GA Aviation Consultants-Newsletter Oct 2016

By Vivienne Sandercock

1. Message from the Editor
2. A small matter of knowledge
3. Africa's 2016's Hazards, Incidents, Accidents and Safety Occurrences
4. Emergency Response Planning
5. Henley Global Safety and Quality Training
6. Kenya: U.S Lauds Kenya on Air Safety but still no clearance for direct flights
7. Naval aviation trying to fix flawed safety culture
8. Air rage is taking off around the world, say airlines
9. Corporate pilots found to skip safety checks on 18% of flights 10. Aviation industry encourages pilots to come forward with mental health problems
11. News from the Johannesburg Airports
12. SAAFA donations
13. Finale
14. IATA Global Aviation Data Management


Whilst the article in Section 7 has its roots in US Naval aviation it has a synergy with both General and Commercial Aviation here in Africa and so I felt that sharing it with you all could be beneficial. In Section 8 there is an article on the ever increasing problem of air rage which in itself presents itself as a serious Safety Hazard which can escalate to quickly into an Incident or worst case scenario an Accident. The shocking statistic of 18% of flights have not had safety checks carried out prior to their departure should be a wake-up call for all of us along with the article on pilots with mental health problems. Remember to always report any worries, hazards, occurrences and incidents through your Company's SMS which should have an anonymous system built into it protecting you from possible repercussions.



40 years of safer aviation through reporting

The U.S. has an incredibly safe aviation system - it's unparalleled when compared to other modes of transportation. The basis for this historic safety record is that we identify and correct safety concerns before they become real problems. NASA's Aviation Safety Reporting System (ASRS) is one of the tools used to make the system as safe as it is.

Celebrating its 40th anniversary this year, NASA's confidential ASRS is widely used by pilots and other airline employees to identify potential hazards. This information is one of 185 data and information sources across government and industry used by the FAA and the aviation community to detect, mitigate and monitor risk.

People working on the front lines of aviation submit their safety concerns to ASRS in the form of incident reports. The system analyses these cases and responds by distributing vital information from its conclusions to the aviation community. The reports, always handled confidentially, are also used to identify deficiencies and discrepancies in the National Airspace System that need to be remedied.

"Voluntary reporting programs have significantly contributed to the nation's impressive commercial aviation safety record," said FAA Associate Administrator for Aviation Safety Peggy Gilligan. "In addition to reporting programs that are investigated and verified, ASRS gives aviation workers another way to report potential safety issues."

Making the nation's airways safer

"Since the implementation of the Aviation Safety Reporting System, approximately 1.4 million reports have been submitted by pilots, dispatchers, mechanics, air traffic controllers, flight attendants, ground personnel, and others," said Linda Connell, director of the NASA ASRS, which is located at NASA's Ames Research Center, Moffett Field, Calif. "Many of those reports have had a direct influence on making the nation's airways safer, and we are extremely proud of these contributions to safety."

Over the past 40 years, the ASRS has issued more than 6,200 safety alerts to the FAA and other decision makers in the aviation community who are in a position to correct unsafe conditions. Recent alerts have addressed a wide range of safety issues, including air traffic departure procedures, aircraft equipment problems, airport signage and marking issues, confusion among similar-sounding navigation fixes, or positions, and aeronautical chart deficiencies. Many of these issues involve significant human factors and performance contributions.

One example of a safety alert issued by ASRS emerged from reports of intense sunlight reflecting off a large concentrated solar power plant in the southwestern United States, temporarily blinding pilots in the cockpit. The pilots reported the safety hazard to ASRS, which then issued an ASRS Alert Message. Ultimately, this process led to the formal marking of the solar

"Aviation Safety, in all of its guises, is GA Aviation Consultants' first and only concern and to that end our clients' safety on the ground and in the skies is our Alpha and Omega."

plant obstruction on charts, so that pilots could avoid flying over the area. ASRS information was also instrumental in the revision of solar plant operations to help reduce the adverse effects of certain mirror array configurations.

Other significant ASRS accomplishments include identification of fire hazards associated with the packaging of lithium ion batteries for shipment in aircraft, health hazards associated with the use of certain de-icing fluids, and the susceptibility of certain pressure-sensitive aircraft systems to icing from super-cooled water droplets.

A research repository for aviation safety

"The ASRS is the largest repository of aviation human factors incidents in the world," Connell noted, "and it has conducted more than 7,200 database searches for government agencies, industry groups, research organizations, aircraft manufacturers, aviation students, and a wide variety of other organizations." Since 2006, all reports are logged and processed with full anonymity and that de-identified data has been accessible to the public. In the last 10 years, the ASRS Database has had more than 189,000 queries.

Like safety alerts and database searches, ASRS research findings have also been influential. ASRS data findings on the content and formatting of aviation checklists and manuals for flight crews were incorporated in a FAA Advisory Circular. An ASRS Alert concerning an aircraft wing oscillation issue contributed to the FAA Aircraft Certification Service taking action to mitigate the problem.

Through its website, the ASRS provides access to a range of safety products, including publications, database reports, program overview materials, and ASRS reporting forms for four categories within the aviation community, divided up broadly as pilots and dispatchers; air traffic controllers; maintenance technicians and ground crew; and cabin crew.

A model for safety reporting systems everywhere

ASRS has become a model for safety reporting systems worldwide. It has become a charter member of the International Confidential Aviation Safety Systems, a group of 13 nations that operate ASRS-like voluntary, confidential, non-punitive aviation safety reporting systems. The ASRS has also been recognized for its safety contributions by other industries, including rail operations in which NASA ASRS collaborated with the Federal Railroad Administration to create and operate the Confidential Close Call Reporting System.


Source, amongst others, PlaneCrash; News24, Aviation Herald, Flight Safety Information

2 Jan 16 Cessna182 0 Uhuru Gardens, Nr. Wilson Airport, Nairobi, Kenya
27 Jan 16 F16 2 near Fayed, Ismailia, Egypt
29 Jan 16 Cessna 425 Conquest 3 3km outside the Hosea Kotuku International Airport boundary, Namibia
03 Feb 16 PA32-300 3 Watville, Benoni, GP, RSA
03 Mar 16 Cessna Caravan 0 Langebaan, WC, RSA
07 Mar 16 PA28 2 10 km outside of Lanseria Airport, GP, RSA
11 Mar 16 Polaris 0 Rand Airport, GP, RSA
14 Mar 16 DHC 3T 2 Samburu East, Kenya
21 Mar 16 Piper PA-31- 35 0 About 50 NM South of FQVL, Mozambique
21 Mar 16 Baron 0 Rand Airport, GP, RSA
24 Mar 16 Jet fighter 0 Yola International Airport in northeast Adamawa State, Nigeria
27 Mar 16 Cessna 206 0 Nr. Hoedspruit, MP, RSA
30 Mar 16 Piper Cherokee 180 0 Kowie River, nr Port Alfred, EC, RSA
01 Apr 16 Microlight 1 Glendale area of KwaZulu-Natal, RSA
18 Apr 16 Tecnam 0 Nr. Lujecweni Village, EC, RSA
30 Apr 16 AN26 5 El Obeid, Sudan
11 May 16 Cessna 172 0 Grand Central Airport, GP, RSA
11 May 16 RV-7 1 Mossel Bay, EC, RSA
12 May 16 Jabiru 1 Kitty Hawk, GP, RSA
21 Aug 16 C210 0 Rand Airport, GP, RSA
28 Aug 16 Chipmunk & C140 0 Rand Airport, GP, RSA
02 Sep 16 DH82 0 Rand Airport, GP, RSA
08 Sep 16 TBA 1 Sanctuary Farm in Naivasha, Kenya
15 Sep 16 Light trainer 0 Malanga Primary School. Malindi, Kalifi County, Kenya
18 Sep 16 F50 0 Bardale Airport, Somalia
28 Sep 16 B190 0 Beni, Democratic Republic of Congo

02 Jan 16 EC130 B4 0 Nr. Parys, Free State, RSA
29 Jan 16 RH44 1 Maswa Game Reserve, Tanzania (shot down)
03 Feb 16 S76 0 136.70 nm from AEHA Field, Bonny Island, inward MMIA Lagos, Nigeria.
11 Mar 16 Enstrom 0 Lanseria Airport, GP, RSA
13 Mar 16 Gyrocopter 2 Ashanti Lodge, Lephalale, Limpopo, RSA
23 Mar 16 RH22 0 Rand Airport, GP, RSA
17 Mar 16 Mil MI 171 12 near Reggane, Adrar Province. Algeria
27 Mar 16 RH22 0 Killer Krankie, Margate, KZN, RSA
09 Apr 16 RH44 1 17 miles SW of Hosea Kutako International Airport
20 Apr 16 H500E 1 Molteblick area about 15 kilometres east of Windhoek, Namibia
07 Jul 16 Military (French) 3 Benghazi, Libya
04 Aug 16 TBA +/- 4 Outside of Port St. Johns, EC, RSA
10 Aug 16 Guimble Cabri 0 Mossel Bay, WC, RSA in a field approximately 200 meters from the N2 close to the Hokaai road stall.
19 Sep 16 MIL 2 El Sheikh Gebyeel Military Airport, Egypt
19 Sep 16 MIL 6 Tobruk, Libya
26 Sep 16 Bell 430 6 Offshore Cabinda, Angola
29 Sep 16 Jet Ranger 1 Kgapane Village, Limpopo, RSA
30 Sep 16 Puma 415 0 Eldas Wajir Country, Kenya

10 Sep B737-399 El Fasher, Sudan 0 A/C was en-route from Khartoum to and was on approach to El Fasher when a large bird impacted and penetrated the nose cone of the aircraft and became embedded in the nose. The crew continued for a safe landing in El Fasher. COM INC
19 Sep E190 Nairobi, Kenya 0 Burst tyre on landing COM INC
20 Sep L29 Rand Airport, GP, RSA 0 Brake failure after landing PVT INC
26 Sep TBA Bugoma School, Kyangwall, Uganda 0 En-route from Entebbe (Uganda) to Bunia (DRC) a/c made an emergency landing on the school playground due to adverse weather. CHRTR HAZ
28 Sep C421 Rand Airport, GP, RSA 0 A/C improperly parked on main apron restricting movement of other a/c PVT HAZ
28 Sep B55 Rand Airport GP, RSA 0 3 greens not indicating prior to landing. A/C landed safely on RWY29 PVT HAZ
29 Sep Seneca Rand Airport, GP, RSA 0 A/C departed with pitot cover still in place PVT


Goma, DRC
Construction Hazards. Unmanned aircraft. Very poor ATC. Possible volcanic activity. Ground based Navaids serviceable but not calibrated. Birds

Libreville, Gabon
Poor ATC coupled with inadequate navaids. Poor Marshalling combined with inappropriate behaviour of drivers on the ramp and taxiways.

Kadugli, Sudan
Poor ATC control of aircraft in the area.

Juba, Sudan
Very poor ATC. Crews must be on the lookout for other aircraft in their vicinity. Vehicular traffic not obeying any regulations in terms of overtaking aircraft on taxiways and weaving in and out of aircraft on the apron. Insurgent/Military activity

Bunia, DRC
Adverse weather caused by the ITCZ.

Kisangani, DRC

Lanseria Airport, GP, RSA
Birds (Guinea Fowl)

Bouake, Cote d'Ivoire
Birds (Falcons)


Blake Emergency Services is the International Crisis Management and Contingency Planning and Response Specialist who, although based in the UK, have extensive experience in Africa having handled accidents, incidents, counselling, repatriation, DNA sampling and confirmation, in amongst others Lagos, Nigeria; Fez, Morocco; Pointe Noire, Congo; Moroni, Comores; Maputo, Mozambique and more recently Ukraine, The Netherlands, Indonesia and Mali. Please go to or contact .

If you are interested in becoming a volunteer for Blake Emergency Services, please contact Rethea at the address given above.

An Emergency Response Plan is a required section of your SMS and may also be added to your Operations Manual.

A conference for existing and prospective clients is being arranged for early 2017. We will publish details when they become available.


Should you wish to make a booking for any of these courses please contact Candice on 011 024 5446 or by email to .

10-11 Oct 2016 Quality Assurance Auditor Course Dan Drew R 2,720-00
24-25 Oct 2016 Human Factors - AME and CRM initial Dr. Joel Hughes R 2,720-00
26 Oct 2016 CRM - Refresher Verity Wallace R 1,150-00
26 Oct 2016 DG - Refresher Verity Wallace R 935-00
02 Nov 2016 CRM - Refresher Verity Wallace R 1,150-00
02 Nov 2016 DG - Refresher Verity Wallace R 935-00
07-08 Nov 2016 Quality Assurance Auditor Course Dan Drew R 2,720-00
21-22 Nov 2016 Human Factors - AME and CRM initial Dr. Joel Hughes R 2,720-00
29 Nov 2016 CRM - Refresher Verity Wallace R 1,150-00
29 Nov 2016 DG - Refresher Verity Wallace R 935-00
05 Dec 2016 CRM - Refresher Verity Wallace R 1,150-00
05 Dec 2016 DG - Refresher Verity Wallace R 935-00
5 & 6 Dec 2016 Safety Management System (SMS) Dan Drew R 2,720-00
5-9 Dec 2016 Integrated Safety Management System Various R 6,800-00

Cost per delegate includes all training materials, refreshments and lunch.
Attendees paying in cash on the day are eligible for a 10% discount
Both Recurrent CRM and Dangerous Goods Training Courses are available upon request - even at short notice.
On request we also offer -
Air Cargo Security (Part 108)
Health and Safety (Medical)
Cargo and Warehouse Security
Risk Management & Investigations
First Aid and the Law
NEW - Maintenance Reliability Programme
NEW - Maintenance Management

Emergency Response, Incident Response, Operations Control and Family Assistance training together with the writing of Emergency Response Plans and Procedures training is now offered through Blake Emergency Services. For more information, please contact Rethea on


The US Department of Transportation (DOT) Thursday praised Kenya's "significant progress" in ensuring civil aviation safety but did not commit to approving direct flights between the two countries. "The US Federal Aviation Administration and the Kenyan Civil Aviation Authority have been in close collaboration as Kenya has marched toward full compliance with international standards," a DOT spokesperson said. "They will remain in close touch and mutually determine next steps."

The official's comments came in response to a Nation query regarding Transport Cabinet Secretary James Macharia's recent claim that Kenya has met all requirements for the start of direct flights between Nairobi and the US.

Kenyan officials have repeatedly suggested during the past year that direct air links with the US would soon be established. But Washington has not publicly committed to allowing airlines to fly that route.

Substantial gains for Kenyan business and the country's tourism industry are expected if passengers and cargo can move more expeditiously to and from the US. Financially troubled Kenya Airways would likely reap benefits if it becomes able to fly directly to US destinations.

Direct-flights are not the same as non-stop flights. A direct flight makes a scheduled stop at an intermediate airport between its point of origin and its final destination. Passengers generally remain on the same plane, however, saving time spent in transit.


Delta Air Lines came close in 2009 to inaugurating direct service between Atlanta and Nairobi, with a stop in Dakar, Senegal. US aviation officials, however, refused to clear the service one day prior to its scheduled start.

Specific reasons for the abrupt cancellation were not provided, with US authorities citing general concerns regarding "security vulnerabilities in and around Nairobi." Kenyan officials reacted angrily at the time to the last-minute US decision.

"Aviation Safety, in all of its guises, is GA Aviation Consultants' first and only concern and to that end our clients' safety on the ground and in the skies is our Alpha and Omega."

Moses Wetang'ula, who was serving as foreign minister in 2009, summoned then-US Ambassador Michael Ranneberger to his office to express Kenya's displeasure.


Aviation safety protocols are, the saying goes, written in blood. That's why every time a helicopter nearly topples on deck, a cable fails to stop a landing plane, or a pilot runs low on breathing oxygen in flight, witnesses are trusted to report it.

In addition to these critical incident reports, squadrons are routinely assessed for aviation safety to prevent the next mishap. But all too often these squadron leaders weren't fixing safety issues over the last three decades, according to the leader of the organization charged with investigating Navy and Marine Corps mishaps, who said some commanding officers stashed the surveys rather than fix the problems. The Navy only got serious about fixing this flawed culture two years ago, he said.

"It was an organization basically frozen in time for about 30 years," Rear Adm. Chris Murray said Sept. 10, referring to the state of things when he took over the Naval Safety Center in 2014. "Great at investigating things, but not doing a whole lot to prevent mishaps." That was most apparent in the aviation community, he said, where squadrons members are anonymously surveyed on safety. "We've been doing surveys in squadrons forever," Murray told the audience of aviators at the annual Tailhook reunion near Reno, Nevada. "Frankly, it was a great one-on-one with our guys and the squadron's CO, but it never really got any further than that." "If we found something that was pretty troubling, that kind of went in the CO's desk," said Murray, a career naval flight officer who has commanded a carrier air wing. "And frankly, some of our COs went, 'Yeah, my [projected rotation date] is in two or three months, so maybe I'm just going to keep that in my desk and let my [executive officer] deal with it.' "

The safety boss said the culture has been revamped so that these squadron surveys are get more scrutiny from higher ups and that officials are using more mishap data to assess the causes of mishaps. A spokeswoman for the Naval Safety Center said Murray's example was intended to show the gravity of the problem and he didn't intend to suggest this was typical.

"Rear Adm. Murray did not intend to suggest that COs shoving safety reports in their desks was ever the norm," said his spokeswoman, Margaret Menzies. "This was more of a metaphor used to gain the audience's attention and reinforce how valuable the information contained in a safety report can be -- and in fact, it should not be shoved in a desk." Naval aviation has faced questions about whether it has been doing enough mitigate known dangers. Indeed, officials are trying to fix oxygen problems in F/A-18 Hornets that some aviators say they've been reporting for years to no avail. And a 2015 Navy Times investigation found that the NSC and Naval Air Systems Command had ignored years of reports that helicopters landing on destroyers and frigates were vulnerable to waves that could wash them overboard -- changes only came in the wake of a 2013 helicopter crash. The Navy Times report was based on 13 official hazard reports in the years before a helicopter tragedy; more sailors came forward after this report to say they had seen waves strike their helicopters.

"These surveys are very in-depth and provided me with a different perspective on what is going well and not so well," retired Capt. Sean Butcher, an HH-60H pilot, told Navy Times. "Sometimes the squadron leadership tells the CO what they think he wants to hear, not what he needs to hear and these surveys help ensure we are on the right track or if we need to change direction a bit." Butcher said he always took action to remedy any problems they brought up, adding he wasn't aware of any fellow COs who swept them under the rug.

Still, there is some debate about how widespread the survey problems were and the severity of the issues that were not reported or fixed. Making changes has largely been left up to the squadron's skipper, according to a retired Navy and Marine Corps mishap investigator. "Yeah, it's not mandatory. It's a CO's mirror, so to speak, on the culture and the command climate," Matt Robinson told Navy Times in a Sept. 19 phone interview. "It's up to them whether they want to address the issues if there are any or not." Still, in most cases he saw, COs took the results and made necessary changes.

"I may have seen it a couple of times where the squadron climate was caustic, but it is very rare," he said. "The survey, from what I have seen, works -- and every single survey that I have heard about, been a part of, the CO has taken the comments to heart and has implemented change to make it better."

Making changes
The year Murray came on board was also one of the worst for naval aviation deaths in years. The old safety survey system has been phased out, according to Murray. Now, after a visit from the safety centre, the results are briefed up the chain of command to helicopter squadron commodores and air group commanders for another set of eyes. That could complicate things, though, Butcher said.

"The survey was only briefed to the COs of the squadron because of concern that sharing potentially derogatory information about the CO and the command to the wing commodore could have a negative impact on the command," he said. "The fear that the commodore's perception of the squadron and ranking of his squadron commanders could be influenced by information from these surveys is a very real concern."

The revamped safety centre has also done a deep dive into its mishap data, mining the causes of accidents in the MH-60 Seahawk and Hornet communities, the two places hardest hit. The compiled reports include unit assessments, hazard reports filed, Aviation Safety Awareness Program filings and causal factors of past mishaps, to widen the investigations beyond Class A mishaps and include data on near-misses and other identified dangers. The so-called hazard maps shed new light on the causes of mishaps as well as any particular geographic problem for VFA squadrons.

Despite his previous assumption that most mishaps caused by human error could be blamed on pilots, due to procedural mistakes, communication errors or just lack of experience, the data show something different, Murray said. It turns out that the Navy has 160 percent more mishaps because of maintenance errors than anything pilots do. They also found that in the VFA community, squadrons based at Naval Air Station Lemoore, California, are much more likely to have maintenance problems than their East Coast counterparts at NAS Oceana, Virginia. "Anyone that's been a [commander, air group] out in Lemoore and a CO at Oceana, like I have been, can tell you that you have maintenance master chiefs waiting like cordwood to be your maintenance master chief at Oceana. That does not exist out in Lemoore," Murray said. He attributed that to Oceana being a more favourable duty station, which can siphon off some more experienced E-9s. That concern has been forwarded to the air boss, Vice Adm. Mike Shoemaker, in hopes of persuading more experienced Hornet maintainers to go to California, Murray said.

With two more weeks to go in fiscal year 2016, naval aviation has seen 14 mishaps this year, including four within three weeks this summer, all Marine Corps Hornet crashes and deaths.

The Marine Corps Times stated that Marine aviation is plagued with problems and it needs serious attention now. Still, that's down from 19 in the previous year, and a vast improvement in the long term, Murray said. "When I started flying in '84, naval aviation averaged 40 class A mishaps a year. Almost all totally lost airplanes," he said, adding that the numbers have been cut in half in each successive decade.



There were 10,854 air rage incidents reported by airlines worldwide last year, up from 9,316 incidents in 2014, according to the International Air Transport Association. That equates to one incident for every 1,205 flights, an increase from one incident per 1,282 flights the previous year.

Incidents have been rising almost consistently since 2007, when the association began tracking the issue. That year airlines reported 339 incidents to the association.

A majority of incidents involved verbal abuse, failure to follow crew instructions and other anti-social behaviour. Eleven percent included physical aggression toward passengers or crew or damage to the plane. Alcohol or drugs were a factor in 23 percent of the cases. In the vast majority of incidents involving drugs or alcohol, the substances were consumed before boarding or imbibed secretly on board, the association said.

Training staff in airport bars and duty-free shops to sell alcohol responsibly, including avoiding offers that encourage binge drinking, can cut incidents by half, the association said, citing an initiative by Monarch Airlines at London's Gatwick Airport.

Airlines already have strong guidelines and crew training on "the responsible provision of alcohol," the association said.

A woman in England pleaded guilty in June to assaulting an EasyJet pilot. Prosecutors said she punched the pilot in the face after he deemed her too intoxicated to fly. In another case, a male passenger allegedly urinated on fellow EasyJet passengers as they were waiting to deplane after landing at Edinburgh.

Six men involved in a drunken brawl during a Jetstar flight from Sydney to Thailand in July were ordered off the plane after it diverted to Indonesia. Incidents have been rising almost consistently since 2007, when the association began tracking the issue.

An American Airlines pilot tackled one passenger to the floor after he tried to force his way off the plane as it taxied to the gate in Charlotte, North Carolina. "You don't put your hands on my flight attendant!" the pilot can be heard yelling on a video taken by another passenger. The unruly passenger was arrested and charged with being intoxicated and disruptive.

Charlie Leocha, president of Travelers United, an advocacy group for airline passengers in Washington, said he knows of no changes in the way alcohol is sold in airports or on planes that would account for the increase in the rate of incidents. But he noted that the increases correspond with efforts by airlines to squeeze more passenger seats onto planes by shrinking legroom and seat width.

"We've always had alcohol sold at airports, we have always had alcohol served on aircraft," he said. "The only difference today is that people now have less space and they are required to interact more intimately with other passengers."

Other recent incidents include a Los Angeles-bound Delta Air Lines flight diverted to Tucson, Arizona, escorted by two Air Force fighter jets, after a passenger refused to return his seat. The following month, the FBI and Hawaii state sheriffs arrested a 35-year-old man who allegedly bit a flight attendant on a Hawaiian Airlines flight from Pago Pago in American Samoa to Honolulu.

Airlines also want more countries to ratify a 2014 treaty that closes gaps in laws for dealing with unruly passengers. So far, only six countries - Bahrain, Congo, Dominican Republic, Gabon, Guyana and Jordan - have ratified the pact.

"Aviation Safety, in all of its guises, is GA Aviation Consultants' first and only concern and to that end our clients' safety on the ground and in the skies is our Alpha and Omega."

"More are needed in order to have a consistent global approach to this issue," said Alexandre de Juniac, the association's director general. "> a href="http:// ">


The plane crash at Hanscom Field that killed seven, including Lewis Katz. Photographer: David L. Ryan/The Boston Globe via Getty Images

Corporate pilots routinely take off without performing required safety checks, a study of thousands of flights by a trade group has found. Prompted by the 2014 crash of a corporate jet that killed billionaire Lewis Katz, which occurred after pilots neglected to ensure their flight controls worked, the National Business Aviation Association discovered that similar lapses are common. The group representing corporate flight departments reviewed data from almost 144,000 flights during three years and found that in more than 25,000 cases, or 17.7 percent, pilots failed to complete the same routine check of a plane's flight controls that doomed Katz and six others on the plane.

"It's very concerning, a rate that high with professional pilots like these guys are," Michael Barr, an instructor at the University of Southern California's Aviation Safety and Security Program, said in an interview. "These aren't weekend pilots. They are professionals who do it for a living." Checking to ensure that a plane's flight controls work properly is required before all flights. A failure to perform the checklists containing such tests and other safety-critical tasks "is one of the mortal sins of flying," Barr said.

The NBAA said in the report, which was undertaken at the request of the U.S. National Transportation Safety Board following its investigation into the Katz crash, that the findings should be used to raise awareness among pilots. The results were "disturbing" and "the data highlights a lack of professional discipline among some crews in not accomplishing manufacturer-directed checklists -- particularly safety-of-flight critical items," the report said. "This report should further raise awareness within the business aviation community that complacency and lack of procedural discipline have no place in our profession," Ed Bolen, president of the Washington-based NBAA, said in comments attached to the report.

A Bloomberg News review last year of business aviation accidents, including both private flights like Katz's and charter flights, found repeated examples of pilots skipping rudimentary safety checks, working fatiguing schedules and overlooking hazards such as ice on wings.

There were five times more fatal accidents involving high-end corporate jets and turboprops piloted by professional crews from 2000 through 2014 than of passenger airlines, which have many more flights, NTSB records showed. In 2007, deaths from crashes of these planes began to surpass those on passenger airlines -- a reversal of the trend stretching back to the dawn of the jet age.

In the May 31, 2014, accident that killed Katz in Bedford, Massachusetts, pilots neglected to release a device known as a gust lock, which holds a plane's flight controls in place on the ground to prevent damage from winds. The pilots would have known that the controls were locked and the plane couldn't take off if they had performed a required check, the NTSB found. The pilots had also failed to complete the checks on all but two of the 176 flights captured on the Gulfstream IV's flight data recorder, or 99 percent, according to NTSB.

2,923 Flights
The NBAA reviewed flight data captured on 379 corporate aircraft from 2013 through 2015. In 2,923 cases, pilots performed no check of the flight control surfaces. On another 22,458 flights, pilots did only a partial check that wasn't complete, according to the report released on the trade group's website Sept. 20. While complete failures fell from 2.8 percent to 1.5 percent after details of the Katz accident were released by NTSB, there was no change in the total rate of all failures.

"This report to the NBAA membership is not only intended to provide closure action to the NTSB recommendation, but also to raise awareness to the broader business aviation community that complacency and lack of procedural discipline have no place in our profession," the group said in the report.

While airlines have numerous layers of protections designed to limit the chances pilots will overlook a safety-critical flight check, corporate flight departments may not always have the same diligence, Barr said.

Such human failures remain one of the biggest challenges to aviation safety, he said. "How you change human behavior is your problem here," he said. "All you can do is educate, educate."


Australia's aviation industry has been trying to change a culture among pilots of under-reporting mental health conditions, particularly since the issue came into the spotlight during the Germanwings disaster in March last year.

Key points:
Germanwings disaster prompted more stringent mental health assessment regime but no regulatory changes made Doctors say pilots under-report mental health conditions out of fear of losing medical licences and jobs Pilots say fear of being honest about mental health issues "has always been there"

Andreas Lubitz, a co-pilot for Germanwings, deliberately flew his plane into a mountainside in March 2015, killing himself and all 144 passengers and six crew. Lubitz suffered from depression and suicidal tendencies and the incident sparked an overhaul of how pilots' mental health is assessed in Europe.

In Australia, the Civil Aviation Safety Authority (CASA) said health examiners had updated internal assessment procedures, but no regulatory changes had been made.

Eric Donaldson, a CASA medical examiner who assesses pilots in the Darling Downs region of Queensland, said rigorous mental health assessments had made pilots fearful about losing their medical licences and jobs if they spoke freely. "I think there's been pressure on CASA since we had the Germanwings accident and there were others," Dr Donaldson said. "People are probably much more conscious of our responsibility than we might have been before."

Kate Manderson, the president of the Australasian Society of Aerospace Medicine (ASAM), said Australia already had a robust and effective regulatory system. "If we see a pilot or air traffic controller that we're concerned [about], we are protected under the law in terms of reporting that directly to CASA, and that's always been the case," Dr Manderson said. "And the mental health assessment has always been part of the way we assess our pilots through questionnaire and mental state examination as well."

David Booth, president of the Australian Federation of Pilots (AFP), said CASA reneged on a tough approach. "What CASA decided they won't be doing is any sort of aggressive psychometric assessment, which was initially proposed after Germanwings," Captain Booth said. "I think the reason for that is there's a view that you could run those sorts of tests on people but ultimately you probably won't detect what you're looking for."

Pilots too afraid to come forward
Dr Manderson and Dr Donaldson both said there had been increased scrutiny and awareness about pilots' mental health and that it had consequences. "I'm not foolish enough to believe that every pilot that I see tells me the truth about his medical conditions," Dr Donaldson said. But Captain Booth said the culture of pilots under-reporting had always been there, generated by fear of losing their medical licence and jobs. "Pilots have always been fearful about coming forward," he said. "I don't believe Germanwings has driven pilots underground. "If we come down hard on pilots who do come forward then we can guarantee that that's exactly what will happen."

Joseph Wheeler, the aviation counsel to the AFP, said there was also fear about loss of licence insurance for pilots. "For example in the Germanwings situation there was a fear, reported by the French authorities, of the pilot about whether he would be covered in the event he had to be suspended from work because he wouldn't meet his medical standards anymore," Mr Wheeler said. "So we need to have better engagement and better policies amongst these loss of licence insurers." Mr Wheeler said programs such as peer pilot support frameworks were helping pilots come forward and deal with potential problems. "Pilots are the only ones who really understand the very peculiar, high pressure and demanding requirements of the aviation profession," he said. "What peer pilot support does is encourage other pilots to look after themselves, to accept imperfections in what is often an environment that doesn't deal well with any imperfections, and helps pilots to identify concerns with each other and seek help. "What we're really advocating is the aeronautical equivalent of mates looking after mates."


Users of the Johannesburg aerodromes must be aware of the fact that they all take Aviation Safety and AVSEC seriously. If you want to use these airports as a Pilot or are employed in any way on them, then we would recommend that you make yourself aware of Part 139 in the SACARs and the Rules and Regulations applicable to that particular aerodrome. Be prepared for fines being levied if you breach any of the SARPs.


Next Safety Meeting - Tuesday 1st November 2016 at 09.00 in the Old Customs Hall
#The wearing of high visibility jackets/waistcoats is mandatory for all persons, excepting for passengers under escort, on airside. (SA CAR 139.02.22(6))
#Drivers found to be speeding on airside will have their access remote taken from them.
#Vehicles being driven on airside must carry proper mandatory insurance cover
#All delivery vehicles and visiting vehicles requiring access to airside MUST be escorted from the access gate to the premises and then after closure of their business back to the gate for egress.
#Cranes are not allowed onto Rand Airport unless their use has been specifically authorised by airport management
? All operators are required to report Bird Strikes to the Safety Office even if there has been no structural damage to the aircraft as a result of the strike.
#Fuel must not be "trucked" into Rand Airport from other sources. Should there be a special requirement permission must be sought from the Airport Manager. The previous "block" method of charging landing fees will now cease with a discount being given to Rand Airport Air BP Customers which will amount to the same charges being levied as under the block system.


Next Safety, Security and Stakeholders Meeting will be held on Tuesday 11th October 2016 at 12.00 in the LIA Training School.
# The wearing of high visibility jackets/waistcoats is mandatory for all persons, excepting for passengers under escort, on airside. (SA CAR 139.02.22(6))
#Drivers shall obey the published speed limits which are 30 on airside and 40 on landside - these have been enforced as from 1st May 2015


Next Safety Meeting will be held on Tuesday 1st November 2016 at 12.00 in the Boardroom
#The wearing of high visibility jackets/waistcoats is mandatory for all persons, excepting for passengers under escort, on airside. (SA CAR 139.02.22(6))
#Drivers found to be speeding on airside will have their access revoked
# Construction Project at the Southern Helipads consisting of the construction of a new concrete slab which will accommodate 3 x helipads and slurry sealing of the dust patches around the new and existing slabs is underway. Taxiway Yankee is closed for the duration of the construction work to mitigate any potential safety occurrences.
# Should an emergency occur pedestrians are requested to stand still in a safe area out of the way of responding AR&FFS vehicles.
#During any emergency Pilots, Instructors and students should try to keep the frequencies as clear as possible.


Should you wish to make a donation to this more than worthy cause then please pay it (via EFT or as a deposit) into; Standard Bank Bedford Gardens; Bank Code 018 305; Account Name: SA Air Force Association (JHB Branch); Account Number: 022 605 568. You may use either your Company or Individual name along with the word donation as the reference.


SITUATIONS VACANT. If you are interested and qualified, please send your CV to

Part Time Consultant Air Safety Officers required who comply with the requirements of SA CARS Part 135, Part 121, Part 127, Part 140, Part 141 and Part 145 - must have had appropriate SMS training, previous experience and preferably been approved by the South African Air Services Licencing Council.

Part Time Quality Assurance Consultants required who are appropriately qualified and comply with the requirements of Part 135, Part 121, Part 127, Part 140, Part 141 and Part 145.

Part Time Aviation Security Consultant required who is appropriately qualified for RSA and International Operations

"Aviation Safety, in all of its guises, is GA Aviation Consultants' first and only concern and to that end our clients' safety on the ground and in the skies is our Alpha and Omega."

Can we help you with your aviation safety and / or quality requirements? Under SA CAR 140.01.2 if you and your organisation hold one of the following
# a category 4 or higher aerodrome licence;
# an ATO approval;
# an aircraft maintenance organisation approval;
# a manufacturing organisation approval;
# an ATSU approval;
# a design organisation approval;
# an AOC issued in terms of Part 101, 121, 127, 135, 141;
# a procedure design organisation approval; and
# an electronic services organisation approval,
then you shall establish a Safety Management System for the control and supervision of the services rendered or to be rendered by that organisation.
If you do not already have an approved Air Safety Officer and an approved Safety Management System then please contact us for assistance.

We, at GA Consultants, deliver the following SA CAA Approved training courses for Air Safety Officers at Rand Airport;
# Safety Management Systems
# Integrated Safety Officer Course
# Quality Assurance Auditor
# Crew Resource Management (Initial and Recurrent)
# Dangerous Goods
# Human Factors for AME's
Should your operation be of a size whereby the full time employment of an Air Safety Officer and/or Quality Assurance Officer is not financially viable then we can provide you with Consultants who have previously held Air Services Licensing Council approval. We can also provide you with a tailor made SA CAA approved Safety Management System and all SA CAA required Manuals for your operation.

For further information on how we can help you please contact Rethea Candice in Hanger 6, Rand Airport, Germiston on 011-024-5446/7 or e-mail

GAC News Letters

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