident in-vestigation; and,

• order of implementing recommendationsand measures based on theresults of accident investi-gation.

The principle goal of accident in-vestigation is prevention of simi-lar accidents in the future. Thestandard establishes that accidentinvestigation should not exceed 30days. When there is a need forspecial time-consuming research ortests, this period may be extendedb y t h e h i g h e s t o f f i c i a l s o fGOSAVIANADZOR.

When an accident occurs, a com-mission is assigned to investigate it, and con-sists of its chairman who is the investigator-in-charge (IIC), his deputy and members. Ifthe investigation commission considers it nec-essary, experts may also be invited to partici-pate. Commissions investigating accidents withlight airplanes and helicopters on behalf ofministries and other governmental bodies, in-clude experts possessing special knowledgein these areas. They also must have experi-ence in the field of accident investigation andhave no direct involvement with these acci-dents.

The standard determines the procedure of re-porting aircraft accidents, as well as the initialactions of aviation officials before the investi-gation commission arrives on the accident scene.After the investigation commission arrives,subcommissions in the main directions of thework are usually formed — flight, engineer-ing and administrative. If the IIC considers itnecessary, he may form other subcommissions.The subcommissions usually are comprised ofworking groups.

The list of members of the subcommission andworking groups and plans of their work areapproved by the chairmen of the subcommis-sions. The major methodological and organi-zational decisions on the investigation are madeby the IIC with the advice of the members of

the commission. After their work is complete,the working groups make reports that are re-viewed and discussed at the meetings of sub-commissions. These reports are used as a ba-

sis for the subcommissions’ re-ports which are then reviewed atthe meetings of the commission.

Based on the results of the inves-tigation, the commission preparesa formal accident report (the act)plus a special report for comput-erized recording, the form of whichis based upon the ICAO AircraftAccident/Incident Reporting Sys-tem (ADREP) system. The dateof the act approval, by senior of-ficials of GOSAVIANADZOR orof ministries of other governmentalbodies which assigned a commis-

sion to investigate an accident with a lightairplane or a helicopter, is considered the dateof the investigation termination.

The standard determines the rights and dutiesof the IIC, his deputy, members of the commis-sion and experts. According to the standard,subcommissions carry out the following:

• The flight subcommission establishesthe correlation between the accident andthe professionalism of the crew mem-bers, the quality of operation procedures,ATC and flight support. It takes intoconsideration the influence of the air-craft structure, environmental and hu-man factors. It also assesses the ac-tions taken by the crew members andauthorities during the emergency.

• The engineering subcommission exam-ines the condition of the aircraft, thenature of its operation and the qualityof maintenance. It identifies possiblestructural and production deficienciesand, if necessary, organizes special testsin order to find the correlation betweenthe accident and the condition of theaircraft.

• The administrative subcommission evalu-ates the search and rescue operations,

The principlegoal of

accidentinvestigationis prevention

of similaraccidents inthe future.


determines the aircraft payload, its dis-tribution and attachment, identifies de-viations from weight and balance stan-dards, renders help to the injured per-sons and their relatives and meets theirclaims, clears the accident site and evalu-ates losses.

The methodological basis for accident investi-gation in the U.S.S.R. includes the followingpublications: Methodological Guide for AccidentInvestigation, adopted in 1977; Medical AircraftInvestigation Manual of 1986; and Methodologi-cal Guide for Analysis of Deviation in AviationSystem During Accident and Incident Investiga-tion of 1987. In addition, Principles of Modellingand Evaluation of Flight Dynamics During Acci-dent Investigation and Principles of Studying HumanFactors in Accident Investigation are also used.

Introduction of new aircraft, new airport equip-ment, improved and broader use of data re-corders and greater emphasis on human fac-tors considerations during accidentinvestigations resulted in the needto update the Methodological Guidefor Accident Investigation. Some prin-cipal changes also were made tothe Aircraft Accident InvestigationManual, that became effective in1989.

The main distinctions of the newedition of the Aircraft Accident In-vestigation Manual compared to theprevious (1988) edition include achange in the classification of air-craft accidents. The definition ofaircraft accidents was brought closeto that of the ICAO definition. In the newedition, practically all the cases previously clas-sified as emergency events, are now consid-ered accidents. This reduces the possibility ofmisunderstanding. The borderline betweenaccidents and incidents has been more clearlydefined.

The latest edition of the manual includes anew approach to classification and analysis ofthe occurrences not classified as accidents.Accident investigation procedures have beenchanged in the following way:

• The IIC’s rights have been broadened.

• A more democratic approach to con-sidering the options of the parties par-ticipating in the investigation is guar-anteed.

• More flexible organizational methodsof investigation have been establishedin everything concerning the member-ship in the investigation commission.

The procedures for developing new measuresbased upon the results of accident investiga-tion as one of the main preventive methodshave become more thorough. Terms and re-sponsibilities for developing such measuresare outlined in the new manual. Records ofrecommendations and monitoring the devel-opment of measures will be computerized.

For the first time, a new inter-agency systemof incident investigation and analysis was es-

tablished for the purpose of de-veloping and implementing pre-ventive measures. Operators andmanufacturers will consider theresults of all incident investiga-tions.

One of the major tasks of the manualis the standardization with ICAOrequirements of classification,methods of accidents investigationand prevention. However, somenational features remain.

ICAO Annex 13 and the manualhave different areas of applica-

tion. Annex 13 determines the procedures ofinvestigation of an accident involving an air-craft of one member state in the territory ofanother member state. It establishes the or-der of cooperation between these states aswell as between the state of manufacture andthe state whose interests may be underminedby this accident. The manual is a purely intr-astate document and considers only investi-gations of accidents with Soviet civil aircraftin the U.S.S.R.. The manual deals only withthe problems of cooperation with the state ofmanufacture.

The definitionof aircraft

accidents wasbrought close to

that of theICAO

definition.


Nevertheless, considering the Annex 13 rec-ommendation concerning possible standard-ization of national and international investi-gation procedures, reviewingdifferences between them is justi-fied. The essence of these differ-ences can be summarized in threecategories.

First, according to Annex 13, thecriterion of an accident is the pres-ence on board the aircraft of crewmembers or passengers. Accord-ing to the manual, the criterion ofthe accident is the presence on boardthe aircraft of any person intend-ing to make a flight, regardless ofhis being a member of the crew ora passenger or some other per-son. Such a distinction is justified by the no-tion that “passenger” and “crew member” inthe U.S.S.R. has a clear legal definition; it iseither a person with a ticket or one who isincluded in a special passenger list (passen-ger), or a person authorized to carry out theflight (a crew member). In this regard, allthose on board the aircraft who have no neces-sary permission, are not considered either pas-sengers, or crew members. At the same time,in terms of consequences of an accident, suchpersons are treated equally with passengersand crew members. The definition used in themanual allows classification of an aviation ac-cident, the case of aircraft capture, hijackingand unwarranted takeoff resulting in seriousconsequences. This is impossible under theICAO definition.

Second, Annex 13 regards as a criterion of anaccident serious injuries of persons outsidethe aircraft. The manual disregards such casesunless they result in substantial consequences

for the aircraft and the people on board. Thisapproach is justified by the fact that these people,having nothing to do with the given flight,

should not be considered as a threatto flight safety and, accordingly,the occurrence of their injuriesshould not be classified as an air-craft accident. Such cases, if theyare of no danger to the safe opera-tion of the aircraft, should be con-sidered an unhappy event ratherthan an aircraft accident. Currently,however, this item of the manualis being revised and is expected tobe brought into full compliance withthe ICAO standards.

Third, Annex 13 also regards seri-ous injuries as a criterion of an avia-

tion accident. The manual classifies an occur-rence as an accident only in case of fatal inju-ries. This approach is determined by the oc-currences with serious injuries to people onboard the aircraft without heavy consequencesfor the aircraft itself. As a rule, these cases areconnected with the carelessness of the injuredperson himself.

The training of civil aviation accident investi-gators is accomplished at the Leningrad CivilAviation Academy. The instructors are teach-ers and professors of the Academy and spe-cialists of GOSAVIANADZOR, as well as ofscientific and research organization of minis-tries and other governmental bodies. In thecourse of training, students learn practical skillsin accident investigation and in decoding andanalyzing data recorder information. Theyare also taught to organize and use a flyinglaboratory that is based aboard an An-12 air-plane, work out recommendations and pre-pare the necessary documentation.

Incident Investigation in Civil Aviation

Accident prevention through identifying andeliminating deficiencies in the aviation sys-tem is the cornerstone of flight safety in theU.S.S.R. This premise, which has been real-

ized by aviation organizations worldwide, isfully recognized by the Soviet civil aviationauthorities, including GOSAVIANADZOR.In addi t ion, the exper ience gained by

… the criterionof the accidentis the presenceon board the

aircraft of anyperson intending

to makea flight … .


GOSAVIANADZOR and other civil aviationauthorities of the U.S.S.R. has brought to theforefront that primary emphasis on accidentinvestigation in the search to identify defi-ciencies is an expensive learning process interms of the grave social and material conse-quences of these accidents.

While analyzing the factors of accidents, theU.S.S.R. has recognized that great human andmaterial losses are the result of a combinationof factors, although each one looked at sepa-rately may seem innocuous from the point ofview of potential consequences. This is pre-cisely why the concept of accident preventionbased on early identification and detection ofdeficiencies through the investigation of inci-dents has gained broad recognition.

The term “incident” has been usedin Soviet civil aviation for a longtime. However, it sometimes hasentailed interpretations that wereat variance with the descriptionaccepted by ICAO. Today, though,the U.S.S.R. interpretation of anincident is in line with that adoptedby ICAO. An incident denotes adeviation from the proper func-tioning of the aircraft, crew, ATCor maintenance service which hasnot caused an accident, but at thesame time posed a potential threatto flight safety. Under a different set of cir-cumstances, it could result in an accident.

Incident investigation in the U.S.S.R. is man-datory. In order to avoid misunderstandingin the classification of incidents, and bearingin mind that there is some ambiguity in theinterpretation of what should be classified asan incident, a list has been prepared that indi-cates 30 specific incidents that are to be inves-tigated. A concept is employed in which asmany incidents as possible are registered andinvestigated. This provides the operator andthe manufacturer with the maximum amountof information available on the identified de-ficiencies.

However, the U.S.S.R. is aware that not all thedeviations have the same impact on safety and,

therefore, must be treated differently accord-ing to the degree of danger they pose. If adetected deficiency belongs to a high-risk areaand could lead to an accident, it receives im-mediate attention and widespread correctiveaction. But if it proves to be less of a dangerand poses no direct threat to flight safety, suchas an unretracted gear after takeoff, decisionson the time and procedures required to elimi-nate this deficiency and the necessity to takeaction on it would be made based upon eco-nomic expediency.

All of the work on incidents can be dividedinto two stages. The first stage is the investi-gation proper. According to the Soviet sys-tem, incidents are usually investigated by theoperators — by the civil aviation units thatare directly involved. Such an order, an ob-

vious departure from the prin-ciple of impartiality, is necessarybecause the corresponding gov-ernment authorities are physicallyunable to investigate all the inci-dents. On a yearly basis, the num-ber of incidents covered underthe accepted official investigationlist alone runs into several thou-sand a year. This high numberof investigated incidents stemsfrom the principle that stresses“more information for accidentprevention.”

In order to neutralize any possible partialityof the operator in the investigation of techni-cal malfunctions, the rules require a manda-tory participation by the manufacturer or ateam from the repair or maintenance facility.The investigations are supervised by GOSA-VIANADZOR and central bodies of the Minis-try of Civil Aviation.

Incidents generally are investigated with thesame principles and in the same order as acci-dents except for some simplification of the pro-cedures. Another difference is that the inci-dent investigation report, prepared by the in-vestigation team, is not final and is subject toapproval by the General Inspectorate on FlightSafety of the U.S.S.R. Ministry of Civil Aviationwith consent from GOSAVIANADZOR.

Incidentinvestigation inthe U.S.S.R. is

mandatory.


The principle goal of the first stage is to gatherfactual information that would be used dur-ing the second stage — analysis and imple-mentation of preventive measures. The sec-ond stage categorizes the data, screens outdeficiencies and produces generalrecommendations to direct the pre-ventive measures.

The main problem at this stage is toprovide an adequate assessment ofthe incident’s degree of danger. Tosolve this problem, a situationalapproach is employed that singlesout four levels of danger of any givensituation:

• adverse flight condition;

• hazardous situation;

• emergency situation; or,

• catastrophic situation.

Incidents characterized by situations from haz-ardous down the list to catastrophic are con-sidered serious. These categories of incidentsreceive priority in planning the preventivesteps.

Incidents are analyzed by a special group ofexperts, mostly representing scientific and re-search bodies of the operator and manufac-turer. Any decision on the necessity and thenature of preventive actions is made by theoperator and the manufacturer within theircompetence.

Implementation of this system has been com-plicated by a few facts which were basicallyassociated with two problems. The first prob-lem is maintenance of a high quality of inves-tigation by the operator. In general, incidentinvestigation is a function that is not typicalfor an operator, at least on the level of re-gional units. First, because it is rather specificand requires the participation of well-trainedexperts who may not be available, and sec-ond, because incidents are so unpredictableand frequent, their investigation distracts theoperator from his direct duties.

In this respect, it is not easy to convince theoperator of the need to investigate as manyincidents as possible. It is even more difficultto convince the operator to launch a compre-hensive and objective investigation. Since the

U.S.S.R. firmly believes in the ne-cessity of thorough incident inves-tigation, one of the primary solu-tions of this problem is the creationof special regional bodies for inci-dent investigations. These bodieswould act independently of the op-erator.

The second problem is purely meth-odological and involves complexissues such as providing adequateevaluation of the level of danger ofthe given incident and determin-ing the effectiveness of the elimi-nation of identified deficiencies.Complexity of the problem is based

on the absence of common formal methods ofconducting analysis. Today, it is being solvedto a certain extent subjectively, using the methodof expert evaluation. This problem might besolved by working out scientifically substan-tiated methods of conducting situational analysis.This is what the U.S.S.R. is doing now, and theresults that have been achieved signal that inthe near future the problem will be solved.

These are, in general terms, the basic conceptsadopted in the U.S.S.R. on the use of incident-related information for accident prevention.It is hoped that their broad implementationwill produce a higher level of early accidentprevention and make it easier to optimize themeasures aimed at the elimination of the iden-tified deficiencies. �

Reference

1. “Statute of the State Supervisory Commis-sion for Flight Safety Under the Council ofMinisters of the U.S.S.R.,” State Supervi-sory Commission for Flight Safety Underthe Council of Ministers (GOSAVIANAD-ZOR). Photocopies of this nine-page stat-ute are available by request from the FlightSafety Foundation.

The mainproblem … is to

provide anadequate

assessment ofthe incident’s

degree ofdanger.


Aviation Statistics

Accident Rates Decline

General aviation aircraft safety data and analysisof fixed-wing aircraft as well as rotorcraft pub-lished by the U.S. National Transportation SafetyBoard (NTSB) generally indicate that the chanceof rotorcraft being involved in accidents in

terms of aircraft hours flown is greater thanthat of fixed-wing aircraft. Figures 1 and 2show the accident rate distribution and trendsfor total accidents and fatal accidents per 100,000aircraft hours for fixed-wing aircraft as com-pared to rotorcraft for the past 19 years.

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••

••

•• •

• • •• • •

1972 1972

Rotorcraft

******

* * * * * * * * *

***

*Fixed Wing Aircraft

0

10

20

30

1978 1981 1984 1987 1990

Tota

l Acc

iden

t R

ate

per

100

,000

Air

craf

t H

ou

rs

Year

Total Accident TrendGeneral Aviation

Fixed-wing Aircraft vs. Rotorcraft1972-1990

Figure 1

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•

•

•

•

••

••

•

•

••

•

••

•

•

•* *

** * * *

* * * * * * * ** *

* *

4

Rotocraft

Fixed Wing Aircraft

3

2

11972 1975 1978 1981 1984 1987 1990

•*

Fat

al A

ccid

ent

Rat

e p

er 1

00,0

00 A

ircr

aft

Ho

urs

Year

Fatal Accident TrendGeneral Aviation

Fixed-wing Aircraft vs. Rotorcraft

Safety Performance of General AviationFixed-wing vs. Rotorcraft

1972-1990

byShung C. Huang

Statistical Consultant

Figure 2


The straight lines in the figures showing theslope of changes are the result of smoothing toillustrate the accident trends. The linear ex-pression shows that, through the years, thetotal accident rates and fatal accident rates forboth fixed-wing and rotorcraft declined. Therates of total accidents and fatal accidents forboth fixed-wing and rotorcraft are very simi-lar. A difference is that the annual distributionof fatal accident rates for rotorcraft fluctuatedsignificantly. In 15 of the 19 years, the annualfatal accident rates of rotorcraft were gener-ally higher than those for fixed-wing aircraft;but in four of the 19 years, the rotorcraft rateswere lower.

A review of the annual frequency of fatal acci-dents reveals that the fluctuation of the acci-dent rates for rotorcraft was primarily due tosignificant changes in the number of annualfatal accidents in different years. However, thegeneral trend is that rotorcraft accident ratesare higher than those of fixed-wing aircraft.

Data Accuracy Depends UponReporting Accuracy

Such a finding is inconclusive, because rotor-craft operational data, particular the accuracyof flight time used to measure safety perfor-mance, was disputed. Some helicopter pilotsand safety engineers have claimed that actualrotorcraft safety is better than perceived6, andthat the accident rates are actually lower thanpublished because rotorcraft flight time couldbe much higher than that reported in annualsurveys. [Prior to 1977, the active aircraft andflight times estimated by the U.S. Federal AviationAdministration (FAA) were based upon anannual FAA aircraft owner census. However,since 1977, the FAA has sampled a small per-cent of registered aircraft activity by means ofan operational survey from which it makesestimates.]

The critics of the estimates pointed out thatthe rotorcraft flight hours collected during thesample survey fluctuated widely; in particu-lar, the flight hour estimates for a few rotor-craft makes/models were significantly differ-ent each year. They concluded that the sample

survey results since 1977 were insufficient foraccurate estimates; consequently, the rotorcraftflight time could be well underestimated. Theaccident rates for rotorcraft could be muchlower if their flight times could be shown tobe significantly higher.

Current Data Collection Ques-tioned

The possibility of inaccuracies in the estimatesof rotorcraft flight hours by the FAA is per-ceivable because the sample survey estimatesare subject to possible errors in many vari-ables. In general, if the number of active air-craft for any rotorcraft make/model is verysmall, and the survey response rate for thatparticular make/model was relatively low, thestandard error of the estimate could be veryhigh. This is true for an estimate involvingany aircraft makes/models.

On the contrary, if sample size is larger and theresponse rate of the survey is higher, the stan-dard errors of survey estimates would be smaller.This is true for any estimate for rotorcraft as awhole. In other words, the estimate of flighttime for all rotorcraft as a whole is definitelymuch more accurate than the estimates of ac-tive aircraft as well as flight time for any par-ticular rotorcraft make/model if that make/model is a subset of the survey estimates.

In the results of the FAA’s annual General Avia-tion Activity and Avionics Survey, the agencyappears to acknowledge the discrepancy ofsurvey estimates. To improve the accuracy ofestimates for rotorcraft, the FAA first increasedthe sample size for rotorcraft in its annualgeneral aviation aircraft survey and later in1989 it conducted a special census of morethan 10,000 registered rotorcraft. Table 1 pro-vides summaries of aircraft hours flown andactive aircraft estimated by the FAA based onthe results of annual sample survey and rotor-craft census programs conducted prior to 1977as well as the special rotorcraft census con-ducted in 1989.

Prior to 1977, the FAA annually sent a surveyquestionnaire to owners of all registered aircraft


requesting them to report registration and activ-ity related information. At that time, the re-sponse rate was higher than 85 percent. Theaccuracy of flight time estimates based upon the1972-1976 census of registered aircraft as shownin Table 1 should be considered highly accept-able. Note that in Figure 1, the total accidentrates of rotorcraft in 1972-1976 were higher thanthose for the fixed-wing aircraft, but the rotor-craft fatal accident rate was higher than the fixed-wing rate in one year and lower in another year.This wide fluctuation appears to be caused bythe significant difference in the number of fatalaccidents each year; the flight time had no sig-nificant effect upon the up and down variancesat all because it did not fluctuate greatly.

Before 1977, the civil aircraft annual censusshowed that the ratio of active aircraft be-tween fixed-wing and rotorcraft shifted from50-to-one in 1972 to about 40-to-one in 1976.Further analysis of the data in Table 1 revealsthat rotorcraft were more active than the fixed-wing aircraft because the average flight timeper year per rotorcraft was more than doublethat of fixed-wing aircraft. From 1977 to 1988,the estimates based on the annual sample sur-vey that included approximately 10 percent ofregistered fixed-wing aircraft and 30 percentto 40 percent of rotorcraft the population showeda similar pattern, with the ratio of active air-craft and flight time remaining in a similarproportion.

Table 1Estimates of Active Aircraft and Flight Hours

Fixed-wing (1) vs. Rotorcraft1972 - 1990 (2)

Active Active Rotorcraft/ Hours (000) Hours (000) Rotorcraft/Year Fixed-wing Rotorcraft Fixed-wing* Fixed-wing Rotorcraft Fixed-wing*

1972 140,295 2,787 2.00% 26,656 1,037 3.89%1973 148,416 3,143 2.11 28,697 1,158 4.031974 155,350 3,610 2.32 28,516 1,414 4.951975 161,570 4,073 2.52 32,365 1,547 4.781976 170,625 4,505 2.64 34,082 1,762 5.18

1977 170,077 3,765 2.21 33,162 1,868 5.631978 182,732 4,100 2.24 33,162 1,397 4.211979 192,667 4,506 2.34 36,760 1,522 4.141980 192,286 5,215 2.71 34,145 1,891 5.531981 193,654 6,246 3.22 34,113 2.303 6.75

1982 193,483 4,942 2.55 30,007 1,628 5.421983 193,660 5,385 2.78 28,917 1,709 5.911984 200,574 5,585 2.78 29,555 1,599 5.411985 191,493 5,546 2.90 28,471 1,766 6.201986 200,176 5,465 2.73 27,234 1,689 6.20

1987 200,153 5,005 3.10 27,067 1,388 5.121988 190,588 5,331 2.80 27,067 1,954 6.221989 197,731 5,946 3.00 27,998 1,813 6.471990 191,825 6,139 3.10 28,823 1,705 5.92

(1) Excludes gliders(2) Prior to 1977, all data was based on annual registered aircraft census. Data estimates

after 1977 (excluding 1989) were based upon annual sample surveys. Rotorcraft data for1989 was estimated based upon a special rotorcraft census.

(*) Indicates rotorcraft as a percent of total fixed-wing.


In 1989, the data for fixed-wing aircraft wasbased upon sample surveys, while the datafor rotorcraft was based upon the special ro-torcraft census; the results showed that fixed-wing and rotorcraft maintain a similar rela-tionship. Although, over the 10-year period,active general aviation fixed-wing aircraftshowed little change, the hours flown shrankfrom 37 million hours in 1979 to 27 millionhours in 1988. On the other hand, active rotor-craft showed a slight increase; the annual hoursflown increased from 1.4 million in 1978 toalmost 2 million hours in 1988.

An analysis in terms of ratio between fixed-wing and rotorcraft — both the number ofrotorcraft as a percent of total fixed-wing air-craft and rotorcraft flight time as a percent oftotal fixed-wing flight time (Table 1) — showeda gradual increase over the period. This is anindication that the rotorcraft category contin-ues to be more dynamic than the fixed-wingcategory in terms of numbers of active aircraftand flight time. Rotorcraft flight time increasedwhile fixed-wing flight time did not; the over-all trend of general aviation activity was slowingdown between 1982 and 1987.

The statistics also show that the active aircraftand flight time of fixed-wing aircraft and ro-

torcraft compiled by annual sample surveysin the period between 1977 and 1988 are com-patible with the data compiled by the special1989 rotorcraft census as well as the surveysprior to 1977. Although the estimated num-bers of active rotorcraft, total flight time andaverage flight time per rotorcraft based on thespecial 1989 rotorcraft census are slightly greater,a comparison of the estimates based on 1988and 1990 general aviation sample surveys tothose estimates based on census, reveals nosignificant difference.

Therefore, it appears acceptable to infer thatsurvey estimates of active aircraft and flighttime for rotorcraft based upon the annual samplesurvey could be slightly higher in some yearsand slightly lower in some other years, butthe differentials appear insignificant. There-fore, it is difficult to conclude that the activeaircraft and flight time for rotorcraft over theyears had been underestimated beyond an ac-ceptable level.

Even if the special 1989 rotorcraft census re-corded slightly more active rotorcraft and flighthours, the accident rate for rotorcraft in 1989as shown in Figures 1 and 2 was not substan-tially lower than that of previous years andsucceeding years because the frequency of ac-

••

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1988 1989 1990

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cident involvement in rotorcraft in 1989 wasrelatively higher.

Safety by Operations Measured

The operation, as well as the function ofrotorcraft, differs greatly from fixed-wingaircraft. Generally, rotorcraft perform land-ings and takeoffs more often than fixed-wingaircraft. If the frequency of landing was usedas a measurement of safety, the outcome ofrotorcraft safety performance could be greatlydifferent. Although the number of total op-erations (takeoffs and landings) of generalaviation aircraft — excluding aircraft usedfor air taxi and commuter operation — isnot readily available, the 1988 and 1990 an-nual FAA General Aviation Activity and Avi-onics Survey reported that fixed-wing air-craft on an average perform about 200 land-ings per year while a rotorcraft performs500 landings in the same period.

In addition, the 1990 general aviation air-craft activity survey conducted at 250 air-ports by the Civil Air Patrol for the FAA re-ported that, in combined operations of localflight and cross-country flight, the fixed-wing,

piston-engine aircraft performs 1.4 landingsper hour; fixed-wing turboprop aircraft, ap-proximately 1.1 landings per hour; fixed-wingturbojet, 0.8 landings per hour; piston-en-gine rotorcraft, 2.4 landings; and, turbine-engine rotorcraft 1.8 landing per hour. Over-all, rotorcraft performed approximately twiceas many landings as fixed-wing aircraft did.Based upon the estimates, the accident ratein terms of total accidents and fatal accidentsper 100,000 landings for 1988 through 1990are presented in Figures 3 and 4. �

Reference

1. “Annual Review of Aircraft Accident Data, U.S. Gen-eral Aviation,” U.S. National Transportation SafetyBoard. Calendar years 1977-1987.

2. “NTSB Brief of Accidents Involving Rotorcraft,” U.S.National Transportation Safety Board. Annual Publi-cation.

3. “General Aviation Activity and Avionics Survey, An-nual Report,” U.S. Federal Aviation Administration.Calendar years 1977 to 1989.

4. “Rotorcraft Activity Survey,” U.S. Federal AviationAdministration. 1989.

5. “General Aviation Pilot and Aircraft Activity Survey,”U.S. Federal Aviation Administration. 1990.

6. Roy G. Fox, “Reporting Helicopter Flight Hours,”Rotorbreeze, Vol. 34, No. 3.

Reports Received at FSFJerry Lederer Aviation Safety Library

Reports

Aviation Occurrence Report-Hydra ManagementLtd. Aerospatiale 332C Super Puma C-GQRL,Quatam River, British Columbia, 03 October1987. — Ottawa : Transportation Safety Boardof Canada, 1991. Report Number 87-P70096.40 p. in various pagings. [Communique TSB#13/91 to be released on 8 July 1991.]

Key Words1. Aeronautics — Accidents — 1987.

2. Aeronautics — Accidents — Helicopters— Fatigue.

Summary: The helicopter had lifted a log andhad begun to move forward when the maingearbox flexible mounting plate failed. Thiscaused the Bendix drive shafts to fail, inter-rupting the transmission of engine power tothe rotor system. The pilot jettisoned the log,but was unable to enter autorotation. Thehelicopter fell to the mountainside and wasdestroyed by impact and fire; the pilot and co-


pilot were fatally injured. The TransportationSafety Board of Canada determined that theflexible mounting plate failed in fatigue be-cause the true number of high-load cycles ap-plied to the plate during heli-logging opera-tions were not taken into account in themanufacturer ’s (Aerospatiale) determinationof the service life of the plate. The operatordid not detect cracks in the flexible mountingplate during inspections the night before andmorning of the accident. [Synopsis] Recom-mendations A91-14 (Analysis of probability offailure of the newly designed mounting plate)and A91-15 (Location and visual inspection ofthe mounting plate) were issued as a result ofthis accident.

Aviation Occurrence Report-Risk of Collision Be-tween: Lockheed L-1011-50 G-Beam and McDon-nell Douglas DC-8-62 N1805 and Boeing 747-100EI-BED, North Atlantic, 09 July 1989. — Ot-tawa : Transportation Safety Board of Canada,1991. Report Number 89A0163. 21 p. [Com-munique TSB #15/91 to be released on 16 Au-gust 1991.] [FSF also has French edition]

Key Words1. Aeronautics — Accidents — 1989.2. Aeronautics — Accidents — Navigation

Errors.3. Air Traffic Control.4. Airplanes — Near Midair Collisions.5. Airplanes — Collision Avoidance.

Title page: “14 May 1991.”

Summary: British Airways Flight 094 was east-bound over the North Atlantic when it begandeviating south of its assigned track at 50 de-grees west longitude. While off course, BAFlight 094 had three risks of collision with twoaircraft and had losses of separation with twoother aircraft at flight level 350. The Trans-portation Safety Board of Canada determinedthat a two-degree input error had been madeduring programming of the flight managementsystem/inertial navigation system (FMS/INS)for the North Atlantic crossing. This errorcaused the aircraft to begin deviating off courseat 50 degrees west longitude. INS cross-checks

were not conducted at 50 degrees west, andthe error went undetected, resulting in a 120-nautical mile deviation south of the assignedNorth Atlantic track. A weakness in the Brit-ish Airways L-1011 fleet’s system of cross-check-ing contributed to the seriousness of this oc-currence. [Synopsis]

Aviation Noise: Costs of Phasing Out Noisy Air-craft. Report to Congressional Requesters/UnitedStates. General Accounting Office. — Wash-ington, D.C. : U.S. General Accounting Office*,1991. Report GAO/RCED-91-128, B-239410.56 p. ; charts.

Key Words1. Airport Noise — Control — Costs — United

States.2. Jet Transports — Noise — Law and Legis-

lation — United States.3. Noise Control — Costs.

Summary: In November 1990, the Airport Noiseand Capacity Act of 1990 (ANCA) was en-acted. This act phases out the noisiest jetscurrently in use (called “Stage 2” jets) by theyear 2000 and limits the discretion of airportsto adopt their own noise restrictions. In re-sponse to congressional request, this reportdescribes the likely effects of ANCA on thecosts of aviation noise restrictions to the air-line industry . GAO estimates that, in theabsence of any additional airport restrictions,phasing out Stage 2 aircraft by the year 2000will cost about $2 billion, if each airline adoptsthe lowest cost method of meeting the requiredStage 3 standards. This cost would rise toalmost $5 billion if all Stage 2 aircraft werereplaced rather than retrofitted with hushkitsor new engines. If the U.S. Secretary of Trans-portation grants waivers allowed in the ANCA,allowing phaseout until the end of 2003 forup to 15 percent of each airline’s fleet, GAOestimates that costs to the airline industry willbe reduced by as much as $100 million be-cause airlines will not have to make expendi-tures to replace or retrofit aircraft as soon asthey otherwise would. The burden of aircraftnoise borne by those living near airports, onthe other hand, would of course be reduced


more slowly. [Results in brief]

Air Ambulance Helicopter Operational Analysis.Final Report/Robert Newman (Systems Con-trol Technology Inc.). — Washington, D.C. :Federal Aviation Administration, Research andDevelopment Service ; Springfield, Virginia,U.S. : Available through NTIS*, [1991]. ReportDOT/FAA/RD-91/7. 167 p. in various pagings: ill. ; 28 cm.

Key Words1. Helicopters.2. Airplane Ambulances — Piloting.3. Airplane Ambulances — Weather.4. Air Traffic Control.5. Aeronautics in Meteorology.

Summary: This study of visual flight rules (VFR)weather minimums and operations areas for he-licopter emergency medical service operators isbased on operator responses to a questionnaire.The national average VFR operations weatherminimums for all respondents was determined.Also, an estimate of the percentage of time thateach respondent cannot fly because of ceilingand/or visibility below their VFR operating mini-mums was determined, as was the average per-centage of time all respondents cannot fly. Analysisof the data indicated that on the average theoperators have voluntarily adopted stricter mini-mums than recommended in the current FAAAdvisory Circular 135-14. Furthermore, the analysisindicated that on the average the operators havemore restrictive daylight minimums than thosein the proposed change to AC 135-14 and lessrestrictive night minimums than those in theproposed change.

The FAA is in the process of determining ifthere is an economic justification for the im-provement of low altitude communication,navigation and surveillance services. The re-sults of this study provides data which willsupport further analysis of the benefits of airambulance helicopters in an IFR environment.[Modified author abstract]

Air Traffic Control: FAA Can Better Forecast andPrevent Equipment Failures. Report to the Chair-

man, Subcommittee on Transportation andRelated Agencies, Committee on Appropria-tions, House of Representatives/U.S. GeneralAccounting Office*. — Washington, D.C. : U.S.General Accounting Office, [1991]. Report GAO/RCED 91-179. 14 p. ; 28 cm.

Key Words1. United States — Federal Aviation Admin-

istration.2. Air Traffic Control — Automation — United

States.3. Air Traffic Control — Equipment and Sup-

plies — United States.

Summary: FAA has not performed a compre-hensive assessment of the reliability of its ATCequipment at en route centers. Consequently,FAA managers do not have the complete pic-ture they need to adequately assess the gravityof problems that maintenance personnel andcontrollers are experiencing with ATC systemequipment. Current indications of problems withantiquated ATC equipment may be a precursorto failures in critical systems. If FAA improvesthe quality of the data it contains, the Mainte-nance Management System Corrective Mainte-nance data base holds the most promise forenabling FAA to take a more proactive approachto managing systems maintenance. [Conclusions]

Annual Report 1990/Transportation Safety Boardof Canada. — Ottawa : Minister of Supply andServices Canada, 1991. 111 p.; charts, ill. Bilin-gual: English and French. ISBN: ISBN: 0-662-58243-8.

Key Words1. Aeronautics — Accidents — Canada.2. Aeronautics — Statistics — Canada.3. Aeronautics — Safety Measures — Canada.

Contents: Members of the Board — Chairperson’sMessage — Introduction — Statistical Over-view (Marine, Commodity Pipelines, Rail, Air)— Activities: Overview, Occurrence Classifica-tion and Response, Investigation Operations,Safety Studies, Technology in TransportationAccident Investigations (Derailment, Fire andExplosion, Remote Sensing, Flight Data and


Cockpit Voice Recorders), Human Factors, Con-fidential Aviation Safety Reporting Program,Communications, Occupational Health and Safety— Findings — Safety Action (including SafetyRecommendations) — Appendices: Transpor-tation Occurrence Statistics 1981-1990.

Summary: By an act proclaimed on 29 March1990, the Transportation Safety Board of Canada,a new independent multi-modal agency, wasestablished. The new Board replaces the Ca-nadian Aviation Safety Board. This is the firstannual report of the TSB.

Civil Aviation Statistics of the World 1990. Six-teenth Edition-1991. — Montreal : InternationalCivil Aviation Organization, [1991]. 171 p. invarious pagings; tables, graphs.

Key Words1. Aeronautics — Accidents — Statistics —

Periodicals.2. Aeronautics, Commercial — Statistics —

Periodicals.3. Airlines — Statistics — Periodicals.4. Aircraft — Statistics — Periodicals.5. Air Pilots — Statistics — Periodicals.6. Airports — Statistics — Periodicals.7. Private Flying.

Contents: Map of ICAO Statistical Regions —ICAO World Statistics: Aircraft, Pilots, Safety,Fleets, Traffic, Finance — Statistics by Regionand State: Aircraft, Pilots, Traffic, General Avia-tion — Statistics for Commercial Air Carriersby State: International Scheduled Airlines,Domestic Scheduled Airlines, Non-ScheduledOperators — Airports — Appendices.

Summary: Includes summaries of statisticalinformation which is being reported regularlyto ICAO but not presently published in otherICAO statistical digests, i.e., civil aviation safety,general aviation, and civilian pilot licenses.Chiefly tables. [Preface]

Civilian Training in High-altitude Flight Physiol-ogy. Final Report/John W. Turner (EG&G

Dynatrend), M. Stephen Huntley Jr. (U.S. De-partment of Transportation), and John A. Volpe(U.S. National Transportation Systems Cen-ter).— Washington, D.C. : U.S. Federal Avia-tion Administration, Office of Aviation Medi-cine ; Springfield, Virginia, U.S. : Availablethrough NTIS*, [1991]. Report DOT/FAA/AM-91/13. viii, 19, [24] p. ; 28 cm.

Key Words1. Flight Training.2. Atmosphere, Upper — Physiological Effect.3. Aeronautics, Commercial — Employees —

Training — United States.4. Air Pilots — Training — United States.

Summary: A survey was conducted to deter-mine if training in high-altitude physiologyshould be required for civilian pilots; whatthe current status of such training was; and, ifrequired, what should be included in an idealcurriculum. The survey included a review ofAviation Safety Reporting System (ASRS ) andU.S. National Transportation Safety Board (NTSB)accident/incidents, current U.S. Federal Avia-tion Regulations (FARs), the Airman’s Informa-tion Manual, and military training courses. In-terviews were conducted with various repre-sentatives of the industry. The survey deter-mined that there is a need for such training. Itwas also found that current training practicesare not uniform and sometimes do not evenaddress those subjects required by FARs. Thereport contains recommendations for subjectsto be included in a core curriculum. [Authorabstract]

Exchange Ideology as a Moderator of the Proce-dural Justice-satisfaction Relationship. Final Re-port/L. Alan Witt, Dana Broach (Civil Aero-medical Institute). — Washington, D.C. : U.S.Federal Aviation Administration, Office of Avia-tion Medicine; Springfield, Virginia, U.S. : Avail-able through NTIS*, [1991]. Report DOT/FAA/AM-91/11. 6 p. ; 28 cm.

Key Words1. United States — Officials and Employees

— Salaries, etc.2. Job Satisfaction.


Summary: The study of 91 civilian U.S. gov-ernment employees in a two-month, full-timetraining program tested the hypothesis thatexchange ideology would moderate the rela-tionship between procedural justice percep-tions and satisfaction with the training expe-rience. Exchange ideology refers to the rela-tionship between what the individual receivesand gives in an exchange relationship. Em-ployee effort based on organization reinforce-ments is a strong exchange ideology. Whenemployees put forth effort without regard towhat they receive from the organization, it is aweak exchange ideology. The data indicatedthat perceptions of procedural justice accountedfor greater variance in satisfaction among traineeswith a strong exchange ideology than amongthose with a weak exchange ideology. Theseresults suggest that the effect of fairness onsatisfaction with a training experience appearsto be dependent on the individual’s exchangeideology. [Author abstract]

Selection Criteria for Alcohol Detection Methods.Final Report/Garnet A. McLean, Bruce W. Wilcox,Dennis V. Canfield (Civil Aeromedical Insti-tute). —Washington, D.C. : U.S. Federal Avia-tion Administration, Office of Aviation Medi-cine ; Springfield, Virginia, U.S. : Availablethrough NTIS*, [1991]. Report DOT/FAA/AM-91/12. 6, A-1, B-1, C-4 p. ; 28 cm.

Key Words1. Drinking and Airplane Accidents.2. Breath Tests.3. Blood Alcohol — Analysis.4. Alcohol.

Summary: The potential need for testing inthe aviation industry for job-related alcoholabuse requires the development of a testingstrategy based, in part, on selection of alcoholtest instruments appropriate to the specific goalsof the U.S. Federal Aviation Administration.The extensive availability of test instrumentswith varying capabilities and limitations makesselection of alcohol test instruments difficulttechnologically, with a considerable potentialfor choosing test instruments of inappropriate

character. The considerations outlined hereinare intended to assist in the selection process.[Author abstract]

Two Studies on Participation in Decision-makingand Equity Among FAA Personnel. Final Report/L. Alan Witt, Jennifer G. Myers (Civil Aero-medical Institute). — Washington, D.C. : U.S.Federal Aviation Administration, Office of Avia-tion Medicine ; Springfield, Virginia, U.S. :Available through NTIS*, [1991]. Report DOT/FAA/AM-91/10. 14 p. ; 28 cm.

Key Words1. United States — Federal Aviation Admin-

istration — Officials and Employees.2. Decision-Making.3. Job Satisfaction.

Contents: The Moderating Effect of Equity onthe Relationship Between Participation in De-cision-making and Job Satisfaction/L. Alan Witt— Perceived Environmental Uncertainty andParticipation in Decision-making in the Pre-diction of Perceptions of Fairness of PersonnelDecisions/L. Alan Witt and Jennifer G. Myers.

Summary: Study 1: Moderated multiple re-gression analyses on data collected from 2,177FAA air traffic controller specialists indicatedthat equity perceptions moderated the rela-tions between participation in decision-mak-ing and level of job satisfaction. Study 2: Datacollected from 357 FAA personnel indicatedthat perceptions of participation in decision-making and environmental uncertainty ac-counted for unique variance in perceptions oflevels of fairness in personnel decisions. [Au-thor abstract]

*U.S. Department of CommerceNational Technical Information Service (NTIS)Springfield, VA 22161 U.S.Telephone: (703) 487-4780

*U.S. General Accounting Office (GAO)Post Office Box 6012Gaithersburg, MD 20877 U.S.Telephone: (202) 275-6241


Accident/Incident Briefs

This information is intended to provide an aware-ness of problem areas through which such occur-rences may be prevented in the future. Accident/incident briefs are based upon preliminary infor-mation from government agencies, aviation orga-nizations, press information and other sources.This information may not be accurate.

approximately 600 feet and, having reachedthe end of its go-around mode, the autopilotdisconnected automatically because of the pilot’snose-down control column input. Grosslymistrimmed, the airplane pitched up steeplyto 88 degrees and the computed airspeed droppedto less than 30 knots. The stall warning wasactuated for approximately four seconds andthen stopped because the airspeed droppedbelow usable computed values and theautothrottle system disengaged. The airplanestalled at 4,300 feet and pitched down to mi-nus 42 degrees during which time the pilot-induced control inputs showed full up eleva-tor.

The airspeed increased as the aircraft descendedrapidly, reaching 245 knots as the aircraft lev-eled off at 1,500 feet. Still trimmed exces-sively nose-up, the aircraft began to climb rapidly.

The second nose-up cycle produced a 70-de-gree pitch-up and another stall 50 seconds af-ter the first one. The nose then dropped tominus 32 degrees and the airspeed built up to290 knots by the time the aircraft leveled off at1,800 feet. During this descent, pitch trim oneand yaw dampers one and two disconnectedand flight directors one and two dropped offline. During both stall cycles, the pilots at-tempted unsuccessfully to regain control ofthe aircraft by means of the autopilot but nei-ther of the two systems would engage.

Another pitch-up followed, during which theaircraft nosed up to 74 degrees and climbed to7,000 feet before stalling, 60 seconds after thesecond stall, and pitching down to minus 32degrees. The aircraft leveled off briefly at 3,600feet and 300 knots before beginning anotherpitch-up.

The nose went up to 74 degrees and the air-craft reached 9,000 feet. However, this timethe pilots’ use of thrust and elevator controlinputs, and probably retrimming the elevator,prevented a stall and the aircraft leveled off at

Pitch-up Leads to Triple Stall

Airbus A310: No damage. No injuries.

The aircraft was being flown on an autopilot-coupled approach. A missed approach wasinitiated at a height of 1,500 feet and the auto-pilot pitched the nose up. The pilot tried tocounteract the pitch-up by pushing forwardon the control column. This action normallydisengages the autopilot; however, the auto-matic disconnect is inhibited during the go-around mode.

Because of the pilot’s control input, the still-engaged autopilot trimmed the stabilizer tominus 12 degrees in an attempt to raise thenose and maintain the programmed profilefor the go-around. The nose-down controlcolumn input from the pilot, meanwhile, de-flected the elevator 14 degrees nose down.However, his nose-down input was overpow-ered by the combined nose-up forces of thestabilizer trim and the thrust increase and flapretraction that were occurring as part of thego-around procedure.

The autopilot captured its preselected missedapproach altitude after the aircraft had climbed

Air CarrierAir Carrier


brake was released and that the pushback shouldbe started. However, a replay of the cockpitvoice recorder (CVR) revealed that the groundcrew had been told that the aircraft was clearedfor the pushback and that the parking brakewas released.

Last-minute Command Changes

Vickers Vanguard 953C: Minor damage. No inju-ries.

The four-engine turboprop aircraft was on fi-nal approach and on glidepath according toboth the visual approach slope indicator (VASI)and instrument landing system (ILS) glide-slope indicators. The first officer was at thecontrols and was making a visual approach.At, or shortly before the landing flare, the captaintook the controls from the first officer becausehe became concerned with the way the finalapproach had developed.

The captain carried out the landing. After touch-down, as the nosewheel was lowered to therunway, the captain gave the controls back tothe first officer. The captain then selected groundidle on the power levers. At this time, severevibration was experienced which was initiallyattributed to nosewheel shimmy. When theaircraft stopped in a right-wing-low attitude,the captain realized that the right-hand maingear tires had burst. After this was confirmedby air traffic control (ATC), the engines wereshut down and the aircraft was evacuated onthe runway.

There were no injuries, but the aircraft sustaineddamage to a landing gear door and the numberthree engine nacelle when the tires burst. Thecaptain reported that the bursting of the tireshad probably been caused by brake application.

130 knots. The speed increased and a milderpitch-up placed the aircraft at 11,500 feet. Controlwas regained by the pilots and the aircraftwas landed with no further incident.

The manufacturer reviewed the incident andreported that the aircraft systems all functionedproperly. The company recommended thatpilots who want to change the direction of theaircraft in such a situation should either dis-connect the autopilot first or engage an auto-pilot mode other than go-around.

“I Don’t Remember Saying That”

Boeing 737: Moderate damage. No injuries.

After a rest period of almost 14 hours, thecrew of two reported for the third consecutivenight of flying. Duty time for a series of cargoflights had begun at 2355 hours and the air-craft was being prepared for the final flightthat was to depart at 0640.

When the dispatcher noted at 0600 that theaircraft would be ready earlier than expected,he obtained the crew’s agreement to requestan earlier slot time for departure which wasgranted, and the departure time was moved to0625. The crew was notified of the change at0615.

While the first officer secured the forward ser-vice door, the captain obtained engine startand pushback clearance and indicated to theground crew by interphone that the aircraftwas ready to be pushed back. By then, thefirst officer had returned to the cockpit andbegan reading off the before start checklistitems to which the captain responded.

The tug began to exert pressure through thetow bar on the nose gear to push the airplaneback; however, the aircraft’s parking brake hadnot been released and the nose gear leg col-lapsed rearward. The underside of the fuselagewas damaged and the aircraft was taken out ofservice for repairs. There were no injuries.

The pilots reported that they did not recallinforming the ground crew that the parking

Air Taxi/CommuterAir TaxiCommuter


Weight and BalanceReview, Anyone?

Cessna 402: Substantial damage. No injuries.

The air taxi flight was due to take off in mid-day during daylight conditions. Nine passen-gers had been boarded without the pilot hav-ing obtained accurate weight information fromthem. The baggage was placed in the aft bag-gage compartment, and as the pilot enteredthe cabin on his way forward to the cockpit,the aircraft’s tail fell to the ramp. The pilotraised the tail and decided to continue withthe flight.

During the climbout at 200-400 feet above groundlevel (agl) the stall horn sounded, and the pi-lot requested that the passengers move for-ward. The passengers did so and remainedforward until the aircraft landed. A stringer,rear bulkhead, elevator control tube and thehousing for the tail navigation light were dam-aged. There were no injuries.

The aircraft’s center of gravity (CG), accord-ing to the accident report, was beyond the aftlimit of the loading envelope. There was noballast in the forward baggage compartment.

The pilot was cited for inadequate preflightplanning and for exceeding the center of grav-ity limits.

Low-airspeed TakeoffLeads to Trouble

Beechcraft B58 Baron: Substantial damage. Noinjuries.

The aircraft was departing from a snow-cov-ered runway with a pilot and two passengers

on board. The runway surface was coveredwith approximately three inches of crusted snow,with the center 15-20 feet packed down byaircraft operations.

The aircraft was slow to accelerate and beganto pull to the left later in the takeoff roll. Thepilot attributed this to a loss of power in theleft engine but, instead of aborting the take-off, he tried to take off. Because the airspeedwas low, the aircraft climbed only a few feetbefore it settled back to the runway. This cyclewas repeated several times, after which theaircraft struck a snowbank along the side ofthe runway in a nose-high attitude. The im-pact tore off the main landing gear and thenose gear collapsed when the aircraft spunaround and came to rest in deep snow to theside of the runway. The aircraft sustainedheavy damage but the pilot and his two pas-sengers evacuated the aircraft without injury.

The engines were checked and run up to take-off power; no discrepancies were found. Acheck of the tire marks on the runway revealedthat the left main gear had been breaking atrail through the crusted snow while the nosegear and right main gear were rolling alongthe packed center portion of the runway nearthe beginning of the takeoff run.

It was concluded that the slow accelerationand left yaw had been caused by asymmetri-cal drag from the left main gear rolling throughthe crusted snow rather than a loss of enginepower, and that the pilot attempted to lift offwithout sufficient airspeed even though di-rectional control was lost. The accident wasattributed to the pilot’s failure to abort thetakeoff when directional control was lost.

Just a Little LowerAnd We Should Be Visual …

Piper PA-31 Navajo: Substantial damage. Noinjuries.

The aircraft was taken on a local test flight atnight. It had been out of service the previoussix weeks for repairs.

Corporate ExecutiveCorporateExecutive


injured, but the damage to the propellers, en-gines and underside of the aircraft was exten-sive enough for the airplane to be consideredbeyond economical repair.

The pilot had not heard a gear-up warninghorn prior to landing and did not rememberhaving checked the gear position indicator lights.The gear lever was in the down position whenthe pilot returned to the cabin after the evacu-ation had been completed, but he consideredthat it could have been knocked to that posi-tion during the evacuation. A maintenanceinspection revealed that the gear warning hornoperated only intermittently.

Late Go-aroundRuins Cow’s Day

Cessna 182: Substantial damage. No injuries.

The aircraft was returning from a flight with apilot and three passengers on board. The con-crete runway was 792 meters (2,600 feet) longand 30 meters (100 feet) wide and was wet.The wind was almost directly across the noseat 5 knots (6 mph).

Crossing the runway threshold with flaps down,the pilot closed the throttle. The aircraft settledrapidly and the pilot flared too high. He thenlowered the nose but overcorrected and theaircraft hit the ground hard and bounced twice.Prior to another bounce, the pilot tried to ini-tiate a go-around, but the aircraft was slow torespond and the end of the runway was reachedbefore the aircraft had reached a safe height.The pilot avoided hitting a fence post but thelanding gear went through an area of treesand bushes that pulled the aircraft down andto the right, whereupon the right main wheelstruck a cow.

Because of repeated ground strikes, the pro-peller was damaged and the aircraft came torest approximately 1,000 feet beyond the endof the runway. There were no injuries to theoccupants but the aircraft sustained major damageto the propeller, landing gear, fuselage and mi-nor damage to the wings and tailplane. Thecow had to be destroyed by a veterinarian.

The pilot executed a few turns and returned tothe airport to fly a few traffic patterns. Whileit was on the downwind leg, the aircraft en-tered a fog bank. The pilot conducted a fullnon-directional beacon/distance measuringequipment (NDB/DME) approach. The air-craft crossed the 5.5-mile DME fix inbound atthe published altitude of 2,100 feet asl (abovesea level); field elevation was 117 feet asl. Ac-cording to the published approach procedure,the pilot was to descend until crossing the 2.5-mile DME fix at 950 feet asl.

However, the pilot anticipated that he wouldshortly encounter visual conditions, so he con-tinued the descent to cross the 2.5-mile fix atapproximately 750 feet asl. The aircraft con-tacted the ground seconds later at 500 feet asl.The landing gear was torn off and the aircraftslid to a stop. The four occupants were able toexit the aircraft without serious injury.

No Horn — No Joy

Piper PA-23-250 Aztec: Substantial damage. Noinjuries.

The flight was planned to transport a numberof passengers to another town. However, someof the passengers failed to arrive at the desig-nated meeting time, so the pilot prepared todepart without them.

Just after the aircraft became airborne, the pi-lot saw the missing passengers arrive at theairport. He decided to remain in the trafficpattern and land to pick them up. He re-ported later that, since he had just taken off,he thought that he had not yet raised the land-ing gear and did not bother to select gear downfor the landing. Subsequently, he landed gearup. Not one of the four persons aboard was

Other GeneralAviation

OtherGeneralAviation


The pilot stated that he was too high and faston the landing approach and did not initiatethe go-around soon enough.

Hidden WiresSnag Helicopter

Enstrom F-28: Substantial damage. No injuries.

The pilot was carrying a passenger to a shoot-ing center operated by a sporting club. In-specting the site from a height of 1,000 feetprior to the landing approach, he observedwire cables that were situated beyond the landingsite he had chosen viewed from the directionof final approach. The inspection altitude washigher than the pilot normally used, but thesite owner had requested that the helicopternot be flown lower because it would frightenthousands of pheasants in pens nearby.

The mid-morning sun was at the pilot’s leftand a five-knot wind from his 2 o’clock posi-tion and reduced speed to a hover taxi as heapproached the touchdown spot. Suddenly,the main rotor mast encountered a power cablethat the pilot had not seen during his pre-landing inspection. The wire broke and be-came wound around the rotating rotor mast,causing the aircraft to land heavily on its skids.The aircraft was extensively damaged but thetwo occupants were able to evacuate it with-out injury.

The wire that was struck had been suspendedfrom poles spaced 100 yards apart and thepoles either side of the helicopter ’s approach

path were embedded in hedgerow trees. Thepilot was unable to see the wire until just priorto impact because it did not contrast with thetrees in the background.

Downwind TurnIn Gusty Air

Enstrom F-28: Extensive damage. No injuries.

The pilot’s mission was to fly with a photog-rapher over and around the dam at a reser-voir. The wind was estimated to be 15-20knots, and the rotorcraft was operating in thelee of high ground that rose 150 feet above thelevel of the reservoir water. Reportedly, therewere pockets of localized turbulence and down-drafts affecting the area.

The pilot picked up the photographer in mid-morning. The helicopter was hovered into thewind at approximately 60 feet above one endof the dam for about 45 seconds, and thenmoved across the water for more photographs.After that task was completed, the pilot turnedthe aircraft from its heading into the wind to adownwind direction and attempted to accel-erate downwind. An immediate loss of heightoccurred, and the pilot increased power to 36inches manifold pressure and pushed the cy-clic control forward to increase the airspeed.

The helicopter continued to descend rapidlyand the indicated airspeed read between 10and 15 mph. Although the engine rpm was atthe top of the green sector, the main rotor rpmwas decaying rapidly, so the pilot elected toditch the helicopter in the reservoir. The wa-ter landing was successful and the two occu-pants evacuated the sinking aircraft withoutinjury.

The helicopter was recovered from the waterthe same day and, although extensively dam-aged, there was no evidence of mechanicalfailure prior to the ditching. �

RotorcraftRotorcraft


LEGEND: AP-Accident Prevention • AO-Airport Operations • AMB-Aviation Mechanics Bulletin • CCS-Cabin CrewSafety • FSD-Flight Safety Digest • HFAM-Human Factors & Aviation Medicine • HSB-Helicopter Safety Bulletin •FSFN- Flight Safety Foundation News

1991 FSF Publications Index

Code Subject Title Bulletin Date

0.00 General

Air Safety in Regional Airlines — Who Owns the Problem? FSD JuneAn American Tableau: The Changing Accident Experience FSD JanuaryAn Unfortunate Pattern Observed in U.S. Domestic Jet Accidents FSD OctoberAviation Safety Record “Enviable” But Future Growth Threatens It,

Says Fokker President at CASS FSFN Mar/Apr/MayCAC Members Offer Guidance FSFN June/July/AugCAC Names New Members and Changes 1992 CASS Site FSFN March/May/JuneCorporate and Regional Operations: The Safety Challenge FSD JuneCorporate Pilot Leader Calls for Renewed Support of Flight Safety Foundation FSFN Mar/Apr/MayExecutive Changes at Flight Safety Foundation Aimed to Meet Development

and Future Objectives FSFN Mar/Apr/MayFoundation Leaders Chart Future Course FSFN June/July/AugFoundation Negotiates for Study of DFDR Use FSFN Sept/OctFSF Says Head-up Guidance System Technology (HGST) Can Significantly

Reduce Civil Jet Transport Accidents FSFN Sept/OctFSF Windshear Training Aid Contract Progresses FSFN Sept/OctIndividual Pilot Input to Flight Safety Programs FSD JuneJust What Are Flight Crew Errors? FSD JulyPresident Reports Foundation’s Status and Asks Support for Organizational Changes FSFN Jan/FebRecession and Gulf War Linked to Flight Safety Foundation’s Appeal for

Financial Support FSFN Mar/Apr/MayRisk Indicators And Their Link With Air Carrier Safety FSD DecemberSpecial Thanks to Outgoing CAC Chairman and Joe Chase Award Recipient Recognized FSFN Mar/

Apr/MayThe Harmonization of Technical Requirements FSD JuneThe Potential for a Major Improvement In Aviation Safety FSD JuneU.S. Organizations Recognize Excellence of FSF Publications FSFN Mar/Apr/MayUse of Flight Data Recorders to Prevent Accidents in the U.S.S.R. FSD AprilVoluntary Compliance the “Bedrock” of Aviation Safety, Says FAA at CASS FSFN Mar/Apr/May

0.50 Obituaries

Flight Safety Foundation Chairman Dies FSFN Jan/Feb

0.75 Special Supplements

Head-up Guidance System Technology (HGST) — A Powerful Tool forAccident Prevention FSD September

1.50 Accident/Incident Briefs

ApproachAir Loads Jam Landing Gear FSD JuneAssumption Leads to the Wrong Runway FSD JulyConcern about Slower Aircraft Unnerves Pilot FSD NovemberDescent Below Glidepath Ends in Disaster FSD OctoberGlassy Water Confuses Height Perception FSD OctoberMan-made Windshear Snaps Gear Leg FSD AugustMissed Weather, Met Mountain FSD OctoberThe Taxiway That Looked Like a Runway FSD November

Collision With Ground/ObstaclesBacked into Obstruction FSD JanuaryCollision on Runway FSD MarchCombination of Ingredients Proves Bad Medicine FSD OctoberDead Tree Snags Helicopter FSD AugustThings That Go ‘Bump’ in the Cloud FSD NovemberToo Slow, too Low FSD June


Trees Block Flat Climb AMB JulyControl Loss

Be Prepared for Clear Air Turbulence FSD JuneHeavy Weather Weighs Down Aircraft FSD JanuaryLow on Experience, Low on Prudence — High on Risk FSD July

Crew AssociatedDemonstration Flight Got Carried Away FSD JuneMoving the Wrong Lever Can Give the Wrong Result FSD JulySleeping at the Controls Can Lead to a Rude Awakening FSD AprilToo Little Sleep Kills FSD NovemberUnder the Clouds and into a Tree FSD FebruaryWhen Things Go Wrong, Other Things Go Wrong FSD April

DistractionA Dangerous Case of Mistaken Identity and False Assumptions FSD JuneBut the Gear Lever Was in the Down Position FSD JulyFlaps-up Speed Exceeded Because of Distraction FSD MarchGame of Musical Chairs Has Off-key Finale FSD MarchOvershot Altitude While Looking for Traffic FSD AugustToo Busy Talking to Passenger FSD August

Engine(s)Ground Checked OK, Flight Check NG FSD JuneTurbocharged Engines Like to Stay Warm FSD April

Fuel ExhaustionA Case for the Visual Fuel Check FSD MayAlmost Made It FSD MarchFuel Shortage Shortens Trip FSD JuneOff You Go, But Keep It Short FSD AprilOut of Fuel and Practice FSD NovemberOut of Fuel Leads to Out of Control FSD DecemberTook Off on Empty Tank FSD JuneWhere Did the Fuel Go? FSD June

Ground ObstaclesHelicopter Took in the Wash FSD JuneJet Blast, Unbraked Cart Result in Dented Aircraft FSD MayParking Problem Plucks Pitots FSD June

Incorrect ProcedureCheck Ride Trick Backfires FSD NovemberConfiguration Warning Saves the Day FSD JanuaryDescended Below Clearance Altitude FSD DecemberEmpty Aircraft Left on Runway FSD AprilForced Landing Practice Taught Another Lesson FSD AugustFrequency Confusion Leads to Collision with Mountain FSD DecemberFuel Flows Downhill and Grounds Aircraft FSD FebruaryInflight Stall Training Taught a Hard Lesson FSD AprilInstructor Confuses Lesson Instructions FSD JanuaryIt Started Off by Being Late FSD JanuaryLack of Practice Leads to Repairs FSD DecemberLanded without Clearance FSD NovemberLong Sideslip Leaves Engines without Fuel FSD JulyMurphy Is My Copilot FSD MarchNot Sure of Door? A Good Thump Is No Cure FSD FebruaryOff-target Toss Tumbles Helicopter FSD JulyOut of Altitude, on Final and into the Game FSD OctoberRapid Rotation Scrapes Tail FSD JanuarySent Helicopter on First Solo FSD FebruarySet-up for Disaster FSD MarchThe Aircraft That Moved by Itself FSD JanuaryThe Pilot Who Thought He Could FSD October

InspectionHurried Departure Goes Nowhere FSD DecemberPre-takeoff Control Checks Can Prevent Catastrophe FSD AprilStrange Noise at Night Makes Flight Interesting FSD August




Who Left the Door Open? FSD AugustLanding

Aircraft Went Astray in Dark of the Night FSD AprilBuggy Airspeeds Bring Bumpy Landing FSD JuneIt Was a Dark and Snowy Night FSD JulyIt’s an Ill Wind That Crosses the Runway FSD JuneLanded Long at Wrong Airport FSD JanuaryLoose Tarpaulin Becomes Wet Blanket FSD MarchLow Speed During Approach FSD MarchMisjudging Height Leads to Early Touchdown FSD AprilPractice Autorotation Proves Costly FSD JulyThe Long and Short of It FSD JanuaryThird Autorotation Was Not a Charm FSD AugustToo High and Fast Became too Low and Slow FSD April

MechanicalDisconnected Cyclic Leads to Loss of Control FSD JuneEngine Problem at Low Altitude FSD JuneSimulated Shutdown Became Realistic FSD JanuaryTwo Warnings Were Not Enough FSD February

Midair/Near MidairFatal Set-up FSDJanuaryFormation Flying Blind FSD December

Rotor StrikeLoose Tarpaulin Becomes Wet Blanket FSD DecemberProtruding Pipe Puts Helicopter Down FSD December

Runway/Taxi ExcursionsDownwind Taxiing Puts Aircraft in Ditch FSD July

Pre-takeoff CollisionA Close Encounter of the Wrong Kind FSD AprilTouchdown Encounter FSD October

Takeoff/OverrotationHeavy Airplane Balks at Flight FSD JunePilot Feels Frosty Hand on the Clouds FSD March

UndeterminedEngine Failure Demonstration Takes an Unexpected Turn FSD FebruaryMystery Break FSD April

WeatherBe Prepared for Clear Air Turbulence FSD MayGround Reference Lost in Whiteout FSD NovemberIncomplete Training Leads to Fatal Encounter FSD DecemberLanded into Fog FSD MarchLost Way in Snow FSD JuneLow on Altitude and Night Experience FSD OctoberLow Visibility Deceives Pilot FSD AprilMedical Flight Got too Low FSD DecemberMorning Rain Mires Aircraft FSD MarchOne Engine Out in Ice But No Emergency FSD AugustPower Lines in the Fog FSD NovemberPowerlines Get in the Way FSD NovemberRunway Incursions in Fog FSD JanuarySevere Icing Is a Severe Threat FSD AugustThe Final Cause: Continued VFR Flight into… FSD MayThe Windshear Gremlin Gives No Second Chances FSD AprilWeather, Powerlines and Helicopters Do Not Mix FSD OctoberWhiteout, Blackout — Same Result During Landing FSD April

Wire StrikeTripped by Unseen Wires FSD October

1.75 Maintenance Alerts


Airworthiness Directives Issued for Boeing 747s and 767s AMB Jan/FebBad Vibes End Flight AMB Mar/AprCorrosion a Concern in Older Cessnas AMB Jan/FebCrash Investigation Focuses on Missing Screws AMB Nov/DecDon’t Believe All Those Advertisements AMB Mar/AprDoor Trouble Defies Crew AMB May/JuneElevator Hinge Pin Suspected as Cause of Inflight Breakup AMB Jan/FebExhaust Pipe Failures Result in Inflight Fires AMB Jan/FebFaulty Maintenance Causes Fuel Farm Fire AMB Nov/DecFOD Jams Landing Gear AMB Sept/OctHuman Factors Cited in Engine Failure Accident of DC-10 AMB May/JuneLoose Actuator Fitting Jams Landing Gear AMB Jan/FebLost Wrench Means Trouble AMB Sept/OctMaintenance Error Is Preventable AMB Sept/OctMaintenance of Emergency Equipment Cited as Safety Factor AMB May/JuneMissing Bolt Results in Gear Up Landing AMB Sept/OctMultiple Problems Ground Mooney AMB May/JuneOil Leak + Dirty Compressor = Fatal Loss of Power AMB Mar/AprSafety Pins Installed — Almost AMB Mar/AprScored Skin Results in Pressure Bulkhead Failure AMB Nov/DecSmoke and Flames In the Cockpit AMB Nov/DecTail Rotor Shaft Bearing Failure Cause of Helicopter Accident AMB May/JuneTake Care with Those Cabin Windows AMB Jan/FebWinter Temperatures Could Increase “Blue Ice” Problems AMB Nov/Dec

2.00 Airports

Airport X-ray Screening Technology Becomes a Viable Explosives Detector AO July/AugAnatomy of a Runway Collision AP OctoberThe Rapid Runway Entry AO May/JuneU.S. Airport Access Control Moves Slowly AO Nov/DecUpdating Airport Emergency Capabilities AO Sept/Oct

2.50 Approach and Landing

Aftermath of a Tragedy AP AugustEarly Descent Leads to Grief AP MarchMain Causes of Hard Landings AP February

3.00 Aviation Medicine

The HIV Positive Crew Member HF&AM Jan/FebUpper Respiratory Infections and the Civil Aviation Crew Member HF&AM May/June

3.50 Awards

Awards Reflect Recognition FSFN Jan/FebBarbour Award Board Meets FSFN June/July/AugDe Florez Award Goes to Three Boeing Employees FSFN Jan/FebEditor Receives Distinguished Service Award FSFN Jan/FebSoviet Pilot Chosen for Heroism Award FSFN Jan/FebThai Airways’ Publication Receives Brownlow Award FSFN Jan/FebUnited Pilot Receives Barbour Award FSFN Jan/Feb

12.00 Communications

The Cockpit-to-Shop Communications Link HSB Mar/Apr

17.00 De-icing

De-icing and Anti-icing Are Major Safety Factors in Winter Operations AMB Nov/Dec

17.75 Design/Development

Advanced Cockpit Technology in the Real World AP JulyNight Vision Goggles May Be in Your Future HSB Jan/Feb

19.00 Education & Training



Accident Reports Offer Hidden Values and Buried Treasures AP AprilEffective Cabin Crew Training CCS May/JuneLearning From the Experience of Others FSD JunePreventing Accidents Through Awareness and Training HSB Nov/DecRegional Airline Command Training FSD JuneSpecial Use Airspace and Military Training Routes AP November

20.00 Emergency Procedures

United 232: Coping With the “One-in-a-Billion” Loss of All Flight Controls AP June

24.00 Flight OperationsChecklist — Guideposts Often Ignored AP MayStall Considerations for Transport Aircraft AP SeptemberWhen A Rejected Takeoff Goes Bad FSD January

24.50 Foreign Object Damage

Blue Ice Is a Continuing Threat to Safety AP December

25.00 Fuels & Fuel Systems

New Do’s and Don’ts about Aircraft Fueling AO Mar/Apr

27.75 Rotorcraft

International Helicopter Guidelines Become Effective AO Jan/FebMeasuring Safety in Single- and Twin-engine Helicopters FSD AugustSet-up for Disaster HSB Sept/OctThe Philosophy and Realities of Autorotations HSB July/AugToo Fast and too Low HSB May/June

28.00 Human Factors

Aircraft Accidents Aren’t — Part Two AP JanuaryCarpal Tunnel Syndrome: A Menace to Health CCS Nov/DecDealing with Stress in the Aircraft Cabin CCS July/AugEating Habits During Layover Affect Flight Performance HF&AM Nov/DecFlying and Diving — A Unique Health Concern HF&AM Sept/OctPolicy and Oversight in Fitness for Duty HF&AM Mar/AprRetired Pilot Mortality Rate Appears Higher Than General Population FSFN Jan/FebSIS — The Ultimate Realism in Simulators HF&AM July/AugSnoring — Danger Signal in the Sky HF&AM Mar/AprUnderstanding and Defusing the Sources of Stress FSD June

30.75 Cabin Safety

Flight Attendants: Aviation’s Under-recognized Safety Resource CCS Mar/AprOccupational Stress in the Aircraft Cabin CCS Sept/OctSafety in the Air — What More Can Be Done? CCS May/JuneThe Case for Effective Child Restraint CCS Jan/FebThe Effect of Passenger Motivation on Aircraft Evacuations FSD June

31.25 Investigation

Investigating the Management Factors in an Airline Accident FSD May

35.00 Maintenance

AMTECH 91 Moves to Orlando AMB Jan/FebAviation EXPO to Be Held in March 1992 AMB Nov/DecCall for NDT Papers AMB Mar/AprCall for Nominations for the Joe Chase Award AMB Sept/OctComputerized Accident Investigation Data Source Being Developed at ERAU AMB May/JuneCorrosion Prevention Program Affects Nearly 3,000 Aircraft AMB Jan/FebEducation Group Offers NDT Training Curriculum AMB Mar/AprElectrostatic Circuit Board Damage Reduced AMB Nov/DecEmployers Expanding Use of Computers in Technician Training AMB May/JuneExpected Results of the F27 and F28 Aging Aircraft Programs FSD June



FAA Issues Directives on Aircraft Corrosion Prevention AMB Mar/AprGo-ahead Given for Boeing 777 AMB Jan/FebHow to Work Safely with Composite Materials AMB Jan/FebMinnesota Holds Technicians Conference AMB Jan/FebNDI Courses Offered AMB Nov/DecNew AMB Editorial Coordinator Appointed AMB Jan/FebSafe Disposal of Toxic Waste Created by Maintenance Activities AMB Sept/OctSandia to Manage Aging Aircraft Research Center AMB Sept/OctScholarship Program Offered to Youth AMB Mar/AprStandards Revised for Grounding/Bonding During Aircraft Fueling Operations AMB May/JuneThe First U.S. Licensed Mechanic AMB Sept/OctThe Mechanic and Metal Fatigue AMB Mar/AprTire Manufacturers Release Warning on Static Electricity AMB Nov/DecTrust Is a Key Word In the Aviation Community AMB Sept/OctWheel Well Fire Warning May Be Difficult to Trace AMB Sept/Oct

35.50 Maintenance Equipment/Services

Air PurifyingRespirator Is Lightweight and Self-powered AMB Mar/AprCombination Socket Fist Square and Hex Fasteners AMB Jan/FebCompact Disc Maintenance Data May Be the Wave of the Future AMB Nov/DecExam Books Updated AMB Mar/AprGet the Goo Out of the Ground Safely AMB Sept/OctHot Hands Offer Safety Warning AMB Mar/AprMagnetic Sweepers Reduce Litter and Extend Tire Life AMB May/JuneNo More Working in the Dark AMB Mar/AprOn Board Corrosion Diagnostic System AMB Sept/OctPaving Blocks Keep Floors Clean and Safe AMB Nov/DecPuller Set Improves Work Safety AMB Sept/OctReference Book For Composites AMB Jan/FebRegulatory Compliance Audits Are Available AMB Sept/OctSafety Cable — An Alternative to Lockwire AMB May/JuneSpecial Packaging of Lubricants Eliminates Contamination AMB Nov/DecSpiral Wrap Protects Wiring AMB Jan/FebTelescoping Towbar for Safer Operation AMB Jan/FebTemperature Monitoring Decals Detect Overheats AMB Jan/FebVideo Analyzer Enhances Remote Visual Inspections AMB May/JuneWalk Safely and Protect the Environment, Too AMB Nov/DecWaterjet System Removes Coatings More Safely AMB Sept/Oct

37.00 Meetings

Cessna CEO Praises “Best Ever” Corporate Aviation Safety Record FSFN Mar/Apr/MayFSF Addresses Aircraft Operator’s Meeting in Brazil FSFN Jan/FebFSF Meets with Soviet Group in Rome FSFN Jan/FebItalian Civil Aviation Director Emphasized Safety; FSF Vice Chairman Support

Broadened Foundation Support FSFN Jan/FebParticipants Have Their Say FSFN Mar/Apr/MayParticipants Have Their Say FSFN Jan/FebPutting the Pieces Together FSFN Jan/FebRecord Attendance of Governors FSFN Jan/FebRetired Texaco Manager of Aviation Services Honored for Aviation Achievements FSFN Mar/Apr/MayRome Meeting Hailed Success FSFN Jan/FebSpecial Thanks Goes to Alitalia FSFN Jan/FebWake Vortex Symposium Announced FSFN Jan/Feb

39.00 Midair Collisions

Midair Collision Avoidance AP December

45.00 Pilot Proficiency

The Three Critical Success Factors AP August

49.00 Regulations

FSF Endorses “Kinder, Gentler” FAA FSFN Jan/Feb



51.50 Sabotage/Security/Terrorism

Terrorism — Dark Times Ahead? FSD JuneTerrorism — Dark Times Ahead? FSD March

53.00 Statistics

1990 Accident Statistics for Worldwide Scheduled Air Carrier andCommuter Airline Fleet FSD April

An Annual Update of Worldwide Jet Transport Aircraft Fatal Accident andHull Losses Calendar Year 1990 FSD May

An Annual Update of Worldwide Jet Transport Aircraft Fatal Accident andHull Losses Calendar Year 1990 FSD June

An Update of Two Safety Rules Relating to Age and Alcohol FSD JanuaryAustralian Civil Aviation FSD DecemberNear Midair Collisions, Operational Errors and Pilot Deviations FSD AugustReviewing Worldwide Airline Fatal Accidents and Jet Transport Aircraft Hull Losses FSD JanuarySafety Changes in Canada, 1990 FSD OctoberSafety Trends in Worldwide General Aviation Operations FSD JuneTrends of Worldwide Bird Strikes Calendar Years 1984-1989 FSD NovemberU.S. Air Carrier Safety Performance Accident Statistics and Trends 1980-1990 FSD MarchU.S. Civil Aviation Safety Records January-April, Calendar Year 1991 FSD JulyU.S. Commuter Air Carrier and Air Taxi Accident Statistics and Trends

Calendar Year 1990 FSD AprilU.S. Transportation Fatalities Calendar Year 1990 FSD OctoberU.S.S.R. Civil Aviation Flight Safety Analysis for 1990 FSD JulyU.S.S.R. Safety Information FSD MarchWas 1990 a “Good” Year? FSD October

59.75 Weather

Lightning Literacy for Ramp Personnel AMB May/JuneThe Case for Better Microburst Detection FSD November


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