AIA / AECMA Project Report
on
Propulsion System Malfunction
Plus
Inappropriate Crew Response
(PSM + ICR)
Volume 1
1 November 1998
G. P. Sallee D. M. Gibbons
AIA Co-Chair AECMA Co-Chair
Foreword
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)
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Howard Aylesworth
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Aerospatiale
|
Johann Hervault
|
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Patrick Zaccaria
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Air Accidents Investigations Branch (AAIB)
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Peter Coombs
|
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K. Smart
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AIR BC
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Hans Lammers
|
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Garrett Smith
|
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Kurt Ruhwald
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Air Canada
|
John Hart
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Air Canada Pilots Association (ACPA)
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Capt. David Edward
|
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Capt. Thomas Jerrard
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Air Transport Association (ATA-STIG – Northwest Airlines)
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Duane Sebens
|
|
Gary Vechik
|
Airbus Industrie
|
Yves Benoist
|
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Capt. Jim Duncan
|
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Jean-Michel Govaere
|
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Anne Jany
|
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Georges Rebender
|
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Capt. William Reichert
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Airline Pilots Association (ALPA)
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Kevin Comstock
|
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William Edmunds
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Capt. Daniel Ford
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Roland Liddell
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Michael Shelton
|
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Tim Hester
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Howard Long
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Capt. John Sciera
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Capt. Roy Tucker
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Allied Signal Engines
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David Looper
|
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William Moring
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Allison Engine Company
|
Donald Risser
|
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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
|
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David Lamb
|
British Aerospace (BAe)
|
Tim Allen
|
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Mike Bayley
|
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Paul Emmerson
|
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Dave Gibbons
|
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Daniel Gurney
|
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Len Houston
|
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Colin Irvine
|
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Martin Maltby
|
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Rene Nibbelke
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CAE Electronics
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Capt. Kip Caudrey
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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
|
CHIRP
|
Peter Tait
|
Cranfield University
|
Helen Muir
|
Embry-Riddle Aeronautical University
|
Marco Pizer
|
European Regional Airlines Association (ERA)
|
Roy Humphreyson
|
|
Ian Wigmore
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Federal Aviation Administration (FAA)
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Kathy Abbott
|
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Donald Armstrong
|
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Anne Azevedo
|
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Tom Boudreau
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Martin Buckman
|
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Tom Clinton
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Ed Cook
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Michael Dostert
|
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William Emmerling
|
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Steven Kolb
|
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Hals Larsen
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Dy Le
|
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George Lyddane
|
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Lee Nguyen
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Lanny Pinkstaff
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Robert Pursel
|
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Thomas Toula
|
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James Treacy
|
Federal Express Corporation
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Capt. Ryan Swah
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Fokker Services B.V.
|
Wim Overmars
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General Aviation Manufacturer’s Association
|
William Schultz
|
General Electric Aircraft Engines
|
Roland Crandall
|
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Tony Freck
|
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Sarah Knife
|
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Joseph Marksteiner
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Gulfstream Aerospace Corporation
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Ted Mendenhall
|
|
William Shira
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Hartzell Propeller Inc.
|
Roger Stallkamp
|
Independent Consultant
|
Tony Wassell
|
International Air Transport Association (IATA)
|
Tore Granaas
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International Federation of Air Line Pilots Assoc. (IFALPA)
|
Capt. Steve Last
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Joint Aviation Authorities (JAA/CAA)
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Robin Boning
|
|
Hazel Courtney
|
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David Lambourne
|
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Rex Riddington
|
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Laurent Gruz
|
KLM
|
Desiree Van Leeuwen
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KLM - IFALPA
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Wynand Moonan
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Lockheed Martin Aero and Naval Systems
|
Richard Trusis
|
NASA Langley Research Center
|
Paul Schutte
|
|
Anna Trujillo
|
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