Dutcher SASS 2018 Dutcher SASS 2018 Mitigating the Role of ... 2018... · Unnecessary Weather Penetration 23% of Fatal Accidents (2012 and 2016) Unnecessary Weather Penetration Failure

WxRiskManagement.com

Mitigating the Role of Weather in Runway Safety Occurrences

John W. Dutcher

::: Singapore – 27 March 2018 :::Singapore Aviation Safety Seminar (SASS)

Safety, Quality & Meteorology Consultant


Runway Safety: The Threat

• Runway Safety - A safe flight from its start to its conclusion.

• Runway Safety:

– Remains one of the most serious threats to aviation safety.– Continues to be one of the industry’s highest priorities.


Safety: Last 20 years

§ Since 1997… § Reduced the hull loss

rate by around 70%.

§ Reduced the fatal accident rate by around 80%.

(Airbus, 2017, p.20)

Hull Loss Accident Rate / Million Flights 1997 through 2016

Runway Excursions (RE)

ü3rd major cause of fatal accidents by numbers.

ü Single biggest cause of hull losses.

(Airbus, 2017, p.24)

% Fatal Accidents by Accident Category 1997 through 2016


Aircraft Accidents & Fatalities

(Dutcher, 2018 after IATA, 2017)

CFITLOC-I

MAC

Runway SafetyAccidents


Runway Safety: The Role of Weather

(Dutcher, 2018 after IATA, 2017)

Fatal Accidents:

43%Accidents:

31%


Runway Excursion – Top Contributing Factors

Latent Conditions

Threats Flight Crew Errors

Undesired Aircraft States

(UAS)

End State

Flight crew Training

Meteorology Manual Handling Flight Controls

Vertical, lateral or speed deviations

Runway Excursion

Flight Ops SOPs ANSP/ATC Interface

SOP Adherence / Procedural

Long, forced, bounded, firm or off-centrelinelanding

Operational Pressure

Airport Facilities Communication Unstable Approach

Safety Management

Aircraft Malfunction

Failure to go-around after destabilisation

Continued Landing after Unstable Approach

49% of Runway Excursions between 2012 and 2016 had Weather as a Contributing Factor.


Decision Making

• Flight crew decisions making contributed to approximately 66% of the accidents (NTSB, 1994).

• Of these, about 75% have been identified as “plan continuation errors.”

ü Why?– Inappropriate assessment of risk; and– External factors.

ü“Plan Continuation Errors (PCEs)”Decisions to continue with an original course of action in the face of cues that signal that conditions have changed.

(Orasanu, 1993; Orasanu & Davison 2001).


Failure to GOA & Unnecessary Weather Penetration

23% of Fatal Accidents (2012 and 2016)

Unnecessary Weather Penetration Failure to GOA

after Destabilised Approach

(Source: IATA, 2017, p.123;p.147)

10% of the accidents (2012 and 2016)

(Source: IATA, 2017, p.124)

7% of the accidents in 2016

70% of pilots were dissatisfied with weather radar training (Goold, 2008)


(Dekker, 2002, p.119)

MURPHY'S LAW IS WRONG!!

WHAT CAN GO WRONG USUALLY GOES RIGHT,

BUT THEN WE DRAW THE WRONG CONCLUSION


Normal people doing normal work...


Operational & Decision Support

Go-Around?

CRM?

Fatigue?

Unnecessary Weather

Penetration

Flight Following?

Critical Decision Event (CDE)

Pressure?

Experience?

Unnecessary Weather

Penetration?

How good is OCC/Dispatch

Support?

Training?

Aircraft equipped to allow rapid updates of weather information in-flight?

Company Policies and

SOPs?

MEL?

Fuel?


Weather Safety Nets

§ SIGWX Progs§ TAFs§ METARs§ SPECIs§ PIREPs / AIREPs§ SIGMETs§ AIRMETs§ Aerodrome Warnings§ LLWS Warnings



Agreement between MET & ATSICAO Annex 3 – 4.2• Recommendation.— An agreement between the meteorological authority

and the appropriate ATS authority should be established to cover, among other things: – a) the provision in air traffic services units of displays related to integrated automatic

systems; – b) the calibration and maintenance of these displays/instruments; – c) the use to be made of these displays/instruments by air traffic services personnel; – d) as and where necessary, supplementary visual observations (for example, of

meteorological phenomena of operational significance in the climb-out and approach areas) if and when made by air traffic services personnel to update or supplement the information supplied by the meteorological station;

– e) meteorological information obtained from aircraft taking off or landing (for example, on wind shear); and

– f) if available, meteorological information obtained from ground weather radar. • Note: See the Manual on Coordination between Air Traffic Services, Aeronautical Information Services

and Aeronautical Meteorological Services (Doc 9377).


SPECIs?ICAO Annex 3 – 4.4 - Special observations and reports

• 4.4.1 A list of criteria for special observations shall be established by the meteorological authority, in consultation with the appropriate ATS authority, operators and others concerned.

• 4.4.2 Reports of special observations shall be issued as:

– a) local special reports, only for dissemination at the aerodrome of origin (intended for arriving and departing aircraft); and

– b) SPECI for dissemination beyond the aerodrome of origin (mainly intended for flight planning, VOLMET broadcasts and D-VOLMET) unless METAR are issued at half-hourly intervals.

ICAO Doc. 8896 – 2.2.3“The issuance of SPECI is not necessary if METAR are issued at half-hour intervals.”


METAR & SPECISupplementary Information

ICAO Annex 3 - 4.5.2 ü Recommendation.— In addition to elements listed under 4.5.1 a)

to k), local routine reports, local special reports, METAR and SPECI should contain supplementary information to be placed after element k).

ICAO Annex 3 - 4.6.8ü Recommendation.— Observations made at aerodromes should

include the available supplementary information concerning significant meteorological conditions, particularly those in the approach and climb-out areas. Where practicable, the information should identify the location of the meteorological condition.


METAR & SPECISupplementary Information

ICAO Doc. 8896 - 2.3.16.3

ü In METAR, where local circumstances so warrant, wind shear should be included as necessary. Information on wind shear is added in the form “WS RWY 12” or “WS ALL RWY”.


METAR & SPECISurface Wind

ICAO Annex 3

ü 4.6.1.3 Recommendation.— For METAR and SPECI, the surface wind observations should be representative of conditions above the whole runway where there is only one runway and the whole runway complex where there is more than one runway.

ü 4.6.1.2 Recommendation.— When local routine and special reports are used for departing aircraft, the surface wind observations for these reports should be representative of conditions along the runway; when local routine and special reports are used for arriving aircraft, the surface wind observations for these reports should be representative of the touchdown zone.


Thunderstorm Avoidance

“Do circumnavigate the entire area if the area has 6/10 thunderstorm coverage.”

Section 8.X AVOIDING THUNDERSTORMS

“Use all available information for this judgement, including PIREPs, ground radar, aircraft radar, tower-reported winds, and visual observations. In the terminal area thunderstorms should be avoided by no less than 3 NM.

Section 8.X DEPARTURE AND ARRIVAL [AVOIDING TS]

* EXAMPLE *

NOT FOR USE

“No Company flight shall be planned or caused to operate at any airport when any of the following are present:• A thunderstorm is over the airport, along the departure or arrival path;”

Section 8.X AVOIDING THUNDERSTORMS


What’s in your Flight Folder?

Prior to each originating flight duty, Flight Crew shall have reviewed latest operational documentation, including FCN.

The following self-briefing package will be provided:

1. Meteorological Information

• TAF – airport forecasts for departure, destination, destination alternate and en-route alternate airports;

• METAR – airport reports for the destination and the CFP alternate airport;

• Significant Weather (SIGWX) charts covering the intended duration of the flight;

• Wind and Temperature chart.

* EXAMPLE *

NOT FOR USE

Section 8.X DISPATCH BRIEFING

Where are the SIGMETs, VOLASH & TC Advisories?


Airline’s Policy on Use of PROB in TAF

• TEMPO (alone), TEMPO FM, TEMPO TL, TEMPO FM...TL, PROB 30/40 (alone)

- Deterioration:

- Transient / showery conditions: Not applicable. Mean wind and gusts exceeding required limits may be disregarded.

- Persistent conditions in connection with e.g. haze, mist, fog, dust/sandstorm, and continuous precipitation: Applicable. Mean wind should be within required limits. Gusts may be disregarded.

- Improvement: In any case should be disregarded.

• PROB TEMPO

- Deterioration: May be disregarded.

- Improvement: Should be disregarded.

* EXAMPLE *

NOT FOR USE

Section 8.X METEOROLOGICAL INFORMATION AND INTERPRETATION


Summary

§ Weather plays a contributing role in 31% of all Accidents.

§ 43% for Fatal Accidents between 2012 and 2016.

• Approx. 50% of Runway Excursions & Hard Landings are Weather Related.

• Approx. 75% of Undershoots & 1/3 of Tailstrikes.


Summary

ü Weather accidents are NOT just a meteorology problem.ü “Can’t control Mother Nature”.

ü We must further support decision making and manage the effect of weather on safety and operation – ideally in a proactive manner.ü Weather Risk Management


Summary

§ Not just a “behavioural problem”…a “Cultural issue!”

§ Industry norms.§ Company norms.

§ Safety Awareness and Training –Importance of Strategic (planning)and Tactical (in-flight) weatheravoidance is best practice.

(Dutcher, 2016 after Darnell, 2006)


Conclusion

ü Identify and address significant holes in MET regulations & procedures/policies.ü Can build-on existing programmes

ü ALARü ICAO Runway Safetyü IATA Runway Safety

ü Decision Support – integrated into other toolsü Translates weather into IMPACTS.

ü Real-time uplink of weather data into the cockpit must be improved.

ü Real-time downlink of weather data captured by the aircraft must be improved.


Thank You!John W. DutcherSafety, Quality & Meteorology ConsultantHo Chi Minh City, Vietnam

[email protected]@wxriskmanagement.com



References• Airbus. (2017). A Statistical Analysis of Commercial Aviation Accidents: 1958-2016.

Toulouse, France: Airbus.

• Australian Transport Safety Bureau. (2009). Runway Excursions. Part 1: A WorldwideReview of Commercial Jet Aircraft Runway Excursions. Aviation Research and AnalysisReport AR-2008-018(1). Canberra: ATSB.

• Boeing. (2017). Statistical Summary of Commercial Jet Airplane Accidents -Worldwide Operations: 1959 – 2016. Seattle, USA; Boeing.

• Dekker, S. (2002). The Field Guide to Human Error Investigations. Cranfield, UK: Cranfield University Press, Ashgate.

• Dutcher, J.W. (2016). Proactive Forecasting Systems for Supporting DecisionMaking. Power Point Presentation presented at the Singapore Aviation Academy –Aviation Weather Risk Management course. Singapore: 11 – 15 Apr 2016.

• Goold, I. (May 1, 2008). Honeywell: Better wx training needed. Retrieved June 10,2008, from http://www.ainonline.com/news/single-news-page/article/honeywell-better-wx-training-needed/.


References• International Air Transport Association. (2017). Safety Report: 2016 (53rd Ed.).Montreal, Canada: IATA.

• International Civil Aviation Organization. (2016). Annex 3 to the Convention onInternational Civil Aviation: Meteorological Service for International Air Navigation. (19thEd.). Montreal, Canada: IATA.

• International Civil Aviation Organization. (2015). Manual of Aeronautical MeteorologicalPractice (Doc 8896). (10th Ed.). Montreal, Canada: IATA.

• Orasanu, J.M. & Davison, J. (2001). The role of risk assessment in flight safety:Strategies for enhancing pilot decision making. In S. Dekker (Ed.), Proceedings of theHuman Error, Safety and System Design Workshop: Diagnosis versus Change. Linkoping,Sweden: Linkoping University.

• Orasanu, J.M. (1993). Decision making in the cockpit. In E. L. Wiener, B. G. Kanki,& R. L. Helmreich, (Eds.). Cockpit Resource Management (pp. 137-172). San Diego, CA:Academic Press.


Extra Slides


Airline Safety Performance - 2017

§ There were 6 fatal accidents with 19 fatalities among passengers and crew.

§ 5 - Turboprop§ 1 - Cargo jet

Note: The crash of the cargo jet also resulted in the deaths of 35 persons on the ground, as well as the crew of the jet.

(IATA, 2018)


Definitions of Runway Safety

Runway Safety (IATA)• Runway excursions, runway collisions, undershoot/overshoots, tailstrikes and hard

landing events.

Runway Safety (FSF)• Any safety issue that deals with the runway environment (or any surface being

used as a runway) and the areas immediately adjacent to it (e.g. overruns, high speed taxiways).

Runway Safety (ICAO)• The state in which risks associated with the operation of aircraft on runways are

reduced and controlled to an acceptable level.


Runway Excursions

(IATA, 2017)


Common Factors

• Thunderstorm or Monsoon Present

• Heavy Rain Occurring

• Runway contaminated with water

• Poor Braking Action Reported

• Crosswind – tailwind - both


Percentage of Runway Excursion Accidents by Continent

(ATSB, 2009)


RE - Distribution of Weather Factors


METAR & SPECIWind Gusts

ICAO Doc. 8896

ü 2.3.9.1 Variations of wind direction and speed given in meteorological reports always refer to the ten-minute period preceding the observation.

ü 2.3.9.3 When the wind is gusty, with variations from the mean wind speed (gusts) exceeding 5 m/s (10 kt), speed variations are indicated.


METAR & SPECIVisibility

ICAO Doc. 8896

ü 4.6.2.3 Recommendation.— For METAR and SPECI, the visibility observations should be representative of the aerodrome.

ü 4.6.2.2 Recommendation.— When local routine and special reports are used for departing aircraft, the visibility observations for these reports should be representative of conditions along the runway; when local routine and special reports are used for arriving aircraft, the visibility observations for these reports should be representative of the touchdown zone of the runway.


Safety: Last 10 years

Fatal AccidentsWorldwide Commercial Jets2007 through 2016

(Boeing, 2017, p.22)

Number of Fatalities & Fatal Accidents2007 through 2016

(IATA, 2017, p.28)


IATA Runway Safety Analysis2010 through 2014

ü 159 accidents (39%) of all commercial accidents occurred in the runway environment.

ü Average of (31.8) runway safety accidents per year.

Accident Category Number of Accidents

Fatal Accidents

Fatalities

Loss of Control In-flight (LOC-I) 38 37 1242

Controlled Flight Into Terrain (CFIT) 34 31 707

Runway / Taxiway Excursion 90 5 174

Top Three Fatal Accident Categories [2010 – 2014]


Overrun Characteristics

(International Coordinating Council of Aerospace Industries Associations, n.d.)


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Dutcher SASS 2018 Dutcher SASS 2018 Mitigating the Role of ... 2018... · Unnecessary Weather Penetration 23% of Fatal Accidents (2012 and 2016) Unnecessary Weather Penetration Failure

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