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Synopsis
A FOKKER 100 WAS DISPATCHED IN NON COMPLIANCE WITH THE
INCORRECT VOICE RECORDER AND FLT DATA RECORDER CTL PANEL
INSTALLED.
Overlooked trim led to 737's post-V1 abort
Investigators have traced the post-V1
abort of a BMI baby Boeing 737-300's
take-off roll to an oversight which left
the stabilizer trim set in the wrong.
The aircraft, departing Birmingham for
Edinburgh in snowy weather on 13
February, failed to rotate at 135 kt when
the first officer pulled on the control
column.
As the aircraft continued to accelerate
to 155 kt the captain opted to reject the
take-off, says the UK's Air Accidents
Investigation Branch. Although the 737
was traveling "well above" the V1 speed of 126 kt, the captain correctly
judged that the aircraft would be able to stop within the remaining length of
Birmingham's 2,600m (8,530 ft) runway.
The AAIB found that the crew had omitted to set the stabilizer trim at the
usual point because of de-icing procedures under way at the time. De-icing
procedures "disrupted" the crew's routine, it says, leaving the stabilizer
trim incorrectly set, and the crew was "distracted" by the unusual
requirement to leave the flaps up while taxiing in slush.
Human Factors Industry News 7
The crew also felt pressured by de-icing holdover time constraints, and the
rotation failure "reinforced" the captain's concerns that ice accretion may
have affected the aircraft's control surfaces.
"When the first officer said he could not rotate the aircraft, the captain
quickly made the decision to reject the take-off, having judged there was
sufficient runway remaining to do so and believing the aircraft was not
capable of flying," says the AAIB.
While the stabilizer setting was incorrect, it was still within permissible
range, so there was no warning horn to alert the crew. Simulator trials
subsequently indicated that the aircraft could have rotated successfully,
and climbed away safely, if the crew had applied a "more forceful" pull on
the control column.
FAA forum promotes safety through sharing
information, best practices
A wealth of information is available on
aviation safety, but improvement is needed
in coordinating and sharing the best safety
practices that could benefit the entire
industry, ICAO Secretary General Raymond
Benjamin said at the annual FAA
International Aviation Safety Forum in
Washington. "There's no need for anyone
not to have access to safety-critical
information," Benjamin said. "We need a
global safety information exchange." Such
an exchange would lead to more "targeted
regulations" and provide data and
information on best practices, he argued.
"It's truly an idea whose time has come."
Benjamin anticipates that the "principle" of the exchange will be agreed upon at a
March ICAO meeting in Montreal. The information network would be Web-based
and supported by both FAA and EASA, he indicated.
Benjamin also noted that international cooperative efforts are underway to
examine issues related to pilot fatigue, which received considerable attention
following the February crash of a Colgan Air Q400 outside Buffalo . "We will look
at all aspects of fatigue management," he said.
Human Factors Industry News 8
JetBlue Airways COO Rob Maruster also spoke out in support of improved
information sharing and leadership by example in developing a strong safety
culture. "As an industry we need to do a better job just speaking to the results,
and the results speak for themselves," he said.
Rather than individual airlines, he argued that FAA, the US Dept. of
Transportation and trade groups like the Air Transport Assn. and the Regional
Airline Assn. should promote both the industry's safety record and the changes
being made to improve it. He acknowledged that some of those changes occur
after fatal accidents. "I don't think we do a very good job talking about the
changes we have made," he said. "As an industry, we need to do a much better
job of speaking to those changes when they are made. In essence we are
becoming safer in many respects."
Human Factors: Beyond the "Dirty Dozen" - Part II
MRO Programs
In their initial HF training, all three
maintenance, repair and overhaul
(MRO) organizations emphasize the "dirty dozen" —
common sources of errors — as well as what’s sometimes called the "just
culture" — a work environment that emphasizes objectivity, analysis and a
　
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