RCDL Safety E-Magazine Sep'16

1 SAFETY MAGAZINE (Sep 2016)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 recent “FLY DUBAI” accident, FMS DataEntry 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 UpdatesInternal Audit was carried out by Flight Safety Team, consisting of Mr Saurabh Tyagi (CFS), Capt.Abhijit Gokhale and Panini Phadnis and findings have been send to respective departments, whichwill soon be closed.Flight Safety Circular 2 has been released to inform about new FDR Review Procedures.Safety Advisory 2 released suggesting Hazards involved in Li-Ion batteries required for PEDs. RCDL Operations Circulars 1. OC 16/2016- Airport Operating Minima: Defence Airports issued on 30th Jun 2016. 2. OC 15/2016- Operating Procedures: SAM Region issued on 22nd July 2016. 3. OC 14/2016- Operating Procedures: CAR Region issued on 22nd July 2016. 4. OC 10/2016- Northern Atlantic High Level Airspace (NAT HLA) Issued on 13th April 2016. DGCA UpdateDGCA ops Circular 05 of 2016 was released giving in-depth information about pacific operations. Incidents and Occurrence in RCDL (2016)Month Aircraft Incidence/ Occurrence Jan’ 16June 16 VT-ISH After landing on ground smoke was observed in lavatory. Report of OEM is stillSep’ 16 VT-AKU awaited on this issue. VT-HMA Rejected Take-Off (Fuelling CAS Message). PIB report submitted to DGCA Corrective action taken. Ground Turn Back (Brake Problem). After inspection it was found that Brake Pressure Transducer Faulty. Safety Magazine (RCDL, Flight Safety)

3 Major Accidents In 2016 1. ASL Airlines (Hungary) Flight 7332 – A cargo flight from Paris to Bergamo, On August 5, 2016, theRunway aircraft slid off a runway on to a road at Bergamo while landing in bad weather conditions. The aircraft Skid was in DHL delivery. The airport was closed for almost three hours after the crash. 2. Batik Air Flight 7703 – A scheduled domestic flight operated by Lion Air's subsidiary BatikRunway Air from Halim Perdanakusuma Airport in Jakarta to Sultan Hasanuddin InternationalIncursion Airport, Makassar. On 4 April 2016, while taking off from Halim Perdanakusuma Airport, the Boeing 737-800 operating the flight collided with a Trans Nusa Air Services ATR 42-600 (registration PK-TNJ), which was being towed across the runway. 3. Egypt Air Flight 804- A scheduled international passenger flight from Paris Charles de GaulleAccident Airport to Cairo International Airport, operated by Egypt Air, which crashed into the Mediterranean Sea on 19 May 2016 at 02:33 Egypt Standard Time. There were 66 people on board: 56 passengers, 7 aircrew, and 3 security personnel. No survivors were found. 4. Emirates Flight 521- A scheduled international passenger flight from Thiruvananthapuram, India,Serious to Dubai, United Arab Emirates, operated by Emirates using a Boeing 777-300. On 3 August 2016,Accident the aircraft carrying 282 passengers and 18 crew crashed while landing at Dubai International Airport, at approximately 12:45 local time. All 300 people on board survived the accident and were evacuated from the aircraft; 24 were injured. An airport firefighter died during the rescue operation and another eight were injured. 5. Singapore Airlines Flight 368- A scheduled international passenger flight from Singapore Changi Airport to Milan–Malpensa Airport in Italy. On 27 June 2016 the Boeing 777-300ER operating the flightEngine turned back to Singapore after an engine oil warning. After the aircraft landed back at Changi Airport Fail the affected engine caught fire, seriously damaging the 777's wing. There were no injuries among the 241 passengers and crew on board. 6. Korean Air Flight 2708 - On 27 May 2016, a Korean Air Boeing 777-300 operating from Tokyo Haneda Airport to Gimpo Airport was accelerating for take-off at Haneda Airport when the aircraft's left engine suffered a failure and a substantial fire ensued. The aircraft rejected the take-offFIRE and the fire was put out by the fire services at the airport. All 319 passengers and crew were evacuated; 12 occupants were injured. Safety Magazine (RCDL, Flight Safety)

4 CASE STUDYFLY DUBAI FZ 981 CRASHINCIDENT:After circling a southern Russian airport for more than two hours because of high ground-level winds andpoor visibility, a Flydubai passenger jet from UAE crashed during a landing attempt, killing all 62 peopleaboard.Flight FZ 981 crashed on landing and that fatalities have been confirmed as a result of this tragic accident.The airplane departed from Dubai International airport (DXB) at 18:20 local time bound for Rostov on Don(ROV) at approximately 00:50 GMT.The flydubai Boeing 737 took off from Dubai and was scheduled to land at the Rostov-on-Don airport at1:20 a.m. Saturday (6:20 p.m. ET Friday), Russian Emergencies Minister Vladimir Puchkov said.But it didn't come down -- about 800 feet from a runway -- until 3:50 a.m.By that point, Russian state media reported, there were winds of about 60 mph.IMPORTANT REFERENCE POINTS:Fly Dubai began operating in 2009 and mostly uses Boeing 737 aircraft.Pilots were \"quite experienced,\" saying the Cypriot captain had flown 5,965 hours while the Spanish co-captain had flown 5,769 hours.According to the airline CEO: The plane had passed the safety check.He added that the aircraft passed a \"C-Check\" on January 21.CAUSE:Authorities have ruled out terrorism as a cause of the crash. Instead, according to investigative committeespokeswoman Oksana Kovrizhnaya, they will be looking at three possibilities: technical issues, severeweather and human error. Safety Magazine (RCDL, Flight Safety)

5The plane's pilot had circled the airport hoping the weather would clear, Russia's emergency minister said.After more than two hours, the pilot attempted to land.Instead, the aircraft's tail clipped the ground as it approached Rostov-on-Don's airport, killing all 55passengers and seven crew members.CNN aviation expert Mary Schiavo said radar suggested the plane had flown three large, looping circlesaround the airport before it crashed.\"Poor visibility is probably the biggest clue,\" Schiavo said. \"But this runway was lit, it had good lighting atone end and passable lighting at the other and it did have an instrument landing system.\"\"With the clue of bad weather and making at least three different circles trying to reorient to thisrunway, it does look like pilot disorientation.\"Aviation safety analyst David Soucie agreed with the ministry's preliminary assessment that weather waslikely to blame.\"It's not likely it was a mechanical failure,\" Soucie said. \"It's most likely a weather-related incident.\"SOURCES: CNN / Flydubai website /Sputnik news/Russia 24 /Ria Novosti Safety Magazine (RCDL, Flight Safety)

6 Common Error Types and Best PracticeMitigations by Phase of FlightPlanning – errors in the data that pilots take onto the flight-deck with them, and ultimately enter into theFMS, can begin well before they board the aircraft:TRAPS MITIGATIONSMass & Balance – aircraft mass and balance data The operator’s quality management system mustlike aircraft basic weight and centre of gravity, include regular audits of the process by which thesewhether it is stored on a database or recorded on data are derived and the accuracy of the valuespaper, may be incorrect and will ultimately affect themselves.the zero fuel weight (ZFW) and ZFW centre ofgravity (ZFWCG) entered in the FMS. All discrepancies should be reported via the safety management system (SMS) reporting program andFlight Plan – the operational flight plan, which addressed appropriately.may be calculated manually by the pilots or moreusually nowadays generated by flight planning Standard Operating Procedures (SOPs) must includesoftware, may be incorrect and include erroneous appropriate cross-checks for all manually calculatedinformation for take-off weight, fuel burn, route, flight planning data.winds and cost index. SOPs must include appropriate gross error checksLoad and Trim Sheet – aircraft loading that is for all computer generated flight planning data.contrary to the loading instruction or mistakes in Pilots should check that the operational flight plancalculations made by the load controller may matches the ATC filed plan.introduce errors to data required for the FMS. SOPs for load control must include appropriateNavigation Database – latent errors may exist in gross error checks and cross-checks for loadingthe navigation database. data. The SMS reporting program must be non-punitive and encourage loading staff to report errors and discrepancies in loading. Education and training for loading staff will help spread an understanding of the importance of loading accuracy. The contracted navigation database provider must be able to demonstrate the assurance processes it uses to ensure accuracy, and undertake to adhere to them. The operator’s quality management program must include regular audits of database accuracy. SOPs must include a check of the navigation database currency before flight. All discrepancies should be reported via the SMS reporting program and addressed appropriately. Safety Magazine (RCDL, Flight Safety)

7Safety Magazine (RCDL, Flight Safety)

8 CASE STUDY- Singapore AirlinesSummary:On 19th December 2013, the left engine of a Boeing 777-200 taxiing onto its assigned parking gate after arrivalat Singapore ingested an empty cargo container resulting in damage to the engine which was serious enough torequire its subsequent removal and replacement. The Investigation found that the aircraft docking guidancesystem had been in use despite the presence of the ingested container and other obstructions within the clearlymarked 'equipment restraint area' of the gate involved. The corresponding ground handling procedures werefound to be deficient as were those for ensuring general ramp awareness of a 'live' gate.Description:On 19th December 2013, a Boeing 777-200 (9VSRP) being operated by Singapore Airlines in a scheduledpassenger flight from Mumbai to Singapore ingested an empty cargo container into the left engine as it taxiedonto the designated arrival gate at Terminal 2 at Singapore with normal daylight visibility. The enginesustained serious damage and had to be replaced. No persons on the aircraft or on the ground were injured.Investigation:An Investigation was carried out by the Singapore Air Accident Investigation Bureau.It was established that the ingested container and two attached baggage trailers had been wholly within thedesignated Equipment Restraint Area (ERA) of the designated arrival gate F37 at the time the gate entryguidance system had been switched on by the ground service provider personnel covering the arrival of theaccident aircraft. They were located just clear of the red hatched area marking the extent of the PassengerLoading Bridge (PLB) safety zone.It was also noted that the commander of the arriving aircraft had observed that the aircraft docking guidancesystem was not switched on, as the gate area was approached and had stopped the aircraft prior to gate entryfor approximately 20 seconds until it was.It was found that the Ground Service Provider's arrival crew - two technicians - had arrived at the gate about25 minutes prior to the expected arrival of the aircraft. The technician in charge of the crew was a 'CertifyingTechnician' (CT) and the other technician was a 'Lead Technician' (LT) under training to himself qualify as a CT.Whilst the CT checked the correct function of the PLB, the LT \"inspected the ERA to ensure that it was clear ofobstructions and equipment\" They then waited below the PLB for the aircraft to arrive and no further inspectionof the area was carried out as it was not required by procedures. About 15 minutes prior to the actual arrival ofthe aircraft, another CT joined the arrival crew and was assigned to act as the chock bearer.Meanwhile, an A330 was due to arrive at the adjacent gate F42 shortly after the 777 had arrived on F37. AnEquipment Operator (EO) from different Ground Service Provider arrived driving a tractor towing two baggagecontainers which, on seeing that the ESA for gate F42 was already full, he then left just within the ESA of gateF37, returning few minutes later to attach an empty cargo container on a dolly to the two baggage trailers sothat all three trailers were within the F37 ESA.The EO then waited for an A320 to depart from gate - F42, expecting that when it did, some of the handlingequipment serving the A320 would be moved which would release some ESA space. However, with the A320still on the gate after Safety Magazine (RCDL, Flight Safety)

9Fig: The empty container dolly and attached baggage containers after the ingestion (reproduced fromthe official report)about 10 minutes, he decided to try and rearrange equipment in the gate F36 ESA to make room for his trailersin the gate F42 ESA. Just as the aircraft docking guidance system had been activated and the 777 wasproceeding into gate F37, he left the area, leaving the baggage trailers and the cargo container behind.The LT acting as chock bearer walked slowly towards the approaching aircraft and \"only then … noticed thecargo container and baggage trailers.” He reported having called out to the technician in charge who wasoperating the PLB to try to get him to stop the aircraft using the guidance system but the noise of the enginedrowned out his voice and the cargo container had been sucked into the left engine before the aircraftreached the stop line.The Investigation noted that the aircraft commander, although he had not announced verbally that the left sideof the gate area was clear, reported that \"he had done a visual sweep of the area from his position and did notnotice any obstructions\". In order to understand what the chances of pilots detecting obstructions on a gatearea which they would not expect if the aircraft docking guidance system was 'live', the Investigation team setup a simulation on the gate concerned using a towed 777 aircraft. This exercise (see the picture on the nextpage) led to the conclusion that \"it was not easy to judge “whether the cargo container and the two baggagetrailers would have been in the ERA or not, although \"one could infer, from the fact that the PLB safety zonecould not be seen\", that the cargo container and the baggage trailers were in the ERA because they werepartially obscuring the marked PLB safety zone and the wheels of the air bridge. The Conclusion of the Investigation was that the ingestion incident was the result of the incorrect positioning of the cargo container/dolly and the baggage trailers in the ERA and:• The failure of the Ground Service Provider's arrival crew to continue to monitor the ERA to ensure that it remained clear of obstructions and equipment, after they had done one round of inspection.• The failure of the inbound aircraft flight crew to detect that there was equipment within the ERA Safety Magazine (RCDL, Flight Safety)

10It was noted that in the light of the findings of the investigation :\"it may be useful for flight crews to check fortell-tale signs that might suggest an abnormal situation in the ERA, for example, when the hatched lines of thePLB safety zone or the wheels of the aerobridge are not visible\".Safety Action taken by the Aerodrome Operator whilst the Investigation was in progress was recorded asincluding the following:• Increased the frequency of airside inspections and safety audits on Ground Service Providers• Has limited the use of gate involved to smaller aircraft to allow provision of a bigger equipment storage area for both this and the adjacent gate and service vehicle access.• Initiated a comprehensive review of the aircraft parking bay layout at the airport.• Replaced all remaining 30-key aircraft docking guidance system operator panels with the 54-key alternative to standardize operating procedures.Also the Aviation Regulatory Authority found that “there was no one organisation or person who was overallin-charge and responsible for the various ground handling activities conducted by multiple parties at the bay\"and has since required that aerodrome operator \"to ensure that there is an overall person-in-charge of theoperations at the bay for each arrival flight so as to ensure that the operations are carried out safely at thebay\".Three Safety Recommendations were made as a result of the Investigation as follows:• That the Aerodrome Operator should look into having a system that can clearly indicate to all working in the bay and adjacent areas the operational status of a bay.• That the Operator should remind its flight crews that if the view of the hatch lines of the PLB safety zone or the wheels of the aerobridge were obscured, it could suggest an abnormal situation in the ERA.That the Ground Service Provider (responsible for the operation of the gate area during the arrival of theincident aircraft) review its procedures to ensure that there will be continuous surveillance of the parking bays. Safety Magazine (RCDL, Flight Safety)