Training is a good thing; it reduces the risk of accidents. Start with the premise that training is part of a 3-legged s

1. Recent Major Accidents & the Capacity of Training To Avoid ThemWorld Aviation Training ConferenceOrlando, FloridaApril 2010Robert Matthews, Ph.D.Senior Safety AnalystOffice of Accident Investigation, FAA

2. Training is a good thing; it reduces the risk of accidents. • Start with the premise that training is part of a 3-legged stool: • Establish good standard operating procedures (SOPs); • Train repeatedly to those good procedures; and • Enforce those good procedures. • This presentation reviews 19 recent hull-losses involving 3 common accident categories to illustrate training’s capacity, as part of this 3-legged stool, to reduce risk. • Bottom Line: training can reduce the likelihood of many serious accidents, though its capacity to do so has practical limits. 2

3. Six Take-Off AccidentsFrom 2006 through 2008 3

4. 27 August 2006; Comair CRJ2 at Lexington (49 fatal) • Early morning flight in night VMC. • Flight crew planned to take off on 22 but lined up on a much shorter runway 26 & began takeoff roll • Ran off the runway end and struck the airport perimeter fence, trees, and terrain Causes, Factors & Issues: • Non-pertinent conversation on taxi & loss of positional awareness. • Failed to cross-check & verify they were on the correct runway. • Crew failed to use available cues & aids to identify location during taxi. • Add airport configuration (short, single taxiway to 2 near-by runway ends) & possible fatigue for Captain. • Crew issues are basic in training programs, including private pilot training. • Score for More Training: Low. Limited to the capacity to instill discipline & adherence to SOPs on every flight. 4

5. 25 Jan 2007, Regional Air, Fokker 100, at Pau-Uzein Airport (No injuries to 54 onboard; 1 ground fatal) • T/O after 50-minutes on ground. WX: snow, broken 1,100, Temp/dew 0/-1C. • Rotated “abruptly” at 128 knots when the crew saw flocks of birds. • A/C immediately banked 35 degrees left, 67 right, then 59 left. • Reached 107 feet, sank, right gear struck runway & A/C bounced. • PIC (PF) aborted at 160 knots. • Touched down right of runway end, crossed a road & hit a truck, killing its driver, then rolled out into a field. Photo: BEA • Causes: Limited awareness by crew & company of effects of ice on the ground; • No tactile verification of wing condition; • Wing design’s sensitivity to icing. • Rapid rotation & lack of “crew vigilance.” Training Score: Moderate; high if good SOPs were in place; they were not.

6. 25 May 2008, Kalitta Air B742 at Brussels (Minor injuries to 5 onboard) • BRU uses 25 for T/O but 20 on Sunday for noise 9,573 feet (1,950 shorter). • Began T/O at taxiway 800 feet down runway; had computed T/O parameters for full runway. • Bird strike & compressor stall at V-1 & ATC noted flames on right side. • Captain continued several seconds, then decided he could not T/O safely & aborted 12 knots above V-1. • All 4 engines were brought to idle and did not deploy thrust reversers. • Overran 1,000 feet down embankment & came to rest with nose overhanging second embankment next to busy rail line. Aviation safety.net Causes: RTO 12 knots past V-1; Miscalculated takeoff parameters. Failed to use thrust reversers. Situational awareness. Training Score: Moderate - - Event complicated by bird strike & compressor stall exactly at V-1. Training still may have helped to emphasize SOPs, including check of computed T/O parameters & use of thrust reversers

7. 7/708, Kalitta Air B742, Bogota (3 ground fatal; 2 of 8 onbd serious) • Night T/O (02:50); ceiling 1,700; calm. • Engine #4 failed on rotation. • Climbed out & began circular engine-out return in Bogota Bowl. • #1 failed 55 seconds after rotation 8.5 miles out at ¼ through circling return. • Seconds later, #2 engine entered compressor stalls. • Made emergency landing in dark field 6 miles NW of airport & struck a farm house; 3 fatal on the ground. Cause: No report yet. Broader Issues still not clear: investigation has become costly JT9D science project. Training Score: Zero. Crew performed well under conditions; 3 engines failed in a mountainous black hole El Tiempo & Reuters

8. 8 Aug 2008, Spanair MD-82 at Madrid (154 fatal & 18 serious) • Awaiting T/O, A/C returned to gate for faulty Ram Air Temperature probe. • Maintenance pulled 2 CBs for ground control relay switch but tagged just 1. • Flight crew later reset tagged CB but not the other CB. • Crew ran all check- lists, yet failed to set flaps (FO simply replied “check” for flaps, but did not set them). • Result: no-flap T/O & configuration warning system was disabled. • Rotated at 154 knots, reached 40 feet AGL, then sank & rolled. Reuters Issues: No final report yet but issues appear to include maintenance SOPs (Tagging) & checklist discipline (flaps) & risk from small disruptions. Bottom line: Moderate. Like LEX, must assume capacity to ensure adherence to SOPs every time, but a better chance here: if either flight crew or maintenance had followed procedures, no accident.

9. 20 Dec. 2008, Continental B737-500 at Denver (5 serious, 115 onboard) • B737 with winglets began T/O on 34R; wind 290 at 24, gusting 32. • A/C weather-vaned & drifted left as engines were nearly spooled up. • Ran off left 40 seconds into T/O roll. • A/C continued accelerating several seconds, then speed brake handle was deployed & A/C began decelerating. • Rolled across turf & down slope, with engines starting to burn. • Successful evacuation Rocky Mountain News Under investigation but likely to include: Demonstrated crosswind with winglets. Crew performance & response to drift. Training Score: Low. Training for crosswinds & use of tiller may have had some effect, but, crew was experienced in make-model. On net, more targeted pilot training probably had only limited hope of avoiding this accident.

10. Findings for 6 recent Take-off Accidents • 3 cases illustrate the value of training to & following good SOPs (BRU, Madrid & PAU-Uzein), while Pau-Uzein also illustrates the need to have appropriate SOPs & guidance in place to start. • Madrid also illustrates the same lessons in maintenance. • But, training had limited hope of directly influencing or averting LEX, DEN or Bogota. • Bottom line for training is mixed: • 3 low scores & “only’ 3 moderate scores, but somewhat higher with good SOPs in place. 10

11. Four Runway Overruns on LandingFrom 2007 & 2008 11

12. 18 Feb 2007: Shuttle America as Continental Connection ERJ-170 at Cleveland (No Injuries to 4 Crew & 70 Pax) • FO flying in first pairing of this crew. Contradicted SOP but PIC was fatigued. • Cleared to runway 28 (6,017 ft). • RVR reported at 6,000 & braking action fair, but glideslope unusable due to deep snow. • Passed FAF & ATC reported RVR at 2,000. • PIC (PNF) reported approach lights in sight & runway in sight at 50 feet AGL. • FO then turned off the A/P to land. • At 30 feet AGL, PIC briefly lost sight of the runway, then regained it, & continued. • In strong gusty winds, high sink rate developed in flare & “likely stalled.” Landed long & hard; gear trunnion fractured. • Reverse thrust peaked at 70% for 2 seconds, then slowly to reverse idle. • Applied 20% max brakes for 8 seconds, then 75%, then 90% when PIC applied his brakes. • Ran off into snow-Ccovered grass & penetrated a fence 150 feet past runway end. Photo: NTSB Causes, Factors & Issues: • Lost visual cues & failed to go around. • Descent to ILS DH instead of localizer MDA (glideslope out). • Landed long on contaminated runway • No max reverse thrust or max brakes. • Captain’s fatigue & fear of reprisal. Training: Moderate on net. Winter ops training & go-around gates score high, but offset by fatigue & violation of several SOPs. 12

13. 17 July 2007, TAM A320-200 at Congonhas, Sao Paolo (All 181 pax & 6 crew fatal; 12 Fatal & 11 severe on ground) • 6,365-foot runway was repaved but not yet grooved; no overrun area. • T/O Porto Alegre with #2 thrust reverser deactivated before flight. • ATC advised crew of light rain & wet runway (35L); wind 330 at 8. • Landed at normal spot but software requires both reversers at or near idle for spoilers to deploy. • #1 engine went to reverse, #2 to “climb.” • Overran left at high speed, over adjacent, low highway; into TAM Express building & gas station. Causes: Runway characteristics; construction; inadequate crew training; Airbus’ lack of warning for braking system failure. • Training Score: Moderate – conceptually high for crew knowledge of software; risk assessment; recognition of single-engine reverse thrust. • But offset by MEL & dispatch procedures (A320 to short, wet runway without T/R) & by airport operations (un-grooved, short runway).

14. 12/16/07: Air Wisconsin as US Airways Express, CRJ-200 at Providence (No Injuries to 3 Crew & 31 Pax) • FO (PF) recently completed IOE in CRJ2; this was his second flight on this route (PHL-PVD) • ILS approach to runway 5 (7,000 feet, snow-covered in rain & mist, in darkness). • Winds aloft at initial descent from 220 at 100 knots (large tailwind component). • 2 miles out at 700 AGL, FO disconnected the A/P & FD to “get the feel of the airplane.” • A/C drifted left & above glidepath. • Broke out at 300 & saw approach lights at 2 o’clock. PIC took control. • FO thought PIC had called for power to idle & FO reduced power without PIC’s knowledge. • A/C reached max 22-degree bank below 100 AGL & descent rate of 2,000 FPM. • “Porpoised” in the flare & landed 1,200 feet long in 9-degree bank; main gear collapsed. • Ran off 3,700 feet on snow-covered grass. Causes, Factors & Issues: • Unstable approach, high sink rate, stall, & hard landing. • FO’s poor execution of ILS approach • Poor communication in cockpit. • Inadequate FO training & experience. Training Score High: time in A/C; Go-around gates; CRM; winter ops. 14

15. 30 May 2008, TACA A320-200 at Tegucigalpa Of 135 onboard, 3 fatal, 60 serious; 2 fatal on ground • Landed near max weight (63.5 versus max 64.5t) on short, wet runway in light drizzle & 12-knot tailwind from nearby tropical storm “Alma. • Runway: 5,410 feet available landing distance at 3,300 MSL; 1% downslope & ungrooved). • A/C was configured for landing in Speed Mode – (above Vref); landed at 139 IAS. • Immediately selected MAX REV. Nose touched down 7 seconds after mains. • Applied manual braking 4 seconds later & max pedal braking 10 seconds later. • Selected IDLE REV at 70 knots & 625 feet remaining. • Overran at 54 knots & dropped down 65-foot embankment onto street. Training Score: Moderate. LOFT, risk assessment & go-around gates score high. Offset by national airport policies, dispatch & crew’s failure to monitor.

16. Findings from 4 Runway Excursions on Landing (CLE, PVD, TEG, SPO) • Training scores range from moderate at TEG & CLE to high at Sao Paulo & PVD. • Some high scores: • More time learning the airplane; • Stable approach & go-around gates (all 4 accidents); • Risk Assessment (all 4 accidents) • LOFT & winter operations (CLE & PVD). • Offset in some cases by: • Airport configurations; • Crew fatigue & violation of established SOPs; • Carrier policies & guidelines (unclear or inappropriate). 16

17. Nine Undershoot Accidents,2008 & 2009 17

18. 17 January 2008, British Airways 777 at Heathrow (1 serious among 152) • Normal approach until 600 feet AGL & 2 miles out, when auto throttle demanded an increase in thrust. • Both engines failed to respond. • Crew moved levers manually & again no response. • A/C lost speed & landed short.Ice deposits of water & fuel (soft & mobile) accumulated in fuel lines. • Restricted flow in fuel/oil heat exchanger (FOHE) in Trent-800. • This led to thrust rollback in flare. Cause: No final report yet. Issue: Rarely identified fuel-heating issue unique to one system. AAIB recommends all CAA’s require the use of anti-icing fuel additives, such as FSII, used in military and high-end business jets. Training Score: zero. 18

19. 21 Feb. 2008, Santa Barbara Airlines ATR42 at Merida, VZ (All 46 fatal) • Airport closes at sundown. Accident A/C last scheduled T/O for day. • Clearance delayed for inbound aircraft. • On taxi, FO (PF) notes gyros had failed. • PIC says equipment is “crap” & says he has had to operate w/o gyros before. • Crew: “Go visual” & “try to reset it in flight.” • Start T/O roll; no brief of visual departure. • On climbout, PIC tells FO “a hair more to the right.” • Then confusion: FO & PIC read different headings, then “PULL UP.” • PIC takes control but confusion continues about heading, with more “PULL UP.” • PIC starts right turn early & strikes 80-degree rock face. Cause: No report yet. Broad Issues: SOPs; Maintenance; Corporate culture Decision making; Situation Awareness CAA (Carrier’s AOC later revoked). Training Score: zero. Lots of conceptual opportunities, but plausibility is over-whelmed by more basic issues.

20. 6 July 2008, USAJET (Cargo) DC-9-15 at Saltillo, MX (1 of 2 pilots fatal) • Crashed ILS approach at night. • Airport at 4,646 MSL & surrounded by mountains. • Visibility 1 mile in fog. • Crew never checked in with tower & did not have current weather. • Video shows A/C flying low, wings rocking, then wing dropped (stalled). • Crashed onto loop road next to major highway. Reuters Cause: No report yet. Possible Issues: Go-around gates, current weather information, SOPs. Training Score: High, depending on strength of SOPs.

21. 14 Sep. 2008, Aeroflot-Nord B737-500 at Perm, RU; (All 82 pax & 6 crew fatal) • Late night approach in rain & fog; A/P & A/T off due to long-recurring A/T problem. • Crew recently transitioned from T-134 & AN-2 (Reversed ADI); both low-time M/M • On final, ATC tells crew they are right of course. • Corrected but climbed from 600m to 900m instead of descending to 300M to land. • ATC advised crew of climb: “Affirmative; we’re descending, then climbed to 1,200m. • ATC instructed right turn for go-around. • Acknowledged but turned left & rapid descent. Impacted industrial area & rail line. Causes: Spatial disorientation (ADI) Pilot workload (independent throttles) Pilot’s BAC, fatigue & lack of CRM Maintenance - - carrying faulty throttle. Carrier’s transition training to 737 fleet. Carrier’s operation of 737 fleet. Training Score: Despite extreme corporate issues, crew pairing issues & maintenance practices, net training score is high because a single item (ADI transition) comes close to a knock-out.

22. 27 Jan 2009, Empire at Lubbock; 1 of 2 crew serious) • Crashed short of 17R on ILS in night IMC. (Wind 350 at 10), visibility 2, light freezing drizzle, mist, 500 overcast. • On descent from FL100 to FL80, ATC advised crew of wind shift. • PIC acknowledged & noted 8-degree drop in outside air temp. • At 0434, cleared to land 17R. • Set flaps 15 but got asymmetric flaps. • Shedding speed on final. • Landed short, struck approach lights, & skidded off right, into grass. • Cause: Still under investigation. • Broad Issues: • Possible flap damage from past events (Engine/wing fire & bird strike). • Asymmetric flaps? • Monitoring airspeed

23. 12 Feb. 2009, Colgan Air DHC-8-400 at Buffalo (All 49 & 1 fatal on ground) • FO arrived EWR on red-eye from West Coast via MEM at 0623. PIC with significant sleep deficit. • Accident flight delayed; T/O EWR at 2120. • Newly upgraded PIC (110 hours in M/M); FO had 700 hours in type. • Steady chatter throughout flight. • Cleared to descend & maintain 2,300. Had been bleeding off airspeed & 20 knots slow. • Failed to note low-speed cues. • A/P disengages; A/C stalled in turn & struck home in dense area, 45 degrees wing low, 30 degrees nose low, & little forward speed. BBC & AP Causes & Factors:PIC’s incorrect response to stick shaker & then stall; failure to monitor airspeed & low-speed cue; sterile cockpit; PIC failed to manage the flight; & inadequate procedures for airspeed selection in icing conditions. Training Score: Lots of conceptual opportunities (transition to DHC-8-Q400, stall recognition, CRM & flight monitoring-SOPs). But effectiveness reduced by constant chatter, lack of professionalism & especially by fatigue. Yet, net score still earns a “moderate.”

24. 25 Feb. 2009, THY B737-800 at Amsterdam (9 fatal & 28 serious, 134 onboard) • Crashed 1km short of Rwy 18 in day-time mist & low ceiling, wind 200 at 10. • At 1,950 feet on coupled approach, left altimeter suddenly read 8 feet. • Crew noted faulty altimeter but did not consider it a problem. • Faulty altimeter reading caused A/C to assume landing logic, so throttles went to retard & A/C lost altitude. • When crew selected 144 knots airspeed but with thrust levers at idle. • A/C commanded more pitch. • Crew did not notice loss of altitude until stall warning at 150 AGL. • Added power & pulled up but impacted before spool-up. Reuters • Broad Issues: (No report yet.) Faulty altimeter; • Knowledge of A/C (A/P reads #1 altimeter); • Flight monitoring & SOPs Training Score: Moderate to high for software & recognizing that A/C reads left altimeter, & that A/C assumed landing logic; offset by maintenance issues.

25. 22 March 2009, Fedex MD11 at Narita (Both Pilots Fatal) • Flared late & touched down flat. • Bounced nose high & PIC pushed the nose over. • Second touchdown landed sharply on nose gear, at 30 degrees nose-down in moderate left roll. • Left wing failed & instant fire ball. • Right wing continued flying; A/C rolled inverted. • Cause: No report yet. • Broad issues: • Familiarity with MD-11 (tendency to pitch up after ground spoiler deployment & crew tendency to over-control). • (Newark & Air China accidents). Training Score: Moderate. Crew experienced in MD-11; had the appropriate training many times.

26. 23 Dec. 2009: American 737-800 at Kingston, Jamaica (4 pax serious, minor-no injury to 144 pax, 4 FA & 2 pilots) • Overran shortly after midnight in “fierce rain.’” • Paxs said turbulence forced crew to halt cabin service 3 times, then terminated service. • Before descent, pilot warned of more turbulence but said it likely would not be much worse. • Crew requested Runway 12 with 14-knot tailwind from 310 degrees. ATC offered Runway 30 but crew repeated request for 12. • Cleared to 12; ATC added that runway was wet. • After descent through clouds, crew made visual contact with runway at @ 800 AGL. • Landed 4,000 feet long on 9,900-foot runway at 162 knots. Overran at 73 mph, through perimeter fence, crossed road & came to rest 175ft past runway end, 12 meters from water line. Under Investigation Possible Issues: • Unstable approach, SOPs. • Risk assessment; go-around gates; approach briefing; CRM. Training Score: High – if good SOP 26

27. Findings from 9 Undershoots On balance, high scores. Zero to little chance in 2 cases (LHR & Santa Barbara). Moderate or moderate-high at BUF, Saltillo & Narita) High at Perm, Amsterdam & Kingston Training issues focus on aircraft characteristics, SOPs, risk assessment & go-around gates. Offset by absence of good SOPs & more basic corporate short-comings in some cases 27

28. Conclusions from 19 Recent Accidents • Though training is not a key issue in every accident, recent major accidents illustrates that training can significantly reduce risk in the large majority of cases. • Training is most effective as an intervention when: • we establish good standard operating procedures ; • we train repeatedly to those good procedures; • we enforce those good procedures; and • we train to the aircraft characteristics. 28