In the year Flight Safety Australia began, the world’s population was 5.7 billion. Australia’s aviation community was just beginning to come to grips with the new-fangled GPS (global positioning system). It was tested and approved by CASA, Airservices Australia and RAAF experts as a primary means of enroute navigation on 7 December 1995. Alongside this dramatic change in navigation instrumentation was a re-classification of airspace to coincide with ICAO specifications, into the format we see today.
IBM’s supercomputer Deep Blue puts a score on the board for robots by beating chess champion Gary Kasparov in one game of chess (but Kasparov won the match 2-1); and John Howard was inaugurated as the 25th prime minister of Australia. Highlights for FSA in 1996 were: the financial benefits of employing safety systems in all facets of an operator’s portfolio and the usefulness of human factors knowledge for engineers. A story on SMS argued the benefits of managing risk using an SMS (safety management system), and added that it could be cost-friendly. Stories on gear-up landings and icing accidents responded to trends on the CASA database.
The epic blockbuster Titanic was in cinemas, and the comet Hale-Bopp was in the night sky (not to be seen again for 2500 years). In aviation, fuel was a hot topic, with reports of incorrect fuelling processes, and improper storage procedures. FSA focused on pilot performance, and factors affecting decision-making, as well as medical issues such as hearing and vision loss, as well as vestibular illusions. Following reports of incorrect installations of GPS on Australian aircraft, FSA also reminded aircraft operators of the importance of correct GPS fitting and operation.
Windows 98 was the latest in computing software, Voyager I overtook Pioneer 10 as the most distant manmade object in existence (it was about twice as far from the Sun as Pluto) and a web company was founded – Google. FSA reported on the proposed mandating by CASA of TCAS (traffic collision avoidance systems) on most turbine-powered RPT aircraft. And a certain sameness was emerging even then in the safety topics: fuel planning (‘Too many pilots are having problems with fuel’ FSA wrote), proper engine checks and situational awareness. In 1998, the dreaded Y2K bug was first mentioned.
The ghastly Snowtown murders came to light after police found bodies hidden in barrels in an unused bank vault. Star Wars Episode I became the highest grossing Star Wars film. FSA focused closer to home, with features on controlled flight into terrain, a significant cause of accidents in Australia. Along the lines of in-flight failures, icing of engines, as well as vacuum pump failures, were highlighted as potentially significant dangers if the correct procedures were not followed. There was a continuing emphasis on safety management systems. The looming end of the century brought the threat of potentially catastrophic computing errors caused by the Y2K bug in aircraft and ATC systems. FSA reported on how operators and CASA were working together to provide solutions to prevent system crashes as 1999 flipped into 2000.
Vladimir Putin became president of Russia. Sydney hosted the Olympic Games and Cathy Freeman claimed gold in the 400m event. It was a tough year for the aviation industry: the fuel crisis was at its peak, because of excess EDA (ethylene diamine) added during the avgas refining process, resulting in the worldwide contamination of fuel reserves. In Paris, Concorde flight 4590 crashed shortly after take-off due, among other factors, to debris on the runway. FSA’s focus this year was on human factors in aviation, in particular runway incursions, and ways to reduce them. Traffic collision avoidance systems (TCAS) were mandated for RPT aircraft this year, an important aid in increasing pilots’ situational awareness. FSA observed that even though TCAS were only mandatory for the ‘heavy metal’, they were also beneficial for general aviation. And Y2K? No big deal.
Airliners flown by Islamic extremists attacked New York and Washington on 11 September, killing almost 3000. Microsoft released Windows XP, arguably the high point of its dominance of computer software. In Australia, FSA featured a long article on human factors in all facets of an aviation organisation, introducing the now widely adopted James Reason Swiss cheese model of accident causation. Reason described the layers of defence in place to stop hazards causing accidents as being like the layers of Swiss cheese, with the holes in the cheese representing holes in the defences that occur naturally during operations. The idea is that an accident occurs when the holes line up, creating a pathway, or window of opportunity, for an accident to occur. Understanding that organisational culture and procedures greatly influence the occurrence of these holes, Reason and his colleagues conjured the notion of organisational safety, complementing the safety management system.
A palindrome year, (the first since 1991), 2002 began with the discovery of a new dwarf planet, Quaoar (‘kwawar’) similar in size to Pluto. Terrorist bombings in Bali killed 202 people, including 88 Australians. In Ukraine a Sukhoi Su-27 crashed during an aerobatics demonstration, killing 77 people, making it the deadliest air show accident in history. In civil aviation, FSA focused on runway incursions. A story on the Linate airport disaster, where a Cessna Citation CJ2 entered a foggy runway as a McDonnell-Douglas MD-87 was taking off graphically illustrated the point. Human factors such as fatigue and situational awareness were also on FSA’s agenda, as well as articles dispelling common aviation myths.
In North America, over 50 million people were without power for up to two days after a small software bug snowballed into an energy crisis. The high-profile space shuttle Columbia disaster also occurred in 2003. Insulating foam shed during launch damaged the thermal protection system, and during re-entry the shuttle disintegrated. FSA discussed health issues for pilots, focusing in particular on heart disease. This was the 20th anniversary of the ‘Gimli Glider’, an accident in Canada where a Boeing 767 crew successfully landed after the aircraft ran out of fuel. Confusion between imperial and metric measurements was implicated, but the event was celebrated as a display of crew skill and initiative. High on his final (and only) approach to the landing field the pilot side slipped the jet. This technique was familiar to him as a glider tug pilot, but was nowhere to be found in the 767 pilot’s operating handbook. The aircraft landed with no serious injuries to those aboard.
This year saw the re-election of George W. Bush as the president of the United States, as well as the opening of two world record breakers: the tallest skyscraper, Taipei 101; and the world’s tallest bridge, the Millau Viaduct. FSA covered flight planning, with a special look at VFR flight into IMC, mishandling go-arounds and failing to fly the plan as major factors in aircraft-related fatalities. Ageing aircraft were emerging as an issue, with an analysis that highlighted the need for increased awareness and management of structural fatigue. Articles also considered procedural issues, following the investigation report into the Überlingen mid-air collision between a Russian Tupolev Tu-154 and a Boeing 757 freighter, where all aboard perished. The TCAS on both aircraft were working perfectly, warning the pilots to avoid a collision. The Tupolev crew disregarded the TCAS; instead following ATC instructions to descend, putting it on course to collide with the 757, which was also descending in response to its TCAS commands.
Batman Begins is released in cinemas and NASA sends a space probe into the comet Tempel 1 to determine its chemical make-up. The Airbus A380 made its maiden flight from Toulouse almost a decade after initial work began on the project. In Flight Safety Australia the focus was on fatigue, sleep deprivation and sleep inertia, the effect sleep inertia can have on decision making, and how and when optical illusions can lead to danger. A story marking the 20th anniversary of the JAL 123 disaster, where a Boeing 747 crashed after a faulty repair failed, highlighted maintenance practices, and the need to follow proper repair instructions.
The year of Italian footballer Fabio Grosso’s controversial dive which ended Australia’s World Cup hopes. The last chromosome sequence in the human genome project was published, completing 16 years of research. In Australian aviation the perennial issue of VFR pilots flying into IMC, one of the biggest killers in general aviation, received further coverage in Flight Safety Australia. Alongside this, icing was (yet again) a topic, with discussion on the conditions for and dangers of icing, particularly in the winter months in the highlands of Victoria and NSW. A flashback to the Milan incident in 2001 reiterated the role of human factors, issues such as fatigue and poor situational awareness, which can lead to simple human errors, and in turn to catastrophic situations. Towards the end of the year, FSA covered the physical and mental health of pilots, in particular heart disease and stress.
Apple’s iPhone introduced a new and compelling technological hybrid – the smartphone. In Australian politics, Kevin Rudd became Australia’s 26th prime minister, after 11 years of John Howard’s leadership. In aviation, FSA warned all pilots to leave aerobatics to the professionals after some alarming reports. The ATSB released the first edition of Australian Aviation Safety in Review, which showed that Australian incident and accident rates had been falling over the years up to 2005, with the majority of accidents involving smaller aircraft. An article on cutting-edge technologies in aviation was published, showing the leaps and bounds made in avionics, composite materials, reduction in cabin noise and nanostructures, and how these were being used in new-generation aircraft such as the Airbus A380 and Boeing 787.
In the quest to understand the universe, the Large Hadron Collider successfully circulated its first proton beam and would later be used to discover the Higgs Boson. Barack Obama became the first African-American to become president of the United States of America. Flight Safety Australia commemorated the 10th anniversary of the deadly dive of Silk Air flight MI 185, which plummeted into the Musi River, killing all 104 on board. The captain was having financial and suspected mental health issues. This led to a controversial discussion in the magazine on pilot mental health, particularly depression in men, as well as bi-polar disorder. This year was also the 20th anniversary of the Aloha Airlines flight 243 explosive decompression and an article about it reinforced the need for proper maintenance of ageing aircraft.
February saw south-eastern Australia sweltering in a record-breaking heat wave, with little or no respite in sight. On 7 February 2009 the heat wave culminated in the Black Saturday bushfires, the worst in Australia’s history, in which 173 people perished. FSA published further information on fatigue in ageing aircraft, alongside the War on Error, an article focusing on error minimisation and management, as part of a wider continuing focus on SMS and human factors. Finally in 2009, an article pondered the future of propulsive power, showing the weird façade of the propfan, essentially an ultra-high bypass turbofan, as well as information on pulsed propulsion techniques.
Researchers discovered that Neanderthals could have interbred with Homo sapiens and contributed to our gene pool. Solar Impulse makes the first 24-hour flight by a solar-powered aeroplane. For Australian aviation, the focus was on navigation. CASA brought Australian airspace into line with ICAO as Class D procedures replaced the Australian-only GAAP. Performance-based navigation, or PBN, took centre stage, in preparation for the eventual transition from ground-based radar to satellite-based systems. Wildlife strikes were the subject of an in-depth feature that concluded there was much more to wildlife management around aerodromes than frequent use of a shotgun. A 15-year retrospective in the November-December edition of FSA showed that although RPT flying hours had risen significantly over the previous 15 years, the number of accidents had remained fairly low and consistent. In the private and business sectors, accidents had significantly decreased, but the number of flying hours had also dropped, although not as significantly. The magazine expanded its focus to consider the effectiveness of training schemes for aircrew, cabin crew, controllers and engineers.
A year marked politically by the Arab Spring revolutions in Tunisia, Egypt and Libya. US President Barack Obama notified the world that US special forces had killed al- Qaeda mastermind Osama bin Laden, in a mission deep in Pakistan. Once again, FSA raised the issue of the ageing Australian fleet. The emerging aviation sectors of fly-in, fly-out (FIFO) charters to mining sites, as well as emerging trends in aerial mustering, were discussed at length in an FSA focus on the growth of the Australian helicopter industry. The magazine expanded its focus to look at ground handling, which was found to be a source of many under-reported accidents.
The world did not end, despite the supposed predictions of b’ak’tun (the Mayan calendar). Curiosity landed on Mars; the giant tortoise Lonesome George died; and the worst power outage in history hit India, with a reported 600 million people without power. FSA set out to stimulate civil discussion on remotely piloted aircraft with an in-depth feature looking at their promise and perils. Another focus was on fatigue, and in particular the new CASA fatigue rules set out in Civil Aviation Order (CAO) 48. The CAO set out limitations on flight times, as well as organisations putting into practice fatigue management and fatigue risk management systems. This year was also the year that FSA highlighted helicopter safety, with the future CASR Parts 133 and 138 aimed at RPT and aerial work helicopter operations respectively. An award-winning FSA story looked at spoken and written language in aviation and the maze of ambiguities, traps and obsolete conventions that pose potential safety hazards. FSA also gave guidance on dangerous goods, focusing on lithium batteries, and the methods of safely extinguishing battery fires.
After an unbeaten record of 25 wins, racehorse Black Caviar was retired, cementing her place as Australia’s most successful racing horse since Phar Lap. Edward Snowden released confidential NSA information showing surveillance on US citizens by their government. Tony Abbott became Australia’s 28th prime minister. FSA examined the safety record of low-cost carriers such as Jetstar and Tiger Air, and cleared the air around how safe these airlines are compared with the more established carriers that have come to be known as legacy airlines. The death of an infant in a parked car in Western Australia triggered a story exploring concepts of error and risk management that concluded error was part of the human condition and that striving as individuals for its elimination, while necessary, was also futile. A more profitable step towards safety was to seek and eliminate the conditions in which error thrives, including fatigue, distraction and dysfunctional system design.
A year of two appalling, but in all probability unrepresentative, airline transport accidents – Malaysian Airlines flights 370 and 17. The year so far has highlighted the electronic flight bag and associated issues for individual pilots; namely, ‘what if my EFB decides it does not want to work?’, as well as issues with approved navigation apps being diluted in an ocean of cheap or free non-approved apps. FSA has also highlighted the fast-growing capabilities of unmanned aircraft, as well as the engineering, media, legal and political innovations required for their full integration into commercial aviation.