Aia / aecma project Report

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AIA / AECMA Project Report
Propulsion System Malfunction


Inappropriate Crew Response


Volume 1
1 November 1998

G. P. Sallee D. M. Gibbons

AIA Co-Chair AECMA Co-Chair


This document reports the results of a study to assess the causes and contributing factors in accidents and incidents where a single benign propulsion system malfunction occurred and the pilot(s) did not appropriately handle the situation. This study was undertaken in response to a Federal Aviation Administration (FAA) letter of 6 March 1996 requesting the Aerospace Industries Association (AIA) to use data from a previous AIA activity and a recent accident as a basis for initiating development of guidelines for an engine failure indications system. The AIA responded to the FAA on 19 June 1996 with a letter proposing to undertake the requested activity. The AIA proposed that the initial focus of activity would be on assembling all of the relevant facts and data associated with historical accidents and incidents, experience with various mitigation approaches, fixed-base and motion based simulator capabilities and programs, and other relevant information appropriate to a thorough study of engine failures coupled with inappropriate crew response(s). Once the data collection process had been accomplished, a follow-on phase would analyze and synthesize these data in order to prepare recommended corrective actions. AIA wrote that AIA believed that all parties would be best served by not prematurely focusing on “a solution”. Upon completion of this work a decision gate would be taken before deciding how to proceed into additional phases that could suggest multiple paths and increased use of resources.

AIA requested The European Association of Aerospace Industries (AECMA) jointly sponsor and Co-chair the project on “Propulsion System Malfunction Plus Inappropriate Crew Response (PSM+ICR)”. Representatives from all affected organizations were invited to participate mindful that the project would ultimately progress into the Aviation Rulemaking Advisory Committee and Harmonization Processes. The organizations represented included regulatory authorities, accident investigation authorities, pilot associations, airline associations, training companies, and simulator, airplane and engine manufacturers.
This report summarizes the facts and data collected, analytical results, conclusions and recommendations for potential corrective action. The report is being transmitted by AIA and AECMA to the Regulatory Authorities for consideration and appropriate action. It has been acknowledged that a similar situation exists in the rotorcraft industry; however, it was agreed in the beginning of this workshop that only Turboprop and Turbofan airplanes would be considered (14 CFR Part 23 & 25). It is recommended that a similar exercise take place for the rotorcraft industry outside of this workshop with the aid of appropriate industry experience.
This report is separated into two volumes. Volume 1 contains the report results and appendices 1 through 3. Volume 2 contains the remaining appendices 4 through 15.

Contributing Organizations and Individuals

Aero International (Regional)

Claude Bechet

J. Andrew Bedson

Aerospace Industries Association (AIA)

Howard Aylesworth


Johann Hervault

Patrick Zaccaria

Air Accidents Investigations Branch (AAIB)

Peter Coombs

K. Smart


Hans Lammers

Garrett Smith

Kurt Ruhwald

Air Canada

John Hart

Air Canada Pilots Association (ACPA)

Capt. David Edward

Capt. Thomas Jerrard

Air Transport Association (ATA-STIG – Northwest Airlines)

Duane Sebens

Gary Vechik

Airbus Industrie

Yves Benoist

Capt. Jim Duncan

Jean-Michel Govaere

Anne Jany

Georges Rebender

Capt. William Reichert

Airline Pilots Association (ALPA)

Kevin Comstock

William Edmunds

Capt. Daniel Ford

Roland Liddell

Michael Shelton

Tim Hester

Howard Long

Capt. John Sciera

Capt. Roy Tucker

Allied Signal Engines

David Looper

William Moring

Allison Engine Company

Donald Risser

Barry Rohm

Association of European Airlines

Peter Malanik

Atlantic Coast Airlines

Ken Latour

Atlantic Southeast Airlines (Regional Airline Association)

Dean Karnatz

Bombardier Aerospace

Jim Donnelly

David Lamb

British Aerospace (BAe)

Tim Allen

Mike Bayley

Paul Emmerson

Dave Gibbons

Daniel Gurney

Len Houston

Colin Irvine

Martin Maltby

Rene Nibbelke

CAE Electronics

Capt. Kip Caudrey

Canadian Airline Pilots Association

Al Murray

Contributing Organizations and Individuals

Canadian Airlines International

Peter Howe

Capt. Jack Tucker

Cessna Aircraft Company

Doug Hazelwood

Donald Mallonee


Peter Tait

Cranfield University

Helen Muir

Embry-Riddle Aeronautical University

Marco Pizer

European Regional Airlines Association (ERA)

Roy Humphreyson

Ian Wigmore

Federal Aviation Administration (FAA)

Kathy Abbott

Donald Armstrong

Anne Azevedo

Tom Boudreau

Martin Buckman

Tom Clinton

Ed Cook

Michael Dostert

William Emmerling

Steven Kolb

Hals Larsen

Dy Le

George Lyddane

Lee Nguyen

Lanny Pinkstaff

Robert Pursel

Thomas Toula

James Treacy

Federal Express Corporation

Capt. Ryan Swah

Fokker Services B.V.

Wim Overmars

General Aviation Manufacturer’s Association

William Schultz

General Electric Aircraft Engines

Roland Crandall

Tony Freck

Sarah Knife

Joseph Marksteiner

Gulfstream Aerospace Corporation

Ted Mendenhall

William Shira

Hartzell Propeller Inc.

Roger Stallkamp

Independent Consultant

Tony Wassell

International Air Transport Association (IATA)

Tore Granaas

International Federation of Air Line Pilots Assoc. (IFALPA)

Capt. Steve Last

Joint Aviation Authorities (JAA/CAA)

Robin Boning

Hazel Courtney

David Lambourne

Rex Riddington

Laurent Gruz


Desiree Van Leeuwen


Wynand Moonan

Lockheed Martin Aero and Naval Systems

Richard Trusis

NASA Langley Research Center

Paul Schutte

Anna Trujillo

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