DAVID LEARMOUNT / LONDON
Last year controlled flight into terrain returned with a vengeance. Was complacency to blame? And how can the situation be improved?
A previously consistent reduction in fatal accident numbers and fatalities since 1996 went into reverse last year. Compared with 2001, fatal accident numbers climbed by seven to a total of 40, and fatalities leapt from 778 to 1,022.
The most dramatic safety characteristic of 2002 was the upward spiral in controlled flight into terrain (CFIT) accidents. CFIT has always been recognised as the worst killer accident category because such crashes are rarely survivable, and this year it dominates the figures. Nearly half of all fatal accidents last year were CFIT, accounting for half of all fatalities. The CFIT trend was evident at the half-year point (Flight International, 30 July-5 August), and has since been confirmed by more events of the same type.
Stuart Matthews, head of the Flight Safety Foundation (FSF) says: "Examination of the CFIT accident statistics shows there was a peak in 1992; another one in 1998 and yet another in 2002. We know that CFIT is the leading cause of aviation fatalities and there is a lot of information out there on how to avoid it. None of the recent accidents involved aircraft fitted with an enhanced ground proximity warning system [EGPWS], so was this a case of the three- to five-year complacency cycle? That is, you train for a problem that then diminishes. As a result, you don't bother quite so much and after a while - three to five years - it all comes back again."
He adds that terrain-awareness warning systems (TAWS) like the Honeywell EGPWS "should all but eliminate the CFIT risk. But it is mostly older aircraft that have to be retrofitted, which represents an economic burden." Matthews emphasises: "The elimination of non-precision approaches will also do much to reduce the risk, as will [ATC radar-based] minimum safe altitude warning systems [MSAWS] ground equipment. These are well known facts, but implementation goes all too slowly and accidents continue to happen as a result."
On 17 December, but for GPWS, a Philippine Airlines Airbus A330 would have crashed into Nimitz Hill on a night approach to Guam's Adana Airport, just as a Korean Airlines Boeing 747 did in 1997, killing 229 people (Flight International, 14-20 January). A tornado had stripped Adana of almost all its approach lights and navigation aids.
Looking at the whole year, Matthews says: "Approach and landing remains the most accident-prone phase of flight. The 2002 figures remain right on the traditional 50%-of-all-accidents mark. Similarly, most CFIT accidents continue to occur during approach and landing. The FSF is doing a lot to implement the many lessons contained in its Approach and Landing Accident Reduction [ALAR] programme.
Meanwhile, evidence has so far led Chinese investigators so far to conclude that the China Northern Shanghai Aviation MD-82 crash into Dalian Bay was caused by a suicide saboteur who set fire to the cabin. Unlike those responsible for the events of 11 September 2001, however, the perpetrator appears to have been acting alone. Security staff and systems, it seems, have to be alert to the possibility of any anomalous behaviour or situation - an almost impossible task. One answer may, however, be to limit the kinds of items that passengers may take in carry-on baggage.
Concerns
The biggest shock of 2002, even though there were other accidents with more casualties, was the mid-air collision between a Baskirian Airlines Tupolev Tu-154M and a DHL Boeing 757 freighter in Swiss-controlled airspace over southern Germany. Collisions have always had a peculiar power to shock, but this one more so because both aircraft carried fully functioning airborne collision avoidance systems (ACAS). But a difference in operating procedures between the crews - a result of varying ATC procedures in their respective countries - led to the collision. The German accident investigation authority (BFU) is due to report on the accident, which also involves ATC staff management issues the Swiss are already addressing. The accident occurred late at night and there was only one controller active at the time, with another taking a break.
Swiss ATM rules have been changed to ensure that however low the traffic intensity late at night, a minimum of two controllers are at their workstations.
In Namibia, there was a non-fatal collision (26 December) which both crews were lucky to escape. Neither aircraft was using ACAS. A TAAG Angola Boeing 737-200's starboard wing tip destroyed a large part of a Cessna 404's empennage when their paths crossed after both aircraft had taken off from different airports serving Windhoek, Namibia's capital. The Cessna returned to base and landed safely , but the 737, with its outboard leading edge damaged, continued to its first stop-off point at Lubango, Angola, then took off again for its destination at Luanda.
Last year, there were two fatal accidents definitely caused by basic aircraft structural failure, and two that look likely to have had the same cause. Three of the aircraft were more than 40 years old. Altogether the break-ups killed 246 people, a total exceeded last year only by the CFIT category. Most of the casualties (225) perished in a China Air Lines Boeing 747-200 off Taiwan that was observed on radar to break up into four separate sections. The investigators say recovered wreckage shows evidence of fatigue cracking in the fuselage near the aircraft's No 5 rear door.
Runway incursion accidents, high profile in Europe in 2001, were reduced in 2002. But this month a Eurocontrol steering committee is to report on how to tackle the issue. It is tasked with making recommendations on a runway safety programme, prioritising short-term measures like the enforcement of the International Civil Aviation Organisation's Annex 14 standards for airport signs and markings, defining a system for the collection and dissemination of runway incursion data, and the assessment of longer-term improvement using technology.
The Eurocontrol Runway Safety Task Force reports that European airports see 70 to 80 runway incursions per million aircraft movements, but study into causal factors is "critically hindered by lack of data", it says.
Other significant European developments this year include the implementation of the European Aviation Safety Agency. From its launch in October, it will concern itself with the enforcement of airworthiness and certification regulation, but gradually it will take up operationsregulation as well.
Meanwhile, the International Federation of Airline Pilots Associations (IFALPA) has renewed its call for pilots not to be subjected to criminal prosecution following accidents that do not involve negligence, and highlights a prosecution by the Nagoya, Japan, public prosecutor of a Japan Airlines pilot involved in an incident in June 1997, flying a Boeing MD-11 from Hong Kong to Nagoya.
Matthews echoes IFALPA's concern: "The Flight Safety Foundation continues to be concerned about the growing tendency for judicial interference in accident investigations and criminalisation of those involved. Judicial interference and prosecutions impede accident investigations, and can inhibit the flow of information, both of which are needed to further improve the safety of an already safe industry."
Pilot reprimanded
The Italian national pilots' association (ANPAC) has raised its voice against what it considers to be a peculiar recent intervention by the judiciary. An Italian pilot, having flown into Fontanarossa, Sicily, on 2 January this year passed through airspace affected by volcanic ash from the nearby Etna volcano. As a result, he required an engine inspection before take-off. This took several hours and caused cancellation of the return flight. The local public prosecutor has reprimanded the pilot for "public service discontinuation and for raising non-existent alarm concerning the presence of volcanic ash". ANPAC says it is "deeply concerned about the occurrence, and that these facts could in any way exert unjustified pressure upon flightcrew judgement in similar circumstances".
Despite the reversal last year of the steep decline in accident numbers, the general trend since 1996 is still downward. The year's key figures - accident and fatality numbers - are still both below the annual average for the last decade.
Perhaps the last word should go to the FSF's Matthews, who says: "The industry's economic problems, exacerbated by security issues, have dominated 2002. However, none of our safety concerns has diminished in any way, and it is imperative the industry keeps its eye on the ball by maintaining focus on safety matters. The industry does not need, and cannot afford, a safety problem on top of everything else."
2002 fatal accidents and fatalities | ||
Flight category | Fatal accidents | Fatalities |
Scheduled | 7 | 652 |
Non-scheduled | 3 | 139 |
Commuter/regional | 12 | 147 |
Non-passenger | 18 | 84 |
TOTAL | 40 | 1,022 |
Source: Flight International