Premium On Safety - Issue 20, 2016 - 1

ISSUE 20 YEAR 2016

Best Practices: Business Aviation Food Security 03
SMS Corner: After the Audit 04
ASI Message: When Honest Mistakes Become Mishaps 06
Helicopter Ops: 2016 Will See First Safety Audits 06
Lessons Learned: Underequipped and Overwhelmed 07

Greetings! How are those New
Year's resolutions holding up? Were
there any safety angles among those
traditional fitness, fiscal, and cerebral
improvements you vowed to strive for
in 2016? If not, it's never a bad time to
become a more vigilant and active agent
for safety. Few workplaces are without
hazards, and few procedures are truly
optimized and bulletproof.
An investigation after a major airline had an alarming close call due to
maintenance being done on the wrong
aircraft revealed that "airplane swap"
errors were a recurring issue, but
because they were usually noticed and
resolved by technicians who did not
report them, work practices that actually
aided the confusion never got scrutinized. Opportunity lost! Now's a great
time to really consider things you're seeing and doing that could hurt you or your
operation, to make a report or spark the
right conversation, and drive changes
before they do. Fly smart and fly safe!

Paul Ratté
Director of Aviation Safety
Programs, USAIG

Loss of Separation

Are You on a Collision Course?


minimum separation. But what are separation
minimums? Rules are different everywhere-
depending on the category of airspace, ATC
technology, an aircraft's equipment, and pilot
capabilities-and they're constantly changing. Loss
of separation can take place anywhere, at any time,
from chocks to chocks. It can occur between aircraft,
aircraft and terrain/obstacles, or aircraft and ground
equipment. The FAA even has a category for loss
of separation between aircraft and a pedestrian. In
the non-aviation world, I'm pretty sure that's called
"distracted walking" and addresses the hazards
created by those obsessed with their cell phones.
Contributing factors affecting LOS are
extensive. They include pilot-controller
Often it's not one but rather a combination
communications, airspace systems,
pilot training, aircraft type, evasive
of hazards that results in a LOS. For example, action, blind spots, inoperable
equipment, weather systems, fatigue,
pilot fatigue, an inoperative glideslope, and
even operations into cold weather, all
of which can result in altimetry errors
an ambiguous clearance may combine to
leading to a loss of separation. The
biggest opportunity for LOS is human
produce controlled flight into terrain.
error in the terminal environment.
However, it can also occur in remote en route
They flew across the approach paths of Runways
areas, low altitude, high altitude, VFR, IFR, and
17C and 17R, then began a climbing right turn
heading straight into traffic. ATC had no way to keep everything in between. New pilots, seasoned
pilots, professional crews, and even the military
aircraft separated as the pilots flew an unpublished
are not immune. Often it's not one but rather a
procedure, resulting in a loss of separation that
combination of hazards that results in a LOS. For
could have ended in disaster.
example, pilot fatigue, an inoperative glideslope,
Loss of Separation (LOS)-a complex problem
and an ambiguous clearance may combine to
with as many pieces and possibilities as there are
produce controlled flight into terrain. The subject
pilots and planes in the sky. A LOS event occurs
of LOS is so complex, it's impossible to address
when two or more aircraft experience a loss of
An aircraft was in the final phase of flight preparing
to land at a busy commercial airport. It had been
a long day for the pilots dealing with weather and
delays. Vectored onto a base leg for Runway 17L,
the pilots were completing the before-landing
checklist when ATC advised them to expect the
ILS 17L. Shortly after, the localizer needle for 17L
came alive and swung across the pilot's primary
flight display. They had not been cleared for the
approach, so the co-pilot immediately attempted
to contact ATC on the last frequency, but there
was no answer. Instead of capturing the localizer
and proceeding inbound, as advised to expect, the
pilots continued on their last assigned heading.

(continued on page 2)


Table of Contents for the Digital Edition of Premium On Safety - Issue 20, 2016