NEWSLETTER

11 AUGUST 2015 INDSAFE NEWSLETTERIndiGoWE ARE MADE IN MANAGING SPEED FUEL MONITORING ‘JUST CULTURE’ INDIGO DURING THE CLIMB PHASE IndSafeHEADLINES !1 Fuel monitoring on the A320 plane.………………………………………………..Pg - 5 Understanding and managing speed during the climb phase…………………..Pg -11 A “Just Culture” in aviation safety reporting system.…………………………….Pg -13 Case study from the SEP desk………………………………………………………Pg -15 AOCS case study……………………………………………………………………..Pg -17 Aviation medical bulletin…………………………………………………………….Pg -19 Report an Incident……………………………………………………………………Pg - 23 icare - Employee Assistance Program (EAP)……………………………………….Pg-24

11 AUGUST 2015 INDSAFE NEWSLETTERDear Colleagues, Stay forever 6E Let’s create and maintain a safe environment. Doing our bit during our preflight and post flight checks helps us stay alert and expect the unexpected. This safety update is a reminder to be vigilant at all times. Article one - Talks of Fuel Monitoring Systems and monitoring of fuel by flight crew. The article covers a couple of incidents on Airbus A320 airplanes regarding undetected fuel quantity issues by maintenance and flight crew during pre and post flight checks. It reviews flaws that can occur inflight with fuel detecting techniques due to computer failure, some of which were not monitored and logged accurately by flight crew. Incidents like these are few and far between but still are a matter of concern. Regular fuel checks, monitoring & reporting are a key to help avert any untoward situation and ensure safe operation. Article two - Examines aspects of establishing a “Just Culture” in aviation safety occurrence reporting systems. A ‘Just Culture’ uses air accident investigation processes solely for aviation safety and to avoid future accidents, not for judicial investigation of those cases. It disagrees with the intermingling of judicial and safety processes. Instead, all air safety investigations and reporting are to be kept completely separate from judicial investigations, to avoid blame and liability while focusing on air safety only. Article three - Looks at aspects of speed control during the climb phase after takeoff. All pilots are to manage a safe and steady climb by closely monitoring the manoeuvring speeds and limit speeds. It also covers operational recommendations advising pilots to manage configuration changes involving gears, flaps and slats retraction among others, while accelerating to climb speed and finally to cruise speed. Our first case study, an incident that involved a minor accident between an empty cargo truck and tractor on the airport periphery road in the early hours of the morning is a reminder, to avoid taking our surroundings for granted. Poor lighting in the area and poor judgement by both drivers may have been the cause of an avoidable situation. 2!

11 AUGUST 2015 INDSAFE NEWSLETTERAnother case study tells of an incident where a passenger inadvertently deployed the over wing exit slideduring the boarding process. These random instances of neglect not only cause structural damage but mayinjure personnel, also adding to unnecessary costs for the airline. Cabin crew and flight crew need to beattentive at all times so incidents like these may be avoided.Once again we wrap this update with health and diet tips. This month’s aviation bulletin by Harvey Watt & Co.gives you an insight into diabetes ,its early detection and heart problems caused due to low physical activityand long hours of sitting.On a more positive note, do read the benefits of exercising regularly and laughing often.Fly Safe-Fly Wise…Capt.Dhruv RebbapragadaChief of Flight Safety !3

11 AUGUST 2015 INDSAFE NEWSLETTER 4!

11 AUGUST 2015 INDSAFE NEWSLETTERARTICLE1FUEL MONITORING ON THE A320PLANE FUEL DETECTIONSince the first A320 entry into service, very few events have Early detection andinvolved undetected fuel quantity issues. An engine failing in management of the issueflight, because of fuel starvation, is a situation all pilots would remains key. The ultimatelike to avoid. Accuracy of the Fuel Quantity Indicator (FQI),during fuel checks before the start of a flight, during the flight safety barrier to avoidand after arrival at the parking stand is essential. finding oneself in a fuel critical situation is fuelShould any fuel discrepancy appear, whether it is intermittent or monitoring by the crew.permanent, effectively tackling the problem is the only way toprevent safety issues.This requires good cooperation between flight crews,maintenance and the manufacturer. Should the LO LVL fuel alert be triggered, it must be trusted!It is the independent voice from the tanks themselves warning you. 5!

11 AUGUST 2015 INDSAFE NEWSLETTERConsidering the consequences of running out of fuel in flight, fuelquantity available on board during the flight is clearly essential tosafety. Early detection and management of the issue remains key.The ultimate safety barrier to avoid finding oneself in a fuel criticalsituation is fuel monitoring by the crew.Event 1 Event 1 : A rapid fuel level decrease in theDuring cruise of an A320 aircraft, there were 3 ECAM warnings. A left tank because fuelrapid fuel level decrease in the left fuel tank as compared to the pump filter cover wasright was noticed by the flight crew. Following the FCOM found to be notprocedure, the crew opened the fuel cross feed valve, only to shut properly fitted.it as soon, because the fuel quantity continued to decrease.Minutes later, engine 1 shut down and the ECAM warning ENG 1 Event 2: DiscrepanciesFAIL triggered. The crew managed to land the aircraft in the Fuel Quantityuneventfully with engine 2 still running, and passengers Indication (FQI)disembarked safely. On landing it was discovered that fuel system.quantity in the right tank was 840 kg’s and the left tank had none. Event 3 : FuelOn closer investigation it was noted that maintenance on the fuel overheads due totanks had been carried out prior to the flight, and both the intermittent computerengines 1 & 2 fuel pump filters had been replaced. On checking, (FQIC) failure1 HP fuel pump filter cover was found to be not properly fitted,with 4 threaded inserts out of 6 being unserviceable, resulting inthe cover remaining partially open. As a result 4 to 5 tons of fuelhad leaked.Event 2In another event, the Fuel Quantity Indication (FQI) system hadbeen showing discrepancies for a while. Given the intermittentnature of the fault, aircraft logbook entries were investigatedhowever no fuel discrepancies were noticed. For the event flight,the aircraft departed with approx. 5000kg of fuel (fuel recordedfrom previous leg was 3800kg and fuel uplift was 1200kg). Theflight crew performed the initial fuel checks with reference to thefuel logs from the previous flights. In spite of fuel being enoughas per reading, fuel quantity fluctuations were experienced duringthe flight and the ECAM alert was triggered. In spite of the flightcrew doing repeated fuel checks at short intervals during theflight, engine 1 shut down during approach and landing wasperformed with engine 2 safely. 6!

11 AUGUST 2015 INDSAFE NEWSLETTERAfter the flight, the left wing tank was confirmed Event 3empty, however it was noted that the FuelQuantity Indication was over reading by 1 ton. On An A320 aircraft, on its third leg of the day whilethe previous two flights, the crews failed to approaching its destination, received a LO LVL alertidentify and properly record the fuel discrepancy on one side. The crew considered it spurious,during pre-departure and post-flight fuel checks. resulting from fuel movement in the tank. Shortly after this first alert, a new LO LVL alert was triggeredThe analysis of the event indicated that the on the other side. The crew continued the flight anddiscrepancy of actual fuel versus the reading was landed uneventfully. The fuel quantity on landingnot noted and registered by the previous crews turned out to be approximately 900 kg.and so continued to go unnoticed by the crew of During the first flight of the day, the flight crew hadthe eventful flight during their preflight check calculated a 500 kg discrepancy at arrival. Nothingresulting in a near emergency. was noted in the log book. During the second flight of the day, the discrepancy calculated by the crew at arrival was almost 3000 kg. The First Officer assumed that they had benefited from some favourable factors such as a direct ATC routing or an early arrival 20 to 25 minutes ahead of schedule. It was also assumed by them that since fuel is sometimes ferried as per company policy that may have been the case.. Nothing unusual was mentioned in the log book. As a result, before the third flight, which was the event flight, the plane was refuelled only a little, because of the fuel over read. The flight crew departed with a significantly overestimated fuel quantity that led to the unanticipated LO LVL alerts on both sides. According to the investigation the fuel over read was due to an intermittent Computer (FQIC) failure. 7!

11 AUGUST 2015 INDSAFE NEWSLETTERHow do we determine the fuel quantityavailable in the tanks? What are the varioussources of information?FUEL QUANTITY INDICATION (FQI) - The FQI system has probes that measure the level of thefuel in the tank.FUEL FLOW METRES - Each engine is equipped with Fuel Flow Meters that measure thequantity of fuel consumed by the engine.LOW LEVEL SENSORS - In addition to the sensors and probes feeding the FQI system, eachwing tank is equipped with three low level sensors. When the remaining fuel in the tank isapproximately 750 kg, a low level alert triggers in the cockpit.When the low level indication is set off it means the tank must have sufficient fuel to meet therequirement of 30 minutes at 1500 ft (corresponding to approximately 1 200 kg). When the alerton both fuel tanks gets triggered the total remaining fuel is: 750kg + 750kg = 1 500 kg.The presence of water in the fuel tanks can lead to fuel fluctuations and over reads as well. 8!

11 AUGUST 2015 INDSAFE NEWSLETTERWhen are the checks During Flightperformed? During the flight, fuel checks mainly aim atPre Flight detecting any abnormal consumption, this could be due to a leak or unanticipated drag that mayThis check is performed to consolidate be caused due to, spoiler or landing gear, slats orinformation about total fuel available. It is a flaps not fully retracted or any other reason. A fueltotal of Fuel on board + Fuel Uplifted by check must be done every 30 minutes or at eachrefuelled waypoint to help ensure there are no undetected fuel leaks. In addition to this the Fuel On Board + Fuel Used values must correspond with value given by the computed flight plan at each waypoint. Post Flight The final check is done once the airplane has reached the parking stand. Maintenance and flight crew need to check for consistency of information provided by all the sources, discrepancies if any and call for timely maintenance action. !9

11 AUGUST 2015 INDSAFE NEWSLETTERWhy is it key to perform regular fuel checks and not miss it?Checking the quantity of fuel on board requires use of several sources of data. Flight crew isequipped with tools to check, Fuel used, the fuel uplifted at the latest refuel, the crosscheckbetween what is expected to be uplifted and what is uplifted, information from the refuelled andfuel consumption figures during flight .To ensure the information remains accurate,fuel monitoring by the crew is essential.Although fuel checks with manual calculationscan sometimes be a tedious task, they form anintegral part to ensure safe operations. Fuelchecks and monitoring is designed to detectan early fuel quantity issue, ensuring timelyand accurate maintenance intervention, andallowing appropriate measures to secure thesafety of the flight.Skipping a fuel check may be a missedopportunity to detect a failure that may not bedetectable later on, at the time of thefollowing check. Whatever the origin of a fuelquantity issue, detecting it as early as possibleallows for managing it and making sureappropriate decisions can be made in time tobest manage the rest of the flight as safelyand efficiently as possible. !10

11 AUGUST 2015 INDSAFE NEWSLETTERARTICLE 2Understanding and The airspeed during the climb is initiallymanaging speed during limited by Air Traffic Control (ATC)the climb phase instructions.This article analyses the importance of For every flight, speeds are computed byspeed control during the climb phase of the the aircraft Auto Flight Systems likeflight after takeoff. Flying a safe and steady Flight management System (FMS) , Flightclimb requires the flight crew’s attention to Guidance (FG) and Flight Envelope (FE)carefully manage the different configuration and are displayed on the Primary Flightchanges, usually consisting of gears, slats / Display (PFD) airspeed scale .They areflaps retraction while sustaining enough lift extremely useful as ‘manoeuvring speeds’to accelerate to the climb speed and and ‘limit speeds’ to safely guide theeventually, cruise speed . It defines the pilots configuration change decisionsdifferent manoeuvring speeds and limit through the climb phase.speeds that are required during the climbphase and how they can be implemented. 1! 1

11 AUGUST 2015 INDSAFE NEWSLETTER Procedures and observing the visual F and S indications on the Primary Flight Display (PFD). Not respecting the manoeuvring and limit speeds leads to adverse consequences. Doing so allows the crew to respect the VFE indication displayed on the Primary Flight Display and thus, avoid triggering an over speed warning resulting in potential structural damage.MANOEUVRING SPEEDS – Helps pilots LIMIT SPEEDS - Any deviations from theaccelerate the aircraft, maintain a manoeuvring speeds F, S and GD during climbsatisfactory climb gradient and manage can have an impact on the aircraft‘sseveral configuration changes at the same aerodynamic performance.time. This includes Flaps, Slats and GreenDot speeds that frame the aircraft climb The limit speed Velocity with Flaps Extendedperformance limits. (VFE) is the maximum speed for high lift configurations, with slats / flaps extended. TheF speed is the minimum speed at which flaps may not be used beyond this speed orflaps should be retracted structural damage may occur to the aircraft.S speed is the minimum slats retraction The common approach Slats and flapsspeed retraction during climb can be managed safely by following Standard OperatingGreen Dots speed is computed by the Auto Procedures and observing the visual F and Sflight systems and is based on the aircraft indications on the Primary Flight Displayweight. Green Dots formula is set up so that (PFD). Not respecting the manoeuvring andthe airspeed provides the best lift-to-drag limit speeds leads to adverse consequences.ratio for a given altitude, air temperature Doing so allows the crew to respect the VFEand aircraft weight, in clean configuration indication displayed on the Primary Flightwith one engine out. Deviating below Green Display and thus, avoid triggering an overDots speed involves an increase in the drag speed warning resulting in potentialon the aircraft and would eventually structural damage.undermine the aircraft‘s ability to continue aclimb. !12

11 AUGUST 2015 INDSAFE NEWSLETTERARTICLE 3A ‘JUST CULTURE’ Both International Civil Aviation Organisation (ICAO) and the European Union (EU)A ‘Just Culture’ examines philosophical and requirement states to establish mandatory andethical aspects of establishing a ‘Just Culture’ voluntary confidential reporting systems. Thisin aviation safety reporting systems. is based on the premise that incidents are often the precursor to accidents and thatCivil aviation is the safest form of mass accidents could have been avoided, if neartransportation. Since World War II, accidents had been reported, investigated andimprovements in aviation safety have brought preventative action taken.down the rate of incidents .This continuedsuccessful reduction in the accident rate over a The ICAO and EU consider that the accident60 year period was no doubt due to the investigation process for civil aviation has beenaccident investigation process created by crucial in increasing aviation safety as a resultthe International Civil Aviation Organisation of lessons learned.(ICAO). 1! 3

11 AUGUST 2015 INDSAFE NEWSLETTERTo capture information during theinvestigation process, aviation professionalsare required, by law, to report these eventswith the understanding that no punitiveaction, either professional or legal, will beinitiated against them. The protection offeredis referred to as ‘Just Culture’ and is definedby the European Union (EU) as a culture inwhich front line operators or others are notpunished for actions, omissions, or decisionstaken by them that are commensurate withtheir experience and training.This process, further states that the sole objective of the investigation of an accident or anincident is the prevention of accidents and incidents, not to blame or create liability. In the past, difficulty has been experienced in getting aviation professionals, whether they are pilots, air traffic controllers, engineers, mechanics, or airport staff, to report incidents or occurrences , due to fear of being dismissed, penalised or ridiculed. Unfortunately, several aviation accident and incident investigation reports, have become the basis for criminal action against aviation professionals. This intermingling of the safety and judicial processes may lead to a detrimental effect on aviation safety, jeopardise the independence ofaccident investigation, and lead to injustice.In case of an air incident, safety investigation, is to be handled by a body in accordance withICAO.However, if the investigation is to evaluate the potential for criminal prosecution, the police,prosecution authorities and the courts have the ultimate responsibility for passing the appropriatesentence once liability and blame have been established. 1! 4

11 AUGUST 2015 INDSAFE NEWSLETTERCASE STUDY, FROM THE SEP DESK - IFLYOver wing slide deployed by Incidents of this nature canpassenger cause damage to life andOn a designated IndiGo flight no passenger had been property. They also add up toassigned the over wing exit seat. Cabin Crew reseated a the airlines maintenancepassenger to the over wing seat. After seeking his costs and result in loss ofconsent, passenger was told by the crew member she goodwill.would return for the safety briefing.Before the crew could return and brief him, thepassenger inadvertently opened the door, inflating theslide. The inflated slide was removed and the plane wasbooked under MEL.This a serious incident, one of this nature can causedamage to property and life. Inadvertent slide inflation cancause fatal injuries to ground personnel working in the areaaround the plane. It inconvenienced passengers who hadto be relocated to another plane causing delays. Incidentslike these add up to the airlines maintenance costs andresult in loss of goodwill. 1! 5

11 AUGUST 2015 INDSAFE NEWSLETTERLet’s review some safety tips which cabin crewmust make a note of. • Cabin crew should be vigilant and profile passengers before relocating them. • Relocation needs to be done once boarding is complete and all passengers are seated. • As soon as passenger has been relocated, cabin crew must brief the passenger on the emergency exit rows. • Be aware of passengers who tell you they have been briefed, while in reality the briefing may not have been conducted. 1! 6

11 AUGUST 2015 INDSAFE NEWSLETTERCASE STUDY(AOCS), REPORT OF A CARGOTRUCK THAT MET WITH AN ACCIDENT –JUNE 2015On XX June 2015 at around 03:40 Hours, an Incidents like these are aEicher Cargo truck was driving on the airport learning for us to stay alertperiphery road to the cargo office after at all times and expect thecompletion of cargo services for flight 6E-XXX at the bay. The cargo truck, driven by a unexpected.GHA operator was empty. A tractor attachedwith a loaded pallet was approaching the The driver injured his right hand and leg and thecargo truck from the opposite side on the cargo vehicle was damaged. Post the accident aperiphery road. As it approached the cargo Breath Analyser test of the truck driver wastruck the tractor driver took a right turn to carried out and found negative. The cargo truckavoid a nearby pit which caused its pallet to driver was taken off duties soon after theslide. Due to the tractors sudden turn the accident. The vehicle entry permit and airportpallet slid in the opposite direction to the left driving permit of the truck driver wasin front of the cargo truck. The cargo truck surrendered to the Airport Authority of India.driver was taken by surprise seeing the pallet After the incident the vehicle was sent for repair.fall right in front of it and tried to avoidcollision by moving off the road. Since spacewas limited he lost control of the vehicle andhit the nearby airport periphery wall. !17

11 AUGUST 2015 INDSAFE NEWSLETTERThe incident was investigated internally at the office of IndiGo Safety and the followingpoints were observed: • The cargo truck was fitted with an approved speed governor and was operational. • The truck was last serviced on December 2014 and is next due for service on Jun 2015. • The driver was not doing overtime duty. • The driver had undergone the last ramp safety training on May 2015. • The driver had a valid airport entry pass and airport driving license. • The cargo driver had no previous accident record before this incident.However it was observed that some things did go wrong and could have been avoided • The cargo driver was not cautious enough to maintain a safe distance from the tractor. • The accident occurred during pre-dawn hours and the area was dark. • Poor lighting on the road may have caused the incident. !18

11 AUGUST 2015 INDSAFE NEWSLETTER AVIATION MEDICAL BULLETINOur medical bulletin this month stresses Water soluble vitamins like B complex and vitaminon the importance of at least 30 minutes of C are relatively harmless and the body canexercise for adults and 20 minutes for kids eliminate excess quantities in the urine. Fat-solubleto help improve heart condition and vitamins (A, D, E and K), on the other hand, are notcognition. easily removed from the body as they are absorbed by the body‘s fat cells where they remainDo visit your physician from time to time, indefinitely.to do an overall health checkup. Getupdates on medication, supplements and Excessive doses of vitamin A can causevitamins your body may need. Also find inflammation of the liver and consumed long termout if you require vaccines, preventive can result in fatal cirrhosis. Vitamin D in excess canscreening or any diagnostic tests. cause injury to the kidneys and ultimately result in renal failure. Vitamin E taken in excess can thin the blood beyond desirable levels and can result in inflammation and blood clots in the veins in the legs.Overdosing on Type 2 DiabetesVitamins Diabetes is caused by a problem in the way yourYou may need vitamin supplements but do body makes or uses insulin. Insulin is needed tonot overdose on them. Vitamins are move blood sugar into your cells, where it is storedessential for proper functioning of the and later used for energy. When you have type 2body, but excess doses can be harmful. diabetes, your fat, liver and muscle cells do not respond correctly to insulin. As a result, blood sugar does not get into these cells to be stored for energy. 1! 9

11 AUGUST 2015 INDSAFE NEWSLETTERType 2 diabetes is a growing epidemic. Pre DiabetesMoreover, it‘s estimated that one-third ofthose with type 2 diabetes are unaware Those with pre-diabetes have blood sugarthat they have this serious illness. Left levels that are higher than normal, but areundiagnosed and untreated, diabetes can not high enough to be classified as diabetes.present numerous health risks, including Early diagnosis and treatment of pre-heart disease, blindness, and reduced diabetes may prevent type 2 diabetes as wellcirculation that can cause infections and as associated complicationsulcers. The American Diabetes AssociationEarly detection and treatment of diabetes recommends routine screenings for type 2symptoms can decrease the chance of diabetes beginning at age 45, especially ifdeveloping the complications of diabetes. you're overweight. The haemoglobin (A1C)If you experience symptoms of severe test is the most commonly used test for this.increased thirst, frequent urination,unexplained weight loss, increased hunger,tingling of your hands or feet, consult ahealth care professional who can run a testfor diabetesIncorporating exercise and a healthy dietcan help in the prevention of type 2diabetes. Disadvantages of Sitting too long Researchers indicate that the modern sedentary workplace (referred to as a “desk sentence”) may contribute more to the decline of our health and fitness than we ever imagined. When you sit for an extended period of time, (more than an hour) your muscles and body start to shut down at the metabolic level and your calorie burning rate immediately plunges. 2! 0

11 AUGUST 2015 INDSAFE NEWSLETTERProlonged sitting increases your risk for heart How healthy is yourdisease because the enzymes that keep heart?blood fats in check are inactive. Moreover,the less you move, the less blood sugar your Having a family history of heart disease orbody uses, and so the risk of developing getting older cannot be avoided. However sometype 2 diabetes increases. If you sit for things that put us at risk can be changed. Theyextended periods each day, research are listed below.suggests that even 30 minutes in the gymmay not be enough to counteract the 1. Cholesterol – The higher yourdetrimental effects of sitting. cholesterol levels, the higher the risk of heart disease. Since it has no symptoms,If you sit from 3 to 8 hours a day, remember, routine blood tests are important tosmall movements like stretching or standing monitor the same.for 60 seconds every 30 or 60 minutes cando wonders to thwart the negative effects of 2. Blood Pressure – High BP is another risksitting. factor for heart disease. Like cholesterol it has no symptoms. Ensure youIf you want to keep your reflexes sharp purchase and consume low sodiummaximum benefits come from 30 minutes of foods.aerobic exercise such as walking or cycling atleast 3 to 5 days per week. 3. Excess Weight also has an adverse effect 2! 1

11 AUGUST 2015 INDSAFE NEWSLETTERStay Fit Laughter is the best medicineFive great tips to help you remain committedto your fitness goals: Do not forget to laugh!! Scientific research shows that humour and laughter are 1. Schedule and keep workout appointments. Schedule your extremely beneficial to one‘s health in a workouts just as you do with variety of ways. Research explores the meetings, doctor‘s appointments and connections between the nervous, endocrine other events. (hormonal) and immune systems. Laughter helps improve immunity, brings down stress 2. Identify goals that are important to levels and improves tolerance to pain. you. Do you want to lose five Research has suggested that laughter pounds? Run 5km? Run for five provides health benefits similar to other minutes? Set small goals for starters. types of aerobic exercise. 3. Seek support to stay motivated. Last but not the least eating and sleeping Surround yourself with people who right are essential for a healthy lifestyle. encourage and motivate you to Don’t forget to focus on ‘whole’ foods as remain active. Better yet, find a part of your diet plan and sleep enough (at workout buddy. least 7 hours) so you feel rested and vibrant 4. Stick with the workouts you like. during your work day. It‘s essential to find an activity you like and want to do regularly. Try !22 exploring new exercise equipment, group fitness classes or joining a sports league with friends. 5. Track your fitness progress. Tracking your workouts so you can see improvements over time improves your motivation and commitment.

11 AUGUST 2015 INDSAFE NEWSLETTERDear Colleagues,Thanks to all, the electronic reporting through portal has increased considerablysince its launch. We have an operational safety reporting system that isimplemented throughout the organisation in a manner that: i. Encourages and facilitates personnel to submit reports that identify safety hazards, expose safety deficiencies and raise safety concerns; ii. Ensure mandatory reporting in accordance with applicable regulations; iii. Includes analysis and management action as necessary to address safety issues identified through the reporting system.With our constant endeavour to make the system more users friendly andinteractive, we will be coming to you with a new medium very soon. !23

11 AUGUST 2015 INDSAFE NEWSLETTER !24

11 AUGUST 2015 INDSAFE NEWSLETTERWish you all safe flights… !25