RCDL Safety E-Magazine Mar 18

1 SAFETY MAGAZINE (MAR 2018)The posting of stories, articles, reports and documents in this magazine doesnot in any way, imply or necessarily express or suggest that all theinformation is correct. It is based on details gathered from various sourcesand is for information purpose only. The Flight Safety Department is makingthis material available in its efforts to advance the understanding of safety. Itis in no way responsible for any errors, omissions or deletions in the reports.In this issue we will be talking about latest circulars, recent incidents in India,FMS Data Entry Error Prevention and other safety articles.Be safe and Enjoy flying!!!!Saurabh TyagiCFS, RCDLPublished By-Flight Safety Department,Reliance Commercial Dealers LimitedReliance Hangar,Gate No-08, Old Airport, Kalina Military Camp,Santacruz (E), Mumbai-29, India Don't Learn Safety by Accident Safety Magazine (RCDL, Flight Safety)

2 Flight Safety UpdatesFlight Safety Circular 1 of 2018 has been released to reiterate BA procedures.Flight Safety Bulletin 1 of 2018 has been released n concern to “PITOT HEATING”FSDS Circular 01 of 2018 has been released to reiterate Acknowledgement procedure.ERP & FSM have been revised to cater changes in Regulations.A new Issue of SMS Manual has been issued.Flight Safety Feeds and Promotions released this year  Runway Incursions at Mumbai Airport. On 22nd Feb 2018 A Flight Safety Survey (SMS) was launched. A SMS training was on conducted 09th December and 27th January. RCDL Operations UpdateOps Circular 03 Series about Latest Document Revisions DGCA UpdateRevision to CAR Section 8 Series F Part VIII - Flight Crew Training and Qualification Requirementsfor Scheduled Commuter and Non-Scheduled Operators having Aeroplanes with AUW Exceeding5700 Kgs DGCA Circulars SSP Circular 02/2018 Guidance Material for preparation of Safety Management System Manual.Incidents and Occurrence in RCDL (2017/18)Month Aircraft Incidence/ OccurrenceDec’ 17 VT-AKU Air Turn Back due to DEEC FailDec’17 VT-JMN/ VT-DHA Ground Collision during parkingJan’18 VT-AHI Air Turn Back due to L FADEC FAIL Safety Magazine (RCDL, Flight Safety)

3 Major Incidents In 2018 1. A Vistara Airbus A320-200N, was in the initial descent towards Pune and an Air India Airbus A319-100 was climbing out of Mumbai. Both aircraft received TCAS resolution advisories, the aircraft crossed each other (the A319 climbed throughNear the level of the A320N, A320N descended through the level of the A319 during theCollission TCAS resolution). After being clear of conflict both aircraft continued to their destinations for safe landings. DGCA reported the separation between the two aircraft reduced to 0 feet vertically and less than 2nm laterally. ATC had cleared UK-997 to descend to FL290 while AI-631 had been cleared to climb to FL270. UK-997 continued to descend below FL270, TCAS resolution advisories were triggered in both flight decks, UK-997 crossed through to level of AI-631. The occurrence was rated a serious incident and is being investigated. 2. An Indigo Airbus A320-200, registration VT-IEH performing flight 6E-334 from Hyderabad to Raipur (India), was enroute at FL330 nearing the top of descent into Raipur when ATC cleared the flight to descend to FL250. Near An Emirates Boeing 777-300, registration A6-EPJ performing flight EK-353 from SingaporeCollission (Singapore) to Dubai (United Arab Emirates), was enroute at FL300 on a crossing flight trajectory. Both aircraft received TCAS resolution advisories and followed the resolution advisories until being clear of conflict. Both aircraft continued their journeys to their destinations for safe landings. India's DGCA reported ATC cleared flight 6E-334 to descend to FL250 through the level of EK-353. Both aircraft received and complied with TCAS resolution advisories, the minimum separation reduced to 700 feet vertical and 1nm lateral. Both crews reported the TCAS RA to ATC, the Emirates crew called the TCAS RA for a total of three times, however, ATC still instructed 6E-334 to descend at FL305 contrary to TCAS resolution advisory instructions. The occurrence was rated a serious incident and is being investigated.. Safety Magazine (RCDL, Flight Safety)

4CASE STUDY- CABIN CREW A well-handled case of burnsThe incident:A passenger complained of hot coffee spillage on his left arm by accident.Cabin crew actions:The crew member approached the gentleman and assured him that there wasnothing to worry about.The crew member assisted the passenger to the lavatory and asked him to puthis hand under cold running water till the burning sensation wears off.The crew member directed him to gently remove any rings and watches.The crew member applied the prescribed ointment followed by burn dressing.The passenger felt better afterwards.Things crew must do:The crew should approach passengers with confidence and keep them calm.The crew should inform passengers that they are trained first aid providers andreassure them.The crew should assist the passenger to the lavatory and check if watertemperature is suitable (water should be cool). Safety Magazine (RCDL, Flight Safety)

5 Failure to Communicate Hearing and understanding –the spoken word is crucial to safe flightLike distortions in the visual modality, distortions in auditory sensation (the receiving of stimuli) andperception (the interpretation of those inputs) can reduce safety margins by adversely affectinghigher level cognitive functions such as decision making. Unlike the visual sense, auditory sensation isomnidirectional, enabling voice messages and aural warnings within hearing range to be detected.However, auditory inputs, such as verbal messages, are transient, can be forgotten and, like visualstimuli, are subject to misinterpretation.This article highlights some of the important factors that contribute to auditory misunderstandingson the flight deck, and suggests mitigation strategies to overcome them.Ambiguous CommunicationThe recent International Air Transport Association (IATA) Phraseology Study found the use of non-standard and/or ambiguous phraseology by ATC was the biggest communication issue for 2,070airline pilots surveyed. Ambiguous messages consist of words, phrases or sentences with more thanone meaning. For example:A flight attendant called the flight deck and told the captain to “turn around” so he turned theairplane back toward the departure airport because he “perceived her comment to mean that theflight was in jeopardy and the aircraft should be turned around and returned to [departure airport].”4However, she had only wanted him to “turn around” to see that the cabin door had opened andneeded closing. Safety Magazine (RCDL, Flight Safety)

6After being cleared to land on Runway 24, a pilot was asked by the tower controller, “Can you makeRunway 15 Left?”The pilot said he could and positioned the airplane to land on that runway. However, the controllerwanted to know if, after landing on Runway 24, the pilot could make the first available left turn ontoRunway 15 Left.Numbers are particularly vexing, especially homophones (words that sound the same as otherwords), such as “two” (“to”) and “four” (“for”). Ambiguous usage or interpretation of these fourwords — cited as the second biggest communication problem identified by pilots in the PhraseologyStudy — was responsible for a fatal CFIT accident involving a Boeing 747 on final approach to SubangAirport, in Kuala Lumpur, Malaysia, in February 1989. The crew misperceived ATC’s clearance of“descend two four zero” (descend to 2,400 ft) as “to four zero” (descend to 400 ft).Since numbers can refer to a variety of parameters in flight — headings, altitudes, airspeeds, etc. —even no homophonic numbers can be confusing. For example, after clearing a Learjet to “climb andmaintain 14,000 feet,” the controller issued instructions to “fly heading two zero zero.” The pilotread it back as “two zero zero” then proceeded to climb to 20,000 ft.Readback-HearbackAccidents can occur if a pilot incorrectly reads back a clearance (the readback problem) and thecontroller doesn’t recognize it (the hearbackproblem). The pilots in the Kuala Lumpur accident andNairobi incident inaccurately read back their altitude assignments and the controllers failed to catchand correct the mistakes. A breakdown in this feedback loop (Figure 1) often occurs whencontrollers are too busy to acknowledge the readback; unfortunately, pilots often interpret thissilence as acceptance of their readback.Pilots sometimes hear what they expect to hear. For example, a wide-body jet was cleared to FL 230on a heading of 340 degrees, and because the flight plan called for a final cruising altitude of FL 340,the crew did not fly the heading because they interpreted the instruction to mean “expect FL 340.”Code Switching Sometimes multilingual speakers switch between English and their mother tongue; or unilingual speakers may switch between different English dialects (e.g., aviation English and normal English). This code switching occurs for a variety of reasons, including the natural tendency to revert to previously learned behaviour when under stress.Code switching may explain the otherwise confusing phrase “We are now at take-off,” spoken by the Dutch first officer (FO) of a KLM Boeing 747 before it collided with a Pan American 747 on a runway at Tenerife in Spain’s Canary Islands in 1977, killing 583 people in the worst aviation disaster in history. The controller interpreted “now at take-off” to mean the KLM flight was in position for take-off; to the FO, using a mixture of English and Dutch grammar, “now at take-off” meant the airplane was actually taking off. Safety Magazine (RCDL, Flight Safety)

7 CASE STUDYSummary:Jet Airways flight 9W354 was involved in an accident after landing at Mumbai.The aircraft landed safely on runway 27 and was about to vacate the runway via taxiway N9 whenthe right main landing gear collapsed. There were no injuries to any person onboard the aircraft.The aircraft sustained substantial damage.Factual Information:The landing was carried out by co-pilot and captain was carrying out Supervised Line Flying (SLF).During landing flare, aircraft floated a little and the touchdown was normal. The aircraft landedwith a vertical acceleration of 1.44 G. About 16 seconds after touch down, at a speed of around 58kts, there was right roll of 4.57° and the aircraft started veering to the right with a noise which feltlike a tire burst to the cockpit crew.To maintain directional control first officer moved the tiller. The aircraft vacated via taxiway N9 andstopped on the taxiway with the tail of the aircraft not fully clear of runway 27. Taxiway N9 is about2600 meters/8550 feet down the runway 27. Flaps were moved to 40, in case if the situationwarranted an evacuation. Thereafter, the captain contacted the Jet Airways dispatcher. Also, theAPU was started and engine no.2 was shut down, followed by engine no.1.Meanwhile the airport fire service attended as the ATC controller had observed sparks from theright side of the aircraft after landing. On arrival of passenger stairs, the occupants were safelydisembarked through the L1 door and no emergency evacuation was carried out.An investigation revealed that a main landing gear aft trunnion pin had failed as a result ofimproper grinding during overhaul. Several trunnion pins were overhauled by the same company.The first failure occurred on April 13, 2015 to a Jet Airways. During landing rollout at KhajurahoAirport, the left hand main gear aft trunnion pin failed.According to maintenance records two sets of trunnion pins had been overhauled. As aprecautionary measure, on 20 August 2015, the aft trunnion pins of VT-JGC were removed from theaircraft. After the accident involving VT-JGD, it appeared from maintenance records that in factthree sets of trunnion pins (including VT-JGD) had been overhauled by the same company. Safety Magazine (RCDL, Flight Safety)

8Probable Cause:The Committee of inquiry determined the cause of accident as \"The RH Aft landing Gear trunnionpin failed due to base metal heat damage as a result of abusive grinding of the chrome plate thatlikely occurred during the last overhaul\". Safety Magazine (RCDL, Flight Safety)

9 COST CUTTING IN AVIATIONGeneral- Aviation is a costly business being labour capital and technology intensive, besidesexternal environment changes. However, cost control has become more and more important foraviation industry in the recent years. The aviation industry has primarily five factors for operationalcost control that include fuel cost reduction policy, operation procedure simplification, employeeproductivity improvement, flight operations, aircraft maintenance cost reduction strategies.Aviation Operating Cost component- The operating cost component perspective can be followedas a combination of Top down and bottom- up procedure thus providing the decision makers andline employees simultaneously with resource allotment references. The five major criteria forreducing operations cost control are as under: a. Fuel Cost Reduction policy- i. Reduce Empty Weight and subsequently dead weight of the aircraft ii. Improve aircraft fuel saving performance iii. Conduct fuel hedging strategies. iv. Optimise fleet dispatch by utilising aircraft as per sectors for best fuel efficiency. b. Employees Productivity - i. Improve employee productivity by optimising FDTL and FTL. ii. Schedule reasonable flight hours for flight and cabin crew iii. Encourage employees to provide cost cutting strategies. iv. Optimise group Insurance for its employees. v. Utilise crew for mixed fleet operations. vi. Keep employees motivated and efficient. vii. Follow policy for employees to last longer in organisation. viii. Adhere to highest standards of training for minimising incidents/accidents. c. Flight Operations- i. Plan efficient flight routes and alternate airports, reduce taxi fuel. ii. Plan good weather routes to avoid diversions iii. Optimise flight speeds for each flight segment using fuel efficient cost index. Safety Magazine (RCDL, Flight Safety)

10 iv. Optimise flight landing procedure using minimum flap and idle reverse thrust landing procedure v. Utilise GPU instead of APU for Ramp operations. vi. Optimise passenger/aircraft utilisation for the same route. vii. Integrate fuel saving policies with internal safety audits. viii. Reduce cost by booking appropriate slots for parking/landings. d. Maintenance Cost reduction- i. Optimise Maintenance scheduling ii. Preventive maintenance plan in place iii. Monitor the life cycle of parts to prevent unexpected malfunctions/breakdowns iv. Reduce the downtime aircrafts to minimums v. Establish maintenance resource sharing networks i.e. sharing hangars, spares, materials thus lowering inventory and maintenance cost vi. Utilise e maintenance supply chain and networks to track orders efficiently and reduce spare inventory cost. vii. Replace old aircrafts viii. Prefer leased aircrafts over purchase of aircrafts.Conclusion- No amount of procedure or system is adequate to ensure cost cutting in aviation ifno structured policy on the subject exists in a company. This policy must be based on factors thatgovern day to day functioning of the company and must be integrated with working ethos andemployees robust feedback system.Helicopters crash rates are @ 9.84 fatality per 100,000h of flight vis a vis fixed wings which is 7.28fatal internationally. Hence, how much ever cost cutting plan is implemented it must notcompromise the quality of training of its crew and maintenance staff to minimise human error andavoiding any damage to reputation due to incidents/accidents.(Capt. JK Mishra)Lt Col JK Mishra is a Helicopter pilot who has had an incident free flying career spanning over 26years, accumulating approximately 8250h and is also a DGCA approved Check pilot on DauphinAS365N3+ helicopter. Safety Magazine (RCDL, Flight Safety)

11 Safety Survey Analysis 1. Are you aware of Safety Management System? Yes- 69 No- 1 2. Do you have Access to organization Manuals and procedures? Yes-70 No-0 3. Have you been given your Job descriptions/ Responsibilities? Yes-66 No-4 4. Have you ever attended the SMS training? Yes-69 No-1 5. You are able to openly discuss safety problems with your manager? Yes-67 No-3 6. You are encouraged to consider safety more important than your regular schedule… Yes-66 No-4 7. Are you aware that Hazards in any organization are linked to the accidents/Incidents? Yes-70 No-0 8. Effective and adequate training is provided to enhance skills to carry out normal duties safely? Yes-68 No-2 9. Do you feel ownership of your Job? Yes-66 No-410. I am satisfied with the safety Promotion Material such as Bulletins, Magazines… Yes-65 No-5 Safety Magazine (RCDL, Flight Safety)