Flight Safety Information February 12, 2010 No.034 In This Issue Trigana Indonesian ATR in emergency landing on rice field Trigana Air Service, ATR-42-300 Lessons Learned from Toyota Wildlife Hazard Studies a Must for Local Airport Safety Airport body scanners violate Islamic law, Muslims say ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Trigana Indonesian ATR in emergency landing on rice field Leithen Francis, Singapore An Indonesian Trigana Air Service ATR 42 made an emergency landing in a rice field today after reporting a failure on one of its turboprop engines. The ATR 42-300, local registration PK-YRP, was on a scheduled flight from Berau to Samarinda in Kalimantan when one of its engines failed, says a Trigana official, who wishes to remain anonymous. He says the pilot decided to divert to Balikpapan airport but then had to make an emergency landing in a rice field about 40 kilometres from there. The incident happened at approximately 11:00 local time, he adds. There were five crew and 51 passengers on board, he says. Only one passenger was injured and "there were no serious injuries", he adds. "We don't have information right now on damage to the aircraft but we have sent a team of engineers to investigate," says the official. Indonesia's National Transport Safety Committee is also investigating, he adds. Trigana is a privately-owned Indonesian passenger and cargo airline that operates on domestic routes. Source: Air Transport Intelligence news Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Trigana Air Service, ATR-42-300 Status: Preliminary Date: 11 FEB 2010 Time: 11:50 Type: ATR-42-300 Operator: Trigana Air Service Registration: PK-YRP C/n / msn: 050 First flight: 1987-05-22 (22 years 9 months) Crew: Fatalities: 0 / Occupants: 5 Passengers: Fatalities: 0 / Occupants: 51 Total: Fatalities: 0 / Occupants: 56 Airplane damage: Minor Location: 33 km (20.6 mls) NE of Balikpapan-Sepingan Airport (BPN) (Indonesia) Phase: Landing (LDG) Nature: Domestic Scheduled Passenger Departure airport: Tanjung Redep/Berau-Kalimaru Airport (BEJ/WALK), Indonesia Destination airport: Samarinda Airport (SRI/WALS), Indonesia Flightnumber: 162 Narrative: An ATR-42-300 turboprop plane, registered PK-YRP, was damaged in a forced landing in a rice field near Balikpapan-Sepingan Airport (BPN), Indonesia. The domestic passenger flight from Tanjung Redep/Berau-Kalimaru Airport (BEJ) was approaching Samarinda (SRI) when the nr.1 engine failed. Samrinda air traffic control advised against an emergency landing there because the airport is situated in a residential area. Also, the runway length is just 1160 m (3800 ft) of the lentgh of the runway and the buildings surrounding the airport. The pilot decided to divert to Balikpapan-Sepingan Airport (BPN) which was 92 km (50 NM) to the South. En route to Balikpapan the nr.2 engine also lost power. The crew carried out a forced landing in a rice field, some five kilometers from the main road from Samarinda to Balikpapan. Aviation-safety.net Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Lessons Learned from Toyota 2010 Failing to "Connect the Dots." How the recent quality troubles plaguing Toyota relates to the SMS implementation efforts in the US Aviation Industry. During many conversations with colleagues and review of the comments to the ANPRM, one of the statements often repeated is: "we already have a quality management system in place, and do not need another such as SMS." There seems to be an underlying misunderstanding between a quality management system and a safety management system. As the President of Toyota stated in an op-ed article (CNN on-line); "we failed to connect the dots with accelerator problems in the United States and Europe" and "the company needed to improve sharing important quality and safety information across our global operations." I argue, that safety is an unspoken and unwritten quality expectation of our customers, and you cannot separate the two. You can have a quality product or service, as defined by the ISO standards, and still not have a safe product or service. Toyotas' problem clearly accentuates this point. Part of the confusion stems from the adoption of some of the same types of tools and techniques used in quality management, to manage the safety system. Trade association presidents, and regulators state that SMS is a businesslike approach to managing safety; and this is correct. However, many people falsely assume this to mean that processes designed to produce a quality product, (repeatedly doing the same thing, without variation) equates to the same thing as repeatedly producing a safe product. In Toyotas case, the accelerator parts were manufactured to a specification (an incorrect one), and the quality system would detect any variance of the process, and adjust the process to bring the production back in line with the specification. In effect, Toyota had a quality product. It was produced as designed, repeatedly without variation outside of established limits. Toyota did not have a safe product, and as stated did not connect the dots between failures of the product during use, to failures of the production process. Because quality management systems measure types of data points, geared towards production costs and sales, some people believe these same types of measures with a "businesslike approach" equates to a safety management system. It is how the tools and techniques are used, along with a focus on investigation of events, which makes the quality and safety management systems different. The quality systems do not investigate incidents or accidents for risk assessment. Quality systems audit output of a process only for variance, and makes adjustments. SMS investigates events, looking for contributing factors from all influencing sources. For example: an altitude deviation will start with establishing if a violation occurred, and if so or not, was it the result of an error, due to risk behavior, latent organizational pathogens, or both. SMS looks at the Human interface aspects (commonly referred to as HFACS) and the organizational, to include the regulatory agencies, the operating environment, and the equipment to determine a root cause and contributing factors. One of the purposes of an SMS is to improve the safety performance, and therefore reduce the exposure to risk of having an accident. It is not focused on the safety record per se. Quality systems are focused on continuous improvement also, but through improving the production record rate. This is another source of confusion between the two management system concepts; improving a safety record, is not the same as improving safety performance. There are many aviation companies that have extremely good safety records, but are operating with risky behavior or inadequate organizational structures, and have just not had an accident yet. A good safety record, just like a good quality record, does not guarantee safety. Toyota has for decades been renowned for their outstanding quality, their reputation was built on their quality, yet Toyota is now faced with a failure to connect safety to their quality. We must ask ourselves, how did this happen, and what does it mean to me? One of the aspects pointed out with Toyotas' problems, has been the management structure, and management involvement. Management's attention and oversight was focused on the business bottom line, and those metrics were quality measures, management was not focused on safety risk assessment or risk management. Safety risk assessment and safety risk management are just some of the components of an SMS, and it requires management involvement. The aviation industry managers should take a lesson learned from Toyota, and ensure that what you do with the management system, i.e. doing the hazard analysis through the investigations of events is not overlooked. The FAA should also take a lesson from this, and ensure the necessary resources are available to connect the dots, between the operators reporting of failures, and the manufactures requirements to correct identified problems. This is where Toyota failed, we should not do the same. I have read many comments from manufacturers and certified repair shops, that leads one to question if there is a true understanding of the relationship and differences between a quality management systems and a safety management system. Such comments as, the QMS is FAA accepted. How can the FAA accept a QMS, which is not a regulatory requirement. Currently the FAA cannot accept an SMS, and is having problems even dealing with official recognition of an SMS. There is no regulatory QMS framework. Other comments such as, the facility has a quality control manual or quality control department. Again, going back to the Toyota example, quality control is not the same as quality assurance, or safety assurance. There are however, some organizations which do understand the quality and safety interface. Such as comments from TIMCO Aviation Services "The main difference between the QMS and the SMS is the identifying defects (QMS) or identifying hazards (SMS). QMS is more customer driven, dealing with produces and services, but SMS is more of a continuous internal health assessment. Having a QMS satisfies most requirements of the policy portionof an SMS, which gives us a good base to begin setting up an SMS." Comments from the organizations that appear to understand the relationships and difference, are those that appear to be able to "connect the dots". These organizations typically have other programs (which are good component parts of an SMS) such as; Internal Evaluation Program (IEP), Continuous Analysis and Surveillance (CAS), required for some operators, Aviation Safety Action Programs (ASAP), and other programs such as FOQA. An example of one of these SMS component programs is the required CAS program for certain types of air carriers. The CAS program is a strategic and important element of the SMS. A good CAS program, designed, developed, and implemented can help the air carrier maintenance repair department "connect the dots" between failures in the field. What may be lacking is the FAA's participation in CONNECTING THE DOTS BETWEEN THE OPERATOR AND THE MANUFACTURER. As the regulator, with oversight responsibility for both the operators and the manufactures, the FAA should bear the responsibility and liability to ensure the dots are connected and appropriate actions taken, this includes within the regulatory environment as well. There is a lot to be learned from Toyota's present situation, and how they got where they are. So what are we going to do about it? Steven C. McNeely Manager, Safety Management Systems Jet Solutions, L.L.C. Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Wildlife Hazard Studies a Must for Local Airport Safety Mary Marsh Reporter 6:11 PM CST, February 11, 2010 Since wildlife and planes don't "mix," the Federal Aviation Administration is tightening how local airports handle area wildlife hazards. From Fort Smith's airport to XNA and Drake Field in Northwest Arkansas, local airports are jumping to action. Airport Wildlife Biologist Kristin Borsch talks about some of the animals she sees around local airports: "your raptors, your hawks, your coyotes, and deer," Drake Field Airport Director Ray Boudreaux agrees: "we run deer off every morning." Boudreaux says for them, the Natural State's abundant wildlife is often a hazard. "We're talking about beaver, we're talking about coyotes; anything that might have a way of getting on a runway that might cause damage to an aircraft. Ever since the Hudson River incident where the aircraft had to ditch because of a goose, it's become a hot topic with the FAA." Boudreaux says Arkansas Game and Fish Commission officials already do yearly wildlife inspections on Drake Field, but Boudreaux says for the FAA, that's not good enough. "They want a registered, certified, FAA-certified wildlife biologist to do the work." He says the "work" requires an expert assessment of any wildlife hazards to airports, nationwide. "They're already conducting a study at XNA, the regional airport. We didn't think we were going to have to do one, but the FAA came down and said, 'yep, do it.' " But, the FAA is paying for the year-long studies, giving Bourdreaux something to sing about, as he works: "Ain't she sweet? She's walkin' down the street." Borsch says solutions to airport animal abundance range from cutting grass and building fences to scaring them away. "An airport can use non-lethal methods to just scare wildlife away from the airfield, if necessary: tools such as pyrotechnics that just make noises." Boudreaux says passengers need not worry: it's their job to keep everyone taking off and landing, animal-free. "That's what our job is: to keep the airport safe for the people who use it." And Borsch says Northwest Arkansas and the River Valley are well on their way to meeting all new FAA requirements: "I will say, the airports that I visited in Arkansas have been very proactive in dealing with wildlife. I'm very impressed." Airport wildlife experts say their prices for these tests vary "wildly," depending on the airport. For more on how many airstrikes have happened in our area over years, log on to: http://www.socrata.com [http://r20.rs6.net/tn.jsp?et=1103033672265&s=6053&e=001ffqBGhsqAz6bc7IrNKdCK8mKWQG2mWh6J3HoRLXfOXKNUwXT9rr_vUSVG12ALyklOUuzMDQYeE1HviMc6kkUBiYIpbNPQdj289P2QzYyud9wESimLYUH865OnRtMAGEH-HffKjDnZJT7CBLEok8yUlDJzTV9ozTJA0qvst5EBxNsfT9dQAeDBwcVeQsRLVFtGBTi0d2WjwEePsZvcGzZRg==] http://www.kfsm.com [http://r20.rs6.net/tn.jsp?et=1103033672265&s=6053&e=001ffqBGhsqAz6Muyn3ys4A649HL0kZvdbMR69Nbh0IoRb5fXFUkppG7dJHakMoWl6Mk6d59ODdqlpTGd6-vTISxd_vyf9GJyFwWi8ObnPmr9fr47aP3DECGdx8ffjMxhx_qxNjMW0oqSpqrelQFp04vvN0wzv4pLPjsbpGbcj_m837dhmDy2yHNKmbQaDdKNNCupldKbP3nucARFJr-sHntGWsPPnNoKvI6-NfNp2TzMo=] Back to Top ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Airport body scanners violate Islamic law, Muslims say By Niraj Warikoo, Detroit Free Press Saying that body scanners violate Islamic law, Muslim-American groups are supporting a "fatwa" - a religious ruling - that forbids Muslims from going through the scanners at airports. The Fiqh Council of North America - a body of Islamic scholars - issued a fatwa this week that says going through the airport scanners would violate Islamic rules on modesty. "It is a violation of clear Islamic teachings that men or women be seen naked by other men and women," reads the fatwa issued Tuesday. "Islam highly emphasizes haya (modesty) and considers it part of faith. The Quran has commanded the believers, both men and women, to cover their private parts." The decision could complicate efforts to intensify screening of potential terrorists who are Muslim. After the Christmas Day bombing attempt in Detroit by a Muslim suspect from Nigeria, some have called for the use of body scanners at airports to find explosives and other dangerous materials carried by terrorists. Some airports are now in the process of buying and using the body scanners, which show in graphic detail the outlines of a person's body. But Muslim groups say the scanners go against their religion. One option offered to passengers who don't want to use the scanners would be a pat down by a security guard. The Muslim groups are urging members to undergo those instead. Two members of the Fiqh Council are from Michigan, Imam Hassan Qazwini of the Islamic Center of America in Dearborn and Imam Ali Suleiman Ali of the Canton Mosque. "Fiqh" means Islamic jurisprudence. The Council on American-Islamic Relations, which has a chapter in Michigan, says it endorses the fatwa. "We support the Fiqh Council's statement on full-body scanners and believe that the religious and privacy rights of passengers can be respected while maintaining safety and security," said Nihad Awad, national executive director of CAIR. A spokesman for the Transportation Safety Administration was not available to immediately comment. http://www.usatoday.com/news/religion/2010-02-11-airport-scanners-muslims_N.htm [http://r20.rs6.net/tn.jsp?et=1103033672265&s=6053&e=001ffqBGhsqAz5p5-8CkyDl1STMtMg0zvLp6SK9n-lyU7WOH1uIwslgePCJoGHkamkFGUyPrAG7vNrSYt4OhSvXW4rwXdMmMTK_SXe7siGIVUzOmggip5elOJIWzwYUtnujLLjQANJ6Y1PQTy4Wqrmp9VXH4SYecmsfb2jEMS_kmUaq-IRA9WlAfKc1RJey9QfB] Back to Top [http://r20.rs6.net/tn.jsp?et=1103033672265&s=6053&e=001ffqBGhsqAz6G6hJeZOLNtwc2jc26wX-w7QlPlNKVNMX1RRVCipn-hBg9MS-Yc0XMKTqg9OWAJ0IudV6epS9tRg==] ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC