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Safety
Issues in International Operations
Last year's fatal accident
near Cali, Colombia has heightened awareness of safety issues associated
with U.S. air carrier flights in foreign airspace. Although language problems
might be expected to be a key factor in foreign airspace incidents, a
recent analysis of foreign airspace operational incidents reported to
the ASRS revealed that the largest percentage -- 40% -- was attributed
to pilot errors. These errors included loss of situational awareness,
confusion, flight crew complacency, and breakdown of CRM -- the same types
of errors that occur in U.S. airspace. Another 25% of the reports cited
a language problem as a primary cause of the incidents, while 20% were
related to aircraft or ATC navigation or communication equipment problems.
A Second Officer's report illustrates
the situational awareness and crew communication problems identified in
many of the foreign airspace incidents analyzed by ASRS:
- After departing
[a foreign airport], I noticed a discussion between the pilots about
being unable to contact ATC due to frequency congestion to obtain a
higher altitude. We were on an IFR flight plan in VMC conditions. We
had just crossed XYZ intersection at FL120. We continued west, on course
into mountainous terrain, 6,000 feet below the minimum crossing altitude
of FL180. We were 14 miles west of XYZ intersection before we received
an urgent clearance from ATC to climb to FL260. We were flying through
valleys into rising terrain and with terrain above our aircraft. I examined
the pilot's departure page and realized how low we really were on the
departure profile.
A new-hire Captain was flying
left seat. A check Captain was flying in the right seat working the radios.
No comments were made by either pilot as to why we proceeded west of XYZ
so far below the minimum crossing altitude.
Lost
in the Translation
The language-related problems
cited by ASRS reporters in foreign airspace operations include unfamiliar
controller phraseology, a controller's unclear English or heavy accent,
and readback/hearback issues. A Captain's report of a near runway incursion
provides a glimpse of the language barrier sometimes experienced:
- During taxi,
Tower issued instructions in a very heavy [European] accent that sounded
like, "Cleared into position and wait." The First Officer,
employing a phraseology that is common in the U.S., asked in a very
clear and enunciated fashion, "Did you clear us into position and
hold?" The Tower's answer was "Yes." I proceeded beyond
the ILS [critical area] hold line. The Tower shouted, "Stop!"
We spotted an airliner breaking out of the clouds. Although we never
penetrated the area of the runway, the sudden stop, the proximity to
the runway, and the sight and sound of the landing aircraft scared all
of us.
It is clear that we misunderstood each other. In all probability, he
said, "Cleared to the hold line and wait." Perhaps if we had
asked him, "Do you want us to go on the runway?" he would
have responded with a strong "No!"
The reporter realized after
the fact that the crew either misheard or misinterpreted the Controller's
clearance. Regardless, the reporter's suggestion is a good one: seek clarification
by rephrasing the clearance in plain, simple words, different from those
used by the controller. Although some foreign controllers may not have
a broad command of English, they often will understand the crew's restated
questions and be able to provide clarification.
Other pilot recommendations
for dealing with language problems include:
- Speak very
slowly; this often results in the controllers slowing down their rate
of speech also, making the instructions more readily understood.
- Anticipate
that the controller may pronounce the fix or identifier differently
than you expected to hear it or than you would pronounce it yourself.
Although the language being
used on the radio may be the native language of that country, the
use of any language other than English can leave many pilots out of the
communications loop. A number of reporters cited this as lack of a "partyline."
Our next reporter explains how this problem can impact safety:
- On approach
to [a foreign airport] , we were cleared for the ILS. When we first
checked in with Tower, we were told to continue...then cleared to land.
At 700 feet AGL, we noticed foreign Aircraft B taxiing onto the extended
threshold for the runway. At 400 feet, the Tower told us to go-around.
We were vectored back for the ILS...and made a normal landing.
Factors: we did not know if the other aircraft was cleared into
position or for takeoff because...the Tower and Aircraft B's aircrew
were using a foreign language. Had they been using English, we would
have heard any conflicting clearance given to Aircraft B.
If pilots think there may be
other aircraft in their immediate vicinity, they need to query the controller
for information or clarification.
Reporters'
Words of Special Thanks
ASRS reporters often express
their gratitude to controllers, fellow crew members, and others for helping
them avoid -- and sometimes survive -- hazardous encounters and experiences.
In our first report, the First Officer of a cargo jet praised the other
flight crew members, and came to appreciate the value of a properly-trained
ground crew, after the aircraft experienced a problem due to unsecured
cargo.
- At 6-8 degrees
nose up, I felt the aircraft shudder and begin to pitch up. At 14-16
degrees, the Captain and I together were holding the yoke to the full
forward position, and the aircraft was beginning to lose airspeed and
still pitching up. The Captain initiated a left bank...and the aircraft
slowly began to increase in speed and decrease in pitch...until ever
-so-slowly, it began to become more manageable.
Five pallets of cargo, a combined total of approximately 20,000 lb.,
had shifted aft two positions, damaging several stringers and knocking
6 x 5 inch hole in the fuselage skin. By pulling back the power, the
Captain was able to pitch down slightly, enough for [the Flight Engineer
and me] to move one heavy pallet forward and tie it into place. With
a shallow descent and a straight-in approach, the Captain was able to
land successfully.
Crew coordination was exemplary during this crisis. At one point I thought
we might not be able to regain control of the aircraft. I would like
to thank the crew for their diligent efforts. We were able to avert
a critical situation, due solely to improper cargo loading and securing.
Flight safety truly is a matter
of teamwork, requiring both flight crew and ground crew to be well-trained
and conscientious in their respective areas of specialty.
"Assault
and Battery of the Wind"
-William
Butler Yeats
An air carrier Captain tells
a harrowing tale of an encounter with wind shear, and extends thanks to
quite a cast of behind-the-scenes actors:
- We performed
a normal takeoff. At approximately 800 feet AGL, our airspeed dropped
rapidly. At the same time, the wind shear warning activated. I put my
hand on the First Officer's hand and together we pushed the throttles
all the way to the stops. Even with the engines giving us everything
they were capable of, our airspeed hung at V2 plus 5 knots. We used
our available energy to arrest the descent, and then evidently burst
clear of the wind shear. The encounter lasted maybe 20-30 seconds. The
remainder of the flight was uneventful.
The Flight Attendant did tell me she heard the wind shear warning from
her jumpseat, and she thanked me for getting us out of the wind shear.
It was not me that saved us. It was our team working together.
I am pleased with the training we have received on wind shear. I want
to thank [everyone] who came up with the wind shear guidance equipment
and the procedures to use it. I want to thank our ground instructors
for teaching us and simulator instructors for testing us and refining
our technique. It works.
Close
Encounters... Of the Political Kind
- Enroute,
the Captain and I got into a political discussion. It developed into
a noisy argument, without our being aware of it until the Flight Attendant
[FA] came into the cockpit and sat down quietly in the jumpseat. It
was probably because our bickering was audible through the door and
was becoming a concern to the First Class passengers. I am thankful
to the FA for being proactive in diffusing the situation.
Kudos to the Flight Attendant
for getting into the Crew Resource Management loop. Now that national
and local elections are past, we expect not to see reports like this one
for a while.
Waxing
Eloquent
Last month we reported on how
an insect nest in a fuel tank vent caused the implosion of the fuel tank.
Here, we look at a case of malfunctioning instruments caused by the human
touch. The Captain of a corporate jet reports:
- During takeoff
roll, passing through 100 knots, airspeed difference was noted between
Captain's and First Officer's airspeed indicators. As airspeed increased,
the difference between the two systems became larger. As the ADC [Air
Data Computer] sensed the airspeed difference, the ADC miscompare alert
illuminated, the yaw damper inop alert illuminated, the yaw damper disengaged,
the elevator trim inop alert illuminated, and the elevator trim disengaged,
along with the autothrottles disengaging. With all these cautions and
their associated chimes, there was a great deal of activity, including
IMC almost immediately after takeoff.
The SID calls for level-off at 2000 feet and 200 knots airspeed. Well,
we missed both of those. The airspeed difference remained for approximately
20 minutes, then went away, restoring all systems.
Cause: the aircraft had been waxed the day before, and burned wax residue
was found in the Captain's pitot tube on postflight.
Meticulous pre-flights are
as important after a wash-and-wax job as after maintenance work.
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ASRS
Recently Issued Alerts On.
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Undetected
generator failure on a B-747
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Failure
of a radar control indicator at a Texas TRACON
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A
hydraulic fluid leak into a B-757 engine pylon
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A
traffic conflict with hang gliders on a California arrival
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A
potential stall on approach attributed to a false GPWS
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August
1996 Report Intake
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Air
Carrier Pilots
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2,178
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General
Aviation Pilots
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831
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Controllers
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177
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Cabin/Mechanics/Military/Other
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49
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TOTAL
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3,235
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