CRM course design and training for Flight Calibration Services

In October 2019 ITS was asked by Flight Calibration Services Limited (Flight-Cal), based at Shoreham in the UK, to provide support for CRM training. Flight-Cal specialise in flight inspections at airports worldwide.

Whenever possible, with any new client, ITS like to undertake a full Training Needs Analysis (TNA) before preparing, and commencing, any training programme. ITS consultants spent three days with Flight-Cal working with all departments, management and flight crew, building a clear understanding of the operation.

When the TNA was completed, the next phase was to design a 2-day initial CRM course that precisely matched the needs and particular issues for the Flight-Cal operation. Once the course was signed-off a training programme was established.

ITS delivered two initial CRM courses at the end of 2019, with more to follow on early in 2020.

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Train the Trainer for Tui Fly

At the beginning of October 2019, ITS returned to Amsterdam to run a train the trainer course for Tui Fly. The course was 3-day duration and was attended by six crew members who were preparing to become ground instructors

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Thailand – Instructor Refresher Training

In early September 2019, ITS returned to Songkhla, Thailand to deliver a series of recurrent training courses to SFS Aviation instructors. SFS is a rotary wing operation serving mainly the offshore oil industry.

Having delivered initial instructor training courses in 2016, ITS now ran the following recurrent courses:

CRM Trainer Refresher

CRM Trainer Examiner Refresher

Assessment Skills for NOTECHS Refresher

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Human Performance & Limitations Instructor training for Tui Fly

During the week of August 5h 2019 ITS ran an HPL Instructor course in Amsterdam for Tui Fly instructors. The course follows the EASA ATPL syllabus and delivers the skills required for instructors to deliver HPL training to pilots and flight attendants. In particular, it enables flight attendant CRM trainers to meet the EASA requirement that they have attended such a course.

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Accident: Caspian MD83 at Mahshahr on Jan 27th 2020, overran runway on landing

 A Caspian Airlines McDonnell Douglas MD-83, registration EP-CPZ performing flight IV-6936 from Tehran Mehrabad to Mahshahr (Iran) with 144 people on board, landed on Mahshar’s runway 13 (landing distance available 2695 meters/8840 feet) at about 07:50L (04:20Z) but overran the end of the runway, broke through the airport perimeter fence and came to a stop on the Mahshahr-Sarbandar Expressway (96) about 170 meters past the end of the runway with all gear collapsed.

The aircraft was evacuated while emergency services began to respond. There were no injuries, the aircraft received substantial damage.

Aviation Herald
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Avianca A319, upset injures 8, on Jan 23rd 2020

An Avianca Costa Rica Airbus A319-100, registration N703AV performing flight LR-693 from San Jose (Costa Rica) to Bogota (Colombia) with 108 passengers and 5 crew, was enroute at FL370 about 150nm southeast of Panama City (Panama) when the crew decided to divert to Panama City due to an upset causing injuries on board and a cockpit indication. The aircraft landed safely in Panama City about 30 minutes later. 6 Passengers and 2 cabin crew were attended to by paramedics.

The airline reported the crew had received an alert on one of the aircraft systems. During the flight an abrupt movement of the aircraft occurred. The crew diverted to Panama City, 6 passengers and 2 cabin crew were treated by paramedics after landing in Panama City.

Mode-S data transmitted by the aircraft show the aircraft at FL370 at about 488 knots over ground as it crossed the coast into Colombia. Within a minute the aircraft turned about 25 degrees to the right and descended to below FL350, another minute later was in a significant climb above FL350 to near FL360 at 410 knots over ground, before settling on FL350 another minute later, the speed over ground continued to fluctuate between 412 and 516 knots until it settled at 449 knots about 6 minutes after the upset, when the aircraft had turned 180 degrees to the left and was on course to Panama City.

Passenger photos show a cabin ceiling cracked by impact, blood stains on the cabin ceiling, a destroyed lavatory and debris all across the cabin.

Aviation Herald

Medellin, Colombia – January 27, 2019: Avianca Airbus A319 airplane at Medellin Rionegro airport (MDE) in Colombia.
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WestJet Q400 damaged by sharp de-rotation at Edmonton

Investigators have determined that a WestJet Encore Bombardier Q400 suffered damage at Edmonton after de-rotating sharply during a high-speed landing.

The Q400 – arriving from Fort McMurray on 19 July last year – had been approaching Edmonton’s runway 12 with storms in the vicinity of the airport.

Its captain opted for a high approach speed of 142kt, about 20kt above the reference, owing to the possibility of a missed approach and the risk of windshear. The crew also planned a “firm landing”, says the Transportation Safety Board of Canada, because of gusting conditions.

Flight-data recorder information shows the Q400 did not reduce speed before touchdown and the aircraft’s main landing-gear sensors briefly switched from ground mode, after touchdown, back to air mode.

The captain then made a full nose-down input to the control column, and the aircraft sharply de-rotated – by 10°/s rather than the typical 4°/s. This was followed by a “bang” and a nose-wheel shimmy, says the inquiry, and the aircraft pulled to the left during roll-out.

Analysis of flight-recorder data shows both the main and nose landing-gear switched to ground mode “nearly simultaneously”, it adds.While no hard landing was indicated to the pilots, they requested maintenance support after taxiing off the runway – although personnel could not attend for 45min owing to a lightning alert.

Both nose-gear tyres were changed before the aircraft taxied to the gate to disembark passengers. Further detailed inspection showed the aircraft had sustained substantial fuselage skin wrinkling on its nose as well as damage to the nose-gear door, nose-gear assembly, and forward bulkhead.

None of the 74 occupants was injured.

WestJet Encore’s operating manual states that crews should add half the gust factor – to a maximum of 10kt – to the normal approach speed when flying in gusting conditions.

This should have resulted in the Q400’s flying at 135kt, and reducing speed to the reference of 122kt at touchdown. The nose-wheel should then have been “promptly” brought into contact with the ground after the main-gear touchdown, says the inquiry.

It states that the damage to the aircraft (C-FKWE) occurred when the nose of the aircraft was lowered at a higher rate than normal, following the high-speed touchdown, and adds that the accident highlights the “importance of flight crews’ adhering to operational procedures and techniques”.
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Envoy E145 at Chicago on Nov 11th, runway excursion on landing

An Envoy Embraer ERJ-145, registration N619AE performing flight AA-4125 from Greensboro,NC to Chicago O’Hare,IL (USA) with 38 passengers and 3 crew, landed on O’Hare’s runway 10L at 07:40L (13:40Z). The tower had reported medium braking action and 4000 feet RVR, when the aircraft skidded left off the runway, skidded sideways further yawing to the left and came to a stop with all gear as well as the right wing tip on soft ground about 5350 feet/1630 meters past the runway threshold, the right main gear had collapsed. A passenger commented: “I think we landed!”. The aircraft was evacuated.

The runway was closed.

The airline reported the aircraft skidded off the runway due to icy conditions at Chicago O’Hare, all 38 passengers and 3 crew left the aircraft without injuries and have been taken to the terminal.

Following the occurrence ATC changed to tell arriving aircraft that braking action was poor. The aircraft had gone around on short final to runway 10L about 25 minutes earlier after being instructed by tower to go around.

Click here to view the video

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Canada issues Emergency AD to limit Airbus A220 engine power settings after recent incidents

Regulator Transport Canada issued an Emergency Airworthiness Directive (AD) to limit certain engine power settings on Airbus A220 aircraft following three recent failures.

Three inflight shutdowns occurred within three months: July 25, 2019, September 16, 2019, and October 15, 2019. In each case, the aircraft involved was a Swiss International Air Lines Airbus A220-300 (formerly named Bombardier CSeries 300) with Pratt & Whitney PW1524G-3 engines. These inflight shutdowns were due to failure of the low-pressure compressor (LPC) stage 1 rotor, which resulted in the rotor disk releasing from the LPC case and damaging the engine.

Investigations are ongoing to determine the root cause, but preliminary investigation results indicate high altitude climbs at higher thrust settings for engines with certain thrust ratings may be a contributor. This condition, if not corrected, could lead to an uncontained failure of the engine and damage to the aeroplane.
Transport Canada issued the AD on October 26, introducing a new Aircraft Flight Manual (AFM) limitation and normal procedure to limit the engine N1 setting to 94% while above 29000 feet. This AD is considered an interim action and further AD action may follow.

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What health systems can learn from aviation

Crew resource management, an aviation strategy that can be adapted to healthcare settings, helps reduce adverse events and results in cost savings, according to a study published in American Journal of Medical Quality.

Crew resource management is a process first used by airplane crew members to spot safety threats, come up with a plan to avoid or lessen them and communicate that plan to the crew. It combines elements of teamwork, such as situational awareness, communication and task management, and human factors, such as coordination and decision-making.

Researchers examined the effect of using crew resource management training at about 3,000 health systems from July 2010 to July 2013. Employees in 12 areas were trained at a cost of $3.6 million.

They found that the total number of adverse events avoided was 735, and cost savings for the health systems ranged from $12.6 million up to $28 million.

They calculated that the overall return on investment for crew resource management training ranged from $9.1 million to $24.4 million.

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