SAE AIR 6237-2016 Loss-of-Control Mishaps in Revenue Airline Service.pdf

1、SAE Technical Standards Board Rules provide that: “This report is published by SAE to advance the state of technical and engineering sciences. The use of this report is entirely voluntary, and its applicability and suitability for any particular use, including any patent infringement arising theref

2、rom, is the sole responsibility of the user.”SAE reviews each technical report at least every five years at which time it may be revised, reaffirmed, stabilized, or cancelled. SAE invites your written comments and suggestions.Copyright 2016 SAE InternationalAll rights reserved. No part of this publi

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4、side USA)Fax: 724-776-0790Email: CustomerServicesae.orgSAE WEB ADDRESS: http:/www.sae.orgSAE values your input. To provide feedbackon this Technical Report, please visithttp:/www.sae.org/technical/standards/AIR6237AEROSPACEINFORMATION REPORTAIR6237Issued 2016-07Loss-of-Control Mishaps in Revenue Air

5、line ServiceRATIONALELoss-of-control remains a major type of mishap to transport airplanes. These have included several high-profile accidents world-wide which emphasize the need to prevent and recover from loss-of-control incidents. This report reviews loss-of-control events to revenue air carrier

6、flights occurring from 1981 through 2010. This SAE Aerospace Information Report is intended to provide a comprehensive reference and background information pertaining to in-flight loss of control mishaps. It is expected that this report will lead to ARP6149.INTRODUCTIONLoss-of-control (LOC) is the m

7、ajor cause of transport airplane mishaps. According to the Boeing Statistical Summary (1)20 fatal mishaps (out of 87 total) were caused by LOC during the decade 2001 through 2010. Controlled flight into terrain (CFIT) was second with 17 fatal mishaps. LOC mishaps resulted in 1756 fatalities, more th

8、an CFIT with 1007. Adoption of electronic means to mitigate the CFIT risk has reduced CFIT numbers in recent years. No such breakthrough has been evident in LOC mishaps.Recent high profile mishaps, such as Qantas 072, Colgan 3407, and Air France 447, re-emphasize the importance of preventing LOC. Fo

9、r this reason, this Aerospace Information Report reviews LOC accidents with a goal of finding trends and patterns.SAE INTERNATIONAL AIR6237 Page 2 of 246TABLE OF CONTENTS1. SCOPE 42. REFERENCES 42.1 Applicable Documents 42.1.1 FAA Publications. 42.1.2 NTSB Publications 42.1.3 ICAO Publications . 42.

10、1.4 References cited in this document:. 52.2 Abbreviations and Definitions . 62.2.1 Abbreviations 62.2.2 Definitions . 73. UPSET REVIEW . 83.1 Incident Data . 93.2 Identification of Accidents . 94. RESULTS 94.1 Aerodynamic Stalls . 104.2 Flight Control Malfunctions . 124.3 Faulty Recoveries . 144.4

11、Spatial Disorientation 144.5 Pilot Involvement in Cause . 154.6 Atmospheric Disturbances 154.7 Takeoff Mishaps 154.8 Airframe Ice. 164.9 Pilot Experience 164.10 Chronological Changes in Mishap Patterns 175. DISCUSSION 175.1 Instrument Skills 175.2 Stall Prevention and Recovery 185.2.1 Stall Training

12、 . 185.2.2 Envelope Protection 185.3 Spatial Disorientation 185.4 Upset Training Effectiveness 185.4.1 Unusual Attitude Recovery . 195.4.2 Upset Recovery. 205.4.3 Final Comments on Unusual Attitude Recovery . 215.5 Takeoff Mishaps 225.6 Up-and-Away Icing Mishaps . 226. CONCLUSIONS 227. RECOMMENDATIO

13、NS. 228. NOTES 238.1 Revision Indicator 23APPENDIX A LIST OF MISHAPS . 24APPENDIX B DETAILS OF MISHAPS 29FIGURE 1 MISHAPS DISTRIBUTED BY PHASE OF FLIGHT 10FIGURE 2 TRAINING EFFECT FOR UAR MANEUVERS. 20FIGURE 3 TOTAL TRAINING EFFECT FOR UER MANEUVERS 20SAE INTERNATIONAL AIR6237 Page 3 of 246TABLE 1 F

14、LIGHT CONDITIONS 9TABLE 2 PRIMARY CAUSE OF UPSET MISHAPS 11TABLE 3 FACTORS IN UPSET MISHAPS 12TABLE 4 FLIGHT CONTROL FACTORS IN UPSETS 13TABLE 5 FBW AND CONVENTIONAL LIGHT CONTROL FACTORS IN JET TRANSPORT UPSETS 13TABLE 6 PILOT EXPERIENCE IN UPSET MISHAPS BY AIRCRAFT TYPE . 16TABLE 7 PILOT EXPERIENC

15、E IN UPSET MISHAPS, 1981-2010, NORTH AMERICAN CARRIERS 16TABLE 8 PILOT EXPERIENCE IN UPSET MISHAPS WORLDWIDE. 17TABLE 9 ACCIDENT CAUSES ON A DECADE-BY-DECADE BASIS 17SAE INTERNATIONAL AIR6237 Page 4 of 2461. SCOPEThe scope of this document is to provide review of recent history of loss-of-control ac

16、cidents during airline revenue operations.2. REFERENCES2.1 Applicable DocumentsThe following publications form a part of this document to the extent specified herein. The latest issue of SAE publications shall apply. The applicable issue of other publications shall be the issue in effect on the date

17、 of the purchase order. In the event of conflict between the text of this document and references cited herein, the text of this document takes precedence. Nothing in this document, however, supersedes applicable laws and regulations unless a specific exemption has been obtained.2.1.1 FAA Publicatio

18、nsAvailable from Federal Aviation Administration, 800 Independence Avenue, SW, Washington, DC 20591, Tel: 866-835-5322, www.faa.gov.General Operating and Flight Rules, Title 14, Code of Federal Regulations, Part 91; cited as Part 91Operating Requirements: Domestic, Flag, and Supplemental Operations,

19、 Title 14, Code of Federal Regulations, Part 121; cited as Part 121Operations: Foreign Air Carriers and Foreign Operators of U.S. Registered Aircraft Engaged in Common Carriage, Title 14, Code of Federal Regulations, Part 129; cited as Part 129Operating Requirements: Commuter and On-Demand Operation

20、s and Rules Governing Persons on Board Such Aircraft,Title 14, Code of Federal Regulations, Part 135; cited as Part 135Airplane Simulator Qualification, FAA-AC-120-40B, July 1991Stall and Stick Pusher Training, FAA Advisory Circular AC-120-109, August 6, 2012Upset Prevention and Recovery Training, F

21、AA Advisory Circular AC-120-111, April 14, 2015Instrument Flying Handbook, FAA-H-8083-15, 2001Enhanced Upset Recovery Training, FAA-InFO-10010, July 6, 2010Manual Flight Operations, FAA-SAFO-13002, January 4, 20132.1.2 NTSB PublicationsAvailable from NTSB Headquarters, 490 LEnfant Plaza, SW, Washing

22、ton, DC 20594, Tel: 202-314-6000, www.ntsb.gov.Notification and Reporting of Aircraft Accidents or Incidents and Overdue Aircraft and Preservation of Aircraft Wreckage, Mail, Cargo, and Records, Title 49, Code of Federal Regulations, Part 830; cited as Part 8302.1.3 ICAO PublicationsAvailable from I

23、nternational Civil Aviation Organization, 999 University Street, Montreal, Quebec H3C 5H7, Canada, Tel:+1 514-954-8219, http:/www.icao.int/Aircraft Accident and Incident Investigation, Annex 13 to the Convention on International Civil Aviation, International Civil Aviation Organization; cited as Ann

24、ex 13SAE INTERNATIONAL AIR6237 Page 5 of 2462.2 References cited in this document:1. Statistical Summary of Commercial Jet Airplane Accidents, Worldwide Operations, 1959-2010, The Boeing Company, Seattle, Downloaded 16 January 20122. Airplane Simulator Qualification, FAA-AC-120-40B, July 19913. Not

25、ification and Reporting of Aircraft Accidents or Incidents and Overdue Aircraft and Preservation of Aircraft Wreckage, Mail, Cargo, and Records, Title 49, Code of Federal Regulations, Part 8304. Aircraft Accident and Incident Investigation, Annex 13 to the Convention on International Civil Aviation,

26、 International Civil Aviation Organization; cited as Annex 135. B. Cheung, “Nonvisual Illusions in Flight,” in Spatial Disorientation in Aviation, F. H. Previc and W. R. Ercoline (eds.), Reston, VA: American Institute of Aeronautics and Astronautics, 2004, Chapter 66. Instrument Flying Handbook, FAA

27、H-8083-15, 2001, p. 5-31-5-337. Airplane Upset Recovery Training Aid, Rev 2, November 20088. A. A. Lambregts, G. Nesemeier, J. E. Wilborn, and R. L. Newman, Airplane Upsets: Old Problems, New Issues,presented at AIAA Modeling and Simulation Technologies Conference, Honolulu, August 2008, AIAA 2008-

28、68679. J. Priest, Quick Look Evaluation of Recurrent In-Flight Simulation Based Advanced Maneuver and Upset Recovery Training, Calspan TM-FRG-URT-0007-R00, September 200710. R. Dorsett, Aircraft Accident Reports on DVD, Flight Simulation Systems, Austin, TX, 200611. D. Hirschman, “The Panic Pull,” A

29、OPA Pilot, October 2011, pp. 91-9312. L. S. Peterson, L. A. Haworth, R. C. Jones, R. L. Newman, R. J. McGuire, A. A. Lambregts, T. McCloy, and T. R. Chidester, An International Survey of Transport Airplane Pilots Experiences and Perspectives of Lateral/Directional Control Events and Rudder Issues in

30、 Transport Airplanes, DOT/FAA/AM-10/14, October 201013. R. H. Hoh, T. K. Nicoll, and P. Desrochers, Piloted Simulation Study to Develop Transport Aircraft Rudder Control System Requirements. Phase 2: Develop Criteria for Rudder Overcontrol, DOT/FAA/AR-10/17, November 201014. W. C. Ocker and C. J. Cr

31、ane, Blind Flight in Theory and Practice, San Antonio, Naylor Publishing, 193215. Gleim Flight Instructor Refresher Course, Gleim Aviation, Flight Instructor Renewal Course Study Materials, 201216. Stall and Stick Pusher Training, FAA Advisory Circular AC-120-109, August 6, 201217. L. Knotts, “The N

32、T-33A Variable Stability Aircraft - Five Decades of Flight Test,” presented at SETP Southwest Section Meeting, October 201118. J. Priest, Research into Reduction of Loss-of-Control Accident Tate in a Meaningful and Measurable Way Through the use of Innovative Pilot Training Technologies, presented a

33、t AIAA Modeling and Simulation Technologies Conference, National Harbor, Maryland, January 2014, AIAA-2014-100519. Upset Prevention and Recovery Training, FAA Advisory Circular AC-120-111, April 14, 2015SAE INTERNATIONAL AIR6237 Page 6 of 2462.3 Abbreviations and Definitions2.3.1 AbbreviationsA/P Au

34、topilotAC Advisory CircularACAS Airborne Collision and Avoidance SystemAoA Angle-of-AttackASN Aviation Safety NetworkASRS Aviation Safety Reporting System (NASA)ATSB Australian Transport Safety BureauBEA Bureau dEnqutes et dAnalyses pour la scurit de laviation civile (France)BFU Bundesstelle fr Flug

35、unfalluntersuchungin (Germany)C/G Center of GravityCFIT Controlled Flight into TerrainECAM Electronic Centralized Aircraft MonitorEFIS Electronic Flight Instrument SystemEICAS Engine Indication and Crew Alerting SystemFAA Federal Aviation AdministrationFBW Fly-by-WireFFS Full Flight Simulator1ICAOIn

36、ternational Civil Aviation OrganizationIFS In-flight SimulatorLOC Loss-of-ControlNASA National Aeronautics and Space AdministrationNTSB National Transportation Safety BoardPFD Primary Flight DisplayPIO Pilot-Induced-OscillationPND Primary Navigation DisplaySDO Spatial Disorientation1 Level D Simulat

37、or (2)SAE INTERNATIONAL AIR6237 Page 7 of 246SMS Safety Management SystemTO TakeoffTSB Transportation Safety Board (Canada)UA(R) Unusual Attitude (Recovery)UE(R) Upset Event (Recovery)URT Upset Recovery TrainingVMC Minimum Control Airspeed2.3.2 DefinitionsACCIDENT (NTSB): An occurrence associated wi

38、th the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage. (3)ACCIDENT (ICAO): An

39、occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which: (4)(1) a person is fatally or seriously injured as a result of being in the aircraft,

40、 direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or - direct exposure to jet blast, except when the injuries are from natural causes, self-inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the are

41、as normally available to the passengers and crew: or(2) the aircraft sustains damage or structural failure which: adversely affects the structural strength, performance or flight characteristics of the aircraft, and would normally require major repair or replacement of the affected component, except

42、 for engine failure or damage. when the damage is limited to the engine, its cowlings or accessories: or for damage limited to propellers, wing tips, antennas, tires, brakes, fairings, small dents or puncture holes in the aircraft skin: or(3) the aircraft is missing or is completely inaccessible.AIR

43、 CARRIER OPERATIONS: Revenue operations that are:(1) Conducted under Part 121 or under equivalent foreign regulations; or(2) Conducted as scheduled, multi-engine operations under Part 135 or under equivalent foreign regulations.INCIDENT: An occurrence other than an accident, associated with the oper

44、ation of an aircraft, which affects or could affect the safety of operations. (3-4)MISHAP: In the context of this report, an accident or an incident.SERIOUS INCIDENT (ICAO): An incident involving circumstances indicating that an accident nearly occurred. (4)SERIOUS INJURY (NTSB): Any injury that:(1)

45、 requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fracture of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; SAE INTERNATIONAL AIR6237 Page 8

46、 of 246(4) involves injury to any internal organ; or (5) involves second- or third-degree burns, or any burns affecting more than 5% of the body surface. (3)SOMATOGRAVIC ILLUSION: The false sensation of body tilt that results from perceiving the direction of a nonvertical gravitoinertial force as be

47、ing vertical. (5)UNUSUAL ATTITUDE: An airplane attitude not normally required for instrument flight. (6) It is often used synonymously with upset. Reference (7) describes an upset as an unintentional exceedance of x Pitch attitude greater than 25 degrees, nose upx Pitch attitude greater than 10 degr

48、ees, nose downx Bank angle greater than 45 degreesx Airspeed inappropriate for the conditionsLambregts et al. (8) modified the attitude limits to match the definition of aerobatic flight found in Part 91: an abrupt change in an aircrafts attitude, an abnormal attitude, or abnormal acceleration.UPSET

49、 An airplane unintentionally exceeding the parameters normally experienced in line operations or a control failure or disturbance that alters the normal response of the airplane to pilot input such that the pilot must adopt an alternate control strategy to regain and sustain controlled flight. (9)3. UPSET REVIEWAir carrier upset accidents were reviewed for the per