ISSUE 002

GainJet Aviation Flight Safety Magazine

Accountable ManagerCapt. James McBride

Flight Safety OfficerDimitrios Paraskevas

Ground Operation Mgr.Georgina Kotsi

Deputy A. Mavrommatis

Maintenance Mgr.Stavros ArampatzisDeputy K. Karalis

Training Mgr.Capt. A. Kourniaktis

Deputy Capt. P. Cullen

Flight Operations Mgr.Capt. Dimitrios Kehayas

Deputy Capt. A. Kourniaktis

Quality Unit DirectorSymeon Roussos

ARSSymeon Roussos

Auditors

Fuel Dept. Flight StandardCapt. N. Serfas

Cabin Crew Mgr.Olga Beglopoulou

MaintenancePart 145

GainJet 145 orContracted

Organisation

MaintenancePlanning/Control

GainJet orContracted Orgn.

Ops

RosterSecurity Officer

Capt. P. Droumpounetis

Dispatchers Pilots Cabin Crew

GainJet Aviation S.AOrganisational Structure

Editorial

Table of Contents

It’s a fact, GainJet is growing. In the last five years, GainJet has grown immensely and is continuously expanding the fleet and its operation. With such an expansion comes great responsibility and an even greater need for safety. Above all, “Safety is our top priority.” Hence, it is my pleasure to welcome you to the 2nd issue of , our bi-annual GainJet Aviation Flight Safety Magazine.

The purposes of our Flight Safety Magazine are as follows:1. To help in the development of our non-punitive and open reporting safety culture.2. To assist in our understanding safety in a proactive way.3. To enable relevant safety information to be disseminated to all.

You will notice that this issue is mainly concerned with winter operations. As summer passes us by, we will be met with different operational and safety hazards during winter weather conditions. Such hazards include, but are not limited to, airframe icing and contaminated runways. Furthermore, in this edition we examine some incidents and operational issues that have recently arisen, in order to learn from them for the future.

A strong belief within GainJet’s corporate culture is to learn from past experiences, whether those of its own operation or those of others. The two accident case studies in this edition have some similarities and focus on accidents that took place during winter weather conditions. In both cases, the aircraft overran the runway, one during takeoff and one during landing, due to hazards created by the weather conditions combined with the lack of adherence to Standard Operating Procedures (SOPs) during such weather conditions.

The Challenger 601 crash during takeoff in icing conditions was the result of overlooked ice formation on the aircraft flying control surfaces and a missed opportunity to take de-icing measures. In this case, following the SOPs during winter operation would have led the flight crew to conduct a visual and tactile examination of the aircraft’s wings, which should have led to de-icing measures taking place.

In the case of the Boeing 737 accident, the crew had several alternative options at their disposal, but due to commercial pressure, decided to land at Chicago Midway Airport on runway 31C despite unfavourable weather conditions. Even though they took this decision, post accident calculations indicate that if the flight crew had used available reverse thrust in a timely manner, then the aircraft should have safely slowed or stopped before overrunning the runway. Here is an example of where the removal of just one error in the chain would have prevented the accident.

In both cases, and while reading all accident reports, please appreciate the fact that those who have gone before us, and in some cases lost their lives, did so in order so that we can learn from their mistakes and avoid such accidents in the future by taking the necessary safety precautions.

Fly Safe!

Andrew HallakEditor,

Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 03Perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 04New Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 04Bi-annual Safety Officer’s Review Jan-Jun 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 05GainJet refines safety systems ready for fleet expansion in large luxury sector . . . . . . . . . . . . . Page 06Contaminated Runways Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 08Fuel Contamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 11Aircraft Ground Icing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 12Case Study –Southwest Airlines Flight 1428 –Boeing 737-74H. . . . . . . . . . . . . . . . . . . . . . . . . . . Page 14Case Study – Canadair CL-600-2A12 Challenger 601, N873G . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 16

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A special thanks to all those who participated in this issue:Captain Ramsey Shaban, Captain James McBride, Mr. Simon Roussos, Mr. Stavros Arampatzis, Mr. Dimitrios Paraskevas, Mr. Rod Smith.

We all have a reasonable perception of safety through reading aviation literature, hearing stories from people who have had incidents, through watching accident investigations on the National Geographic channel etc.

However, our challenge lies in implementation. Implementation is a combination of mentality, human resources, culture, qualified and trained personnel,

quality assurance, training, having a non-punitive culture, and the list goes on.

Crudely put, this process is ‘positive indoctrination’ which translates to positive Implementation and hence the issue of our magazine.

I hope you enjoy the new edition of Blue Skies.

Perception

New GenerationI have been in the commercial aviation industry for a few years now and hopefully still have a few more years left in me. During my time as a manager one of the most gratifying elements has been to see the development of our people to reach new positions, gain promotion, achieve their ambitions etc. It is with pleasure that I am able to observe two of GainJet’s people growing into new roles with this issue of Blue Skies and I am referring to Andrew Hallak as Editor and Dimitrios Paraskevas as Flight Safety Officer. Both of these gentlemen are youthful and enthusiastic (hence the New Generation tagline) but they have great qualities of professionalism and commitment which we shall see them put to good use in the months and years to come. I commend all of us at GainJet to give them our full support and assistance in their new

positions and we shall see them blossom and develop along with others from within the company for the good of all.

There was never any chance of my continuing as Editor for very long – one issue is enough! I was only there to kick-start the project and now I feel we have reached ‘self-sustaining RPM’ – long may it continue. I would urge any GainJet employees who feel they would like to write an appropriate article for publication to send it to the editor. When you think about it, ‘Safety’ is not just in the care of the Management, it pertains to every single one of us – please get writing! Remember that your work should be original and if it includes extracts from elsewhere, then the proper references and accreditations should be appended.

By Captain James McBride CEO and Accountable Manager

By Captain Ramsey ShabanPresidentGainJet Aviation S.A

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Bi-annual Safety Officer’sReview Jan-Jun 2011Another six months have gone by since the company’s last safety review and a lot has happened since then. As the newly appointed Flight Safety Officer, I hope to carry on the good job that my predecessor, Captain Panagiotis Droumpounetis, has done in continuously improving our safety standards and bringing synergy to all departments through our safety programme.

As you will see, GainJet has improved on flight safety issues since the last conducted safety review, but is still striving to eliminate even the smallest of occurrences.

The flight operations department is working hard in order to keep all flight and cabin crew well trained, current and up to date on company, aircraft manufacture, and EASA/CAA/HCAA procedures.

Furthermore, in order for a smoother operation, we have appointed a person in charge of crewing and scheduling, which allows for follow-up on crew rotations to be easier and more effective.

Our Flight Operations Manager and Flight Standards department have made a great step forward in getting our company approved for Electronic Flight Bags operation, which means better organisation in the cockpit. This also allocates time, that was once wasted on paperwork and documents, to ensure the highest standards of safety are implemented.

Please always remember that safety is our top priority.

Following below is a review of the first half of 2011:

By Dimitrios ParaskevasFlight Safety Officer

Occurence Reports

Technical

Human Factors

ATC

Various

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DATE TYPE OF INCIDENT LEVEL OF SERIOUSNESS CASE OPEN/CLOSED

March Engine cover (umbrella type) damage LOW CLOSED

April Fuel contamination HIGH CLOSED

April Abnormal engine response HIGH CLOSED

April Trim Runaway HIGH CLOSED

May Noise violation LOW CLOSED

GainJet refines safety systems ready for fleet expansion in the large luxury sectorGainJet Aviation is expanding its fleet with a particular focus on the luxury ‘large delegation’ sector where there are rising requirements for safety, security, comfort and cost-effective services. The expansion will see the addition of a second 757-200 with a bedroom to ensure the opportunity to rest as well as work on intensive trips that can be as long as nine or ten hours and complementing the further GainJet choice of two 737-300s. Capt. Ramsey Shaban, President of the growing international private aviation company says: “The world economic crisis means that governments are looking to cut costs but they require the same high standards of service where private aviation is concerned. At the same time the need for top-level diplomacy at prime ministerial and presidential levels is rising as governments attempt to defuse or resolve problems such as experienced recently in the Middle East and Africa.” The ability to offer 48 or 78 seat aircraft with a huge luggage capability is important to attract the business of a number of organisations with international commitments and itineraries ranging from orchestras to sports clubs. Football, once largely confined to seasons, now operates almost continually with international and prestige cups filling practically all the gaps between domestic leagues. All-year round sport, and the business and lifestyle expectations of the rich and famous, have not suffered the same cut backs as the major economies in the recession. However, they do want greater value for money while expecting the same high standards to be maintained. That means, as CEO and Accountable Manager James McBride points out, a demand for cost-effectiveness and ready availability, with companies such as GainJet having to carefully factor in optimum maintenance and safety schedules. “Safety is the number one priority and GainJet’s present and coming growth brings with it an added responsibility to ensure our systems and training continues to seek out improvements and that nobody is ever complacent.” GainJet, headquartered in Athens but with an

international spread of business in Europe, the Middle East and Africa and other key regions such as North America and the Far East, is gearing up in advance to reflect its status as an operator of a 10-strong charter fleet including the Global Express XRS, the G-450 and five G-200s. First priority“While the demand for the larger luxury market provides us with a key focus it is important to be able to offer a spread of aircraft with ready availability,” says marketing director Andrew Hallak. “We are increasingly doing this but we have planned the expansion down to the last detail. GainJet is always aware that, while all aspects of service, marketing and sales are important, safety is the first priority.” From the safety and service aspects, there is no substitute for experience. Key members of staff including Safety Officer Dimitrios Paraskevas and Quality Unit Director Simon Roussos had long experience to which they have added the knowledge of the refinements and requirements of private aviation. Roussos points out that the aviation industry has come to recognize that effective safety management systems (SMS) are necessary in today’s complex operating environment. “Managing safety in aviation has been elevated to a new level with the current emphasis on SMS and at GainJet there is a strong focus on proactive preventative risk management. There are major programmes in place designed to continually identify hazards and ensure that we have the best tools to gather data and analyse risk.”

Maintenance manager Stavros Arampatzis and senior operational personnel including Georgina Kotsi, captains Dimitrios Kehayas, Anestis Kourniaktis and Andreas Mavrommatis all know that private aviation has massively different demands and expectations from military and civil aviation. And, as cabin crew manager Olga Beglopoulou confirms, experience is not enough - only a starting point. “New cabin crew have to love the job and thrive on the demand for a 24-7 commitment. There is no such thing as completely free time off or opportunities to relax on duty. All staff must also have enthusiasm and a commitment to training. Many people make the mistake of believing the safety of a flight is only

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in the hands of the flight crew. However, it is the duty of every member of staff, including the cabin crew, to ensure that all safety procedures are followed.” With GainJet since before it was founded more than five years ago, she points out that the company began managing aircraft for one client and now also has six which are for private use. “The service levels for one or six or 16 are the same,” she says. “It is not easy to achieve complete client satisfaction on each flight and harder still to keep reminding yourself that there is always more to learn. However, that is the business we are in. The best restaurants have owners that live and breathe hospitality and keep adding refinements and that is also true of private aviation.”

Unobtrusive landingCapt. McBride says there is a direct and positive relationship between enhanced quality and commercial success with superior flying being just one aspect. “Our pool of more than 40 pilots has captains with exemplary military and scheduled airline experience. But there are always new challenges in private aviation. The need for smooth and unobtrusive landings is obvious. However, it takes added expertise to make a perfect landing and turn to the edge of a red carpet without affecting the line-up and playing of the welcoming band as you taxi and ease to a halt. It is taken for granted by GainJet clients that the pilots not only have superior flying skills but also have the positive personable attributes that characterise the best in the hospitality sector.”

The inter-change of knowledge and procedures is more straight-forward in a small team such as the one that managed GainJet’s first aircraft more than five years ago than in a dynamically growing organisation where a G-550 is on order for 2012 and a G-650 is expected in 2014. Where a managed and charter fleet is approaching 18 or 20 aircraft with more than 100 staff there has to be tight and strong organisation with a constant evaluation of how to prevent mistakes that may have marred the reputations of other private and scheduled airlines.

GainJet has formalised the study and analyses of errors in other organisations that have led to incidents and combined those studies with an internal reporting system designed to foster clear communication between everybody in the company continually eliminating the potential for mistakes. Capt. McBride says: “Incidents are typically caused by a chain of perhaps 7 to 11 errors or miscalculations and removing even just one causal factor can prevent an incident. We therefore have a ‘no blame’ culture at GainJet in that, if someone makes a mistake and

recognises and reports it, they will not be punished. This helps us identify potential problems and prevent them happening.” Safety Officer Dimitrios Paraskevas says GainJet regularly reviews its overall company performance and sets safety targets with incidents reviewed and lessons from them openly discussed and reviewed. These may range from a rejected take-off to a bird strike or a fuel truck leaking during refuelling.

“Our measures complement the regular inspections from the various authorities and it all comes down to continually increasing the quality of service,” Paraskevas says. GainJet, he adds “encourages a multi-skilled environment where all staff can learn from each other.”

Safety marginsCapt. Kehayas, Flight Operations Manager, says that safety margins increase if the staff and company continually become more proactive and less reactive enabling them to head off problems before they arrive. He adds: “There has to be a strong focus on redundancy – that extra layer of protection that ensures important safety actions are carried out and that nothing falls through the organisational cracks.” Kehayas, who brought 35 years of airline experience with him to GainJet, says: “We work like a family within GainJet passing on our knowledge. There is no substitute for experience. But however much experience you have, and however much progress you may make, there is always room for improvement. And at GainJet, we always strive for improvement” Capt. Ramsey Shaban says that broadened and deepened safety management systems always have to be in place before new aircraft are brought into service. “GainJet is already of a size where the safety management systems have to be proactive and flexible enough to bring added aircraft and new staff up-to speed in advance. This will be even more important in coming years as we increase our fleet. Problems that are identified and solved cease to be problems and GainJet’s philosophy is to enable everybody to anticipate difficulties and address them.”

By Rod SmithFreelance Aviatioin Journalist

Contaminated Runways OperationsSome people say that “life is never simple”. Perhaps they are referring to operating high performance aircraft to and from airports with contaminated runways? Of course normally we would not operate flights using these runways if we could avoid them, but there are other factors involved, the main one being that we are not engaged in recreational flying – our mission is commercial aviation and we do not fly just for the fun of it.

We must be objective about each and every flight we undertake and consider what is possible, disregarding what may or may not be desirable.

Note that the maximum contamination which is acceptable for takeoff or landing is 13mm depth – or as defined by the particular Aeroplane Flight Manual if this is more restrictive. Dry snow maximum depth can be considerably more depending upon the manufacturer – B737 is 60mm maximum depth for takeoff.

Effects on Takeoff PerformanceContamination on the runway has adverse effects on acceleration before getting airborne and similar performance penalties for deceleration in the event of a rejected takeoff. Therefore a much lower V1

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Safety is our paramount consideration of course and therefore we must carefully assess the risks involved during winter operations.

It is true to say that safety margins are reduced when aircraft are operated on contaminated runways, but that is not to say that these operations are “unsafe”. We must be clear in our deliberations, calculating very precisely and professionally using all of the available data to determine the performance parameters applicable to each particular scenario.

Firstly we should revise the definitions:

• Wet Runway – shiny in appearance with depth of water less than 3mm (JAR-OPS 1.480).

• Contaminated Runway – more than 3mm depth of water, slush or snow covering more than 25% of the runway surface to be used. Or a runway covered in ice or compacted snow. (JAR-OPS 1.480).

speed will need to be used to take account of these factors. The reason for the slower acceleration is extra drag caused by the increased “rolling drag” of the tyres and “impingement drag” of contaminant which is thrown up into the path of the advancing landing gear/airframe. In addition there is reduced directional control as the friction coefficient is less on the contaminated runway therefore often the manufacturer will set a lower demonstrated crosswind limit. Performance calculations should be carefully checked to confirm that the conditions permit the takeoff to be made at the aircraft weight determined. Pilots should be aware that the reduction in acceleration is stated to be 20% with 6mm of contamination and 40% with 13mm. The reduction in V1 can be as much as 20 knots.

Pilots should also consider the fact that reports of contamination have been known to be unreliable at some airports and if there is any doubt, then it would be wise for the operating pilots to make an assessment themselves to corroborate, or otherwise

American Airlines B757-200 runway overrun. RW19, Jackson Hole, Wyoming.AA2253 29DEC10. No ground spoilers and late reversers

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the information they have already received. For example there is a significant difference between wet snow and dry snow. ‘Dry’ snow crumbles to powder in your hands when you try to compact it, whereas ‘Wet’ snow will form easily into snowballs. The wet form of contaminant is the more dangerous of the two for aircraft performance calculations.

There are recommended techniques for each aircraft type when dealing with takeoffs from contaminated runways and these are all detailed in the appropriate FCOM or FCTM. For example during taxi out (pre-takeoff) along contaminated taxiways, Boeing recommends delaying the extension of takeoff flap setting until at the holding point. This is to prevent the flaps being contaminated with snow and slush which is displaced by the manoeuvring of the aircraft on the ground – thrown up by the landing gear and jet efflux. Proactive CRM and Situational Awareness are paramount here to keep the operation safe and to ensure that the aircraft is correctly configured for takeoff after arriving at the holding point for the runway in a non-standard config.

The pilots should take time to check and double-check all calculations made regarding takeoffs from contaminated runways and if there is any doubt, then they should contact their appropriate Flight Operations Manager to confirm the validity of the technical data they have been supplied with. Commercial pressure should be resisted to be sure that the safety margins are not eroded further than by the difficulties posed by the operating environment. Finally it is worth mentioning that if the pilots are finding the takeoff calculations getting close to the absolute limits, then they have to ask the question, “Why not delay the flight until runway conditions improve?”

Effects on Landing PerformanceLanding Distance Required (LDR) is increased by up to 40% when the runway is wet and potentially by up to 300% when the runway is contaminated. In reality of course this means that if an aircraft required an LDR of

4000 ft under normal circumstances, this may become 12,000 ft and could exceed the available length of paved surface… The results of a runway ‘overrun’ are obvious – See picture below

The performance effects of runway contamination for landing aircraft are ‘decreased deceleration’ (less effective braking action) and ‘reduced directional control’. The combination of these could result in an aircraft leaving the paved surface after landing, especially in the event of landing with a crosswind. All manufacturers publish reduced crosswind limits with wet, contaminated and slippery runways and pilots operating during the winter should be familiar with these.

An example table from Boeing is depicted below:

This aircraft was wrecked after the accident that took place due to contaminated runway hazards

Remember that the crosswind limits published in the Flight Crew Training Manual (FCTM) for the aircraft should be used as guidelines and not absolute limits. If the amount of crosswind is approaching the limit then a prudent Commander may exercise his better judgement and decide to divert to the alternate airport.

Assuming that the pilots are in possession of accurate information and that their calculations have sufficient safety margin in them to permit the landing on the contaminated runway, then it is vitally important that the recommended technique is used. Again the FCTM refers to this and should be consulted by the pilots. Some important factors to bear in mind are as follows:

Runway Surface Conditions Crosswind Component

Dry*** 36

Wet 32

Standing Water/Slush 20

Snow –No Melting 25

Ice –No Melting** 15

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• Plan to use maximum retardation aids as recommended by the FCTM.

• These may include, Max reversers, Max Ldg flap setting, Max autobrake

• Excess IAS on touchdown = extra landing roll +1000ft per 20 kts fast

• Excess height at threshold = extra runway +1000ft per 50ft high

• Groundspoilers are essential – increase braking effect on the wheels by 70%

• If a/c is going to land beyond 1000ft point – Go Around!

There will be further operational considerations also – for example most operators will recommend leaving flaps extended after landing all the way to the ramp so that engineering department may inspect for damage. Also to ensure the flap surfaces will not be damaged on retraction if ice, snow and slush are adherent.

There are many sources of information regarding operations on contaminated runways and some of them are given below:

• htt p : / / b ra h i mta h i r i . b raveh o st . co m / 0 3_ContaminatedRunway.pdf

• http://www.iasa.com.au/folders/Safety_Issues/RiskManagement/wet-runway-ops.html

• http://www.nlr.nl/smartsite.dws?id=4381

Finally it must be borne in mind that for many operators (those in Scandinavia, Russia and Alaska for example) operating in winter conditions with various contaminated runways is perfectly normal. Providing our pilots take similar care regarding performance calculations and operating techniques, the operations will be performed safely. If in any doubt, the Flight Operations Management here in Athens is always ready to advise and support the operating teams out in the field. Sometimes just a telephone call is all that is necessary to clarify a specific course of action and Dispatch/Operations is open 24/7.

Fly Safe!

By Captain James McBrideCEO & B757 TRE

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Fuel ContaminationProblem Case

Fuel drawn from the sump drain contained 20% water in 1 litre of fuel. The water was a muddy brown colour with a large amount of debris, which contained what appeared to be dead microbiological growth.

The fuel phase was tested for live microbiological growth, the result being a very low count. The water phase was also tested for live microbiological growth, the result being a very low count. The fuel in this sample was very cloudy.

Accidents attributed to power plant failure from fuel contamination have often been traced to:

1. Inadequate pre-flight inspection by the pilots. 2. Servicing aircraft with improperly filtered fuel

from small tanks or drums. 3. Storing aircraft with partially filled fuel tanks. 4. Lack of proper maintenance. Fuel should be drained from the fuel strainer quick drain and from each fuel tank sump into a transparent container, and then checked for dirt and water. When the fuel strainer is being drained, water in the tank may not appear until all the fuel has been drained from the lines leading to the tank. This indicates that water remains in the tank, and is not forcing the fuel out of the fuel lines leading to the fuel strainer. Therefore, drain enough fuel from the fuel strainer to be certain that fuel is being drained from the tank. The amount will depend on the length of fuel line from the tank to the drain. If water or other contaminants are found in the first sample, drain further samples until no trace appears.

Water may also remain in the fuel tanks after the drainage from the fuel strainer has ceased to show any trace of water. This residual water can be removed only by draining the fuel tank sump drains.

Water is the principal fuel contaminant. Suspended water droplets in the fuel can be identified by a cloudy appearance of the fuel, or by the clear separation of water from the coloured fuel, which occurs after the water has settled to the bottom of the tank. As a safety measure, the fuel sumps should be drained before every flight during the pre-flight inspection. Also, fuel tanks should be filled after each flight or after the last flight of the day to prevent moisture condensation within the tank.

To prevent fuel contamination, avoid refuelling from cans and drums.

The two major units for measuring the size of contaminants are microns or solids and parts per million (ppm) for water. There are approximately 25,400 microns in 1 inch.

To be acceptable for delivery to aircraft, jet fuels must be clean and bright. They must not contain more than 5 ppm free water or 2 mg/ litre particulate contamination. The terms clean and bright have no relation to the natural colour of the fuel. Jet fuels are not dyed and they vary from clear, water-white to straw-yellow coloured. Clean means the absence of any cloud, emulsion, visible sediment, or free water. Bright means the fuel looks shiny and sparkly A cloud, haze, specks of particulate matter or entrained water indicate that the fuel is unsuitable and point to probable breakdowns in fuel handling equipment or procedures. If contamination limits are exceeded, delivery of fuel to aircraft should be stopped and corrective measures completed before resuming fuelling operations.

A micro scopic view of a human hair, which is about 100 microns in diameter, compared with a 5-micron contaminant. Part per million is the reference used for water contamination

By Simon RoussosQuality Manager

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Aircraft Ground IcingAnyone who has driven on slushy highways or walked on ice covered sidewalks knows that extra attention and care is needed during poor weather conditions. The same applies to aircraft operation. In addition to the problems of runway contamination, we also must ensure that the aircraft’s critical surfaces are not contaminated with frost, ice or snow. As winter approaches, it is a good idea to take a few moments to review flight operations during icing conditions. Fine particles of frost or ice distributed as sparsely as one per square centimeter over an aircraft wing’s upper surface, can negatively affect its lift enough to prevent it from taking off safely. Even small, almost invisible, amounts of ice formed on an aircraft’s wing surfaces can cause significant performance issues and aerodynamic penalties, which could lead to fatal accidents. Ice or frost formation can result in localized, asymmetrical stalls on the wing, which can result in roll control problems during lift off. For many years in the past, many pilots believed that only visible ice contamination on a wing can cause severe aerodynamic and control issues. The continued occurrence of icing-related accidents proves that some pilots make the mistake of not recognising that even tiny amounts of ice adhering to a wing can have disastrous consequences. Many pilots also may believe that if they have sufficient engine power available, they can simply “power through” any performance degradation that might result from almost imperceptible amounts of upper wing surface ice accumulation. However, engine power will not prevent a stall and loss of control at lift off, where the highest angles of attack are normally achieved. It is now common practice that no amount of frost, ice or snow adhering to the aircraft’s critical surfaces is acceptable. Aircraft surface contamination makes no distinction between large aircraft, small aircraft or helicopters. In all cases, the performance penalties and dangers are just as serious. It is important to note that it is nearly impossible to determine by observation alone whether a wing is wet or has a thin film of ice. So ice formation or contamination on the wing surfaces may be very difficult to detect from the cockpit, cabin, or front and back of the wing because it is clear/white. It is important to perform a tactile examination of the critical surfaces to ensure that they are clear of any ice formation or contamination. If it is detected that ice or contamination has formed

on the aircraft’s critical surfaces, it is imperative that de/anti-icing fluids are applied before takeoff.

The fluids that have been developed are called Type I, II, III, and IV. Type I fluid is used primarily as a heated de-icing medium that is considered “unthickened”. It is sprayed on hot at high pressure to remove any formed snow, ice, or frost. It is also used by smaller aircraft (rotation speeds over 60 kt and ground acceleration times exceeding 16 seconds) for de-/anti-icing; however, the protection is for a short period of time because it quickly flows off surfaces after application. Type I fluid is usually orange. Type II fluid was developed as an anti-icing protection agent. The thickening properties of this fluid prevent immediate flow off aircraft surfaces, which extends the Holdover Time (HOT) compared to Type I fluid. However, its use is only intended for large aircraft with rotation speeds in excess of 100 kt and ground acceleration times greater than 23 seconds. Type II fluid is usually light yellow.

Type III fluid was developed as an anti-icing fluid similar to Type II fluid; however, its use is intended for slower aircraft with rotation speeds over 60 kt and ground acceleration times exceeding 16 seconds. Type III fluid is usually light yellow.

Type IV fluid was developed as an anti-icing fluid similar to Type II fluid but with greater HOT qualities. Its use is also for large aircraft with rotation speeds in excess of 100 kt and ground acceleration times greater than 23 seconds. Type IV fluid usually is green.

When de-/anti-icing an aircraft, it is essential to first confirm that the fluid being used is appropriate for the aircraft type. The pilots operating handbook (POH) or aircraft flight manual (AFM) should explain which fluid is appropriate for the specific type of aircraft. Be sure to follow the instructions carefully. It is important to consider the fact that smaller aircraft are limited to Type I fluid. A Type III fluid has been developed for smaller aircraft types but it is only available in limited regions. It is anticipated that this fluid will be more widely available in the next few years. The advantage of Type III fluid is that it contains some thickeners to increase HOT (Holdover Time). However, you must be sure that the aircraft manufacturer recommends the use of Type III fluid before using it.

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Some people believe that any fluid can be used on any aircraft. This is not the case. For example, there are a number of aircraft (specifically smaller ones) that are not approved to use Type II or Type IV fluid. In such a case, it is imperative that the use of Type II or Type IV fluid is completely avoided. In conditions where icing formation has occurred, de-/anti-icing fluids are only required until the aircraft becomes airborne, after which the on-board de-/anti-icing systems operate. The rotation speed of an aircraft is important, as this determines which de-/anti-icing fluid should be used. Serious aerodynamic problems can occur from incorrect fluid use. The result could be disastrous, since the fluid will not shear off (blow off) on the take-off run, which may cause aerodynamic problems just after takeoff.

Holdover tables can help understand the differences between de/anti-icing fluids. When using a holdover table for guidance, use the correct table for the fluid being applied. Using the incorrect holdover table will lead to incorrect values for the integrity of the fluid and your HOT.

In some cases where there probably hasn’t been any accumulation or adherence of snow/ice to the aircraft’s critical surfaces, it may not be necessary to de-/anti-ice; however, it is imperative to be extra careful and double-check the critical surfaces to ensure that no contamination is present. This can only be done on the walk-around while conducting a visual and touch (tactile) inspection of the surfaces.

It is necessary to be extra careful at night or during times where visibility is limited, as visual detection can be hindered and could lead to a misdiagnosis.

It is important to note that anti-icing fluids (Types II and IV) have been known to remain in aerodynamically quiet areas such as elevators, ailerons, flaps, and hinge lines etc., after takeoff. In this case, there is the possibility that they may re-freeze while airborne, causing control restrictions. Be aware of the manufacturer’s recommendations to inspect and clean these areas after anti-icing to ensure no fluid remains trapped.

Another issue that tends to occur during winter operation is active frost. Active frost usually occurs when the temperature/dew point spread is small (within 2°C) and the dew point and aircraft temperatures are below freezing (0°C). Such conditions combined with VFR conditions of clear sky and calm winds enhance the possibility of active frost formation.

Active frost continuously grows in mass and thickness, and will continue to form after being removed; whereas inactive frost, such as hoar frost, can be removed and normally will not form again. If you choose to operate in these conditions, it is imperative that de/anti-icing measures are taken.

By Stavros ArampatzisMaintenance Manager

De-/anti-icing liquid is being applied to the aircraft to remove and protect the aircraft’s critical surfaces from contamination.

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Case StudyRunway overrun and collision in winter weather conditionsSouthwest Airlines – Flight 1428 – Boeing 737-7H4 December 8, 2005

On Thursday 8th December 2005, Southwest Airlines Flight 1248 was scheduled to arrive at Chicago Midway International Airport (MDW) from Baltimore-Washington International Thurgood Marshall Airport (BWI). The flight had already been delayed for a few hours departing BWI due to snowstorms and bad weather conditions in the Chicago area and the Boeing 737-7H4 circled over a small area in northwest Indiana several times before attempting to land at MDW in a snowstorm. It was reported that there was around 20 cm of snow on the ground in the surrounding area and snow was falling at a moderate rate at the time of the accident. However, airport officials confirmed that the runway had been recently cleared and treated with deice fluid. After landing at MDW, the aircraft ran off the departure end of runway 31C, the nose gear collapsed and the aircraft slid through the airport barrier wall and onto the roadway, where it struck vehicles and finally came to a stop in the middle of the busy road. A child in one of the vehicles was killed, some motorists were injured, and 18 passengers received minor injuries. The airplane was also substantially damaged.

In its report, the National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the flight crew’s failure to use available reverse thrust in a timely manner to safely slow or stop the airplane after landing in such weather conditions on a contaminated runway, which resulted in a runway overrun. This failure occurred because this was the pilots’ first experience and lack of familiarity with the airplane’s autobrake system distracted them from thrust reverser usage during the challenging landing. Another factor that contributed to the accident was the pilots’ failure to divert to another airport given reports that included poor weather conditions, poor visibility, mixed/poor braking actions and a tailwind component greater than 5 knots.

Through its investigation, the NTSB found that the pilots had received detailed weather information for MDW and two alternate airport destinations in their dispatch documents and were well informed of the winter weather conditions in the area. They had also obtained weather updates while en- route from BWI to MDW and had discussed conditions under which

The Boeing 737-74H overran the runway, crashed through an airport barrier wall and slid to a busy roadway, where it collided with some vehicles before finally coming to a stop in the middle of the road.

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they would divert to one of the alternate airports. Therefore, it is clear the pilots knew the conditions and had even discussed the possibility to divert, but decided to land at MDW anyway.

The crew had several alternative options at their disposal. They could have held in the air in order to wait for the weather to improve, which may have allowed them to use the originally selected longer runway 13C, or they could have diverted to an alternative airport, such as Chicago O’Hare International, whose longer runways were only 10 minutes flying time away. However, these options would have entailed

considerable additional expenses for Southwest, missed connections and significant inconvenience for passengers. These inconveniences, along with the fact that the flight was already significantly delayed, put pressure on the flight crew to make a decision to land in such unfavorable conditions.

Even though the weather conditions were extremely unfavorable, the NTSB found that the pilots would have been able to stop the airplane on the runway if they had commanded maximum reverse thrust promptly after touchdown and maintained maximum reverse thrust to a full stop.

The CVR recorded that prior to landing the MDW Air Traffic Controllers advised the flight crew to “continue

for 31C. The winds zero nine zero at nine, brakin’ action reported good for the first half, poor for the second half.” Therefore, the flight crew were aware of the conditions surrounding the landing. Perhaps they miscalculated the landing requirements due to mixed runway conditions. Flight data recorder information reveals that the thrust reversers were not deployed until 18 seconds after touchdown, at which point there was only about 1,000 feet of usable runway remaining. The Captain stated that he could not get the reverse thrust levers out of the stowed position. However, the first officer after several seconds noticed that the thrust reversers were

not deployed, and activated the reversers without a problem.

It was found that the flight crew’s delay in deploying the thrust reversers cannot be attributed to mechanical or physical difficulties. The pilots’ first use of the airplane’s autobrake system during a challenging landing situation led to the pilots’ distraction from the otherwise routine task of deploying the thrust reversers promptly after touchdown.

This case study uses excerpts from the NTSB accident report NTSB/AAR-07/06For more information please visit: http://www.ntsb.gov/doclib/reports/2007/aar0706.pdf

The aircraft crushed several cars on a busy road after it crashed through the airport barrier wall, injuring several motorists and killing a young boy.

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Case StudyCrash during takeoff in icing conditionsCanadair CL-600-2A12 Challenger 601, N873GNovember 28, 2004

On November 28, 2004 Canadair CL-600-2A12 Challenger 601, Reg. N873G, had arrived in Montrose Regional Airport in Montrose, Co. from Van Nuys, Ca. in bad weather conditions with no incident. The aircraft was parked on the ramp in snow fall and freezing temperatures for about 45 minutes where it was refuelled and passengers boarded, and then taxied out for runway 31. During takeoff, after rotation, the aircraft swerved to the left, then right, and then left again, collided with the ground, slid around 450 meters, went through the airport fence, broke up into several pieces, and caught fire. The captain, the flight attendant and one passenger were killed, while the first officer and two passengers were seriously injured. In its report, the National Transportation Safety Board (NTSB) determined that the probable cause of the accident was the flight crew’s failure to ensure that the airplane’s wings were free of ice or snow contamination that accumulated while the airplane was on the ground, which resulted in an attempted takeoff with upper wing contamination that induced the subsequent stall and collision with the ground.

Other contributing factors to the accident were (1) the pilots’ lack of experience flying during winter weather, (2) the flight crew’s rush to depart that led them to use runway 31, which was shorter than the originally planned runway 35, which was blocked by operating snow plows. At the time of the aircraft’s arrival into Montrose and through till after the accident, weather observations were falling “wet snow” and freezing temperatures. In these conditions, there is great risk of contamination or ice formation on the aircraft surfaces, and the flight crew members should have carried out an inspection of the airframe before takeoff.

The CVR recorded that before engine start the Captain asked the First Officer “how do you see the wings?” The first officer stated, “good,” and the captain replied, “looks clear to me.” That was recorded 16 minutes before the aircraft’s takeoff roll. Furthermore, a pilot-certified witness on the ramp believes he saw contamination on the aircraft’s wing, but was not certain to what extent. He also stated that he never observed any of the flight crew members conduct a

Due to contaminated wing surfaces, the Challenger 601’s performance after liftoff was impaired, which resulted in this fatal accident

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tactile examination of the wing surfaces. According to regulations, a pre-takeoff contamination check must be completed within 5 minutes before takeoff any time conditions are such that contamination may be present on the aircraft. According to the NTSB report, for an aircraft to lift off and transition to a positive climb angle, its flight controls must be configured for takeoff, it must achieve sufficient airspeed during the ground roll, and it must pitch up to a sufficient angle to allow the wings to achieve an acceptable AOA. In addition, the wings must be free of contamination to generate the required lift at the appropriate airspeed and AOA. The investigation found that the aircraft’s performance and acceleration during the takeoff roll were normal. Rotation and liftoff occurred at the expected elapsed time and airspeed. The aircraft’s performance after liftoff, however, was severely impaired. Yet there was no indication that the flight crew noticed any abnormal performance at the time of liftoff before it failed to establish a positive climb. Although the aircraft achieved the appropriate liftoff airspeed, pitched up, and lifted off the runway, it was airborne only 8-9 seconds and did not transition to a climb. The study showed that an aerodynamically clean airplane at the same airspeed and liftoff would have transitioned to a positive climb.

About 4 seconds after the airplane’s estimated liftoff, the CVR recorded the first officer ask the captain if he wanted the landing gear raised, which indicates that the airplane had lifted off and that the first officer expected it would transition to a normal climb. Within 1/2 second of the first officer’s question, however, the airplane’s stickpusher horn activated, indicating the airplane had achieved a sufficiently high AOA to activate the stall protection system sequence. Under normal circumstances and at the airspeed the accident airplane achieved, it should have begun generating excess lift and accelerating into a climb at an AOA lower than that required for activation of the stickshaker or stickpusher. Within 1 second of the stickpusher horn (about 5 seconds after the estimated liftoff) the CVR recorded a “bank angle” warning, which indicated that the bank angle had exceeded 17º. So, the aircraft remained near the ground and rolled abruptly several times before it collided with the ground. Previous NTSB findings have shown that large rolling motions, similar to the ones of this case, are often caused by local separation of airflow from the wing due to upper wing surface contamination. This type of contamination can accumulate while an airplane is parked and exposed to freezing precipitation and it accumulates on upper surface areas that cannot be

protected by the wing leading-edge anti-ice system. The presence of upper wing surface contamination is likely because the airplane was parked on the ground for 40 to 45 minutes during freezing precipitation and was not deiced.

The significant causal factors which lead to this accident were identified as follows:

1. Failure of the flight crew to carry out the necessary visual and tactile examination of the wing surfaces prior to flight.

2. The flight crew failed to recognize the presence of runway contamination as a consideration in determining the runway length required for takeoff. As recorded by the CVR, the Captain initially planned to take off from runway 35, which is 10,000 feet, but a snow plow was operating on that runway, and he did not know how long it would take for it to finish. In his haste to depart, he elected to depart from runway 31, which has 7,500 feet TORA.

3. The Captain’s pre-takeoff discussions with the First Officer indicated that they consulted the performance planning tables for dry runway conditions only.

4. Although it was not determined whether the airplane’s anti-icing systems were “on” or “off ” the CVR indicates that the captain initially chose to turn the systems “off” because the use of anti-ice systems reduces the available engine power for takeoff.

5. The presence of runway contamination increases takeoff runway lengths required due to the reduced acceleration during the takeoff ground roll, as well as reduced braking effectiveness during an aborted takeoff.

6. During the pre-takeoff planning discussion regarding which runway to use, they decided to use runway 31 (7,500ft TORA) even though the required runway length would be 8,000 feet in such conditions. After the decision was made, the CVR recorded the First Officer stating “these numbers are always conservative anyway”. This audible phrase by the First Officer, is evidence of ‘Confirmation Bias’ which is itself a symptom of lack of Situation Awareness (SA) and therefore poor CRM was judged to be a contributory factor.

This case study uses excerpts from theNTSB accident report NTSB/AAB-06/03For more information please visit:http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-briefs/AAB06-03.pdf

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SAFA Inspections Results 2010-2011

De-icing Holdover Times Table

• JAR OPS-A 8.2.4.4 Holdover times for ground de-icing• The start of the holdover time is from the beginning of the de-icing treatment.• The upper holdover time limit represents light precipitation conditions while the lower holdover time limit represents

moderateprecipitation conditions.