Eurocontrol Case Study
Eurocontrol Case Study
Eurocontrol Case Study
The ability or opportunity to understand and judge an event or experience after it has occured
EUROCONTROL
Emergency and
unusual situations
in the air
17 minutes
by John Barrass
Summer 2012
Contents Summer 2012
Hind ight 15
The ability or opportunity to understand and judge an event or experience after it has occured
4 COO’S KEYNOTE
4 Serious about safety by Joe Sultana
Joe Sultana’s
keynote
6 EdiTOrial
6 Surprise, surprise... by Tzvetomir Blajev
p. 4
10 Emergency and unusual situations in the air by Carlos Artero
14 Sudoku of teamwork by Maciej Szczukowski
16 This is a dangerous issue by Professor Sidney Dekker
62 SKYBrarY dOWlOad
62 ATC Operations in Weather Avoidance Scenarios
2
Being prepared –
for worse than ‘expected’!
p. 18
CONTaCT uS
The success of this publication depends very much on you.
We need to know what you think of HindSight.
Please tell us what you think – and even more important, please share your
difficult experiences with us!
4
HindSight 15 Spring 2012 5
EDITORIAL
Surprise, surprise…
C an training and everyday practice with
normal operations provide the skills
and knowledge to deal with the unex unex-
same time coping, potentially, with impulses for autonomic,
startle-triggered, reactions.
pected, unfamiliar, and very often never- Let us take as an example the situation where the stall pro-
experienced-before, situations? tection system of an aircraft has been activated. In the past
pilots flying multi crew public transport aircraft were gener-
Surprising situations do happen to us. ally advised that their response to such a warning should
They sometimes trigger a physiological only involve the minimum reduction in aircraft attitude
reaction known as the startle response. needed to recover from the ‘edge’ of the fully stalled con-
This is a knee-jerk and instinctive reaction dition. This advice implied that the loss of aircraft altitude
to a sudden, unexpected external resulting from the recommended response should be mi-
stimulus like someone firing nimised. Thus implication soon became a widely accepted
a gun behind us when we objective in its own right. The important strategy to recover
were not expecting it. became obscured by a secondary consideration. The result
was that pilots who did not understand the aerodynam-
ics of the stall simply responded to
this rare event in a way that failed
Pilots and controllers are to restore a normal flight condition.
6
A few months ago, Kahneman
published another book1 which
I would like to spend some time
discussing from the perspective
of our current theme. In his new
book Kahneman describes our
thinking process as consisting
of two systems – System 1 and
System 2. System 1 thinks fast,
is unconscious, intuitive and
effort-free. System 2 thinks
slow, is conscious and analyti-
cal. System 1 recognises pat-
terns in a fraction of a second,
and ‘automatically produces an
adequate solution to the chal-
lenges’. System 2 is systematic
but tires easily; therefore it
usually accepts what the fast
System 1 tells it.
HindSight 15 Summer 2012 1- “Thinking fast and slow”, daniel Kahneman, New York, 2011 7
EDITORIAL
Su rp rise
Te am
fa ctor Kn ow ledge -
ng ba se d
b r iefi
Kn ow n, Pre- St rate gie s
Sometimes, I hope very rarely, the situ
situ-
Ex pe cted
ation will develop suddenly and will be
both unexpected and unknown. Then
there is not much in the way of a pre-
,
l ys i s formed strategy available. What one
In tu iti ve
Pe rs on al An a do w n
Kn ow n, Kn ow ledge - l- needs to do is to prevent or reduce the
Ex pe rt ise dr i l
Un pe cted
ex ba se d likelihood of such situations.
Sk ill-ba sed St rate gie s
There are known but unexpected situ situ-
ations with sufficient time for personal
reflection but not for use of team re re-
Pe rs on al an d Te am , sources. An example of this would be
He ur ist ic-ba se d the Airbus 320 ditching in the Hudson
Un kn ow n, ? St rate gie s River in 2009 after the loss of almost
Unex pe cted
of th um b, all engine thrust following a multiple-
Common sen se, ru le
ro r
tr ial an d er
Avai la ble engine bird strike at low level.
ti m e
Av ail able time fo r Av ail able time fo r Finally, there are those cases that
No time, reflec tio n bu t no t reflec tio n an d fo r combine unexpected but relatively
Su dden co op erat ive frequent and known situations with
fo r co op erat ive
st rate gie s st rate gie s sudden development and no time
for reflection. If these cannot be
prevented then the best strategy is
to train for them extensively so that
an optimum reaction becomes second nature and is more
likely to be intuitively applied if needed. This is the famous
the distinctive situations, which are associated by the dif- rule for becoming an expert by spending 10,000 hours on
ferent combinations of surprise for System 1 and available training and practice. Take your time!
time for System 2. I have attempted to visually represent the
diversity of these combinations above. Intuitive reaction is not always bad; it helped us survive in
the Darwinian sense. Flying and providing air traffic control
There are situations, represented in green, where there is ei- to modern aircraft, however, is less of a reaction from the
ther sufficient time for the crew to adopt knowledge-based jungle and more about preparation.
strategies or which can be reasonably expected, such as
wind shear encountered when approaching to land at an It is true that the design of aircraft and ATC systems should
airport with significant convective weather in the vicinity. be human-centred, accommodating instinctive human
In this latter case the expectation can trigger a pre-briefing reactions. But this assumes that someone will know ev-
for the actions required if an actual encounter occurs, and erything about humans and their reactions and will suc-
although the situation is sudden and there is no time for cessfully integrate this into the design of machines and pro-
System-2 type of thinking, after the encounter the strategy cedures. Obviously, this is not fully achievable and there will
is still knowledge-based. An example of such a team knowl- be situations that surprise us. If these situations have poten-
edge-based strategy is the Airbus 380 emergency landing tially dangerous outcomes, if what is at stake is an accident,
in Singapore in 2010. then when confronted with emergencies one should be
equipped to adopt the best available strategy which mini-
Other situations involve unforeseen or highly unlikely mises ‘blink’ and maximises ‘think’. The challenge is how to
events but with sufficient time available either for personal train the professionals to ‘think slow’ but faster.
or team System-2 type thinking. The available knowledge-
based strategies are generic rather than specific. Enjoy reading HindSight!
8
Hind ight 15
The ability or opportunity to understand and judge an event or experience after it has occured
whilst at night two controllers were used. I had a strip indicating the expected arrival and when the
plane did not call me, I tried to reach it on the radio but
During the day, there was hardly any IFR traffic, while at there was no response. I called the ATC of the departing air-
night there were many cargo flights. However, there was port, who told me that traffic had been told to contact me
some VFR activity during the day, more in summer than in ten minutes ago. I tried to contact the plane again with no
winter. VFR traffic flying through our CTA was supposed success.
to call, but sometimes didn’t. Departing traffic often
failed to say goodbye before losing radio coverage. The I looked at the flight plan. It was due to land at my airport,
airport had no radar, and the ACC radar could not de
de- make a short stop and then fly to Germany IFR. I asked the
tect traffic below 5000 ‘. airport office why it was coming to us and they told me
that it had to refuel before
continuing because its de-
Carlos Artero parture airport had no fuel
available. This was a com-
has been an Air Traffic Controller in AENA, I kept calling the plane from time mon story.
10
EDITORIAL
The DETRESFA phase was now active. This situation was that peak. When the cloud cleared a bit, they were able
obviously now an incident, so I searched for the official to see the peak. And right there, the remains of the plane
incident reporting form, which I had never filled in be- could be seen.
fore, and I called the Tower Chief to ask how to fill it in.
When the Chief learned that a DETRESFA was active, the
first thing he asked was why he had not been advised of To sum up, I came to the following conclusions:
the situation earlier. Of course he was right. I had been
alone when he could have been with me. He had twen- n We must comply with all security protocols,
ty-five years’ experience, had worked in several depart- whether we think a plane is safe or not.
ments and knew a lot.
n We must be careful and aware in everything we
The Tower Chief came immediately to the airport. I told do, as we may be slow to act if we assume that
him what had happened and he spoke to the ACC, the the abnormal situation is just an everyday
military and different people at the airport. Then he left problem, such as VFR traffic leaving without
and went to gather information from the airport. Soon he saying goodbye before leaving radio coverage.
called me from the flying club, to tell me to call up the heli-
copters and tell them to look at a particular location. When n During any emergency situation, we must have
this message was passed on, the helicopters confirmed another person to help us. If we are working
that they had been trying to check it but it was covered in on our own, we must secure the presence of at
cloud. The location was a peak that rose above the other least one other person as soon as possible.
mountains in the area where the terrain was flat except at
it wi
article of Carlos. We thought :
ition
content of this HindSight ed be drawn before the ones me
ntioned in the
clusions to
op ini on there are however a few con d after this accident.
A brave story by Car los Art ero. To my
cha ng es in pro ced ure s an d responsibilities were introduce
sting to know what
article. It would also be intere nce s still exist? (I’m afraid they do
in many places).
y or do the se circ um sta
Are we talking histor ATCO with little
sho uld be par t of ini tia l an d refresher training. Even an
nt and emergency procedure
s on of undesirable Single
n Training on incide
fam ilia r wit h the act ion s to be taken, certainly in a situati
ced of and
experience should be convin e.
described that wasn’t the cas
Person Operations (SPO). As of other traffic if traffic had inc
reased
erg en cy an d the ha nd lin g
ling of the em mselves. Calling
n What had happen
ed to the quality of the hand em erg en cy are already an extra workload by the
generated calls becaus e of the
during the process? The many early point in time in the
be par t of the pro cedures at a well determined
desirable SPO sho uld bination with the
in a second person during un ula tio n me asu rem ent s to mitigate the risk of SPO in com
n of traffic flow reg
process as well as the activatio
handling of an emergency.
ll described.
n Responsibilities of
activation of SPO should be we
personal interpretation.
A lot less will then be left to
12
EXPECT THE
UNEXPECTED!
SAFETY ALERTS
Keeping Your Heads Up!
All EUROCONTROL Safety Alerts available on:
www.skybrary.aero
Subscribe to:
www.eurocontrol.int/safety-alerts
HindSight 14 Winter 2011 EUROCONTROL
13
EDITORIAL
Sudoku of teamwork
By Maciej Szczukowski
I’ve never been a fan of a Japanese game called Sudoku. I’ve always felt
that the “need“ to fill in a form with a scheme of numbers is fully satisfied
by completion of my yearly tax returns and I don’t need to bother with
any complex calculations, even if only for fun. A few weeks ago though,
the circumstances of a rather dull meeting pushed me into trying it.
Why am I writing about these two – a simple game An air traffic controller cooperates with his colleagues in,
and a complex aircraft emergency? What do for example, establishing certain spacing minima on ap-
they have in common? I would say that it is the proach but when it comes to making the decision whether
problem of choice when no definitely right or not to fit in a departure between two landing planes, it
answer is apparent. Sudoku may sound trivial is an individual controller who has to solve the problem. At
here but that is something that really fasci
fasci- that very moment only this particular decision counts. And
nated me when I started playing. The rules if anything goes wrong, it is the controller who will have to
are clear, the “game answer the questions “why” and “what for”. Not the team as
plan” is simple – a whole.
just like procedures
Maciej or operational in-
structions are (or at
When I recall the day of the LOT 16 belly landing, I end up
thinking about all the people involved in trying to help find
Szczukowski least should be). In the best possible outcome to the shared problem. Probably
has been an Air Traffic Controller, for over Sudoku, you select all the available manuals were open at the right page and
10 years, at Warsaw Okecie Airport, Warsaw, relevant informa- checked, both in the air and on the ground. Everybody was
Poland. He also holds a PPL. tion, compute it in trying to recall their simulator and ground school training
your brain and then, sessions for ideas. All of us were trying really hard to take
14
a broad view of all the 81 fields of
our airfield-airspace-Sudoku board
and gather as much information as
possible from the fields already filled
in. It was the teamwork we were trained
to do.
This is a dangerous
By Professor Sidney Dekker
This issue of HindSight could turn out to be the most dangerous one
yet. Here is why. A number of the stories shared in HindSight represent
best practice in the field. They make, either implicitly or explicitly,
suggestions about how emergencies and unusual situations can be
handled well. This seems like a really good idea. Share ideas,
publicise best practice, learn from each other.
16
issue It is incredibly sad if a profession feels that it cannot safely share
lessons about its best practices. It is even sadder that this is the
result of self-censorship imposed for fear of prosecutors. Self-
censorship is defined as the act of withholding, classifying or
hiding one’s own work out of fear of how others may react or
use the information—but without overt or prior pressure from
People who censor themselves So how do we get out of this situation? The risk, most promi-
nently, is in publishing stories about our own best practice as
may end up affecting a lot of other if they are authoritative, as if they are the final word. Because
then others can read those stories, compare them to evidence
people when they don’t share of actual practice, and point out where our colleagues failed.
what they have to say. What we need to do then, is make sure that our stories of best
practice are never closed. That they remain forever open. What
“best practice” is changes over time, it changes per perspective,
per country, per operational centre. That way, we can never be
Against the background of more and more criminalisa- pinned down by somebody who says: “this is your best prac-
tion of professional errors, this makes sense. Their fears are tice!” We can always respond by saying, “Well,
well-grounded. Prosecutors in a number of countries have yes, it was, according to that person at that
been using incident and accident reports liberally as a ba- time. But look, here are twenty-six other
sis for prosecution already. So it isn’t a large stretch of the publications on this particular practice,
imagination that prosecutors would put the incident or and it reveals a lot more possibilities of
accident report (which details how things were not done what ‘best’ means.” If we keep the notion
well) next to a book that shows how things are practiced of best practice negotiable, we not only
well. The gap between the two will be an index for the keep up the constant development and re-
strength of their case against the practitioner in question. finement of our professional excellence. We
can also keep our colleagues out of trouble.
So publishing our best practices is like giving prosecutors
all the answers in the back of our book – well before any
test. The authors of the letter write, “Rather than alienat-
ing several of our international professional organizations,
we have decided to put the book on hold.” And then they Professor Sidney Dekker
warn, “to retreat and isolate ourselves and train our next is Professor and Director of the Key Centre for Ethics, Law, Justice
generations of practitioners with a litigious, defensive and Governance at Griffith University, Brisbane, Australia.
mindset will bring advanced knowledge [of our best prac- Author of best-selling books on human factors and safety,
tices] to a halt.” he has had experience as an airline pilot on the Boeing 737.
Being prepared –
for worse than ‘expected’!
By Captain Ed Pooley
OK, there is an Emergency – A multi crew public transport
aircraft has declared a ‘MAYDAY’.
You have rapidly ‘woken up’ and are tem- roles between the two pilots – PF ‘pi-
porarily saying goodbye to the predict- lot flying’ and PM ‘pilot monitoring’ – is
able routines of your day-to-day comfort sensible. Often, it will be a good idea
zone and beginning to respond – just as for the aircraft commander to remain
you were trained to. or become PM so as to be able to stra-
tegically manage the problem and
But you know that as a controller you act as chief communicator with
will, more often than not, be trying to the co- pilot flying / managing
assist the pilots by doing whatever you the aircraft. This may help the
can to reduce their suddenly increased clarity of communications
workload without knowing the full facts to ATC from the aircraft
of the situation they are facing. Some- since communications
times, you know that awareness of more are then direct from
of these facts would enable you to help the decision maker
more. Other times, it may not – possibly instead of being
(but certainly not necessarily) because routed through
you cannot grasp the significance of the junior pilot.
‘technical’ information. Either way, you
usually (correctly) judge that the last However, what
thing an overloaded flight crew need is I really want to
any more than the minimum of R/T to ‘discuss’ is the pre-
deal with. sumptions that a
controller handling
From the pilots’ perspective, I can an emergency might
tell you that: reasonably make about
the professionalism of the
n They will frequently delay declar- flight crew they are trying to help. Hav-
ing an emergency to the extent ing looked around at your fellow con- pilots who train in pairs in their simu-
that you will suspect one exists trollers, you will probably have decid- lators, the value of the training to one
before they do. ed long ago that some of them seem pilot is often at least partly dependent
n If they want something specific to perform better under the pressure on the aircraft knowledge, manage-
from you they’ll usually ask for it. of a relatively short lived emergency ment and handling skills (relative to
n As they have absolutely no idea than others even though you’ve all re- rank and experience) of the other.
how much you are likely to under- ceived the same training and passed
stand about the technical details the same competency checks. If, as a controller, you make the as-
of their emergency, they will usu- sumption that, by and large, the two
ally communicate these based on Well surprise, surprise, it’s much the pilots don’t usually make emergency
their assessment of ‘need to know’. same for pilots who, like controllers, situations worse even if their actions
are trained and especially assessed in may have contributed to or even
Many aircraft operators advise that at ways which largely remove any ele- caused them in the first place, you may
the onset of an emergency, a review of ment of surprise from what occurs. For be wrong.
44
18
HindSight 15 Summer 2012 19
THE VIEW FROM ABOVE
Interestingly, some pilots who realise obsessively, trained for happens but
that they’ve messed up sometimes the response ‘on the day’ ignores al-
perform with great skill when respond
respond- most every critical element of that
ing to the situation they’ve created. training. In June 2010, a ‘classic’ Boe-
Many will remember the Air Transat ing 737 being operated by what was
pilot who ran out of fuel on the way then the low cost division of Royal Air
across the Atlantic in 2001 and then Maroc, Atlas Blue, hit a flock of geese
successfully glided his Airbus A330 65 just after getting airborne at Amster-
miles to a pretty creditable safe arrival dam. It took a full four minutes (which
at Lajes in the Azores. Many other pi pi- is a very long time in an emergency)
lots pull off successful outcomes after before the pilots got around to the
the onset of sudden emergencies they thing they were persistently (and al-
had no part in creating which invari
invari- most obsessively under current regu-
ably depend on both their flying latory requirements) trained to do first
skills and their knowledge of and without delay – to carry out the
how planes fly in gener
gener- memory actions for the (single) en-
al and how their parpar- gine failure that they recognised had
ticular aeroplane resulted from bird ingestion. And in
works. Recent what can only have been some sort
examples in
in- of irrational panic response, the first
clude the well- action of the Captain, having just lost
known post 50% of his thrust, was to order that the
bird strike still in-transit landing gear be re-se-
ditching in lected down because it was indicating
the Hudson unsafe. Yet all landing gear indicates
by a US Air
Air- unsafe when it is moving to a selected
ways A320 position. And even if the unsafe indi-
in 2009 cation had been indicated by gear in a
and the al al- previously locked position, the imper-
most as well ative after losing half your thrust near
known British the ground is to climb to a safe height
Airways Boeing using what remains and minimising
777 undershoot at drag by ensuring that the landing gear
London Heathrow in 2008 fol fol- is up as quickly as it would normally be
lowing almost complete fuel starva- starva after any take off and the failed engine
tion due to fuel feed icing on short is ‘secured’. Those actions collectively
finals. and significantly reduce drag, which
itself would otherwise reduce the rate
Some
But then there are ‘the others’. Some- of climb.
thing which has been regularly, even
In this case, ATC were aware straight
away `what` had happened but could
not have guessed what would come
Captain Ed Pooley is an experienced airline pilot who for next. The requested and issued radar
many years also held the post of Head of Safety for a large short haul airline operation. headings provided by ATC were com-
pletely ignored and as daylight faded,
He now works as an independent air safety adviser for a range of clients and is currently
an erratic nine minute perambulation
acting as Validation Manager for SKYbrary. began which took the aircraft over
some of the suburbs of Amsterdam
20
at or below the height of the tallest
buildings. It was accompanied by, at
times, an almost continuous (and val-
id) activation of the on board Ground
Proximity Warning System (GPWS).
In this particular instance, the appli-
cable ATC procedures – give radar vec-
tors – seem to have completely failed
to take account of the risks of giving
such vectors below MRVA (although
at least in this case the aircraft was in
VMC). The message here is that the
controller could not have known and
could hardly have expected what was
actually happening on board the aero-
plane even when it was already clear
that there were some major control
difficulties.
and heading instrumentation for both standby compass which is difficult to use
The controller could not pilots. The evident difficulty which the in a turn.- quite possibly the combined
crew were having in controlling their cause of his inability to fly headings. De-
have known and could aircraft manually using the standby spite the flight crew failing to recognise
hardly have expected attitude display and the standby com-
pass was compounded by insufficient
that their situation amounted to a MAY-
DAY scenario, instead describing it as just
what was actually language proficiency to properly com-
municate with ATC the nature and ef-
a ‘navigation problem’, ATC also came in
for a bit of criticism on account of their
happening on board the fects of their problem – surely an expe- slowness to recognise the de-facto emer-
Interceptions of Civil
Operation of SSR and
“Sid”
Synopsis
Released on 22 December 2011
d
By Richar
Law re n ce
EUROCONTROL has learnt of incidences where flight safety has been compromised
“
and unnecessary TCAS Resolution Advisories (RAs) triggered during interceptions
of civil aircraft because of misunderstanding regarding the operation of aircraft
During the past few months the transponders and the properties of ACAS II.
EUROCONTROL Safety Alert service has
been approached by a number of stake-
holders requesting the promulgation of a
Safety Alert covering a variety of topics. In ICAO Provisions – ACAS II
the pages that follow, I will describe two of n PANS OPS (Doc 8168, Vol I),
the Alerts that I hope will spark your interest. Definitions: “Airborne collision avoidance system (ACAS). An aircraft system
based on secondary surveillance radar (SSR) transponder signals which operates
As previously, my intention is to try and independently of ground-based equipment to provide advice to the pilot on po-
bring new information to the table. The aim tential conflicting aircraft that are equipped with SSR transponders.”
is to feature more in the way of feedback, Chapter 3, § 3.1.1 “Resolution Advisories (RAs)… propose vertical manoeuvres
responses, comment and analysis to get the that are predicted to increase or maintain separation from threatening aircraft.”
most from each Alert.
n Annex 6, § 6.18.2: “…all turbine-engined aeroplanes of a maximum certificated
take-off mass in excess of 5,700 kg or authorized to carry more than 19 passengers
If you would like to know more about the
shall be equipped with an airborne collision avoidance system(ACAS II).”
EUROCONTROL Safety Alert service, register
as a subscriber, submit a suggestion or have
a subject that you wish to consider then ICAO Provisions – Interception of Civil Aircraft
please contact me at richard.lawrence@
n Annex 2, Chapter 3, § 3.8.1, Note. “As interceptions of civil aircraft are, in all cas-
eurocontrol.int. es, potentially hazardous, the Council has formulated special recommendations
which Contracting States are urged to apply in a uniform manner”.
22
Aircraft -
ACAS II
n ICAO Doc 9863: Airborne Collision Avoidance System (ACAS) Manual, Appendix 7
“A7.2 ADVICE FOR NON-MODE S-EQUIPPED A7.3 ADVICE FOR MODE S-EQUIPPED FIGHTER
FIGHTER AIRCRAFT AIRCRAFT
A7.2.1 Arrangements to be used by military fighter A7.3.1 Covert intercepts are intended to prevent the fighter
aircraft for covert intercepts from responding to ACAS interrogations while the fighter can still
respond to ATC ground-based interrogations.
A7.2.1.1 When closing in on an aircraft to be intercepted, the
military pilot disables Mode C. (Some military users switch the A7.3.1.1 In this case, the intercepting pilot will select an Inter-
transponder off or to “Standby” resulting in no reply to any in- cept Mode. Under these conditions all replies to UFФ (short air-air
terrogation.) In this procedure, the lack of altitude information surveillance) and UF16 (long air-air surveillance) interrogations
will prevent all RAs. will be suppressed. Nevertheless the fighter’s transponder will re-
spond to all ground-based ATC system interrogations. Therefore,
A7.2.1.2 At least under peace-time conditions, Mode A trans- the fighter remains visible to ATC.
missions should be enabled at all times to make the fighter
aircraft visible for SSR/IFF ground radar systems (but without A7.3.1.2 The fighter with activated Intercept Mode will continue
altitude information). to be a threat to all ACAS-equipped aircraft, if the Intercept Mode
is not cancelled after the end of the mission.
A7.2.2 Arrangements to be used by military fighter
for demonstrative intercepts A7.3.2 Demonstrative intercepts are intended to keep the In-
terceptor visible to both the intercepted aircraft and to ground
A7.2.2.1 During this type of intercept, it is highly desirable to surveillance.
avoid RAs, even though the intercepted aircraft detects the
approaching Interceptor. There is no other alternative for non- A7.3.2.1 To avoid that an ACAS-equipped aircraft generates an
Mode S-equipped fighters than to eliminate the altitude value RA against an approaching Mode S-equipped fighter, the height
in Mode C messages. In this case, only the framing pulses will value in ACAS replies (DF 0 or 16) must be suppressed, but replies
be transmitted. If there is no altitude value in the Mode C mes- are still available for Mode S ground interrogations. If there is no
sages, ACAS will detect the military aircraft, but only TAs can be altitude information in the replies to ACAS interrogations, the
generated. Ground-based systems can track the fighter aircraft, fighter will be recognized by ACAS, but only TAs can be generat-
but without altitude information. ed. For ground-based Mode S interrogators there will be no differ-
ence from the normal behaviour, and the controllers have control
A7.2.2.2 There should be an indication on the control panel or of the whole air situation.
the IFF function display of the fighter aircraft when the altitude
reply information is inhibited in this way. A7.3.2.2 A software change will be necessary to military Mode S
transponders on fighter aircraft, and when the Intercept Mode is
enabled there should be an indication within the pilot’s normal
viewing area.”
44
EUROCONTROL Comment
to-air communication of Mode C data but preserves the
air-to-ground link so that controllers can still see the inter-
ceptor and its altitude. For those Mode S-equipped fight-
ers that do not have Intercept Mode capability, the issue is The interception of civil aircraft clearly requires close coop-
that Mode S continues to send out altitude information to eration and coordination between the authorities prosecut-
all air and ground receivers even if the Mode C element is ing the mission, i.e. the military pilots and military air de-
suppressed. fence/ATC, and the civil ATC provider looking after the civil
aircraft.
The solution to this difficulty, adopted by a number of
air forces, is for the interceptor to switch OFF the Mode S Within Europe, the NATO EUROCONTROL ATM Security Coor-
transponder, in total, at the appropriate point in the inter- dination Group (NEASCOG) monitors these activities and takes
ception. The pilot can still relay altitude information to the any necessary steps to ensure such operations are conducted
military control authority who in turn can advise their civil- safely and efficiently.
Further reading
n SKYbrary - ACAS
n EUROCONTROL ACAS II Training Brochure:
http://www.eurocontrol.int/msa/gallery/content/public/documents/ACAS_training_ver20.pdf
n ICAO Annexes 6 and 10 (Volume IV).
n ICAO Doc 4444, PANS ATM.
n ICAO Doc 9433 - Manual concerning Interception of Civil Aircraft: (4.1.2.16, Note).
24
rEquEST FOr SuppOrT MESSagE
(EUROCONTROL Note: “Necessary advice” includes “essen- The general findings were that:
tial information” such as reduced TORA/LDA that may be as-
sociated with any WIP/construction work.) n ANSPs followed the existing ICAO provisions and phraseol-
ogy. There was no call to introduce similar wording in Eu-
rope. However, 2 CAAs (one European, one African) thought
Analysis that it might be worth debating the merits of adopting the
US FAA phraseology.
When construction work reduces the length of the runway n ANSPs are aware of the impending proposed change to
distance available for take-off and landing, it is imperative ICAO EUR SUPPS to replace “TAKE-OFF” with “TOR-AH” in the
that this information is made available to aircraft opera- context of runway intersection departure clearance phrase-
tors and flight crews in a timely manner. In turn they must ology. (See below for more about this specific issue)
be aware of, and fully understand, the messages they may n One aircraft operator recommended that all runway dimen-
hear/see on the ATIS/DATIS and/or receive from ATC as part sion changes should be promulgated in metres in addition
of their air traffic clearance. to feet.
There are existing ICAO provisions covering these circum- After discussions with EUROCONTROL Agency in-house runway
stances and the FAA has complemented them by introduc- safety and procedures experts, it was decided that no further
ing its own bespoke phraseology as a safety risk reduction follow-up action should be taken. However, the situation will
measure. Flight crews should therefore be aware of specific continue to be monitored through mechanisms such as EVAIR
(regional and local) procedures and phraseologies that ex- (EUROCONTROL Voluntary ATM Incident Reporting), the Safety
ist to inform them about reductions in TORA/LDA associ- Improvement Sub Group (SISG) and the European Working
ated with runway construction/WIP scenarios. Group for Runway Safety (EWGRS). At national/local level, Lo-
cal Runway Safety Teams (LRST) can also maintain an overview.
Information requested
Air navigation service providers, aircraft operators, aero-
drome operators, local runway safety teams, and national
aviation authorities are invited to note the subject and sub-
mit their national/local procedures relating to such cases,
including ATIS and/or ATC phraseology to be used and
aerodrome (temporary) signage.
26
Further reading
n FAA InFO Notice 11015 dated 1 September 2011.
http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/info
n FAA Air Traffic Organisation Policy Notice N JO 7110.564 - 22 September 2011.
http://www.faa.gov/air_traffic/publications/
n ICAO Annex 14, 2.8 Declared Distances.
n ICAO Annex 14, 2.13 Coordination between Aeronautical Information Services and Aerodrome Authorities.
Case Study -
The garden party By Bengt Collin, EUROCONTROL
One hour after the time announced in Alberto, his butler, barbecued. After berto moaned before giving up. The
the invitation, late visitors kept drop- some mild persuading he agreed to visitors seemed happy, he especially
ping in. Irritating! Why couldn’t people use the new barbecue sauce found in noted Anne, dear old Anne. Instead
show some respect? He was a well re- a glossy magazine, olive oil, garlic, soy of bringing her usual boyfriend, she
spected man in his best years, known sauce and black pepper, all topped had brought a compact dog named
for his strict principles. He was dressed with a large glass of Jack Daniels. Why Davidic. For the moment Davidic was
in rather formal leisure clothing. Al- should Alberto always have a different lying on the grass enjoying life, eating
though the weather had stayed warm opinion? “It is unnecessary to use that a Chorizo sausage. At least the dog
and dry, the sky was as blue as the wa- barbecue sauce, it’s too expensive”, Al- liked the new barbeque sauce! “He
ter in his swimming pool. He would understands everything I say to him”,
never dream of wearing shorts, shorts Anne explained. “He even understands
are for boy scouts, not real men he French”. She was abruptly interrupted
thought, overlooking his large man- by the noise from a big aircraft passing
sion with a stiff upper lip. straight over them on a very low alti-
tude. They are not allowed to fly over
here, it is forbidden. He would call the
airport immediately and complain!
28
as he was talking to his First Officer.
They had never trained for situations
The pilot of the diverting aircraft called
like this in the simulator; it was always
landing aids out of service, TCAS, en-
him, requesting an immediate turn and
gine failures, but never this. direct route to his new destination,
“Recycle the gear”. This did not help, “Control E-line 123 fuel at minima”.
the gear remained down, by how
much they did not know. He could read
his First Officer’s mind like an open He was working the South sector. approve the direct route, without re-
book. “No, we do not need to return, The Planner informed him of a re- ally knowing why. Perhaps it was his
we can continue with reduced speed vision. One of the aircraft heading old training to react to trigger words,
and at a lower altitude. Tell control we northbound, instead of passing at who knows? When he heard the word
request flight level one one zero ini- high altitude, would be diverting to fuel, he definitely reacted. Today stu-
tially and with lower speed. We don’t an airport in his FIR. It would enter at dents were instructed to ask whether
want to end up back at an airport with a much lower flight level than nor- or not the pilots had declared an
no engineering support”. The First Of- mal. His work went on like it always emergency, strict and time consum-
ficer received the clearance. They’d did while he kept this information ing he thought.
better contact their company about stored somewhere deep inside his
the now-necessary transit stop, it was brain. Suddenly he started think- The First Officer calculated the fuel us-
obvious they couldn’t reach the final ing about the time when during a ing the FMS; “we’ll be below minima if
destination without refuelling. holiday he’d visited a bar in beau- we continue”, he quietly informed his
tiful Leyton, a picturesque part of Captain. “We’re actually already below
He was an experienced controller; east London. A tall, enormous scary the fuel level where the book says we
after passing his final tests ten years looking guy had come up to the bar should divert to the nearest suitable
ago, he’d always thoroughly enjoyed on his right-hand side, and ordered airport. But company ops has chosen
his job. Now it was even better after a small bottle of Babycham (a light this for us, they initially thought we
he’d met Sandra, another controller, a sparkling perry). Why was he think- could continue even further to one
dark-eyed beauty with an impressive ing about things like that? Better
intellect. He spent the first two hours not mention this to Sandra. The pilot 44
of his shift in the radar simulator; it of the diverting aircraft called him,
was years since they’d had a full day’s requesting an immediate turn and
periodic training. The shortage of con- direct route to his new destination,
trollers was more or less permanent “Control E-line 123 fuel at minima”.
and the increase in traffic didn’t make Although the aircraft was still in the Bengt Collin
things better either. This year they airspace of the adjacent FIR, he ap- works at EUROCONTROL
were being trained for radar failure. proved the request straight away. HQ as an Senior Expert
Yet again, he thought; it had been the Long afterwards he thought about
involved in operational
same last year too. Might as well be why he had done that; nothing
ATC safety activities.
trained in the kitchen, one of his col- had forced him, nothing had indi-
leagues commented; if you have no cated that something was seriously
radar picture, why not sit somewhere wrong. He certainly wasn’t allowed Bengt has a long background as Tower and
comfortable with a nice cup of cof- to do so without prior coordination, Approach controller at Stockholm-Arlanda
fee and a sandwich, after all it’s only a after all the aircraft wasn’t in his own Airport, Sweden
simulation, isn’t it? airspace. He had just felt he should
Case Study
The garden party (cont’d)
30
CASE STUDY
improved despite the concomitant Anyway, because the theme of this troller once there was no alternative,
growth in traffic. He certainly reacted HindSight is how controllers can and including allowing routing through
inappropriately in granting the direct should respond to aircraft in actual the Restricted Area given that no ac-
routing before the aircraft entered or potential difficulty, I’m going to tual hazard to anybody was created
his airspace without coordination. He focus on the actions of the featured by allowing this….
also ignores the absence of any decla- area controller. Did they help avert
ration of urgency (PAN, PAN) or emer- an accident? Or did they encourage a
gency (MAYDAY) from the aircraft in dysfunctional flight crew to press on A RECOMMENDATION
support of the successive requests towards a potentially hazardous out-
for expeditious routing, and responds come? Actually, I’d say the controller’s As I’m only allowed one, I’ll go for
without the normal question on fuel initial response was counterproduc- a comprehensive and indepen-
endurance which would follow a PAN tive to safety. Had he sought both a dently conducted review of how
or MAYDAY declared because of con- declaration of urgency or emergency the ANSP conducts internal inci-
cern about fuel endurance. and some more information from the dent investigations predicated on
crew before giving a direct routing, a guarantee that the undoubted
The Aircraft Operator doesn’t come this might, just might, have jolted recommendations for safety im-
out of this saga too well either. How- the crew into realising that what they provement which it would gener-
ever Operations Control seeks to as- were attempting was indeed a fool- ate would be adopted. But I’d also
sist their en route pilots in command hardy violation. But of course nobody suggest the instant removal from
by telling them what would be com- (except of course the Chairman of the ANSP payroll in any capac-
mercially helpful, this should not be the ANSP Investigation!) would argue
ity of the Investigation Chairman
able to be perceived with the help given by the con-
on the grounds that it’s probably
as anything more
unrealistic to expect him to be
than assistance given
capable of genuine attitudinal re-
without knowledge of
all the pertinent facts form.
or their short-term forward
projection.
32
Case Study Comment 2
by Dragan Milanovski
A big plane at low altitude passing straight over the garden party
spiced up the seemingly dull event. I also find it very difficult to under-
stand why someone would complain about an isolated case, probably
interesting for most of the people at the party, and how a barbecue
sauce can be too expensive?
The fortunate outcome of this incident evaluate different options and provide scene was pretty much set, and there
might lead us to believe that the ac- information later on. He could have were no other options. The story sug-
tions taken by the two controllers were asked the transferring controller for gests that if this information had been
appropriate to the situation and that the reason for the diversion. An aircraft available to the pilots, they would have
by exercising their best judgment and experiencing a landing gear problem decided to divert to another airport
expertise they significantly contrib- (as described in the story) is likely to be (Bollibompa) where the risk of running
uted to it. Furthermore, the controllers short of fuel and ask for direct routing. out of fuel before landing would have
had to face consequences for infring- been a lot lower than in this case.
ing “stupid” rules during the process,
just because people with very little or
Was it just their I have to rule out the stress/pressure
no understanding of the job had pow-
erful political influence. Typical… or
personal negligence, of having to deal with an unusual/
emergency situation, especially for
maybe not. ignorance, or perhaps the area controller, as well as inexperi-
ence in the job. A bit of ignorance from
Let’s look at whether the controllers something else? the approach controller probably
from the story could/should have played a very small contribut-
taken a different course of action and ing role in the event (restricted
rule out pure luck in combination with With this in mind, asking the previous area established due to po--
favourable weather conditions. More controller for a release for turn makes litical reasons – according to
importantly, let’s try to find out why a lot of sense. Information about the his understanding), as well as
they acted as they did. Was it just their suitable airports in the vicinity, which a bit of negligence from the
personal negligence, ignorance, or could have been essential to pilots for area controller (allowing
perhaps something else? decision-making, was not provided (al- his mind to wander to
though it wasn’t essential in this case).
44
The area controller in charge of the More importantly, prior coordination
South sector received a revision for a with the approach controller should
flight about to enter at a much lower have taken place well in advance and
flight level than expected and divert to the pilots should have been informed Dragan Milanovski
an airport in his FIR. When the aircraft about the restricted area and the ex-
is an ATC training expert at the EUROCONTROL Institute of
called he reacted instinctively and ap- pected distance to fly to touchdown.
proved the direct routing as requested
Air Navigation Services in Luxembourg.
without prior coordination. The argu- The last opportunity was missed by Most of his operational experience comes from Skopje
ment that he had no time (which at the approach controller when he re- ACC where he worked for a number of years on different
the end proved to be crucial), and that ceived an early call from the Captain. operational posts.
he had to do it, is not entirely correct. He also did not inform the pilots about
Valuable time, from receiving the revi- the restricted area and the 30 degree- Now, his day-to-day work involves ATC training design as
sion until the initial call, was not used turn that the aircraft is expected to well as Initial Training delivery for Maastricht UAC.
effectively to understand the situation, make later on to avoid it. After this the
34
restricted area, at first the pilots do not
reply and then first try to talk their way
out of complying with the instruction
without giving any information before
eventually revealing the real reason.
Once they have done so, the controller
immediately helps and does all he can
to get them on the ground as swiftly
as possible. All he can do is react. Only
then is the supervisor alerted.
tions and followed their would have been delayed even more
and aggravated the circumstances
formed that the ATC provider would
stick to the noise abatement proce-
best judgment. which were already underestimated
by everybody involved. Only when the
dures in normal operations. But an air-
craft low on fuel is no longer “normal
Fuel Low Level warning light came on operations” and in any case, I’m sure
It is a pity to see that the “top floor” was the gravity of the situation clear. that, at the end of the day, the neigh-
of the ATC provider does not seem to So in the end his training led him to do bours would prefer a safely landed
be interested in the story the people the right thing to help the aircraft. The aircraft to one which crashed in the
who were working that particular air- approach controller could only react as vicinity but on the noise abatement
craft have to tell. On the basis of only the real situation revealed itself bit by track. They should be able to complain
a few facts, the staff are threatened bit. He is the last one in the chain and and be told what was going on, per-
and intimidated. There is one-way he is the one who has to suffer from haps via a hotline, but if a reasonable
communication – top down: “You the accusations made by the Investi- explanation is then given, they should
acted wrongly! Prepare for the conse- gation Commission. The aircraft crew accept it. If such events were to hap-
quences!” With such behaviour there might have backed him, but I doubt pen every week of course, it would be
will never be open and honest com- that there will ever be any exchange a different story.
munication about what was going about the incident between the pilots
on and what could be learnt from it. and the controller. As long as the air-
Managers and supervisors should be craft landed safely there is nothing to
there first and foremost to protect talk about – that is how many people
A RECOMMENDATION
their staff, provided they acted with think. Exchanging experiences usually Communicate! Talk and ask. Ask
good intentions and followed their implies admitting one’s mistakes or again until you have understood
best judgment. There are always going revealing operational procedures you fully. Involve other people, col-
to be situations where you have to act would rather keep inside the company leagues, supervisors, hear their
first and ask questions later. The South or both, so it hardly ever happens. opinion and get their help. Then in
Sector controller later remembers his the end no one is confronted with
instant reaction to the trigger words And finally: The neighbours of the air- an unpleasant surprise.
“fuel at minima” instead of thinking port have to understand that there are
The aviation playground is open, e.g. Seen more closely, it seems that the After a MAYDAY call there should
as regards the political, economic and events described were often inde- not be any doubts that the flight
operational perspectives, which are pendent and that the causal connec- concerned may not be able to com-
spiced up with unexpected events. tion was rather loose for the actors ply with all clearances, restrictions or
The framework is a combination of involved. Also the possibility of dif- limitations. Without a declaration of
multi-level and multi-dimensional ferent people controlling the factors emergency, the controller needed
decision-making processes. The high- governing the actual situation was not to help the aircraft based on his gut-
end players are added to the play- obvious. The captain failed to respond feeling and professional assessment.
ground to comply with the social, rationally to the reducing fuel endur- At the end of the day it may be that
technical and economic constraints. ance, the controller was not aware of his “mistake” averted a catastrophe.
It would be possible to consider many how bad the situation was in the air-
perspectives in this story. In my com- craft and his attempt to avoid the re- It may be that pilots are not very
ment I will focus on a single safety is- stricted area was rejected by the pilots. keen to declare an emergency if
sue, which could have had a positive it seems that the situation can be
impact on the event. It can be said that the situation could managed without it. Use of a MAY-
have been clearer for everyone. The DAY call may be avoided even it
We know that aviation is a complex outcome was fortunate – a catastro- would clarify many things in the
system. When the unusual happens, phe like the New York accident in 1990 handling of abnormal situations.
it is typical that things start to pile up. where an aircraft burned all its fuel
In many incidents and accidents it is without declaring an emergency was Avoiding the use of MAYDAY may
possible to see – especially in avoided. have deep roots in aviation history.
hindsight – a continuous It is a known fact that culture is not
chain of events. In the sto
sto- Communication plays an essential changed overnight – sometimes
ry here, the situation was role in every abnormal situation. In an not in decades. The clear declara-
similar. Dominos were fallfall- American study the most prominent tion of an emergency is not just a
ing down and the situation communication problem in accident pilot-ATC communication issue. It is
was moving fast towards cases was recognised as communica- also an important CRM issue inside
the conclusion. Or was it? tion never starting. Another big issue the cockpit. Efficient communica-
was unclear or incomplete communi- tion is essential for the modern avia-
cation. tion system and appropriate use of
emergency communications should
According to EU OPS, the pilot in com- be a top priority in the industry-
mand is allowed to deviate from the wide safety debate.
Sami Laine rules and regulations if necessary for
safety reasons in an emergency. That
completed an MSc in accident and safety
gives a lot of freedom to the Captain, A RECOMMENDATION
investigation at Cranfield University. He is
but what exactly is an emergency? Was The aviation community should
First Officer in the Finnair A340/320 fleet, the plane in the story in an emergency initiate cultural discussion of
flight safety analyst and editor-in-chief of the situation, or was the situation merely abnormal and emergency com-
Finnair safety magazine. His earlier working escalating towards an emergency? munications and the use of
experience was with the Maritime Rescue MAYDAY and other distress or
Coordination Centre, Helsinki. By declaring an emergency, all the emergency communications.
players are on the same wavelength.
36
TALES OF OPERATIONAL SAFETY
E.r.
By Alberto Iovino
For family reasons, I happen to be acquainted with the first aid
emergency protocol for the management of pulmonary oedema. ...
The relevant list of actions is some- correspond to what you could read
times deployed on posters, hung on a behind what was happening. Or pos-
wall in the emergency room, so that, sibly not, and this might, incidentally, Alberto Iovino
if you were allowed inside, you might be among the reasons why you would is currently head of ATS Operational Procedures
watch patient and doctor fighting not actually be allowed inside.
Unit of ENAV Italy. Formerly an airline employee
their way through life and death right
under the list of actions which are sup- Emergency rooms are, by definition,
for 8 years, he became an ATCO in 1997,
posed to be taken in such a circum- places where people deal with emer- working as tower, approach and area controller.
stance. Amazingly, you would be able gencies. From an ATC perspective, it is
to follow the meaning of most of what as if, in a corner of control towers and
you would see, as it would perfectly control centres, a couple of working
positions were consistently reserved I have no knowledge of any provider
for individuals with a remarkable organised in this way, for reasons that
sense of self-importance and spas- can be quite easily presumed. On
modic muscular movements of the the other hand, if the idea somehow
face, often smoking cigarettes (yes, it sounded appealing to you, then it
is forbidden, but what the hell, those might be worthwhile asking ourselves
folks deserve some privileges): the why.
emergency team, tough people in
charge of getting going when the go- In an emergency, you feel more com-
ing really gets tough. fortable when handled by someone
you consider a specialist. One may be
able to become so through training
and experience; an emergency team
member would be somebody specifi-
cally trained to deal with emergency
situations beyond the average of his/
her colleagues, having had the op-
portunity to become more and more
familiar with the matter through re-
peated exposure to such situations.
In the emergency team scenario,
negative features peculiar to those
circumstances, such as uncertainty,
unfamiliarity and excitement, should 44
37
TALES OF OPERATIONAL SAFETY
E.R. (cont’d)
38
ATC will have already developed a feel- whenever practicable, to have some veillance controller would highlight that
ing of something going wrong. extra time to look for. position indication and start consider-
ing who is below, what aerodromes
There is no arguing that declaring an In the case of the shipwreck, some “at are in the vicinity, and so on. In a future
emergency is something that should be first glance” elements may sound un- which is already here, we will talk much
done as soon as that is the case, neither pleasantly familiar: there is a problem, less on frequency, as information will
before, nor afterwards. What people the crew tries to handle it and only flow on CPDLCs, Mode S downlink pa-
from the ops room might sometimes when it overwhelms them is informa- rameters and stuff like that; there, you
ask for is a reasonably earlier involve- tion spread outside. Once again, it are available for what may become very
ment whenever rush moments don’t makes sense, you do not declare an useful residual voice communications.
spring abruptly, but instead gradually emergency for a mere trifle; in fact, If those who are asked for assistance
develop from some initial “early warn- the precise moment when MAYDAY are involved at the potential outset of
ing” signs, or through subsequent steps needs to be called is sometimes obvi- the problem, they will be more aware
which evolve from a relatively insig- ous, sometimes hard to decide. Simply and ready to assist; today’s emergency
nificant anomaly into genuine distress. sharing pilots’ concerns with those team member on duty is the same guy
This already widely applies whenever they may later on call for help could who earlier gave an update on QNH,
such anomalies (the classic red light sometimes save the day. and there is really nothing to complain
on the cockpit panel) imply unusual about.
behaviour, such as the request to de- This is not an invitation to ‘cry wolf’, nor
lay take-off after a twenty-minute taxi to offload responsibilities. Relevant
MAYDAY MAYDAY!!
to “perform some checks”. Otherwise, calls should be very explicit about
when there are no immediate outward the fact that no special assistance is
consequences, the flight crew might needed thus far (unless it is), but not
simply not deem informing ATC to be a unnecessarily specific, merely point-
fitting action. ing out that something non-routine is
under scrutiny, and that the situation
Seen from below, perspective changes might potentially evolve into a higher
a bit. Let us focus on the fact that we degree of complexity. I guess any sur-
are not talking here about circum-
stances that could take place on the
ground, such as a power failure in a
control centre, or a full loss of sur-
veillance data, which are commonly
referred to as contingencies, and for
which backups and recovery proce-
dures are also in place; instead, this is
about an on-aircraft crisis which the
people on board have to cope with on
the basis of their procedures, judg-
ment and skill. What we are asked to
do is to act on the remaining traffic,
in order to avoid additional trouble,
and to provide it with all possible
assistance, which eventually means
getting everything and everyone
ready for a possible unfavourable
outcome and, before that, passing
on useful information to contribute
to a happy ending. This information,
such as the infamous nearest suitable
airport, is something which it is nice,
A very important factor during these orities as well as possibly deal with the a non-pilot to understand.. And of
situations is pilot-controller communi- violation of active military airspace. In course to be able to communicate it to
cation. In a technical emergency the pi- the case of an emergency descent it is the next unit so that they understand
lots are usually so busy troubleshooting more reaction than action, but it has to as well.
and working checklists that communi- be coordinated, sooner or later.
cation with ATC is some way Over the years I have also got the feel-
down their priority list. I Usually, “small technical problems” ing that pilots try to avoid having to
was once allowed to wit- aren’t small technical problems. Pilots declare an emergency for as long as
ness a flight simulator seem to have a tendency to play down possible. The trouble is that without
emergency training the significance of the problematic emergency status, it becomes rather
session for the annual situation they find themselves in, God difficult to coordinate good direct
pilot check, and it was knows why. Whenever I hear those key tracks or arrange priority landing, and
very impressive to see words, I go to red alert. I make sure no no transit through active military areas
the workload they were aircraft is passing right underneath is possible.
confronted with. that other aircraft. I pick up my pen
and blank sheet of paper. I pick up the Probably all of us have witnessed a
telephone without dialling. Because situation where we look in disbelief at
Eileen Senger 95% of the time the next transmission our colleague with the “did he really
of that aircraft will be “…request im- say that?”- question mark on our face.
is an Air Traffic Controller at EUROCONTROL’s
mediate descent”, “…request diversion “Radar, we have a woman giving birth
Upper Area Control Centre in Maastricht. to XXXX” or sometimes a very technical
She works in the Hannover Sectors which description of the once small problem
cover north-western Germany and is an OGTI. that now requires a lot of questions
and explanations back and forth for
40
problem… just following another procedure (unless
the other plane gets so close that they can
see it and judge it). Then again, the death of
a person onboard seems abstract to us, to
them it may be shattering.
42
Our air traffic controller, being a sharp In the Hudson story I was incredibly the time it did not seem that way!
guy, came on the ether and demand- impressed by the controller’s reac- Certainly, Captain Sullenburger
ed to know why we were descending, tion and the determination to assist as had much less with his 3mins and
at which point I had a difficult decision much as possible even faced with an 31 seconds of flight ahead of him,
to make. Dear reader, please remem- apparent change in plan. In the end it which only goes to show what a re-
ber that this was the “V Force” and they reached a point where Captain Sullen- markable performance it was, not
did not take lightly such mistakes and burger was rightly so focused on flying just from the crew perspective but
errors. Therefore, I am quite proud of the last part of the approach to the wa- also from the controlling team who
my instinctive response which was ter that he was unable to respond to assisted him.
that we had “suffered a pressurisation the final offers of assistance.
problem” which indeed we had. There were two post scripts to my
You do not have much pressuri- own story. The first happened
sation when the engines are not If ever you are faced with an aircraft whic many years later when I was
h
working, so whilst telling a hope- has lost all useful engine power, it is having a beer in some hotel
nec-
fully forgivable white lie, I tried to essary for the controller to imagine bar and was joined by an an-
the
save us all the formal embarrass- workload in the flight deck under such other pilot. It turned out he
cir-
ment of what would surely follow cumstances and to mentally put hims too had flown Vulcans and
elf or
plus all the beers we would have herself there alongside the crew. Initi after a couple more beers he
ally,
to buy in the bar later when the following such a failure, there is quite decided he wished to make
a lot
other crews discovered our story. to do to stabilise the emergency. In prio a “confession to me”. Yes, you
rity
order:
have guessed it, during a
So what is this story all about and routine landing his co-pilot
n Establish a glide descent
why do I tell you it now? This at the right had inadvertently shut down
speed. Normally, crews will know the
whole tale came to mind not all engines, in this case as he
speed to fly but will probably not have
long ago when I had the chance flared to land, just as my own
an instinctive idea of the glide rate
to talk to Captain Sullenburger co-pilot had done. With some
which can vary quite a lot depending on
following his amazing landing considerable shame and much
the nature of the engine failure(s) and
on the Hudson, which I was able more wisdom than I had then I
the configuration of the aircraft.
to discuss with him. One of the confess that neither of us had
most interesting questions is n Head in the right direction
declared our respective experi
experi-
what, if any, real assistance ATC . This is where ences with the result that this
a good controller can surely assist and
can provide under such circum- it helps if that controller also knows the design weakness continued
stances and he shared with me weather situation at any potential suit- and probably there are other
his immediate need for direc- able airfield. guys out there somewhere who
tional assistance to the nearest can tell similar stories. The need
airfield. The first turn is critical n Get on with the drills and for a non-punitive culture could
procedures
if you are at low altitude. It can that may improve the situation. Here not be better demonstrated.
make the difference of making again the controller can assist by bein
g
it or not. In his case he was in- aware and rather than trying to “ove The second post script was that
r
deed too low and chose a well control”, leave the crew to get on with as we dropped from 40000ft
known alternative. In my case, their work of systems recovery. to about 25000 in our “de-pres
“de-pres-
I was higher and was able to surised” emergency we “fell”
regain the power I needed to straight ahead through the tim tim-
land normally. Had my engines not ing and tracking box, but there
re-lit immediately, I know that the key Of course the biggest variable is al- was no limit on the height accuracy,
information I would have needed was ways the likely time available and so we ended up achieving one of
– what is my nearest suitable airfield, this is dictated normally by the the best bomb scores we had all
what are the weather conditions there height at which all this starts. In season for that exercise. Some days
and what is their contact frequency. my case we had lots, although at you get very lucky!!
The grand slalom skier who misreads ond too soon and compensating for a quence of pattern matching and de-
a turn through a gate and tumbles wet surface too late. What few people cision making. It is at this point that
down the side of the run, the Olympic realise is that the brain will now have the brain defaults to the situation ex-
diver who mis-times their exit from a learnt another slightly different se- plained above, and the outcome often
multiple twisting somersault, and the quence from the original motor pro- relies on the quality of unusual circum-
rally driver who trusts in the friction of gramme, which it will match to the stance and emergency training, expe-
their high performance car on a slip- new context if the same circumstanc- rience and the ability to accept what
pery road, all reflect on the moment es are encountered. I will return to this the facts of the situation are
they lost control. At the point that the later in this paper. rather than what we
pre-programmed motor sequence of would like them
these highly skilled actions is being These are all examples of split-second to be.
executed, the human has little to do adjustments made when things go
but wait for the outcome. In the ex- wrong, but what of the situations in
amples above, the sequence of mo- aviation, with which we are typically
tor programmes has been disrupted more familiar, and in which we often
by inputs which were adaptive: have a slightly longer time frame to
weighting too much on one ski, recover? Interestingly, humans usually
initiating the twist a nanosec
nanosec- have a similar response to unusual or
emergency situations and these fol-
low a set pattern – indeed they can
be found in any traumatic response.
Firstly we may have a shock or startle
Anne Isaac reaction. The strength of this will de-
leads the Human Performance pend on both the individual involved
development work in the and on how many times they have
pilot/controller interface in NATS, UK. She gained encountered this situation before. At
her PhD in Cognitive Neuropsychology at Otago this point we will suspend belief, for a
moment (classically we look to any
University in New Zealand. Her previous work
other person in the direct vicin-
has been in the development of incident
ity for confirmation that what
investigation tools and techniques in European has just been experienced is
ATM, the introduction of TRM into the ATC shared).
environment and the introduction of Day to
Day Safety Surveys techniques into NATS. Once it has been estab-
She has written several book chapters, lished that something
academic papers and the book Air Traffic has indeed gone wrong,
we attempt to compare
Control: the human performance factors.
the situation with past
experiences and start a se-
44
This final response is a very strongly to tackling these situations and, typi- But first we need to appreciate the dif-
developed behaviour which promotes cally, supports a safe and expeditious ferent ‘world views’. A controller’s re-
survival in extreme situations, but this outcome. However there will still be sponsibility is focussed on separation
behaviour often leads us to ignore the examples in which highly trained of individual aircraft (although often
unusual facts in favour of disbelief crews simply don’t believe the indica- they will consider aircraft in pairs or in
since we want and need a safe out- tions from instruments and tragically some cases multiple pairs); however,
come. their training, as individuals or crews, they have many of these to consider
leads them to disbelieve what is pre- and as such, arguably, their world view
Knowing how humans respond to sented to them. In extreme cases they is a ‘many to one’ dynamic. By contrast,
unusual or emergency situations may even ignore the warnings. In the pilots are responsible for the safety of
has led airline manufacturers to sup- air traffic environment checklists are their aircraft and as such their flight
port crews with emergency protocols less evident; however, training in un- is associated with a ‘one in many’ dy-
which support their decision-making usual circumstances and emergencies namic. Both the controller and the
and can eliminate failures in a system- is practiced with regular periodicity. pilot seek the same safe outcome but
atic manner. This leads to a more their perspectives or ‘world views’ will
comprehensive History would suggest that it is not differ and as such their priorities may
approach until an incident attributed to both be misunderstood, especially in an
controllers and pilots or vehicle driv- emergency.
ers occurs and is investigated jointly
that it is acknowledged how little each
professional group knows of the oth- Both the controller and
er, particularly in an emergency or
unusual event. There are fewer
the pilot seek the same
and fewer opportunities in the safe outcome but their
training of all parties to share
common training scenarios. perspectives or ‘world
As a result knowledge re-
garding the ‘world view’
views’ will differ and as
of each team is often
unknown or misun-
such their priorities may
derstood. be misunderstood,
especially in an
emergency.
HindSight15
15Summer
Summer2012
2012
HindSight 45
FROM THE BRIEFING ROOM
What PILOTS should know about CONTROLLERS: What CONTROLLERS should know about PILOTS:
n Although controllers will probably have more emer- n Many airlines use an emergency acronym to brief
gencies in their shift cycle than pilots, they remain un- flight-deck and cabin crews which helps simplify the
certain if they are not given what they perceive as es- communication exchange. One example is the use of
sential information. Their priority in an emergency is to a NITS brief which includes –
move any conflict traffic, which means their workload - Nature of the problem
increases in the area of communication and coordina- - Intention
tion. A good example of these different priorities can - Time needed – to sort out the problem
be heard in the last R/T exchange from the US Airways - Special instructions if required
A 320 aircraft which ditched in the Hudson River.
n The priority for the pilots, depending on the emer-
gency, is to fly their aircraft and inform their crews
about intended decisions. Often ATC is low on their
priority in the first minutes of the emergency.
n Selecting 7700 helps controllers to identify aircraft n At all times, but particularly in an emergency, pilots
which need ‘special attention’ or have an emergency. prefer to be given distance information – in miles, not
Controllers will treat all 7700 squawks as needing pri- periods of time – in minutes
ority and arrange their traffic accordingly. The other n Pilots have advised that they find it very helpful to
advantage is that the 7700 squawk is also ‘seen’ on ra- receive ATC guidance that is prefixed or suffixed with
dar by all controllers throughout their airspace, which the statement “ when able”
increases their situation awareness and readiness to
assist.
n Controllers will assume pilots will announce ”PAN n ‘PAN’ and ‘MAYDAY’ does not necessarily mean a pilot
PAN” for special attention regardless of the outcome. needs immediate landing or the nearest airfield.
Controllers will assume pilots will announce “MAYDAY n Pilots also advise that in most unusual or emergency
MAYDAY” when requiring immediate support. Both situations they prefer to be given airspace to sort
‘PAN’ and ‘MAYDAY’ announcements carry almost equal themselves out. The only exception is an explosive
attention and the controllers will allocate a dedicated decompression or smoke/fire in the flight-deck or
controller and frequency if required. cabin.
n At all times, but particularly in an emergency, the ‘world view’ of the two crews/teams differs. This clearly dictates the
priorities of the two parties and therefore the reason these situations can be difficult to manage. In these situations
each team can lose overall situation awareness of the other team and this may introduce unwanted communication,
and this uncertainty may increase stress for each team.
n In emergency situations, which require an immediate climb/descent, each airline (and often different fleets within
the same airline) may fly a profile not anticipated by the controller. Some pilots prefer a straight ahead climb/descent
and some prefer a turning descent. What an airline/aircraft type requires and what controllers expect they want, or
will do, are often completely different.
1- Multi-Crew resource Management is a workshop which is facilitated by TrM facilitators together with CrM instructors and focuses on a discussion regarding the
interface risks found between pilots and controllers. The participants are made up of a mixture of pilots from different flying disciplines and controllers who also have
different controlling experience.
46
“ Although expert
decision makers
may make small
Finally, let us return to the phenom-
ena of motor programmes and the errors, they generally
recognition of unusual or emergency
situations. The response of the brain, avoid major mistakes.
and the consequent behaviour, is al-
ways a result of experience and ex- They seem to have
pertise. Once any professional has
learned the basic skills, rules and
discovered that for
procedures of their work they will
have sufficient knowledge to work
many decisions,
in a normal situation. However, once coming close
an unusual or emergency situation is As on nearly every
presented, the person will be limited is often good enough: of Apollo 12 went sm
manned flight since
oothly – but only un
1965, lift-off
til sev-
in their response and also subject to
several decision-making, behavioural the key is not to worry enty-eight seconds
to anyone, including
after ignition when
, unknown
the astronauts on bo
biases. These include any of the fol-
lowing:
about being exactly the booster was str
radioed down the ala
uck by lightning. Pe
te Co
ard,
nrad
“
New “Level off, level off” RA
My article in the July 2007 The development of version 7.1 was ini- Additionally, there have been numer-
tiated by EUROCONTROL following the ous cases of level bust when pilots
issue of HindSight about TCAS discovery of two safety issues with the following the “Adjust vertical speed,
mentioned a forthcoming current TCAS II version 7.0. Since its intro- adjust” RA went through their cleared
change to TCAS II the intro- duction in Europe in 2000, TCAS II has been level, often causing a follow-up RA for
the subject of monitoring. In the course of the other aircraft above or below, and
duction of the new version analysing recorded and reported events, disrupting ATC operations.
7.1. After an admittedly rather many cases were found in which pilots did
not respond correctly to the “Adjust verti- In version 7.1 the “Adjust vertical
lengthy process, a regulatory
cal speed, adjust” Resolution Advisories speed, adjust” RA is replaced with a
decision was published on 20 (RAs). In a few of these cases a midair colli- new “Level off, level off” RA. The new
December 2011: all existing sion was avoided by chance. RA always requires a reduction of
vertical rate to 0 ft/min, i.e. a level off
TCAS II version 7.0 installa- The “Adjust vertical speed, adjust” RA re- which needs to be achieved prompt-
tions must be upgraded to quires the reduction of vertical speed to ly, not at the next standard flight level
version 7.1 before 1 December 2000, 1000, 500, or 0 ft/min., as indicated (e.g. FL 200, FL 210, etc.). The “Level
on the flight instruments. In those cases off, level off” RA may be issued as an
2015 and new aircraft must involving an incorrect response, the pilots initial RA or as a weakening RA fol-
be equipped with version 7.1 increased their vertical speed instead of lowing, for instance, a “Climb, climb”
reducing it, consequently causing a dete- or “Descend, descend” RA as the ver-
from 1 March 2012 if operat-
rioration of the situation. This is currently tical distance between the aircraft
ing in European airspace1. the most common RA, representing up to increases due to the initial response
The first aircraft equipped two-thirds of the total RAs. taking effect.
“Climb, climb” RA
350 ft
FL340
“Clear of Conflict”
4500 ft/min.
FL330
1- The European version 7.1 mandate sets earlier “Adjust vertical speed,
equipage requirements than those published by adjust” RA (1000 ft/min.)
iCaO (1 January 2014 – new installations,
2500 ft/min.
1 January 2017 – existing units).
48
“Climb,
ARRIVED
FL220
Level bust
0 ft/min
Version 7.1:
“Climb,
Improved reversal Threat’s non-compliance
climb” RA
detected, reversal RA issued
logic
A second change is also Pilot does not comply with RA
or TCAS unequipped aircraft following
introduced in version 7.1 Version 7.0: No reversal an ATC instruction or visual avoidance
– improved reversal logic,
which is also expected to
enhance safety. This change
is transparent to controllers
and pilots.
The new version 7.1 issue a reversal RA to the aircraft which
is manoeuvring in accordance with the
Version 7.0 allows reversal RAs (i.e.
“Climb, climb NOW” and “Descend, de-
is compatible with all RA on the basis that it is this aircraft
which is more likely to respond cor-
scend NOW”) to be issued when the existing versions being rectly to a reversal RA.
current RA is no longer predicted to
provide sufficient vertical spacing.
operated today, both In single equipage encounters (i.e.
version 7.0 and version when only one of the conflicting air-
However, there have been cases in craft is TCAS II equipped), version 7.1
which a reversal RA failed to occur 6.04a (which is still in use will recognise the situation and will is-
when two converging aircraft re-
mained within 100 feet of each other.
by some aircraft, mainly sue a reversal if the unequipped threat
aircraft moves in the same vertical di-
This scenario can occur when one air- outside Europe). rection as the TCAS II equipped aircraft.
craft is not following the RA properly or
is not TCAS II equipped and follows an There is therefore no Compatible versions
ATC instruction or performs an avoid-
ance manoeuvre based on visual ac-
need for ATC to know Until the whole fleet of aircraft oper-
quisition. Significant examples of such which version of TCAS II ating in European airspace has been
events include the Yaizu (Japan) near
midair collision (2001) and the Über-
the aircraft operates upgraded, conflicts will occur between
aircraft using different versions of
lingen (Germany) midair collision because proper TCAS- TCAS II. The new version 7.1 is compat-
(2002). ible with all existing versions being op-
TCAS coordination is erated today, both version 7.0 and ver-
aking place in all sion 6.04a (which is still in use by some
aircraft, mainly outside Europe). There
coordinated encounters. is therefore no need for ATC to know
which version of TCAS II the aircraft
operates because proper TCAS-TCAS
Stanislaw Version 7.1 improves the reversal logic coordination is taking place in all coor-
Drozdowski by detecting situations in which, de-
spite the RA, the aircraft continue to
dinated encounters. In fact, ATC does
not need to know whether the aircraft
is an ATM Expert at EUROCONTROL HQ in converge vertically. A feature has been is TCAS equipped or not or is operating
Brussels, working in the area of ground and added to the TCAS logic which moni- with TCAS temporarily inoperative (as
airborne safety nets. Previously, he worked as tors RA compliance in coordinated allowed under Minimum Equipment
a system engineer with Northrop Grumman encounters (i.e. when both aircraft are List exemptions), because the provi-
and as an Air Traffic Controller in Poland and TCAS II equipped). When version 7.1 sion of air traffic services to aircraft
New Zealand. detects that one of the aircraft is not equipped with TCAS shall be identical
responding correctly to an RA, it will to those that are not equipped.
50
17
by John Barrass, SKYbrary Editor
minutes
S
UPS flight 006, en route from Dubai to Cologne, recently levelled off
moke from an onboard fire breathing and you have an in- at FL320 when the crew advised ATC that the fire warning systems
is likely to contain toxic sub- creased sense of self-awareness for the cargo compartments indicated an onboard main deck fire
stances that irritate the skin, and alertness, possibly because and advised ATC that they needed to land as soon as possible. *
eyes and respiratory system. of that enclosed feeling and
ATC advised the crew that Doha International Airport was at the 10
Furthermore, the two main smoke possibly also because of the
o’clock position at 100 nm. Although Doha was closer, the Captain
gases, carbon monoxide and hydro- increased levels of oxygen and
gen cyanide, are very rapidly disabling adrenalin in the blood stream. elected to return to Dubai and the crew declared an emergency.
if breathed in. Smoke can therefore 3 minutes after the first alarm bell, the flight crew put on their
quickly incapacitate the crew unless Because of the oxygen masks, oxygen masks and goggles. The crew experienced difficulties com-
they wear goggles and breathe 100% the voices of other crew mem- municating via the intercom with the masks on.
oxygen. Smoke also reduces visibility, bers are slightly muffled and
making it difficult, if not impossible, for your own voice sounds as if it 5 minutes after the first alarm bell, the Captain told the Co-Pilot to
the crew to see instruments or see out is coming from somewhere pull the smoke evacuation handle and advised ATC that the flight
of the window. In such circumstances, else, just like it does when you deck was “full of smoke”.
a crew can become disorientated, lose have a heavy head cold. Add to
7 minutes after that first alarm bell, the Captain declared a lack of
situational awareness and then lose that the reduced visibility, and
oxygen and left his seat, possibly to get a portable oxygen bottle,
control of the aircraft. there is a sense of detachment
but he did not return.
and isolation. In a benign envi-
Many airlines conduct smoke training ronment, such as an exercise, 9 minutes after the first alarm bell, the Co-Pilot advised ATC that he
sessions where, for example, crews when there is no actual threat, would remain on the Bahrain frequency, as it was not possible to see
are given experience in locating and it is actually quite relaxing and the radios.
fighting simulated fires, while wearing in similar training I have no-
breathing apparatus, in a smoke filled ticed how many people have 14 minutes after the first alarm bell, the Co-Pilot asked for radar
cabin. their eyes closed. guidance due to difficulty viewing the instruments...
HindSight 15 Summer 2012 *gCaa accident report No. 13/2010. (preliminary report) - http://www.skybrary.aero/bookshelf/books/1485.pdf 51
FROM THE BRIEFING ROOM articles on SKYbrary relating to the events and issues discussed above:
http://www.skybrary.aero/index.php/Smoke_gases
http://www.skybrary.aero/index.php/in-Flight_Fire:_guidance_for_Flight_Crews
http://www.skybrary.aero/index.php/in-Flight_Fire:_guidance_for_Controllers
17 minutes (cont’d) http://www.skybrary.aero/index.php/B744,_en_route,_persian_gulf,_2010_(aW_FirE)
ed an immediate threat to the safety of message. ATC reacted quickly to our On 11 May 1996, a fire broke out on
the aircraft. The Captain opened his side emergency call. Although the active board a Valujet DC9. The fire damaged
window and someone, possibly me but runway was 24, we were given imme- the aircraft flying controls before the
I can’t remember, opened the roof es- diate clearance to land straight in on crew were able to land the aircraft and
cape hatch. The impact on visibility on Runway 36. We were on the ground it crashed in the Florida Everglades. All
the flight deck was instantaneous – the within 6 minutes of the first signs of of the occupants were killed. The first
smoke disappeared completely – there smoke and probably in the bar within indications that the crew had were
was a lot of noise but the pilots could another 6 minutes. an unusual sound followed swiftly by
now see. Of course, opening the win- major electrical problems and physical
dows is not an option at FL320. It’s all about time. Crews need to de- signs of fire. Little more than 3 minutes
velop a mindset that, following any in- after those first indications of a fire, the
I recall the flight engineer being busy dication of fire, an immediate landing aircraft crashed.
attempting to isolate the source of the is essential.
smoke but to no avail – it later transpired On 2 September 1998, while cruising
that the source of the smoke was an au- Masks, goggles, hoods and oxygen at flight level 330, the crew of Swis-
topilot unit under the flight deck and the provide protection from the effects sair Flight 111 smelled an abnormal
smoke was working its way up behind of smoke. Depressurisation, and odour in the cockpit. Their attention
the panelling before entering the flight opening flight deck windows, vents was then drawn to an unspecified
deck from above. It is worth noting that and hatches, help to clear the smoke, area behind and above them and
many flight crews experiencing a smoke and there are devices available to they began to investigate the source.
event may never succeed in identifying improve visibility on a smoke filled Whatever they saw initially was shortly
the source of smoke and any associated flight deck. However, an aircraft oxy- thereafter no longer perceived to be
fire in the time available to them. While gen system has finite capacity. It was visible. They agreed that the origin of
it is of course important to make every not uncommon in my experience the anomaly was the air conditioning
effort to isolate the source of the smoke for the portable oxygen bottles to system. When they assessed that what
and fight the fire, the top priority is to become exhausted well before the they had seen or were now seeing was
get the aircraft on the ground as soon as time advertised – masks leak, people definitely smoke, they decided to di-
possible. breathe more heavily when engaged vert. They initially began a turn toward
in physical activity, and oxygen bot- Boston; however, when air traffic ser-
Luckily, we were just 10 nm to tles may leak between periodic ser- vices mentioned Halifax, Nova Scotia,
the south of the nearest air air- vicing, etc. as an alternative airport, they changed
field. I recall that the radio the destination to Halifax International
call I made did not adhere
to standard phraseology An on board fire can Airport. While the flight crew was pre-
paring for the landing in Halifax, they
but ATC certainly got the
affect aircraft systems were unaware that a fire was spread-
ing above the ceiling in the front area
and the structural of the aircraft. About 13 minutes after
the abnormal odour was detected, the
integrity of the aircraft aircraft’s flight data recorder began to
John Barrass leading eventually, and record a rapid succession of aircraft
systems-related failures. The flight
served for 20 years in the UK Royal Air Force
and Canadian Forces in a variety of flying,
inevitably, to loss of crew declared an emergency and in-
dicated a need to land immediately.
instructional, and command appointments control About one minute later, radio com-
before becoming an aviation consultant. munications and secondary radar con-
tact with the aircraft were lost, and the
John has worked on most of EUROCONTROL’s A fire in the air can affect aircraft sys- flight recorders stopped functioning.
safety enhancement initiatives and is the tems and the structural integrity of the About five and a half minutes later, the
current editor of SKYbrary. aircraft – out of control, a fire will even- aircraft crashed into the ocean about
tually result in loss of control. five nautical miles southwest of Peg-
52
http://www.skybrary.aero/index.php/dC93,_en-route,_Everglades_Fl_uSa,_1996_(gNd_FirE_lOC)
http://www.skybrary.aero/index.php/Md11,_en-route,_atlantic_Ocean_near_Halifax_Canada,_1998_(aW_FirE_lOC)
http://www.skybrary.aero/index.php/reflections_on_the_decision_to_ditch_a_large_Transport_aircraft
gy’s Cove, Nova Scotia, Canada. The The crew will wish to minimise fre- On 16 May 1995, an RAF Nimrod suf-
aircraft was destroyed and there were quency changes in order to reduce fered an uncontrollable fire in one of
no survivors. workload and avoid the chance of an its four engines, which subsequently
incorrect frequency selection and loss spread to the adjacent engine and
A smoke or fire event on an aircraft of communications. threatened the structural integrity and
presents a challenging situation for a therefore likely controllability of the
controller. Initially, the controller might Communications with the aircraft aircraft. Hearing a report from the rear
be advised of a technical problem and may be particularly difficult. The situ- crew that the wing was “melting”, and
a possible need for a precautionary di- ation on the aircraft may mean that fearing that he may have only seconds
version. This is understandable – the the aircraft does not respond to calls, before the wing failed, the captain
crew may be unsure of the nature of information passed to or by the air- decided to ditch the aircraft into the
the problems they are experiencing. craft may be misunderstood, informa- sea. All of the occupants survived. It is
Several minutes may therefore have tion may need to be relayed through most likely that, had he tried to reach
elapsed before an emergency is for- other aircraft or ground stations, fre- the nearest runway, he would not have
mally declared. Nevertheless, the con- quency changes may not be possible, made it.
troller should use this time to consider and communications may be lost al-
options and warn those he may need together. If communications are lost To handle an emergency such as this,
to call upon if the situation develops completely, then the controller will where time is critical, controller over-
into an emergency. need to anticipate the actions of the load is likely if support and supervisory
crew based on previously declared in- back-up is not immediately forthcom-
solved and the flight was able to make all staff involved in handling the US/E;
a safe landing somewhere, or the US/E arranging access for accident inves-
Bert Ruitenberg couldn’t be resolved and there was an tigators to the controller(s) involved;
accident. (Admittedly this is a some- and last but not least, providing factual
is a retired TWR/APP controller, supervisor what simplistic view, but please in- information on the event and what’s
and ATC Safety Officer who worked at Amsterdam dulge me for the sake of the point I’m being done about it to all ATC staff (or
Schiphol. trying to make.) Now it’s important to indeed all employees of the ANSP) and
realise that US/Es normally don’t hap- the media.
pen in isolation – there is other traffic in
the sector or at the airport that also ex- To start with the first item from the list
As is evidenced by this very issue of Hind- pects to be handled in a safe, efficient above, there’s nothing worse than leav-
Sight, a lot of attention in the ATC world and orderly manner. And this applies ing a controller who just lost an aircraft
is currently being focused on the han- both during the “lifespan” of the US/E to handle subsequent traffic at a work-
dling of emergencies and unusual situa- and after its outcome. So how is your ing position. Even if the US/E aircraft
tions. And rightly so, I say, for ATC can be ATC working environment organised was the only one that the controller
a powerful resource for pilots who find to help controllers cope with handling was working with, the controller should
themselves in an unusual situation or regular traffic after the outcome of a be relieved and taken to a quiet place
an emergency (which will be US/E from US/E turns out to be an accident? to await initial counselling (e.g. critical
now on). I’m a supporter of controller re- incident stress debriefing). And please
current training programmes that focus Issues that should be considered don’t let this poor controller wait unac-
on US/E, especially where these include include, but are not limited to, ur- companied for the counsellor to arrive
sessions in which pilots interact with gent relief from their position for the – make sure that a trusted colleague is
controllers to analyse and discuss such controller(s) who last communicated with him/her during that time, if pos-
events. But I’m not sure that everywhere with the aircraft that had the US/E; sible.
in the ATC world the same amount of reduction of the traffic complexity, if
consideration is given to what happens necessary by establishing temporary Meanwhile, the other controllers in the
in an operations room or tower in the traffic restrictions, for the airport or operations room or tower have the dif-
moments immediately after a US/E has sector(s) concerned; counselling of ficult task of handling the other traffic
been dealt with, i.e. after the outcome of the controller(s) involved, e.g. through as if nothing happened. They prob-
the US/E. a critical incident stress management
programme; conducting an operation-
There can be two different outcomes: al debriefing with the participation of
either the US/E has been successfully re-
54
ably will be very much by conducting an operational debrief
debrief- author
the investigating author-
aware of what their ing with all staff involved when the ity in which controller ac
ac-
colleague(s) experienced a few mo- outcome of the US/E is a happy one. cess is described and agreed, and have it
ments earlier, yet they have to face Was internal and external communica- in place before an actual accident hap hap-
the well-intended “good day” check-in tion adequate during the event? What pens. And if I may volunteer any guidance
calls from unsuspecting pilots on their was it that saved the day? Was the for such a protocol, arrange for priority to
frequencies. Depending on how close contribution from ATC in resolving the be given to counselling over investiga
investiga-
they were to the handling of the US/E event a structural one, or was it some- tion, and for meetings with controllers
before it resulted in an accident, they thing that strongly depended on the or other staff at a suitable location in an
too may require relief from their work- individual skills and knowledge of the ANSP building rather than at the private
ing position in order to go and receive controller(s) involved? In the case of the homes of those concerned.
counselling. But there simply may not former, was everyone happy with the
be sufficient relief staff available on way things went internally or is there The final point from my list above is on
short notice for that to be realised, still room for improvement? And in the communications about the event to the
hence the second item in the list above: case of the latter (above), how can that workforce in the organisation. In fact, the
reduction of the traffic complexity. If same level of skills and knowledge be communications requirement is broader
you can’t get all controllers off position instilled in the other controllers? than just the workforce itself, for after an
after an accident has happened, then accident the organisation will be in the
at least make their work as easy as pos- Earlier I equated an accident investiga- media spotlight almost instantly. EURO-
sible at such a time. tion to an operational debriefing, but CONTROL have produced a superb docu-
that equation is of course incorrect. To ment called “Just Culture Guidance Mate-
A further item from the list above is an the participants an investigation is of- rial for Interfacing with the Media “, which
operational debriefing. This is some- ten perceived as more threatening than I believe provides excellent guidance for
thing I strongly suggest be done after an operational debriefing, and one ANSPs on how to prepare for having to
either of the two possible outcomes of of the reasons for that is that in an in- communicate about an accident, both
a US/E, by the way. Where the outcome vestigation there are usually outsiders internally and externally.
was an accident, it almost goes with- involved, i.e. State safety investigators,
out saying that all staff involved are at people from outside the ANSP. And In conclusion, in this article I hope to
some point interviewed by an inves- whilst they are working in the interests demonstrate that there’s more to han-
tigation commission or are at least in- of aviation safety, they often want to dling unusual situations and emergen-
vited to provide a written statement on interview the controller(s) involved in cies than “just” the technical ability of the
their actions at the time of the event. the accident as soon as possible after air traffic controllers. Providing recurrent
The aim of this investigation of course the event, which can cause a conflict training with tailored simulator scenarios
is to determine what happened, how with the counselling process and thus is one thing, but it also pays to give seri-
it happened, and what can be done to be inconvenient for the controller. Or ous thought to managing what happens
prevent a similar event from happen- it can even interfere with the control- after the event is over. If you only start
ing again. But why wait for an accident ler’s private life if the investigators insist thinking about that while an event is un-
when your aim is to improve safety? on interviewing the him or her at their folding, chances are that you’re too late to
home (be it in person or by telephone). manage it effectively.
I submit that there is potentially as To avoid emotional complications at a
much to learn for future improvements time when they are least needed, it is
advisable to develop a protocol with
Fixed wing
or
helicopter?
Editorial note: Situational examples
are based on the experience of the
authors and do not represent either a
particular historical event or a full de-
scription of such an event. The scenarios
are rather exemplified facts aligned to
illustrate operational safety and human
performance considerations.
4p58
56
HindSight 15 Summer 2012 57
HINDSIGHT SITUATIONAL EXAMPLE
THE FACTS
Read the story as it develops, You use the intercom system to coor-
position yourself in the context dinate with the controller in the tower
without knowing the actual about this flight. Since it’s a helicop-
outcome. How confident are you ter, different limits for special VFR op-
that you would never get into a erations are applicable than for fixed
situation like this? wing aircraft and the tower control-
ler and you both agree that the flight
can be given permission to cross the
control zone under special VFR pro-
cedures. You call the pilot and you
give the clearance to cross the control
zone special VFR at an altitude of 1200
feet. After the pilot acknowledges the
clearance, again in a poor quality radio
transmission, you instruct him to con-
tact the tower for further guidance.
The pilot switches to the other fre-
quency, and you turn your attention to
the inbound IFR passenger flight that
has just checked in on your frequency.
While providing the inbound passen-
ger aircraft with radar vectors to the
instrument landing system (ILS) for
It’s a quiet day at the regional airport You are aware that normally requests the runway in use at your airport, you
where you’re working as a radar ap- for VFR crossing of the control zone are monitor the conversation between
proach controller. The weather condi- handled by the tower at your airport. the helicopter and the controller on
tions are marginal, or at least below the tower frequency. The quality of the
the limits for VFR operations. You’ve What would you do? transmissions by the helicopter is still
just finished a coordination phone poor, but you hear the pilot acknowl-
call with details about an inbound IFR You decide you’ll transfer the aircraft edge the request from the tower con-
flight, a twin turbo propeller aircraft, to the tower frequency in a proper troller to “report one minute before
which is a scheduled passenger flight manner. Since you have no flight plan crossing overhead the airport”.
to your airport. data for this particular flight, you carry
out an electronic search for the flight What would you think?
An aircraft checks in on your frequen- in the automated flight data system
cy, but you’re unable to understand to which the radar equipment at your Shortly thereafter the pilot of the IFR
the full call sign because the quality airport is linked. The search does not passenger flight reports established
of the radio transmission is poor. After produce any results, but that is not un- on the ILS, so you transfer that flight to
asking the pilot several times to repeat usual for VFR flights in your area. Con- the frequency of the tower controller.
the call, you finally are able to get the sequently you make a manual flight You continue to monitor the conversa-
five characters that make up the call plan input for the flight to appear in tions on the tower frequency, and on
sign (and aircraft registration). You also your automated system as a VFR cross- your radar screen you also monitor the
understand that the aircraft is a heli- ing helicopter, using the minimum progress of the helicopter. You hear
copter on a VFR flight plan, and that amount of required data to get the in- the pilot of the helicopter reporting
the pilot is requesting clearance to put accepted by the system. This input “one minute before overhead” to the
cross the control zone of your airport also produces a related flight strip in tower controller, and at the same time
from the southeast to the northwest. the tower. you see that the flight track of the he-
58
DATA, DISCUSSION AND HUMAN FACTORS
HUMAN PERFORMANCE
- TEM ANALYSIS
60
FLIGHT DECK
PERSPECTIvE
Skybrary download
If you need to find out something about aviation safety, we suggest
you go first to www.skybrary.aero. It doesn’t matter whether you are
a controller, a pilot or a maintenance engineer, SKYbrary aims to have
either the answer you are looking for or a direct route to it.
Description
This article provides generic advice only on the effective man-
agement of air traffic during periods of convective weather
avoidance. The guidance provided in this article must not take
If by any chance you can’t find what you want, precedence over local operating instructions and air traffic man-
please remember that SKYbrary is a dynamic agement strategies that controllers are required to follow when
work-in-progress which needs continuous user adverse weather avoidance is in progress.
feedback and benefits from user support. Be sure
to tell the SKYbrary Editor about any difficulty Cumulonimbus Clouds
you may have had making it work for you. If you
can directly help us by identifying material we Convective clouds present a serious hazard to aviation. Aircraft
could use or even fill a gap by writing some con- entering a Cumulonimbus (Cb) cloud may experience severe
tent yourself then please tell us too! turbulence, icing, lightning, precipitation (especially Hail), and
strong winds (both vertical and horizontal). These hazards, indi-
We aim to provide wide coverage through both vidually and collectively, can lead to structural damage, injuries
original articles and, especially, by hosting the best to crew and passengers, loss of separation/level bust as a result
of what’s already been written so that a wider audi- of an inability to maintain assigned height, and loss of control.
ence can access it more easily in one place. Where possible, flight crews will wish to avoid passing within 20
nm of a cumulonimbus cloud.
SKYbrary is also the place where you can access:
62
SKY
brary
ATC Operations in Weather Avoidance Scenarios
Particularly intense Cbs, often associated with squall Weather Avoidance Characteristics
lines, may also present related phenomena such as Tor-
nados, Gust Fronts, and Microbursts, all of which can When air traffic is avoiding Cumulonimbus cells, particularly
have an impact on air traffic management and airport in congested airspace, the workload of the controller in-
infrastructure. creases significantly. In such scenarios the increase in work-
load is caused by:
Aircraft equipped with Weather Radar are able to iden-
tify the areas of cloud with the greatest vertical wind n Non standard traffic flow – the traffic flow is irregular
shear and navigate through (or if not possible around) and not easy to anticipate because of:
areas of convective activity. - the changing intensity of cells, both vertically and hor-
izontally (for further information see the article “Life-
Controllers should note that flight crew workload in- cycle of the Thunderstorm)”
creases significantly in a weather avoidance scenario - the situational awareness of the flight crew and rout-
not just because of the decision-making associated with ing decisions they take based on the display on their
weather avoidance but also because of Turbulence, weather radar (for further information see the article
management of In-Flight Icing, and increased commu- “Weather Radar: Storm Avoidance)”
nications. Particularly dense cells, or groups of cells, can n the altitude of aircraft,
attenuate radar and radio signals, thereby causing loss n the onward routing of the aircraft,
of radar contact and poor quality or lost communica- n the training and experience of the flight crews, and
tions. n operator’s procedures.
n Reduction in available airspace – controllers will have
less airspace volume available for conflict resolution tasks
with a consequent impact on sector capacity;
n New conflict points – new random crossing points are
likely to occur as a result of the disrupted and non-stan-
dard traffic patterns;
n Increased frequency occupancy time – radio commu-
nication is likely to be prolonged due to the necessity to
clarify the details associated with the avoidance actions
as well as revised onward routing clearances. Usage of
non standard RTF is likely to increase;
n Increased manual (telephone) coordination – tele-
phone coordination with adjacent sectors or ATS units is
likely to increase due to the necessity to coordinate the
details associated with the avoidance actions (change of
routes and flight levels);
n Rapidly changing situation – isolated Cb cells can quickly
evolve into a squall line and make navigation through the
line of Cbs increasingly challenging for the pilots;
44
64
SKY
brary
munications difficulty and the flight safety risks, an aircraft Effects
alters course without clearance. If it is necessary to leave
controlled airspace the pilot must request permission to Possible effects of adverse weather avoidance include:
re-join. ICAO Doc 4444 (PANS-ATM) provides the following
procedures intended for deviations around adverse meteo- n Pilots may be unwilling to execute a turn, as instruct-
rological conditions: ed by the controller to avoid conflict, due to the prox-
imity of adverse weather;
n Doc 4444 - 15.2.3.1 Procedures related to emergen- n Pilots may be unwilling to descend due to the prox-
cies, communication failure and contingencies - imity of an adverse weather area;
15.2.3.1.1 n Pilots setting a heading or altitude not expected by
the controller;
When the pilot initiates communications with ATC, a n Pilots changing the assigned heading after clearing
rapid response may be obtained by stating “WEATHER weather (CB) without informing ATC. In general pi-
DEVIATION REQUIRED” to indicate that priority is desired lots request deviation from the planned route due to
on the frequency and for ATC response. When necessary, CBs but sometimes, when clear of weather, they turn
the pilot should initiate the communications using the back to their planned route without prior notification
urgency call “PAN PAN” (preferably spoken three times). to ATC;
n Increased communications with pilots;
n Doc 4444 - 15.2.3.1 Procedures related to emergen- n Increased communications with adjacent ATC units
cies, communication failure and contingencies - to coordinate avoiding actions;
15.2.3.1.2 n Some flights may not be able to follow missed ap-
proach procedure due to thunderstorm areas near
The pilot shall inform ATC when weather deviation is no the airport (APP/TWR environment);
longer required, or when a weather deviation has been n Some flights may initiate a go around on final due to
completed and the aircraft has returned to its cleared severe turbulence, wind shear, or a flooded runway
route. (APP/TWR environment);
n More requests to use a different runway for depar-
Weather Avoidance Procedures in Oceanic Airspace ture or arrival due to sudden changes of wind com-
The crews should notify ATC and request clearance to devi- ponents in combination with wet runway and ra-
ate from track, advising, when possible, the extent of the de- dar-derived information on adverse weather on the
viation expected, expressed in a new heading, and for how climb out route, (APP/TWR environment);
long the crew intends to proceed on the deviation heading. n Increased controller and pilot workload;
n Reduced sector capacity - The complexity of the traf-
n Doc 4444 - 15.2.3.2 Actions to be taken when fic situation (traffic demand, non-standard routings,
controller-pilot communications are established - potential conflicts) may necessitate the implemen-
15.2.3.2.2 tation of flow measures in order to ensure safe ATC
service provision during periods of massive adverse
n Doc 4444 - 15.2.3.2 Actions to be taken when weather avoidance.
controller-pilot communications are established -
15.2.3.2.3
44
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brary
Organisational measures
n Provision of sufficient number of controllers during peri-
ods with forecast severe convective weather;
n Use of weather radars/ weather displays to enhance in-
formation provided to controllers;
n Use SIGMETS and associated weather forecasts to im-
prove prediction of sector loading;
n Train controllers to deal with weather during live train-
ing; use simulator training to build in more resilience in
controllers’ skills;
n Provide a periodic refresher course to OPS supervisors
n Consider adoption of a generic checklist for OPS super-
visors.
es including: radar observations, adjacent ATS units, Weather Avoidance Decision Support
MET office reports, unit briefings and reports from pi-
lots. Being constantly aware of any ongoing deviations
Systems
and flight crews’ intentions should provide precious It is generally agreed that decision support tools may be
time for the separation of affected nearby traffic; instrumental in the management of convective weather
n Develop strategies – the executive (radar) and planner avoidance scenarios in congested airspace. Such tools will
controller should develop strategies and practice mu- use the weather forecasts to estimate the impact on ATC
tual crosschecks of the current, planned and intended provision and consequently suggest air traffic management
weather avoidance actions; strategies.
n Provide timely information to and coordinate with the
adjacent sectors regarding any deviations which will af- In research funded by the NASA Ames Research Centre, the
fect them; MIT Lincoln Laboratory has developed an en-route Convec-
n Pro-actively seek information regarding traffic which is tive Weather Avoidance Model which outputs three-dimen-
likely to enter their own sector; sional weather avoidance fields. “The probabilistic Weather
n Request any necessary details from the flight crews on Avoidance Fields identify regions of airspace that pilots are
the planned avoiding actions i.e. heading(s) on which likely to avoid due to the presence of convective weather”
the aircraft will be flying, as well as the estimated dura- (for details see Further Reading).
tion and/or the distance the aircraft will proceed on the
heading(s); The concept for the future trajectory-based operations is
n Provide extra room for manoeuvring, if in doubt that the that it will be necessary to automatically generate flight
traffic will request further deviation provide extra space trajectories through or around convective weather which
for separation, issue instructions for flight level change pilots will find acceptable.
as necessary, provide traffic information, as necessary;
n Inform pilot if weather avoidance will take pilot outside
controlled airspace, and offer an appropriate service.
Further Reading
n Aircraft Emergency and Unusual Situations -
http://www.skybrary.aero/index.php/Category:Aircraft_Emergency_and_Unusual_Situations
N° 1
January 2005
N° 2
January 2006
N°
June 2006
3 N°
January 2007
4 N°
June 2007
5 N°
January 2008
6
COLLISION
Putting Safety First in Air Traffic Management
COMMUNICATION
HINDSIGHT IS A “Hindsight”
The ability or opportunity to understand and judge AIRSPACE CONFLICT AVOIDANCE
WONDERFUL THING an event or experience after it has occured.
WORKLOAD
an event or experience after it has occured.
By Tzvetomir Blajev “Hindsight” “Hindsight”
Coordinator - Safety Improvement Initiatives, The ability or oportunity to understand and judge The ability or opportunity to understand and judge “Hindsight”
and Editor in Chief of HindSight. an event or experience after it has occured. an event or experience after it has occured. The ability or opportunity to understand and judge By
By Ian
Ian Wigmore
Wigmore
Win a free trip for two to Paris:
an event or experience after it has occured.
See
See page
page 22
22
“With the benefit of hindsight I would
“Hindsight”
THE APPLICATION OF
IS AIRSPACE PENETRATION
The ability or opportunity to understand and judge
have done it differently”.
See page 26 an event or experience after it has occured.
OFFSET TRACKS
How often do we hear responsible people If we learn the right lessons we will stand with your colleagues - think what you AN ATC PROBLEM OR NOT? ANOTHER SUNNY DAY IN SWEDEN
saying these words? Often, it is an attempt a much better chance of reacting correct- would do if you had a similar experience.
See page 3 IN EUROPEAN AIRSPACE
to disguise the fact that they had not
prepared themselves for some unusual
ly when we are faced with new situations
where a quick, correct decision is essen-
We hope that you too will join in this
information sharing experience. Let us
BY BENGT COLLIN WORKLOAD A STRANGE CONCEPT BY ROLAND RAWLINGS
situation. Yet hindsight is a wonderful tial. This magazine is intended for you, the know about any unusual experiences See page 5
thing and can be of great benefit if used controller on the front line, to make you you have had – we promise to preserve BY
BY PROFESSOR
PROFESSOR SIDNEY
SIDNEY DEKKER
DEKKER See page 8
intelligently to prepare ourselves for the know of these lessons. It contains many your confidentiality if that is what you See
See page
page 66
unexpected. There is much to be learnt examples of actual incidents which raise wish. Working together with the benefit
from a study of other peoples’ actions - some interesting questions for discussion. of HindSight we can make a real contribu-
good and bad. Read them carefully - talk about them tion to improved aviation safety. Front Line Report
The Briefing Room
by Bert Ruitenberg
Editorial 121.5 - Safety Alerts
Learning from Experience
EUROCONTROL Safety New Clearance Related Loss of Separation 11 THE HUMAN FACTOR COLUMN WORKLOAD VERSUS BOREDOM
Enhancement Business Division 2 to Levels 4
Disclaimer
27
28
Hand-over/Take-over of
Operational Position 6
Runway Excursion
Level Bust
19
EUROCONTROL DAP/SAF January 2005 EUROCONTROL DAP/SAF January 2006 EUROCONTROL DAP/SAF June 2006 EUROCONTROL DAP/SSH January 2007 EUROCONTROL DAP/SSH June 2007 EUROCONTROL DAP/SSH January 2008
7
8: winteredition’09 “Hindsight” the ability or opportunity to understand and judge an event or
N°
EUROCONTROL
The ability or opportunity to understand and judge an event or experience after it has occured EUROCONTROL EUROCONTROL
The ability or opportunity to understand and judge an event or experience after it has occured The ability or opportunity to understand and judge an event or experience after it has occured The ability or opportunity to understand and judge an event or experience after it has occured
July 2008
WEATHER Are you responsible Level Bust... Airspace Infringement - Runway excursion
“Hindsight”
EUROCONTROL
DISCLAIMER
The views expressed in this document are not necessarily those of
EUROCONTROL which makes no warranty, either implied or expressed,
for the information contained in it and neither does it assume any legal
liability or responsibility for the its accuracy, completeness or
usefulness.