An American Tableau: The Changing Accident Experience2 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JANUARY 1991 Aviation Regulation (FAR) Part 121 operations are all-inclusive

F L I G HT SAFE TY FOUN D A TI O N • F L I G H T S A F E T Y D I G E S T • JANUARY 1991 1

“Safety is an accumulative process; it does notstop or start on signal. It is not a year-to-yearaffair. It must be measured period by period.” —Stuart Tipton, president Air Transport Associa-tion, U.S., before the U.S. Senate Aviation Sub-committee, March 3, 1961.

Accident statistics are unreliable indicators ofthe industry’s safety performance; they do notreflect the true risk of flying because the ele-ments of chance often play a role in the un-eventful outcome of potential accident situa-tions. Unfortunately, such statistics remainthe only available yardstick until more realis-tic safety indicators are developed.

What makes accident rates even more ques-tionable is the widely used International CivilAviation Organization (ICAO) accident defi-nition; it does not differentiate between air-craft accidents and industrial mishaps due tothe inflexibility of the intent-for-flight clause.The result is that accident rates are weightedwith occurrences that unnecessarily downgradethe industry’s safety performance. In addi-tion, official accident rates often do not takeinto account a type of mishap that is of greatconcern to the traveling public: accidents in-volving suicide, sabotage, and military action.

These biasing effects have been avoided asmuch as possible in the preparations for this

study. Furthermore, to limit the scope of thisdiscussion while at the same time zeroing inon the traveling public’s safety concerns, thedata deal only with Fatal accidents, involvingjet transports in Part 121 passenger operations(scheduled and non-scheduled) during the 20-year period 1970-1989.

According to U.S. National Transportation SafetyBoard (NTSB) data, 61 fatal accidents fall intothat category. However, 11 of these are moreappropriately identified as industrial accidentsand are excluded from this study. These wereall single-fatality accidents, mostly involvingground crew personnel working around air-craft. None of these mishaps would have preyedupon the public’s basic fear of becoming in-volved in a fatal accident.

A prime example of the lack of the realism inthe accident definition can be found in the1981 record of U.S. air carriers. That year theywere statistically charged with four fatal acci-dents in passenger operations characterizedeven by the NTSB as “four bizarre single-fa-tality accidents.” Although the board admit-ted that “those four accidents produced a dis-torted [fatal accident] rate,” there are no indi-cations that efforts are in progress to formu-late a more meaningful accident definition.

The officially reported hours flown in U.S. Federal

An American Tableau: The ChangingAccident Experience

A critical look at the safety aspects of deregulation and a call forthe air transportation industry to earn the public’s trust in

its safety performance during the next decade.

byGerard M. Bruggink

Aviation Safety Consultant

F L I G HT SAFE TY FOUN D A TI O N • F L I G H T S A F E T Y D I G E S T • JANUARY 19912

Aviation Regulation (FAR) Part 121 operationsare all-inclusive. Since this study is concernedonly with passenger operations in jet trans-ports, these yearly totals were reduced by 10percent before calculating the hours flown be-tween fatal accidents. The reported deathsinvolve aircraft occupants only. Deaths of othersare listed in Table 3.

The 1970-1989 Record

When the provisos in the previous section areapplied to the published NTSB accident data,the fatal accident experience of U.S. air carri-ers during the decade before and after de-regulation (1978) compares as shown in Table

1.

According to this broad comparison the carri-ers made striking improvements in their acci-dent record; they doubled the number of hoursflown between fatal accidents during the firstdecade of deregulation. One is tempted toconclude that the airline deregulation Act of1978 had no negative impact on a steadily im-proving record. However, that favorable im-pression turns out to be a delusion when the

20-year record is tabulated in 5-year segmentsas shown in Table 2.

The interpretation of this table presents twochallenges:

• The best-ever performance of the indus-try occurred during the first five yearsof deregulation (1980-1984). Operatingmore than six million hours between fa-tal accidents is a superlative achievementusing any criteria.

• Following five years of steady improve-ment, the 1985-1989 period shows anabrupt reversal of that trend.

These two unusual aspects of the post-deregu-lation period will be addressed under the separateheadings of “The 1980-1984 Period” and “The1985-1989 Period.”

The 1980-1984 Period

It can hardly be claimed that deregulation’sdestabilizing effect on the work force — com-pounded by the 1981 air traffic controllers’strike — was instrumental in setting theindustry’s remarkable record. One the con-trary, it seems more likely that this feat wasaccomplished despite deregulation. By wayof explanation it can be postulated that thefirst half of the 1980s saw the payoff of safetyinitiatives taken in the 1970s, such as line-oriented flight training (LOFT) and cockpitresource management (CRM).

It should be noted that there were no fatalaccidents in three of the five years concerned(See Table 3). Moreover, the NTSB listed acrew member as a factor in only two of thefive accidents: The Boeing 737 takeoff acci-dent in Washington, D.C., U.S., and theMcDonnell Douglas DC-10 runway excursionin Boston, Mass., U.S., both during January1982.

In its report of the Boeing 737 accident, theNTSB implicated a new phenomenon in aircarrier operations when it attributed the crew’s“low experience in jet transport winter opera-

Table 2

Aircraft Hours FlownFatal Occupant Between FatalAccidents Deaths Accidents

1970-1974 19 1058 1,500,0001975-1979 11 1030 2,700,0001980-1984 5 222 6,600,0001985-1989 15 1216 3,100,000

Table 1

Aircraft Hours FlownFatal Occupant Between FatalAccidents Deaths Accidents

1970-1979 30 2088 1,930,0001980-1989 20 1438 3,970,000

Change -33% -31% +105%


Table 3Fatal Jet Transport Accidents

U.S. Passenger Operations under Part 1211980-1989

Fatalities

Crew & FlightDate Location ACFT. Carrier Pass. Other Phase Nature of Accident

13 Jan. 82 Wash. DC B-737 Air Florida 74 4 T/O Stalled after T/O. (Contam. wings & insuf.thrust)

23 Jan. 82 Boston DC-10 World 2 - A/L Runway excursion during landing (Icy runway)9 July 82 New Orleans B-727 PanAm 145 8 T/O Windshear during T/O11 Aug. 82 Honolulu B-747 PanAm 1 - Other Suicide/Sabotage20 Dec. 83 Sioux Falls DC-9 Ozark - 1 A/L Collision with snow sweeper during landing1 Jan. 85 La Paz B-727 Eastern 29 - Other Controlled flight into terrain (cause undeterm.)2 Aug. 85 Dallas L-1011 Delta 134 1 A/L Windshear during landing approach6 Sep. 85 Milwaukee DC-9 Midwest Ex. 31 - T/O Stalled following engine failure on T/O12 Dec. 85 Gander DC-8 Arrow Air 256 - T/O Stalled after T/O. (Cause undeterm./Disputed)14 Feb. 87 Durango B-707 Skyworld 1 - Other Turbulence16 Aug. 87 Detroit DC-9 Northwest 154 2 T/O Stalled after T/O. (Configuration problem)15 Nov. 87 Denver DC-9 Continental 28 - T/O Stalled after T/O. (Contamin. wings)7 Dec 87 San L. Obispo BA-146 PSA 43 - Other Suicide/sabotage28 Apr. 88 Hawaii B-737 Aloha 1 - Other Explosive decompression (Cabin roof rupture)31 Aug. 88 Dallas B-727 Delta 14 - T/O Stalled after T/O. (Configuration problem)21 Dec. 88 Lockerbie B-747 PanAm 259 11 Other Sabotage8 Feb. 89 Azores B-707 Indep. Air 144 - A/L Controlled flight into terrain24 Feb. 89 Honolulu B-747 United 9 - Other Explosive decompression (Cargo door failure)19 July 89 Sioux City DC-10 United 111 - Other Catastrophic engine failure (Loss of hydraulics)20 Dec. 89 New York B-737 USAir 2 - T/O Rejected T/O (Rudder trim problem)

1438 27

tions” to the “rapid expansion of (the carrier)wherein pilots were upgrading faster than theindustry norm to meet the increasing demandsof growing schedules.”

Whether it was the NTSB’s intent or not, thatexplanation for the crew’s low experience es-tablished a link between the competitive pres-sure designed into deregulation and the de-grading of existing and proven industry norms.Furthermore, by factoring the crew’s limitedexperience into its causal statement, the NTSBgave indirect recognition in 1982 to a new ac-cident-enabling agent: the deregulation fac-tor.

The other takeoff accident in this period wasattributed to windshear and, in essence, wastreated as an act of God, thereby absolving thecrew.

The 1985-1989 Period

There was only one accident-free year (1986)

in the most recent 5-year period. (See Table 3).The fatal accidents are spread evenly over theother four years. Although no statistical sig-nificance can be attached to these relativelylow numbers, a comparison of the frequencyof occurrence of certain types of accidents overthe 20-year period may highlight the changesin the accident experience that took place overthe last 10 and, specifically, the last five years.(See Table 4).

To start on a positive note, consider the fol-lowing statements: the air carriers were notinvolved in any fatal midair collisions in the1980s; the number of fatal approach and land-ing accidents was reduced from 19 in the pre-deregulation period to four in the subsequentperiod; and the number of controlled-flight-into-terrain (CFIT) accidents decreased fromseven to two.

Perhaps the most disturbing change over theyears is the increase in the number of fataltakeoff accidents. Following a distribution of3-2-2 over three previous 5-year periods, these


went up to 6 in the 1985-1989 period. In fiveof these six cases the aircraft stalled on take-off; the circumstances were:

• Engine failure (1)

• Wrong aircraft configuration (2)

• Contaminated wings (1)

• Unknown (1) (The DC-8 accident in Gan-der, Newfoundland)

The other takeoff accident during this periodoccurred during a rejected takeoff (RTO) in-volving the rudder trim setting.

In each of the 1985-1989 takeoff accidents in-vestigated by the NTSB, the first sentence inthe causal statement attributes the accident tosome form of failure on the part of the flightcrew. A similar judgment was made in one ofthe two takeoff accidents in the 1980-1984 pe-riod. (This was the already-discussed Boeing737 accident.)

When crew involvement in takeoff accidentsduring the 10 years of deregulation is com-pared with that of the preceding years, one

begins to wonder what has happened to crewproficiency. (See Table 5).

The disproportionate element of the crew as afactor in takeoff accidents during the 1980-1989 period suggests a general decline in thecommitment to excellence on the part of thecrews as well as the system behind them. Sincederegulation is the principal variable in thiscomparison, it seems logical to review the ac-cident reports of the most recent 5-year periodfor evidence similar to that revealed in theBoeing 737 takeoff accident in the 1980-1984period.

In two of its reports covering 1985-1989 take-off accidents, the NTSB alludes to what canonly be interpreted as a deregulation factor.In the DC-9 accident in Denver, U.S., (1987),the NTSB found the pairing of the two pilotsinappropriate due to the “low experience levelof both crew members in the DC-9.” In thecausal statement, the board cited “the absenceof regulatory or management controls govern-ing operations by newly qualified flight crewmembers.” A safety recommendation whichaddresses that hazard was made to the FAA.To the writer ’s knowledge, this safety issuearose for the first time in post-deregulation

Table 4

Selected Elements ofFatal Jet Transport Accidents

U.S. Passenger Operations Under Part 1211970-1989

1970- 1975- 1980- 1985-1974 1979 1984 1989

Fatal Accidents 19 11 5 15Crew/Pass. Deaths 1058 1030 222 1216

Phase of Flight: Takeoff 3 2 2 6 Approach/Landing 12 7 2 2 Other 4 2 1 7Midair Collisions 3 1 - -Sabotage/Suicide 1 - 1 2Windshear - 1 1 1CFIT 6 1 - 2Stalled on Takeoff - - 1 5Improper T/O Configuration - - - 3Catastr. Equipment Failure - 1 - 3


years.

The second accident involving crew experi-ence and crew pairing was the Boeing 737 RTOin New York, N.Y., U.S., in September 1989(FSF Human Factors and Aviation Medicine bul-letin, January/February 1991, “When A Re-jected Takeoff Goes Bad,”). How-ever, this factor was not listed inthe NTSB’s causal statement. Oneof the board members took excep-tion to this omission; he would havepreferred the addition of a contrib-uting factor dealing with the carrier’sfailure to provide an adequatelyexperienced and seasoned flightcrew. Although the NTSB does notmake the connection, certain eye-brow-raising elements in the cir-cumstances surrounding the take-off can only be associated withderegulation’s relaxing influence onoperational practices. To mention just a few:the first officer, who was at the controls dur-ing the night takeoff, was making his first un-supervised line takeoff; this was his first tripafter a 39-day nonflying period; the captainhad about 140 hours as a Boeing 737 captain.

In its causal statement dealing with the Boe-ing 727 takeoff accident in Dallas, Texas, U.S.,(1988), the NTSB included as a contributingfactor the carrier ’s “slow implementation ofnecessary modifications to its operating pro-cedures, manuals, checklists, training, and crewchecking programs which were necessitatedby significant changes in the airline followingrapid growth and merger.” The accident re-port contains this interesting reaction of a con-curring/dissenting board member: “I cannotsupport the language in the board-adoptedprobable cause which suggests that [the car-rier], one of the major players in the airlineindustry and the aviation economy, was some-how victimized by the circumstances of itseconomic environment.”

This review of the 1980-1989 takeoff accidentexperience suggests that the deregulation fac-tor was involved in at least the three caseswhere lack of crew experience and inappro-priate crew pairing were cited. The extent to

which the deregulation factor serves as an ex-planation for the crew’s substandard perfor-mance in some of the other cases is difficult toassess.

It can only be observed that a crew’s disre-gard of checklist procedures and sound oper-

ating practices is not a problem that developsovernight. There must be deeper roots. Asthe NTSB found in one of these cases: “[Thecarrier ’s] corporate philosophy of permittingmaximum captain discretion contributed to thepoor discipline and performance of [the] flightcrew.” Perhaps, corporate preoccupation withcompetition and economic survival detractsattention from the operational norms that haveserved the industry so well in the past.

Catastrophic Equipment Failures

There were three catastrophic equipment fail-ures in the recent five-year period which putthe lives of 746 aircraft occupants in extremejeopardy. Levelheaded and competent crewsmanaged to save 625 of them.

In retrospect, at least two of the accidents dem-onstrate a tendency that has existed in theindustry and its regulatory arm for years thatcan only have been aggravated by deregula-tion: delaying the costly fix of a known prob-lem until an accident changes the prioritiesputs a stop to procrastination.

The Boeing 747 cargo door accident near Ha-waii in 1989 had its parallel in the events pre-

Table 5

1970-1979 1980-1989

No. of takeoff accidents 5 8

No. of T/O accidents for whichcauses were determined 4 7

No. of cases in which the crewwas cited as “primary factor” 0 6


ceding the catastrophic DC-10 accident nearParis in 1974. In both cases the handwritinghad been on the wall for a considerable timebut, apparently, there was no one in a respon-sible position with the intelligence and theintegrity needed to accept the significance andconsequences of that message.

With regard to the Boeing 737 cabin roof sepa-ration over the Hawaiian Islands in 1988, itsuffices to say that the problems with agingaircraft were known long before this grim re-minder.

The final report on the DC-10 that crashed inSioux City in 1989 cites the cause as the disin-tegration of the number two engine fan disk,which severed the aircraft’s three hydraulicsystems thus disabling the flight controls, leavingit to the crew’s skill and ingenuity to get theaircraft to an airport. (An allusion by the NTSBto maintenance deficiencies that could haveallowed an existing hairline fracture in the fandisk go undetected for some time before thefailure has been disputed by the carrier ’s en-gine overhaul facility.)

There had been a similar occurrence in Sep-tember 1981, when the fan module of the numbertwo engine of a Lockheed L-1011 separatedthrough the “S” duct above the aft fuselage,following a fan shaft failure. Three of the fourhydraulic systems were crippled; the fourthwas damaged but not severed, and the crewwas able to make a safe landing. In its reporton the accident, the NTSB stated, “A separa-tion of the entire fan module, however, wasnot considered as a possible occurrence dur-ing the design of the airframe and, thus, wasnot an influencing factor in the placement ofredundant systems.”

The Sioux City accident provided some be-lated preventive insight. The FAA has comeout with a proposed airworthiness directive(AD) that would require modification of DC-10 hydraulic systems to prevent a loss of flightcontrol in case of major damage to the system.

The Role of Regional Airlines

A review of air carrier accident experience inpassenger operations would not be completewithout considering the growing dependenceof smaller communities on regional airlines(commuters). Of particular interest in thatregard is the development of the hub-and-spokesystem, dominated by the large carriers. Didthe proliferation of smaller aircraft that servethe spoke dwellers now only add to the con-gestion of airspace and airports, or did it alsodiscriminate against that segment of the popu-lation safety-wise?

According the the April 1988 report of the Presi-dential Aviation Safety Commission, “The com-muter industry has amassed a safety record inthe post-deregulation years that is about fourtimes worse than that of the jet carriers.” TheCommission emphasizes that the record of thelarger commuter carriers is about twice as goodas the commuter industry’s overall record.Recognizing the higher risks for the spokedwellers, the Commission recommended “re-ducing differences in equipment standards …and operating practices between regional andnational carriers.” That recommendation issupported by Table 6.

Actually, in terms of hours flown between fa-tal accidents in scheduled service, the recordof the commuter industry as a whole duringits best five-year period (1985-1989) was eighttimes worse than that of the major carriersduring the same period. The only encourag-ing aspect of this record is that it has beensteadily improving.

The public’s apparent acceptance of the re-gional carriers’ accident record might be in-terpreted to mean that the major carriers canafford to further reduce their safety-relatedexpenditures. This would be a grave mistake.The public’s perception of air safety is gov-erned mainly by the frequency of headline-making mishaps. Commuter accidents seldommeet that criterion on a national scale.

Deregulation proved that it was not concernedabout safety but the price of the air fare thatpreviously had kept people from flocking tothe airports. However, if the major air carri-ers were to assume that the public would tol-erate the lowering of their performance to one


million hours between news-making fatal ac-cidents in passenger operations, there wouldbe about one such event each month. In thatcase the public might find cause to differenti-ate between “good” and “bad” carri-ers and, perhaps, even to shun cer-tain types of aircraft. This wouldmake safety a competitive issue, atleast to the extent that the public stillhas options in long-distance travel.

As an aside, it should be mentionedthat deregulation discriminated againstthe spoke dweller in another respect.The author ’s situation can be used asan example. He lives 171 air milesfrom the nearest hub airport. Beforederegulation his community was served byfive daily DC-9 fights; the same service isnow performed by 15 commuter flights. Thestandard, one-way DC-9 fare in 1979, duringthe height of a fuel crisis, was $51. In July1990 (before the events in the Middle East),the fare of the largest of the two commuterswas $125. Deregulation gave the hub dwell-ers an economic as well as a safety advantageover spoke dwellers.

Growing Need to AddressSafety Aspects of Deregulation

The study shows that there was a distinct changefor the worse in the accident experience ofU.S. air carriers in passenger operations dur-ing the second half of the 1980s. The contribu-tion of deregulation to that record could besubstantiated only in those accidents whereflight crew experience was identified as a fac-tor. This does not mean that experience levelsin other areas, like maintenance, have not beenaffected since it is mainly the flight crew’sexperience that gets routine scrutiny in acci-dent investigations.

In this author ’s view, the Airline DeregulationAct of 1978 was a well-intended but draco-nian experiment implemented with some na-ive assumption about the infrastructure’s ca-pacity to absorb the anticipated growth in thetraffic and the FAA’s ability to monitor theburgeoning industry. By giving free rein to

the driving forces of economics and corporateambition, the industry entered a period of up-heaval whose full impact on the competenceand the commitment to safety of the work

force may not be felt until the 1990s.

The subject was addressed by John H. Enders,president, Flight Safety Foundation, and JeromeF. Lederer, FSF president emeritus during theirpresentation at the 1987 Conference on Trans-portation Deregulation and Safety. They de-clared that “safety and economics are inextri-cably linked.” They further stated, “there ap-pears to be an uncoupling that has taken placebetween the economics of airline operationand the technical operation itself.” The latterstatement brings to mind the following meta-phor. Deregulation was expected to trim ex-cess fat from the pampered goose that lays thegolden eggs. This occurred without delay.However, in the process the goose lost notonly its fat but also some of its resistance toabuse, because of the uncoupling between thosewho look after the daily health of the gooseand those who claim its eggs.

The ostensible and nobel goal of deregulationwas to make air travel affordable to the masses.In that regard it has been declared a “smash-ing success” that has saved the public about$100 billion over the last 10 years. These al-leged benefits went mainly to those who hadthe willingness and the time to put up withthe uncertainties, inconveniences and callous-ness of a deregulated environment for the sakeof a non-refundable discount ticket. The con-comitant crowding of more seats into theeconomy section of airplanes without increas-ing their emergency exit potential is a safety-

Table 6

Regional Airlines

Hours FlownFatal Hours Between FatalAccidents Flown Accidents

1975-1979 33 4,500,000 136,0001980-1984 30 7,000,000 233,0001985-1989 25 9,500,000 380,000


An Update of Two Safety RulesRelating to Age and Alcohol

byShung C. Huang

Statistical Consultant

related deregulation factor in itself. And somay be the trend towards smaller crews andfewer engines in overwater operations.

The eventual success of the U.S. deregulationexperiment will depend upon the industry’sability to maintain the public’s trust in its safetyperformance in the next decade. The industry’srecord over the past five years seems to justifythis final conclusion: Unless the deregulationfactor is treated with the same concern as thehuman factor, the accident experience of the1990s may force a return to square one. ♦

About the Author

Gerard M. Bruggink has been an aviation consultantsince his retirement from the U.S. NationalTransportation Safety Board (NTSB) in 1979. Hehas published more than 25 papers on various aspectsof aviation safety during that period.

During his 10 years at the NTSB, Bruggink servedas field investigator, chief of the Human FactorsBranch, accident inquiry manager, and deputy directorof the Bureau of Accident Investigation. He wasan air safety investigator for the U.S. Army SafetyCenter, chief of the Human Factors Branch at theAviation Crash Injury Research Division of theFlight Safety Foundation and was a flight instructor,safety officer and accident investigator for the U.S.Air Force and U.S. Army contract flight schools.

Prior to emigrating to the United States, Brugginkwas a flight instructor, safety officer and accidentinvestigator for the Netherlands Air Force. Anative of the Netherlands, he was a fighter pilotduring World War II. He saw action in the Pacifictheater and became interned as a prisoner of war.

Bruggink has been honored with the James H.McClellan Award from the Army AviationAssociation of America and the Jerome LedererAward from the International Society of Air SafetyInvestigators.

Aviation Statistics

The Age 60 Rule

The U.S. Court of Appeals in Chicago, U.S.,recently upheld a 30-year-old Federal Avia-tion Regulation (FAR) that requires commer-cial pilots to retire at age 60.

The U.S. Federal Aviation Administration (FAA)established the retirement rule in 1960 andhas argued consistently that pilots older than60 years have higher accident rates and thatallowing pilots to continue flying after age 60would be dangerous.

Critics of the rule say that commercial pilotsin their 60s have experience that benefits pas-sengers. They cite the 1989 accident involvinga United Airlines jetliner in Sioux City, Iowa,to back their case. In that crash, a 57-year-oldpilot landed the jet despite a crippled hydrau-lic system and loss of flight controls. Anotherairline jet accident is cited by critics to sup-port their arguments. On February 24, 1989, acargo door of a United Airlines Boeing 747failed and a 10- by 40-foot section of frontfuselage tore away shortly after takeoff fromHawaii, causing an explosive decompressionand destroying two engines. Nine passengers


were sucked into the void. At the controlswas Capt. David Cronin, 59 years old, a 35-year veteran, who used his experience, skillsand good judgment to bring the aircraft backto Honolulu and landed safely. His courageand experience saved more than 335 lives. Butwithin four weeks David Cronin reached age60 and United Airlines retired him.

The three-judge panel of the Court of Appealsfor the Seventh Circuit voted 2-1 on October31, 1990 against a group of airline pilots whowanted to overturn the age 60 rule. In itsopinion, the Court criticized the evidence pre-sented by both sides. While the court said ithad seen no compelling evidence that grant-ing exemptions would increase the risk of ac-cidents, it also said it had not seen strongevidence that the experience and skill of a 60-year-old pilot clearly overwhelms the dangerof deterioration of piloting skills or suddenincapacity associated with aging.

The court said it could not “justify a conclu-sion that, on average, experience sufficientlyoffsets possible age-related impairment of healthor skills to clearly guarantee a net constancy[of] or increase in safety.” In writing for themajority, Judge Richard Cudagy said that “safetyis the dominant and controlling consideration,”but that “the FAA should not take this as asignal that the age 60 rule is sacrosanct anduntouchable.” However, the senior judge, HubertWill, wrote a strongly worded dissent. Be-cause there was no compelling contrary evi-dence, the court did not overrule the agency’sconcerns and deferred to the FAA, concludingthat the agency’s order denying the petitionsfor exemption was supported by substantialevidence. The court, however, urged the FAAto increase its effort to accommodate the pi-lots’ points of view.

The No Drinking Rule

U.S. Federal Aviation Regulations prohibit theuse of alcohol by crew members within eighthours of flight and also prohibit a person fromacting as a flight crew member while underthe influence of alcohol (Appendix 1).

In March, 1990, three airline pilots flew a Boe-ing 727 with 91 passengers aboard from Hec-tor International Airport, Fargo, North Dakota,U.S., to Minneapolis-St. Paul International Air-port, Minnesota, while intoxicated. Based onan anonymous tip to the FAA and action bytwo of the agency’s inspectors, the pilots werearrested when the plane landed. On an emer-gency basis, the FAA quickly revoked the li-censes of the pilots and the airline fired themafterwards.

In August 1990, a Minnesota jury convictedthe three pilots of a felony count of operatinga common carrier while under influence ofalcohol or drugs. In late October, a federaljudge sentenced them from 12 months to 16months in jail. The captain was given a 16-month jail term; the co-pilot and the flightengineer were sent to jail for one year. Allthree were also placed on three years of “su-pervised release,” similar to probation.

On November 29, 1990, a new regulation be-came effective that was intended to detect pi-lots who may have a history of drug and alco-hol abuse before cockpit safety is affected. Itwas designed to identify and ground pilotsinvolved in alcohol- or drug-related motor ve-hicle offenses that result in conviction or ad-ministration actions such as driver ’s licensesuspension or revocation.

Under the new rule (14 CFR Parts 61 and 67 asamended — Appendix B), the FAA may denyan application for any certification or rating,or suspend or revoke any pilot certificate orrating if the person has two or more alcohol-or drug-related driving convictions or admin-istrative actions within a three-year period af-ter the rule became effective.

In addition, a pilot is required to provide awritten report to the FAA within 60 days afterany covered motor vehicle action. The reportmust include name, address, date of birth, air-man certificate number, date of conviction andthe name of the state that holds the record,together with a statement to describe whetherthe motor vehicle action is related to the sameincident or “arose out of the same factual cir-cumstances related to a previously-reported


motor vehicle action.” The FAA may, fromtime to time, review the National Driver Reg-ister files to uncover failures to report suchconvictions (Appendix C). Pilots failing toreport such convictions would be subject todenial of an application for any certificate orrating, or suspension or revocation of any cer-tificate.

91.11 Alcohol or drugs.(a) No person may act or attempt to act as a crew

member of a civil aircraft—(1) Within eight hours after the consumption of any

alcoholic beverage;(2) While under the influence of alcohol;(3) While using any drug that affects the person’s

faculties in any way contrary to safety; or(4) While having .04 percent of weight or more alco-

hol in the blood.(b) Except in an emergency, no pilot of a civil air-

craft may allow a person who appears to be intoxicatedor demonstrates by manner or physical indications thatthe individual is under the influence of drugs (except amedical patient under proper care) to be carried in thataircraft.

(c) A crew member shall do the following:(1) On request of a law enforcement officer, submit

to a test to indicate the percentage by weight of alcoholin the blood, when—

(i) The law enforcement officer is authorized understate or local law to conduct the test or to have the testconducted; and

(ii) The law enforcement officer is requesting sub-mission to the test to investigate a suspected violation ofstate or local law governing the same or substantially

The new rules also require that at the time ofapplication for a pilot certificate, each personwho applies for a medical certificate shall consentto the release of information from the NationalDriver Register to enable the FAA to obtainand review motor vehicle offense informationrelating to the applicant. ♦

Appendix A

14 CFR Part 91 - General Operating and Flight Rules

similar conduct prohibited by paragraph (a)(1), (a)(2), or(a)(4) of this section.

(2) Whenever the Administrator has a reasonablebasis to believe that a person may have violated para-graph (a)(1), (a)(2), or (a)(4) of this section, that personshall, upon request by the Administrator, furnish theAdministrator, or authorize any clinic, hospital, doctor,or other person to release to the Administrator, the re-sult of each test taken within four hours after acting orattempting to act as a crew member that indicates per-centage by weight of alcohol in the blood.

(d) Whenever the Administrator has reasonable ba-sis to believe that a person may have violated paragraph(a)(3) of this section, that person shall, upon request bythe Administrator, furnish the Administrator, or autho-rize any clinic, hospital, doctor, or other person to re-lease to the Administrator, the results of each test takenwith four hours after acting or attempting to act as acrew member that indicates the presence of any drugs inthe body.

(e) Any test information obtained by the Adminis-trator under paragraph (c) or (d) of this section may beevaluated in determining a person’s qualifications forany airman certificate or possible violations of this chapterand may be used as evidence in any legal proceedingunder section 602, 609, or 901 of the [U.S.] Federal Avia-tion Act of 1958.

14 CFR Part 61Aircraft, Airmen, Alcoholism, Aviation safety, Drug

abuse, Recreation and recreation areas, Reporting andrecord keeping requirements.

14 CFR Part 67Airmen, Aviation safety, Health, Reporting and record

keeping requirements.

The AmendmentsIn consideration of the foregoing, the [U.S.] Federal

Aviation Administration amends part 61 and part 67 ofthe [U.S.] Federal Aviation Regulations (14 CFR parts 61and 67) as follows:

Appendix B14 CFR Parts 61 & 67 as amended

Part 61—Certification: Pilots and Flight instructors1. The authority citation for part 61 is revised to

read as follows:Authority: 49 U.S.C. App. 1354(a), 1355 1421, 1422,

and 1427; 49 U.S.C. 106(g) (Revised Pub. L. 97-449, Janu-ary 12, 1983).

2. By amending § 61.15 by adding new paragraphs(c), (d), (e), and (f) to read as follows:

§ 61.15 Offenses involving alcohol or drugs.(c) For the purposes of paragraphs (d) and (e) of this

section, a motor vehicle action means—(1) A conviction after November 29, 1990, for the

violation of any Federal or state statute relating to the


operation of a motor vehicle while intoxicated by alco-hol or a drug, while impaired by alcohol or a drug, orwhile under the influence of alcohol or a drug;

(2) The cancellation, suspension, or revocation of alicense to operate a motor vehicle by a state after No-vember 29, 1990, for a cause related to the operation of amotor vehicle while intoxicated by alcohol or a drug,while impaired by alcohol or a drug, or while under theinfluence of alcohol or a drug; or

(3) The denial after November 29, 1990, of an appli-cation for a license to operate a motor vehicle by a statefor a cause related to the operation of a motor vehiclewhile intoxicated by alcohol or a drug, while impairedby alcohol or a drug or while under the influence ofalcohol or drug.

(d) Except in the case of a motor vehicle action thatresults from the same incident or arises out of the samefactual circumstances, a motor vehicle action occurringwith three years of a previous motor vehicle action isgrounds for—

(1) Denial of an application for any certificate orrating issued under this part for a period of up to oneyear after the date of the last motor vehicle action; or

(2) Suspension or revocation of any certificate orrating issued under this part.

(e) Each person holding a certificate issued underthis part shall provide a written report of each motorvehicle action to the FAA, Civil Aviation Security Divi-sion (AAC-700), P.O. Box 25810, Oklahoma City, OK 73125,not later than 60 days after the motor vehicle action.The report must include—

(1) The person’s name, address date of birth, andairman certificate number,

(2) The type of violation that resulted in the convic-tion or the administrative action;

(3) The date of the conviction or administrative ac-tion;

(4) The state that the holds the record of convictionor administrative action; and

(5) A statement of whether the motor vehicle actionresulted from the same incident or arose out of the samefactual circumstances related to a previously-reportedmotor vehicle action.

(f) Failure to comply with paragraph (e) of this sec-tion is grounds for—

(1) Denial of an application for any certificate orrating issued under this part for a period of up to 1 yearafter the date of the motor vehicle action; or

(2) Suspension or revocation of any certificate orrating issued under this part.

Part 67—Medical Standards and Certification3. The authority citation for part 67 is revised to

read as follows:Authority: 49 U.S.C. App. 1345(a), 1355, 1421, and

1427; 49 U.S.C. 106(g) (Revised, Pub. L. 97-449, January12, 1983).

4. By adding new § 67.3 to read as follows:§ 67.3 Access to the National Driver Register.At the time of application for a certificate issued

under this part, each person who applies for a medicalcertificate shall execute an express consent form autho-rizing the Administrator to request the chief driver li-censing official of any state designated by the Adminis-trator to transmit information contained in the NationalDriver Register about the person to the Administrator.The Administrator shall make information received fromthe National Driver Register, if any, available on requestto the person for review and written comment.

Issued Washington, DC, on July 26, 1990.James B. Busey,Administrator.

The National Driver Register (NDR) is a computer-ized file of persons whose driver permits have beensuspended or revoked. The NDR is maintained by theNational Highway Traffic Safety Administration (NHTSA)of the U.S. Department of Transportation. While partici-pation of permit-issuing jurisdictions is voluntary, it is acentral contact point for federal and state authorities intheir efforts to ascertain possible problem drivers ap-plying for original and renewal licenses.

The NDR is not a file on all licensed drivers in theUnited States but an index of adverse driver record filesmaintained by the states. It contains only data appro-priate to its service as a clearinghouse for informationpertaining to license actions. The NDR contains infor-mation regarding any individual:

1. who is denied a motor vehicle operator ’s li-cense for cause

2. whose operator ’s license is canceled, revoked,or suspended for cause

3. who is convicted of:

a. operation while under the influence of al-cohol or a controlled substance

b. a traffic violation in connection with a fatalaccident, or reckless driving

c. failure to render aid or provide identifica-tion when involved in an accident

d. perjury or false affidavits relating to motorvehicle operation.

Any individual who has applied for or has receivedan airman’s certificate may request the chief driver li-censing official of a state of transmit information con-tained in the National Driver Register about the indi-vidual to the Administrator. The Administrator shallmade information received from the National DriverRegister, if any, available on request to the individualfor review and written comment.

Questions regarding the NDR should be directed to:National Highway Traffic Safety AdministrationU.S. Department of TransportationWashington, D.C. 20590

Appendix CNational Driver Register


Reports

Reducing Runway Incursions: An FAA Report/U.S. Federal Aviation Administration. — Wash-ington, D.C.: U.S. Federal Aviation Adminis-tration, April 1990. 72p. in various pagings.[Copies available from FAA assistant admin-istrator for aviation safety, safety InformationOffice at (202) 267-7770.]

Key Words1. Airports — Runways — Safety Measures.2. Airports — Ground Operations.3. Runway Incursions.

Contents: Introduction — Approach — Prin-cipal Causal Factors of Runway Incursions —Runway Incursion Activities (Associate Ad-ministrator for Air Traffic) — Runway Incur-sion Activities (Office of Airport Safety andStandards) — Runway Incursion Activities(Office of Flight Standards) — Runway Incur-sion Activities (Advanced System Design Ser-vice) — Conclusions and Recommendations— Appendix A: Runway Incursion Team Mem-bers — References — Glossary of Acronyms.

Summary: In 1987, the FAA administratordirected that the assistant administrator foraviation safety (ASF) undertake a focused ef-fort to identify the causes of runway incur-sions and recommend measures for alleviat-ing the problem. This report is a product ofthe Phase II effort, designed to examine therunway incursion problem from the multipleperspectives involved — the tower cab, theairport, the cockpit, and engineering — andto combine these perspectives in an analysisthat would serve as the basis for an integratedFAA program to address the problem. Rec-ommendations include procedures; training;awareness; signs, marking, and lighting; andsimplification of surface traffic movements.

Medical Risk Assessment and the Age 60 Rule forAirline Pilots. Requested by Subcommittee on

Reports Received at FSFJerry Lederer Aviation Safety Library

Investigations and Oversight, Committee onPublic works and Transportation, U.S. Houseof Representatives. — Washington, D.C. : U.S.Congress, Office of Technology Assessment(OTA), September 1990. 13p., charts, graphs.

Key Words1. Air Pilots — Certification — United States.2. Air Pilots — Legal Status, Laws, etc.. —

United States.3. Air Pilots — Health and Hygiene — United

States.4. Retirement Age — United States.5. Aeronautics, Commercial — Law and Leg-

islation — United States.6. Aeronautics, Commercial — Safety Mea-

sures — United States.

Summary: Early in 1990, the Subcommitteeon Investigations and Oversight of the HouseCommittee on Public Works and Transporta-tion asked OTA to examine the medical as-pects of the federal regulation (14 CFR 121.383(c)and 14 CFR 67) prohibiting pilots older than60 from flying for airlines. The Subcommitteealso requested that OTA analyze the state ofthe art of medical risk assessment. To respondto the Subcommittee’s questions, OTA inter-viewed FAA officials and medical experts andreviewed aeromedical literature, pilot healthand safety data, and medical technologies. Thekey findings include statistical data on pilotperformance and age (pilots between 60 and69 years old who are permitted to fly underFAA’s strictest medical requirements (Class Iand II medical certificates) have an accidentrate twice as high as similar pilots who are inthe 50s; sudden physical impairment has notbeen a factor in airline accidents); medical screen-ing technologies do not exist which would predictthe development of medical conditions thatcould affect pilot performance and even if theprocedures did exist they would not be suffi-cient to ensure that current levels of pilot per-formance would be maintained if the age rulewere abolished; improved neuropsychological


measures of cognitive performance would needto be developed and validated before FAA couldreliably ground on the “high risk” pilots whoare over 60; medical costs, and other economicissues. [Summary]

Windshear Case Study: Denver, Colorado, July 11,1988. Final Report / Herbert W. Schlickenmaier(Federal Aviation Administration). — Wash-ington, D.C. : U.S. Federal Aviation Adminis-tration Advanced System Design Service; Spring-field, Virginia, U.S. : Available from NTIS*,November 1989. Report DOT/FAA/DS-89/19. 552p., ill., charts.

Key Words1. Verticial Wind Shear — Colorado — Den-

ver.2. Wind Shear — Colorado — Denver.3. Wind Shear — Detection — United States.4. Microbursts.5. Airports — Colorado — Denver — Traffic

Control.6. Aeronautics — Safety Measures.7. Meterology in Aeronautics.

Summary: On Monday, July 11, 1988, foursuccessive United flights had inadvertent en-counters with microburst windshear conditionswhile on final approach to Denver StapletonAirport, each resulting in a missed approach,subsequent delay, and uneventful arrival. Afifth flight executed a missed approach with-out encountering the phenomena. All of theflight crews were trained utilizing the resourcesof the Windshear Training Aid. There was nodamage to aircraft and no passenger injuries.At the time the aircraft encountered themicroburst, the Terminal Doppler Weather Radar(TDWR) Operations Test and Experiment wasin progress and detected divergent flow thatintersected the operating zones for the approachrunways. This Windshear Case Study out-lines the technical details of the encounter, aswell as describes insights gained from this con-frontation that should be applied to futureinvestigations of aircraft encountering windshear.This study summarized information from sev-eral sources including flight crew comments,air traffic control operations and surveillanceradar data, flight data recorders, data fromthe TDWR and the Low-Level Wind Shear Alert

System, technical details of the event meteo-rology, and data from the Terminal Area Simu-lation System.

Medically Disqualified Airline Pilots in CalendarYears 1987 and 1988. Final Report / Leslie E.Downey and Shirley J. Dark (Civil Aeromedi-cal Institute). — Washington, D.C. : U.S. Fed-eral Aviation Administration Office of Avia-tion Medicine; Springfield, Virginia, U.S. : Avail-able from NTIS*, June, 1990. Report DOT/FAA/AM-90/5. 11p.

Key Words1. Air Pilots — Certification — United States.2. Air Pilots — Medical Examinations — United

States.3. Air Pilots — Diseases — United States.4. Airlines — Employees — Medical Exami-

nations — United States.

Summary: This study presents comprehen-sive data reflecting pertinent denial rates re-garding the medical and general attributes ofthose airline pilots denied medical certifica-tion in calendar years 1987 and 1988. Theoverall denial rate of this group is 4.3 per 1,000active airline pilots. Age-specific denial ratesfor airline pilots increase to the highest rate atage interval 55-59. The most significant causesfor denial by pathology series are: (1) cardio-vascular (34%); (2) neuropsychiatric; and (3)the miscellaneous category. The most signifi-cant causes for denial by specific pathologyare: (1) coronary artery disease; (2) use of dis-qualifying medications; (3) psychoneurotic dis-orders; (4) myocardial infarction; and (5) dis-turbance of consciousness.

Development of a Crashworthy Seat for CommuterAircraft. Final Report / Van Gowdy (Civil Aero-medical Institute). — Washington, D.C. : U.S.Federal Aviation Administration Office of Avia-tion Medicine; Springfield, Virginia, U.S.: Avail-able from NTIS*, September, 1990. Report DOT/FAA/AM-90/11. 12p.

Key Words1. Airplanes — Seats — Testing.2. Airplanes — Seats — Design and Construc-

tion.3. Airplanes — Seats — Safety Measures.


4. Airplanes — Seats — Crashworthiness.

Summary: A series of dynamic impact testswas conducted using a prototype seat with anenergy absorbing mechanism as part of theseat pan. The seat frame was designed torepresent a typical commuter aircraft passen-ger seat. Tests were conducted in an orienta-tion simulating a vertical impact with a 30-degree nose-down aircraft attitude. The im-pact severity for these tests ranged from 15 to33 Gs. Seat pan stroke and occupant lumbarreaction forces were measured. Results indi-cate the axial force measured in the lumbarspine of a fiftieth percentile Hybrid II dummycan be limited to a peak value less than 1500pounds during vertical impact tests of 33 Gwith a seat pan stroke distance of 6.3 inches.

New Zealand Civil Aircraft Accidents 1989. —Wellington, New Zealand : Office of Air Acci-dents Investigation; [September], 1990. 35p.

Key Words1. Aeronautics — Accidents — Statistics —

New Zealand.

Summary: The information in this Summarycovers all notifiable accidents to civil aircraftof New Zealand registry which occurred andwere notified, during the calendar year 1989.Includes Airline, Public Aircraft, General Avia-tion, Gliding, Hang Gliding.

Human Error in the Cockpit / Beat Ruegger. Zurich: Swiss Reinsurance Company, Aviation De-partment, Mythenqual 50/60, P.O. Box 8022Zurich, Switzerland; [October], 1990. 43p.; ill,charts, graphs, color photos.

Key Words1. Aeronautics — Accidents — Human Fac-

tors.2. Aeronautics — Human Factors.3. Aeronautics — Safety Measures.4. Air Pilots — Errors.5. Airplanes — Piloting — Human Factors.

Contents: Introduction — Aerospace medi-cine — On the origins of human error — Hu-man support — The costly and tedious les-sons of accidents — Incidents as a source ofknowledge — Enterprise and responsibility —

Public and civil aviation authorities — Qual-ity control to promote progress.

Windshear—Optimum Trajectory, Human Factorsand Miscellaneous Information / William W. Melvin(Air Lines Pilots Association). — Warrendale,PA : Society of Automotive Engineers, 400 Com-monwealth Drive, Warrendale, Pa. 15096-0001USA; 1990. Report SAE 901995. 14p., ill, ref-erences. Presented at the Aerospace Technol-ogy Conference and Exposition, Long Beach,California, October 1-4, 1990.

Key Words1. Air Pilots — Training.2. Airplanes — Piloting — Human Factors.3. Meteorology in Aeronautics.4. Windshear.

Summary: Optimal trajectory studies of air-craft in wind shear have resulted in insight ashow to best fly an aircraft in a wind shear;these also question some previous (and cur-rent) recommendations. Recent accidents andincidents give new support for some old ideas.Human factors problems of information transferto and from the cockpit and pilot interfacewith the aircraft are discussed. Some miscel-laneous information is included for the recordwith reintroduction of some old data whichare important but not currently provided topilots. Because of the chronological record,the miscellaneous information is discussed first.[author abstract]

Aircraft Accident Report, Boeing 737-2L9, OY-MBV, Roenne Airport, Bornholm, 24 March 1989.— [Copenhagen], Denmark : Aircraft AccidentInvestigation Board; [September] 1990. ReportAAIB 3/90. 85 p. in various pagings, ill.

Key Words1. Aeronautics — Accidents — 1989.2. Aeronautics — Accidents — Approach.3. Aeronautics — Accidents — Flaps.4. Aeronautics — Accidents — Hydraulic Sys-

tems.5. MAERSK Air — Accidents — 1989.

Summary: The scheduled Maersk Air flightfrom Copenhagen to Roenne, 4 crew and 63passengers, had proceeded normally until thefinal approach to land. When flap 30 was


called and selected, the flap did not travelfrom the flap 25 position. The First Officerinformed the Captain, who was the pilot fly-ing, about the flap problem. About 25 sec-onds later the First Officer advised the Cap-tain that the “A” hydraulic system had failed.No warning lights were observed by eitherpilot at this stage. On landing the engine thrustreversers could not be activated, the speedbrake lever was activated manually and wheelbraking was not noticeable. The aircraft con-tinued at high speed, overran the runway endand came to a standstill 425 meters beyondthe runway end, the left main gear and nosegear collapsed. There was no fire. An emer-gency evacuation was executed. There wereno injuries to persons.

Examination of the aircraft by the AAIB re-vealed that the flap flow limiter valve hadfractured, releasing the hydraulic fluid andrendering the “A” hydraulic system inopera-tive. The “B” hydraulic system was operativeand so was the “standby” hydraulic system,but the “standby” hydraulic system was notselected.

The following causal factors were identified:

1. The Captain became the victim of task satu-ration leading to fixation.

2. The Captain only perceived the flap prob-lem and decided that a landing should be made.He disregarded the hydraulic failure as he statedthat he did not observe any warning lights.Thus the non-normal procedure was not per-formed.

3. The Captain did not discontinue the ap-proach and perform a go-around as he should,since the aircraft was not configured for land-ing as briefed.

4. Crew coordination was not satisfactory.

5. It is probable that the aircraft hydroplanedduring portion of the roll on the runway.

6. Under the given circumstances the aircraftcould not be stopped on the runway. [Synop-sis]

*U.S. Department of CommerceNational Technical Information Service (NTIS)Springfield, Virginia, U.S. 22161 U.S.Telephone: (703) 487-4780.Reference

Advisory Circular 120-35B, 9/6/90, Line Opera-tion Simulations: Line-Oriented Flight Training,Special Purpose Operational Training Line Op-erational Evaluation. — Washington, D.C. : U.S.Federal Aviation Administration, AFS-210; Sep-tember, 1990. 22p.

Key Words1. Flight Simulators — Design.2. Line-Oriented Flight Training (LOFT).

Note: Cancels AC 120-35A dated August 11,1981.

Summary: This advisory circular presents guide-lines for the design and implementation ofLine Operation Simulations, including Line-Oriented Flight Training (LOFT), Special Pur-pose Operational Training, and Line Opera-tional Flight Evaluation. This document doesnot interpret the regulations; interpretationsare issued only under established agency pro-cedures.

Advisory Circular 121.195(d) - 1A, 6/19/90, Op-erational Landing Distances for Wet Runways;Transport Category Airplanes. — Washington,D.C. : U.S. Federal Aviation Administration,June, 1990. 5p.

Key Words1. Airports — Runways — Law and Legisla-

tion — United States.2. Airports — Runways — Length.3. Slush on Pavement, Runways, Etc.

Notes: Cancels AC 121.195(d) - 1, dated 11/19/65.

Summary: This advisory circular (AC) setsforth an acceptable means, but not the onlymeans, of showing compliance with FederalAviation Regulations Part 121.195(d) pertain-ing to operational landing distances on wetrunways. It is for guidance purposes and pro-vides an example of a method of compliancethat has been found acceptable. [purpose] ♦


Accident/Incident Briefs

This information is intended to provide an aware-ness of problem areas through which such occur-rences may be prevented in the future. Accident/incident briefs are based upon preliminary infor-mation from government agencies, aviation orga-nizations, press information and other sources.This information may not be accurate.

Air CarrierAir Carrier

Runway Incursion in Fog

McDonnell Douglas DC-9: Aircraft destroyed.Fatal injuries to eight, various injuries to 21.

Boeing 727: Damage to right wingtip. No inju-ries.

The DC-9 was taxiing toward the takeoff endof runway 21C for a southbound departurefrom Detroit Metropolitan Airport, Michigan,U.S., headed for Pittsburg. The Boeing 727was preparing to take off on runway 3C, theother end of runway 21C, headed for Mem-phis.

According to preliminary information, theweather was so foggy at 1400 hours that theDC-9 crew members told ground controllersthat they were having trouble “keeping trackof where they were” and that the aircraft missedone assigned taxiway turnoff and was directedto another taxiway that would take it to thetakeoff end of its assigned runway. Visibilitywas one-quarter mile in fog when the DC-9departed its gate.

The DC-9 apparently entered runway 21C in-

advertently and the crew was reported to haveindicated uncertainty of the aircraft’s locationin the fog; mentioning to ground controllersthe possibility that they may have strayed ontothe active runway by mistake and being ad-vised to exit the runway immediately. Theaircraft was headed south along the runway.

In the meantime, the Boeing 727 had been clearedfor takeoff from the other end of the samerunway.

About one minute after the DC-9 crew real-ized it may have entered the active runway,the Boeing 727 appeared out of the mists fromthe opposite direction traveling approximatelyat rotation speed. The right wingtip of the 727sliced along the top of the fuselage of the DC-9 and sheared off its right engine. The DC-9caught fire and was gutted down to the win-dow line during which eight persons in thepassenger compartment, including a flight at-tendant, received fatal injuries.

The Boeing 727 was stopped about 2,500 feetfarther along the runway. There was damageto the wingtip but there was no fire and noone aboard was injured.

The accident is currently under investigationby the U.S. National Transportation Safety Board(NTSB) which is expected to release its find-ings later.

The Aircraft ThatMoved by Itself

Lockheed L-1011 TriStar: No damage. No injuries.

The ground crew indicated that wheel chockswere in place shortly after arrival at the slop-ing ramp. The parking brake was released andthe passengers disembarked. While the bag-gage was being loaded for the next flight leg,the air turbine motor (ATM) was operated to


check its serviceability since it had produceda low pressure warning during the approach.

When the passengers were about to board, thesenior cabin crew member reported that thejetway was misaligned with the aircraft doormaking it difficult to board the passengers.While this was being checked, it was also no-ticed that the nosewheel tires were turned about50 degrees from the straight-ahead positionthat they had been left in during parking. Itwas estimated that the aircraft had rolled backabout 18 inches.

The ground crew reported that the aircraft hadbeen properly chocked on arrival and the en-gineering officer reported that the captain’ssteering handwheel had been centered beforeand after the check of the ATM. Investigatorsconsidered the most probable cause was inad-equate chocking on the sloping parking rampand procedures were instituted by the carrierto chock the main wheel tires in addition tothe nose wheel tires in such instances.

The Long and Short of It

Cessna 402: Substantial damage. No injuries.

The pilot was on a visual flight rules charterflight carrying seven passengers. The flighthad proceeded normally toward the destina-tion that was at an unimproved airstrip. Windwas light and variable.

After a normal approach, the pilot landed ap-proximately 650 feet beyond the threshold ofthe 2,700-foot runway which consisted of shortgrass. (The runway had a 180-foot overrun,followed by a shallow depression 115 feet wideand a highway with powerlines above it.) The

Air Taxi/CommuterAir TaxiCommuter

pilot immediately applied maximum brakingbut the grass was wet from a recent rain. Theaircraft skidded on the slippery surface. Thepilot decided not to attempt a go-around be-cause of the obstructions at the end of therunway. He could not stop the aircraft in timeto avoid overrunning the runway and the air-craft rolled through the depression and turned90 degrees to the left. The left main gear andthe nosewheel collapsed and the aircraft stoppedapproximately 400 feet from the end of therunway. The occupants all departed the air-craft without sustaining injury.

The pilot had operated into the airport onetime previously and had not received any re-port in the runway condition prior to depar-ture. According to investigators, the aircraftowner’s manual indicated that the aircraft wouldhave required at least 2,400 feet to stop underthe existing conditions.

The cause of the accident was attributed to thefact that the pilot did not receive runway con-dition information prior to departure, the poorbraking because of the wet grass surface andthe touchdown 650 feet beyond the runwaythreshold.

It Started OffBy Being Late

Piper PA-34-200T Seneca: Substantial damage.No injuries.

The pilot of the charter flight was behind sched-ule. As he rushed through pre-takeoff prepa-rations, the top latch of the passenger doorwas inadvertently left unlatched.

After takeoff, the pilot realized that the pas-senger door was not locked and decided toreturn to the airport to correct the situationbut, to save time, he landed downwind. How-ever, a high sink rate developed during theflareout with the aircraft in a right-wing-lowattitude and it landed hard in the right gearduring a sideslip to the right despite the addi-tion of power by the pilot. He went aroundand, after selecting gear up, noticed that fullaileron deflection and considerably rudder


deflection were required to keep the aircraftflying straight. A visual check by ground per-sonnel during a flyby confirmed that the rightgear was hanging down and was rotated 90degrees from its normal alignment.

The pilot diverted to an airport that had betterfacilities and executed a successful emergencylanding. During the rollout on the left mainand nose gear, the pilot held the right wing offthe ground until the airspeed decreased to thepoint where the wing could no longer be heldup aerodynamically and the aircraft’s rightwing settled to the runway. The aircraft sus-tained substantial damage but there was nofire and there were no injuries.

The cause was attributed to the failure of theright main landing gear due to overload. Acontributing factor was the unlatched door andmention was made that the pilot also was pre-occupied with business matters and had notreceived adequate rest for a few days.

Heavy WeatherWeighs Down Aircraft

Cessna 310: Aircraft destroyed. Fatal injuries toone.

The pilot planned to make a business flightbetween two points in the northeastern sec-tion of the United States. It was dark at thetime of departure approximately 2115 hoursand the weather was misty and foggy, with apartial obscuration and a ceiling of 1,000 feetovercast, four miles visibility, fog and haze.

Before departure, the pilot was cleared to takeoffor runway 21 and, after departure, to turnright on a heading of 340 degrees and climb toand to maintain 5,000 feet. Two radio trans-missions were received from the pilot by ATC

personnel following which there was no fur-ther contact. Wreckage was later found twomiles from the airport on a bearing of 170degrees from the airport. The aircraft hadcrashed in wooded, rolling terrain and wasdestroyed; the pilot, the only occupant, hadreceived fatal injuries.

The cause was reported as pilot disorientation(vertigo) during the initial climb and a loss ofcontrol. Factors contributing to the accidentwere listed as darkness, low ceiling and fog.

Landed Long At Wrong Airport

British Airspace BA-31 Jetstream: Substantialdamage. No injuries.

The business aircraft with two crew membersand nine passengers had departed an Oregon,U.S., airport headed for Tri-Cities Airport, Pasco,Washington, as its intended destination. Thetime was 2238 hours on a moonlit night.

The pilot mistook nearby Kennewick Vista Air-port, with its similarly oriented runway pat-tern, for his destination airport and made theapproach to the wrong airport. He landedlong and was unable to stop on the pavedsurface. The aircraft overran the 3,490-footrunway 2 at Kennewick Vista and collided withrunway end lights; it came to rest 450 feetbeyond the end of the runway. The aircraftsustained substantial damage to tires and landinggear but there were no injuries to the 11 occu-pants.

Lengths of the two similarly oriented runwaysat the intended destination airport were 4,435feet (runway 3R) and 7,700 feet (runway 3L).

Fatal Set-Up

CorporateExecutive

Corporate Executive

Other GeneralAviation

OtherGeneralAviation


de Havilland HD82A Tiger Moth and Piper PA-28-181 Archer: Both aircraft destroyed. Fatal in-juries to four.

The Archer was returning to the U.K. airfieldfrom a training flight and the Tiger Moth wastaking off. There were three persons aboardthe Piper, an instructor, a student pilot and apassenger. The single occupant of the TigerMoth was flying the aircraft from the rear cockpit.

At about 1642 hours, the pilot of the Archerreported inbound to the airport from the north-west and that he had the field in sight. Ap-proximately a minute later, the pilot of theTiger Moth reported that he was climbing out,heading away from the airport to the north-west.

About two minutes later a Mayday messagefrom the pilot of another aircraft reported thathe had just witnessed a midair collision andthat both aircraft were down. He subsequentlyhelped direct rescue services to the scene. Bothaircraft had been destroyed and all occupantshad received fatal injuries. Later examinationof the wreckage established that the aircrafthad struck each other with their right-handwings, each in a relative bank to the left of 50degrees to each other and each about 20 de-grees to the left of directly opposing headings.

According to eye witness reports and a reviewof radar records, investigators noted that thetwo aircraft had been flying directly towardseach other for about two minutes at a closingspeed of about 180 knots, with the Archer de-scending for landing and the Tiger Moth climbingout on course. With his northwesterly head-ing, the pilot of the Tiger Moth would havebeen heading almost directly into the late af-ternoon sun, towards an airplane with colorsof light grey and blue. Weather was clear, withvisibility of more than 12 miles and one-eighthcloud coverage at 4,000 feet; the collision oc-curred at 1,800 feet above ground level. Thepilot of the descending Archer faced a back-ground of rural countryside, and an airplanethat was painted green and white, and waspossibly hidden below his field of vision bythe nose cowling of his aircraft. Although theArcher was equipped with strobe and landing

lights, investigators could not determine fromthe wreckage whether any lights had been onprior to the collision.

Considering that the aircraft were banked awayfrom each other at the time of the accident, thepilots may have seen each other ’s aircraft atthe last moment but too late to avoid the colli-sion.

Simulated ShutdownBecame Realistic

Piper PA-23-250 Aztec: Substantial damage. Noinjuries.

During a dual instruction flight at Chandler,Arizona, U.S., the pilot receiving training wasaccomplishing a go-around maneuver. As theaircraft was climbing through a height of 400feet, the instructor shut down the left engineby closing the mixture control. The pilot prop-erly feathered the left engine.

The instructor went to bring the left engineback out of the feather position but the pro-peller remained feathered. The instructor wasunable to restart the left engine and the air-craft could not climb. The aircraft was force-landed with gear-up.

Backed into Obstruction

Sikorsky S-61: Aircraft destroyed. Fatal injuriesto six, other injuries to seven.

The rotorcraft with a crew of two and 11 pas-sengers was headed for a floating oil platformin the North Sea off the Shetland Islands. Therig had a helipad on top adjacent to a derrickmounted at the edge of the tower. Nine outgo-ing passengers were assembled on a level be-

RotorcraftRotorcraft


low the landing pad.

Weather in the area was calm and improvingfrom early morning fog to low-lying stratuscloud up to heights between 100 to 600 feet.Visibility varied between one and four nauti-cal miles. During its approach, the rotorcraftpassed behind a tanker moored to the oil rigand established a hover adjacent to and ap-proximately 50 feet higher than the landingpad. It then moved to its right, crossing theedge of the deck. According to witnesses, atthis point the aircraft seemed to drift slightlybackwards and appeared in imminent dangerof striking the crane with its tail rotor.

Before the helipad landing officer could radioa warning to the crew, the tail rotor bladesstruck the crane structure and the helicopteryawed to the right and descended. It impactedthe edge of the deck and the main rotor bladesbegan to disintegrate as they struck the sur-face. Before any occupants were able to evacu-ate, the aircraft fell from the deck into thewater, 100 feet below.

The aircraft sank in a minute and shortly af-terwards seven persons were sighted floatingin the water and were rescued. The wreckagewas salvaged with the bodies of the remain-ing occupants inside. Initial investigation ofthe aircraft and the cockpit recorder indicatedno evidence of an unusual incident or aircraftmalfunction.

Instructor ConfusesLesson Instructions

Robinson R22: Substantial damage. No injuries.

It was the instructor’s fourth instructional flightof the day. He was about to end a one-hourexercise teaching traffic patterns and emer-gencies. He had just demonstrated an engine-off landing that he had initiated by closing thethrottle when the helicopter had reached 300feet after a takeoff; a successful touchdownwas completed on the designated grass areato the west of runway 01. Wind was from thenorth at seven knots.

The instructor next briefed the student on thetechnique for a low-level, power-off landingfollowing a normal transition from takeoff toforward flight. After the rotorcraft had attaineda height of between 50 and 60 feet and a for-ward speed of approximately 65 knots, theinstructor closed the throttle, lowered the col-lective pitch and flared the rotorcraft. The air-craft was leveled as it approached the groundbut it ran on with a high forward speed. Be-cause of the rough terrain in the touchdownarea, the aircraft bounced twice and yawed tothe left before stopping upright, but with theright-hand skid displaced because of upwardbending of the cross tubes. The tail boom hadbeen severed by the main rotor and the de-tached tail rotor assembly had ended up half-way between the location of the helicopter ’ssecond bounce and where it stopped.

Written instructions relating to engine failurepractice after takeoff stipulated that this wasnot to be done below 200 feet and at a windspeed of less than 10 knots. The instructornoted that when planning the final exercise hehad temporarily confused the conditions foran engine failure after takeoff with those forone from low-level cruise.


1990 FSF Publications Index

0.00 General

ATC Coordination Between Eastern and Western Europe FSD JulyBusiness Aviation in a Turbulent Environment FSD JulyBusiness Aviation in the ’90s FSD JulyCongested Airspace FSD JulyCorporate and Commuter Technology FSD JulyEast German ATC Coordination FSD JulyECAC Task Force on the Integration of European Air Traffic Control Systems FSD JulyFSF President, Secretary Briefed by Flight Research Institute-USSR FSFN Sept/OctHow Close are Commercial Air Carriers to (Probably) Perfect Safety? FSD JanuaryHow to Encourage Employee Safety AMB Mar/AprNTSB Publishes ‘Most Wanted’ List of Safety Items FSFN Nov/DecMemorial Fund Benefits Foundation FSFN Mar/AprRegional and Commuter Aircraft Service Center Under Construction AMB Nov/DecReviewing Aviation Safety in Japan FSD NovemberSophisticated Flight Data Information Offers Enhancements to Industry FSFN May/JuneThe Air Transport Policy Framework of the EEC FSD JulyThe European Community — A Status Report for Aviation FSD JulyThe Future of the Civil Aviation System FSD JanuaryToday’s Professional Airline Pilot: All the Old Skills — and More FSD JuneU.S.S.R. to Share Aviation Safety Data With Flight Safety Foundation FSFN July/AugWhat is the IAC? FSFN Sept/Oct

0.50 Obituaries

John J. Swearingen, Safety Pioneer FSFN Nov/Dec

1.50 Accident/Incident Briefs

Aborted TakeoffAbort after Liftoff FSD AugustWhoa, Nellie! Go, Nellie! Oops! FSD December

ApproachContinued Approach After Windshear FSD SeptemberCrashing the Gate FSD JanuaryIs That GPWS For Real? FSD OctoberLight in the Gloom Almost Spelled Doom FSD MayPower Reduced, Aircraft Settled FSD DecemberProblems During Foggy Approach FSD FebruaryRainy Night, Unstabilized Approach FSD MarchStorm Diversion Ends in River FSD JanuaryVision Problems During Approach FSD January

CargoUnexpected Tie-Down FSD May

Collision With Ground/ObstaclesBase Leg was the Final One FSD MayBetter of Two Evils FSD DecemberCrash into Sea FSD JanuaryHeavy Helo Has Departure Problem FSD FebruaryInto the Trees And Back Out Again FSD JuneMountain Encounter in Heavy Weather FSD FebruaryNo Safe Way Through the Pass FSD OctoberNot Enough Elbow Room FSD AprilRocks in the Clouds FSD JuneShort Cut Wasn’t FSD JulySun Gets in my Eyes FSD May

LEGEND: AP-Accident Prevention • AO-Airport Operations • AMB-Aviation Mechanics Bulletin • CCS-Cabin CrewSafety • FSD-Flight Safety Digest • HFAM-Human Factors & Aviation Medicine • HSB-Helicopter Safety Bulletin •FSFN- Flight Safety Foundation News

Code Subject Bulletin Date


Things that Go Clunk Before the Flight FSD JanuaryToo Close For Comfort FSD October’Twas a Dark And Stormy Night… FSD JulyWho Has the Runway? FSD August

Control LossMidair Stop Went Awry FSD MayWatch Out For the Wind Machine FSD MayWell, Blow Me Over FSD July

Crew AssociatedApproach Didn’t Work-Neither Did ‘Salvage’ FSD AprilCareless Paperwork Stowage Can Affect Safety FSD JuneFatal Combination Comes Together FSD DecemberFlapless Landings Flop FSD AprilForgot Something After Go-Around FSD AprilInvitation to Murphy FSD JulyLack of Sleep Affects Performance FSD NovemberNot in Top Form? FSD MarchPilot’s Pocket Snags Collective FSD FebruaryPoor Choice of Runway FSD MarchPull a Tiger ’s Tail And You Get Bit FSD AugustReading Road Signs Can Lead to Trouble FSD AprilRemember the NOTAM FSD DecemberToo Low, Too Slow FSD NovemberUnattended Helo Has Mind of Own FSD DecemberWho Put on the Brakes FSD March

DistractionCheck — and Recheck FSD JuneConfusion During Look-See FSD JuneDistraction and Busted Altitudes FSD JanuaryDistraction Bugaboo Strikes Again FSD FebruaryDistraction Leaves Murphy at Controls FSD AugustDistractions Permitted — Checklist Items Omitted FSD JuneFlaps Came Up Instead of Gear FSD AugustLook What You Made Me Do FSD AprilRough Weather Causes Distraction FSD OctoberThird Bounce No Charm FSD February

Emergency LandingLate Change of Mind Has Unwelcome Result FSD SeptemberLessons Learned From Hijacking FSD DecemberPilotage A ‘Lost’ Art? FSD October

Engine(s)Engine Problem After Takeoff FSD JuneHorn Blows Before Power Goes FSD JanuaryLow Reversal After Takeoff FSD SeptemberNo Power of Demand FSD JanuaryWith One Engine Gone, It Didn’t Carry On FSD May

Fire - InflightAnother Reason Smoking and Flying Do Not Mix FSD May

Fuel ExhaustionForgot to Refuel? FSD AugustFuel on Board But None Available FSD NovemberNo Juice, No Go FSD NovemberSeeing the Sights FSD JuneWaited too Late with Low Fuel State FSD April

Ground ObstaclesRoller Coaster Thrills Pilot FSD FebruaryWhen Things get Hurried, The Harried get Hassled FSD April

IceIce in the Intake Causes Close Call FSD FebruaryThe Carburetor Ice Gremlin FSD March



Incorrect ProcedureAirplane Worked Just Fine FSD JulyAutomatic Rough Over the Boondocks FSD NovemberClassic Case of Wrong Handle-itis FSD MayConfusion over Flame Causes Consternation FSD FebruaryDownwind Turn Close to the Ground FSD AugustExtra Hand on Controls Foils Demonstration FSD FebruaryFlaps Not Set for Takeoff FSD JuneIs That GPWS For Real? FSD OctoberLever Location Confuses Pilot FSD JulyNo, the Other Left! FSD AprilOverzealous Nose Lowering Leads to Confusion FSD MayPitch Down Results in Helicopter Put-Down FSD JunePlastic Fuel Can FSD JunePracticed too Hard? FSD DecemberStudent Did Not Relinquish Controls FSD FebruaryThe Trap of Assumption FSD MarchThings That Almost Go Bang in the Night FSD NovemberWhen the Whistle Blows, It’s Time to Go Around FSD May

InspectionSecure All Loose Articles FSD JanuaryThe Ice Man Took Control FSD December

LandingAssumed Zig Became Zag FSD MayIt All Started With a Delayed Descent FSD JunePunch in the Nose FSD JuneRemembered Gear But Not in Time FSD July

Landing GearBut I Saw the Three Green Lights FSD FebruaryClose Encounter of the Wrong Kind FSD JanuaryDid I or Didn’t I? FSD FebruaryGo-Around Attempt After No-gear Touchdown FSD SeptemberThe Mystery of the ‘Up’ Gear Lever FSD OctoberWhy Checklists Were Invented FSD December

MechanicalUnheeded Light Makes For Interesting Flight FSD JulyWhich Instrument Can Be Trusted? FSD January

Runway/Taxiway ExcursionsA Word of Caution Thrown to the Winds FSD NovemberBack to the ‘Good Old’ Tailwheel Days FSD AprilEasy on the Brakes FSD FebruaryExcessive Expediting Leads to Embarrassment FSD SeptemberFinish of a Fortress FSD JanuaryFlying Before The Storm — Almost FSD OctoberGo-Around Ends in Overshoot FSD FebruaryLittle Lights Can Cause Big Problems FSD OctoberOne Thing Led to Another FSD MarchThe Uselessness Of Runway Behind FSD JulyWet Runway Causes Grief FSD AugustWhere Did the Runway Go? FSD February

Takeoff/OverrotationGo-Around Against the Odds FSD MayIt’s a Pull — Not a Yank FSD MayLate, Long And Unlucky FSD OctoberUnneeded Training Realism Gives Hard Lesson FSD September

UndeterminedTakeoff Emergency in Wilderness FSD February

WeatherA Hop, A Skip And a Bump FSD JulyA Load of Trouble FSD MarchContinued VFR Flight Into… FSD September



Continued Visual Flight Into … ? FSD MarchContinued VMC in IMC FSD AprilDisappeared in Rain FSD MarchFickle Winds Demand Vigilance FSD JulyFickle Winds Fracture Airplane FSD AugustInadvertent Flight Into Turbulence FSD JulyInadvertently Entered Clouds FSD MayInto the Mists Without a Flight Plan FSD AprilSudden Entry Into Fog Bank FSD February‘Twas a Dark and Rainy Night FSD SeptemberUntimely Gust Encounter Upsets Rotorcraft FSD SeptemberWindshear Affects Helo Pilots, Too FSD JulyWindshear on Final Bends Airplane FSD November

Wire StrikeA Light in the Gloom Almost Spelled Doom FSD MayHelicopter Pulls The Plug at Show FSD OctoberLow on Height and Experience FSD AprilObstruction Observed Too Late FSD JuneToo Low, Too Fast FSD November

Weight and BalanceCheck that Loadsheet To Prevent Surprises FSD SeptemberEverybody Up Front Is Only for Church FSD JuneHeavy Load Leads to Trouble FSD AugustImproper Loading Proves Fatal FSD November

1.75 Maintenance Alerts

A Little Dab Will Do Ya AMB May/JuneAiring the Brakes Is Not a Good Practice AMB May/JuneAnother Exhaust System Failure AMB Nov/DecAssumption Leads To Takeoff Abort AMB July/AugBlocked Line Stops Fuel AMB May/JuneBrake Failure Wreaks Ramp Havoc AMB Jan/FebBroken Brakes Bring Bother AMB Mar/AprBroken Rule Results In Broken Hip AMB Sept/OctCan of Worms AMB May/JuneClutch Slips, Helicopter Falls AMB May/JuneCorrosion Again Rears its Ugly Head AMB Jan/FebDoes Murphy Make Blue Ice? AMB Nov/DecDrag Didn’t Stay AMB Jan/FebEasily Fixed Wire Gives False Fire Warning AMB Mar/AprEngine Failure AMB Jan/FebExpensive Fix AMB July/AugFatigued Brakes Couldn’t Take the Heat AMB July/AugFatigue Fractures Flap Fitting AMB Jan/FebFor Want of Bolt A Nose Gear as Lost AMB Mar/AprFouled Valve Squanders Fuel AMB July/AugFuel Tank Explosion Results in Fatalities AMB Sept/OctHalf a Shim Not Enough AMB July/AugHard Landings Find Weakness AMB Mar/AprHelicopter Dances To Strange Beat AMB Mar/AprInsulation Interference AMB Sept/OctLoose Fit Sinks Airplane AMB July/AugLoose Joint Causes Anxious Moment AMB Mar/AprLoss of Stability Bends Helicopter AMB May/JuneLube Block Breaks Engine AMB May/JuneMurphy’s Law Strikes Again AMB Sept/OctMuscles No Match for Volts AMB May/JuneMystery of the Missing Fuel AMB Nov/DecPass the Earplugs, Please AMB Sept/OctPowered-Down Ferry Flight AMB July/Aug



Spark + Oxygen Leak = FIRE AMB Nov/DecSurprise Safety Hazard AMB Mar/AprUnexpected Retraction AMB July/AugUnlocked Drag Links Can Cause Trouble AMB Mar/AprUnset Sealant Restricts Visibility AMB July/AugWater Leak + High Altitude = Ice AMB Sept/OctWheel Declares Independence AMB May/JuneWhoops! AMB Nov/DecWith This Ring I Put Thee at Risk AMB Jan/FebWorn Safety Pin Retracts Nose Gear AMB Nov/Dec

2.00 Airports

Design Airports for Safety AO July/AugMaintaining Safety and Security During On-Airport Construction AO Nov/DecPrecision Runway Monitors AO Mar/Apr

2.50 Approach and Landing

Facing the Runway Overrun Dilemma AP SeptemberFoundation Briefed On Curved ILS Approach FSFN July/AugImproved Microburst Warnings Aim for Safer Terminal Operations AP July

3.00 Aviation Medicine

Aspartame — Not For The Dieting Pilot HFAM Mar/AprFoundation Endorses Drug/Alcohol Safeguards FSFN May/June

3.50 Awards

Aviation Maintenance Technician of 1989 Honored in U.S. AMB Jan/FebAwards Recognize Safety Accomplishment FSFN Nov/DecCall for Nominations for the Joe Chase Award AMB Jan/FebFirst Aviation Mechanic Recognized Posthumously AMB May/JuneFlight Instructor and Maintenance Technician of the Year Honored FSFN Nov/DecFoundation Twice Blessed With U.S.S.R. Gagarin Medal FSFN July/AugHeath Honored by Academy FSFN Nov/DecJoe Chase Award Goes to Krumal AMB May/JuneMaintenance Technican of the Year Honored AMB Nov/DecPlaque Honors Foundation FSFN May/JuneRecognition for Helo Technicians AMB July/AugTechnical Educator Recognized by FAA AMB July/AugU.S.S.R. Foundation Presents Awards FSFN Nov/Dec

5.00 Birds

FSF Zeros in on Bird Hazard FSFN Sept/OctHow Airports Reduce Dangers of Bird-Strikes AO Jan/Feb

12.00 Communications

Communication from the Cabin Crew To the Cockpit Crew CCS Jan/FebMy Own Mouth Shall Condemn Me AP JuneReadback Error AP MaySatellite Communications and Navigation FSD JulySome Aviation Frequency Management Concerns FSD JuneThe Communications Procedures That Save Lives AP June

18.00 Ditching

Helicopter Ditchings: Canada Studies the Impact HSB May/June



19.00 Education & Training

Aviation Computer Science Course Developed AMB Sept/OctCooperative Training for Aviation Technicians: An Opportunity for the Corporate and Commuter Communities AMB July/AugCorporate Operator Training in the ’90s FSD JulyDecision Making Workshop is First Lederer Library Lecture Series Offering FSFN Mar/AprEnders to Consult for Aviation Psychology Publication FSFN July/AugFoundation Helps Organize Industry Training Committee FSFN May/JuneFoundation Intern’s Paper Published FSFN July/AugLederer Library Tests New Software To Provide Worldwide Electronic Access FSFN Nov/DecMeeting the Demand For Aviation Technicians AMB July/AugPreparing for the Unexpected: A Psychologist’s Case for Improved Training FSD MarchRecruitment and Training FSD JulySafety Book Presented to Lederer Library FSFN July/AugTechnical Education — Working Within the System FSD MarchTechnical Scholarships AMB Mar/AprThe Importance of Training In Aviation’s Future FSD DecemberThe Pilot Shortage and the Effect of Entry Level Experience on Type Conversion Training FSD JulyTraining the Aviation Professional of thes: Recognizing the Needs FSD JulyTraining the Entire Flight Department FSD FebruaryTroubleshooting Taught by Computer AMB July/AugWelding Training ‘On the Tube’ AMB May/June

20.00 Emergency Procedures

Disaster Preparation for Corporate Operators AP OctoberPassenger Protection and Safety CCS May/June

24.00 Flight Operations

A Typical Aviation Safety Audit FSD AugustEnter At Own Risk HSB Sept/OctMountaintop Disaster HSB May/JuneWhen is a Hard Landing Hard? AP MayWhose License is it Anyway? FSD April

27.75 Helicopters

Helicopter Crashworthiness — Part Two HSB Jan/FebHELP — A Lifesaver Plan That Works HSB Mar/AprInflight Icing and the Helicopter HSB Nov/Dec

27.85 Hijacking & Terrorism

Civil Aviation and the Aircraft Bomb FSD Sept/Oct

28.00 Human Factors

Aircraft Accidents Aren’t AP DecemberCockpit Resource Management — A Practical Application FSD JulyCockpit Resource Management — The Only Way to Go AP NovemberColor Vision and Cockpit Operations HFAM May/JuneContact Lenses in Aviation HFAM Sept/OctDecision Making for Air Ambulance Administrators HSB July/AugHow Effective is Cockpit Resource Management Training? FSD MayHuman Factors and National Goals HFAM Jan/FebHuman Factors in Cabin Safety CCS Mar/AprHuman Factors in the Aircraft Cabin CCS Nov/Dec



Human Factors Worth Considering When Starting CRM Training FSD JulyMinimizing Diurnal Desynchronization HFAM Nov/DecOrchestrating The Human Symphony In Flight Operations HFAM Mar/AprPilots’ Sunglasses: Mystique or Mandate? HFAM July/AugResource Management in the Cockpit FSD JulyStress, Behavior, Training and Safety CCS May/JuneSubtle Incapacitation of Pilots: How To Tell If Your Captain Has Died AP JanuaryThe Flight and Duty Time Dilemma AP FebruaryThe Human Factor AO May/JuneVisual Illusions Can Spoil Your Whole Day AP March

30.75 Cabin Safety

Foundation Endorses Infant Seat Improvements FSFN May/JuneImproved Child Protection Endorsed CCS July/AugIndustry Proposal Addresses Service Carts CCS May/JuneThe Case for Upgrading Cabin Crew Status CCS Sept/Oct

31.25 Investigation

Investigating Foreign Aircraft Accidents In the U.S.S.R. FSD December

35.00 Maintenance

Airworthiness Directives Aimed at Aging Aircraft AMB May/JuneAre Wooden Propellers On the Way Out? AMB Mar/AprBlast Room Claims Safer Paint Stripping AMB May/JuneBorescope by the Book AMB Sept/OctBorescopes Help Solve Inspection and Maintenance Problems In Aviation AMB Jan/FebBulletins Describe Use and Care of Aviation Tires AMB Jan/FebCarrying the Flame is for Love and The Olympics AMB Jan/FebContinued Airworthiness of Aging Corporate Aircraft AMB Mar/AprCylinder Coating Process AMB July/AugDon’t Get Caught With Your Parka Down AMB Nov/DecFokker 50 Hot-High Variant to use PW 127 Turboprop Engines AMB Nov/DecFrostbite Warning Worth Repeating AMB Jan/FebFSF Represented at Aging Airplane Symposium FSFN May/JuneHow to Practice Good Tire Sense AMB May/JuneIndustry Updated On Aging Aircraft AMB Mar/AprLights, Air, Power, Action AMB Sept/OctNew Engineering Resource: Lightning Protection of Aircraft AMB Nov/DecPiper Gear Leg Checks Called For AMB July/AugProgram Introduced to Prevent Back Injuries on the Job AMB Jan/FebPut Some Ears in Your Toolbox AMB Sept/OctThe SRM — A Book for Many Reasons AMB Sept/OctTwinjets Mark Five Years in Extended Range Service AMB Sept/Oct

35.50 Maintenance Equipment/Services

Adjustable Wrenches AMB Sept/OctBarrel Top Mat AMB Nov/DecCarpet Tape Resists Fire AMB Jan/FebContinuous-Length Cable Ties AMB Sept/OctCorny Absorbent Is Environmental AMB Nov/DecDrip Pan Catches Leaks AMB July/AugFlame-Resistant Fiber Developed for Aircraft Interiors AMB Sept/OctFluid Service Carts Go to the Aircraft AMB July/AugFuel Test Instrument Measures Contamination AMB Nov/DecHydraulic Lift Table Eases Manual Strain AMB July/AugIcemelter Promises Safety with No Corrosion AMB Nov/DecInfrared Heaters AMB Mar/Apr



Lifting Table Lightens Loads AMB Mar/AprSocket System Claims Better Grip AMB Mar/AprMetal Fires Meet Their Match AMB Sept/OctMonitor “Cleans” Aviation Fuel AMB Jan/FebScissor-Lifts Take the Strain AMB May/JuneWater Detector For Fuel Checks AMB May/JuneWind Shelter Shields Mechanics AMB May/June

36.00 Management

Air Safety Management — Executive Aspects FSD JulyIntern Joins Foundation Staff FSFN Mar/AprLessons Learned from Safety Audits FSD JulyMaginnis Elected Vice President of Foundation FSFN Nov/DecSafety Audits and Operator Goals FSD August

37.00 Meetings

CAC Meets FSFN July/AugCorporate Seminar Convenes in Montreal FSFN July/AugEuropean Seminar Addresses Future FSFN May/JuneFSF and FSF-USSR Meet FSFN Mar/AprFSF to Hold Safety Data Meeting FSFN July/AugGet Your CASS Cassettes Here FSFN July/AugIAC Holds Summer Meeting and Workshop FSFN Sept/OctIASS Committee Meets in Rome FSFN July/AugRegional Safety Conference Convened In Amman, Jordan FSFN May/JuneTrade Shows Coming Up AMB Jan/FebVolanic Ash Symposium Scheduled FSFN Sept/OctWorkshops Highlight IAC Meeting FSFN May/June

51.50 Sabatoge/Security

Radical Right Terrorists vs. Radical Left Terrorists: Their Theory and Threat FSD AprilDangerous Goods and Air Safety FSD SeptemberSecurity for Corporate and Regional Operators FSD July

53.00 Statistics

A Decade of Development and Safety Performance Worldwide Civil Aviation 1980-1989 FSD NovemberA Decade of Progress and Difficulty. A review of U.S. Airline Growth and Safety Performance 1979-1989 FSD MarchA Statistical Analysis of General Aviaiton Flying In Relation to Pilot Age and Certificate FSD AprilAn Inferential Analysis of Safety Performance of U.S. General Aviation Fixed-wing Aircraft 1978-1987 FSD AugustBack to Basics II - An FAA Accident Prevention Program For The Nineties FSD JulyCivil Aviation and Safety in United Kingdom A Decade of Progress 1980-1989 FSD OctoberThe Head and Tail of U.S. General Aviation FSD MayThe Medical Risk of Airline Pilots Over Age 60 FSD DecemberUntimely Gust Encounter Upsets Rotorcraft FSD SeptemberU.S. Transportation Fatalities and Trends In the Eighties FSD SeptemberWorldwide Airline Safety Records Calendar Year 1989 FSD FebruaryWorldwide Airline Jet Transport Aircraft Fatal Accidents and Hull Losses - A Review of 31 Years of Operations FSD June

59.75 Weather

Insidious Rotor Ice HSB Jan/FebThe Lowest Form of Cloud AP August


Documents

An American Tableau: The Changing Accident Experience2 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JANUARY 1991 Aviation Regulation (FAR) Part 121 operations are all-inclusive