10 JULY 1910 — 2010 11 100 YEARS

10 JULY 1910 - 2010 11 100 YEARS ULM ACCIDENTS Belgian ULM Federation – Safety Conference 10/10/2010 1

The Air Safety Investigation • As part of the global Aviation sphere, an investigation is conducted for each accident and serious incident by an independent enquiry body, aimed to; – Determine the causes of the accident. – Determine if all conditions that were defined by rules and regulations to ensure flight safety were followed (such as risk factors in design). – Define recommendations in order to prevent future accidents. • It is not the purpose of this investigation to apportion blame or liability. 2

In Belgium; the Air Accident Investigation Unit. • All accidents and serious incidents occurring in Belgium, on aircraft, helicopters, gliders, balloons, ULM, DPM, regardless of their registration is investigated by a cell functionnally independent from the BCAA, and all other interrested parties. • Independent doesn’t mean isolated; it is part of the world’s network of the State’s Aviation Investigation Bodies. • The cell reports to the President of the Board of the SPF/FOD Mobility and Transport. 3

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ULM • First pendular (Delta Plane Motorized) design in 1966 • First crossing of the Channel in 1978 by Mr D. Cook. • Commercial development from 1979. • Evolution from 2 -axis to 3 -axis. • In Belgium, first ULM registered (501) in 1982. 5

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Evolution • 1982: Weedhopper, Chickinox – 80… 100 km/h – Basic – 2/3 axis – Range: … 200 km… • 2010: VL-3 Sprint, Dyn. Aero MCR 01, WT 9 Dynamic…. – 220…. 250 km/h, – flaps, retractable gear, avionics, – Range over 1000 km • 550 OO- registered ULM; • 571 ULM pilot licence (363 training licences) • 300 -400 foreign-registered ULM. 7

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Evolution in pilot’s / owner’s expectations • In 1982, ULM /DPM, a sporting way of flying, outside the limits of parachuting, delta plane. • In 2010, an efficient alternative to general (certified) aviation. ULM becomes a means of transport. • Beyond 2010 ? ? – The Need for Speed ? 9

Evolution • From the user’s perspective, the difference between General Aviation and ULM becomes very thin. • However, ULMs are characterized by a huge variety of different design types, with low production rate and configuration variation between individual airplanes. – Manufacturers come and go, – Assembly of the same ULM type by different companies induce differences in built configuration. • The above makes it more and more difficult to speak about ULMs in a general way; variation in quality is wider than General (certified) Aviation. 10

EVOLUTION: MORE ULM FATAL ACCIDENTS ? Fatalities: (up to now), In Belgium, on average 2 /year, comparable to General (certified) Aviation. FATALITIES: Figures limited to Belgium. 2009: + 2 in France. 2010: + 5 in France. 11

WHAT ARE THE EXPECTATIONS FOR THE ULM-ACCIDENTS CASUALITY RATE ? • On Belgian soil, 4 deads in 2010. (casuality rate of U. S. Forces in Iraq 3. 6 killed /1000 troop / year – 8 years – 152000 troops – 4424 killed). • In France and Belgium in 2010, 9 Belgian deads to-date. 12

Comparison with the road • In Belgium, the road kills 1000 people on average per year. • Fleet of vehicles: 6 000 units (5 mio cars). • For 1000 cars, the road kills on average 0. 16 person per year. • If we combine these figures with the yearly utilization rate of cars (1 h per day) versus ULM (40 h per year), we can conclude that ULM / General Aviation flying is considerably deadlier than the road. 13

What can we learn from accident investigation ? 14

The investigation process A long process (Months) • Collect all factual elements, – – – The flow of events; The pilot (training, experience, …) The aircraft (contact w/manufacturer) Meteo, Comm, Radar, Flt recorders (GPS, ECU, camera, …) Impact, aircraft damage, • Analysis. (incl. simulation, testing, …) • Define all possible causes. • From the causes, define remedial action. The depth of the investigation is somewhat influenced by the expected ROI. 15

Accident analysis • Accidents do not occur “by accident”; Accident are caused by a series of events. • There are no “isolated cases”; causes of accidents are often recurrent. • Out of the ULM accident data base, we can conclude; – There are recurrent technical problems specific to ULM. – The traditional causes of aviation accidents are also known to ULM (fuel shortage) – 80% of the causal factors are human-related. 16

Main causal factors (122 accidents – fixed wing and ULM) 17

Specific problems with ULM • Technical causes can be (easily) identified; but fire can be devastating. • There’s another problem for the investigator, a lot of landmarks are missing. – ULM requirements are national, – Certification not applicable. – Wide variety of products. 18

About certification. • Everyone would agree that ULMs of to-day are as good, even a lot better than the ‘certified’ airplane. • ULMs are designed to fly. ULM are quality products; they meet your expectations (simple to handle, fly fast, cheap in usage, …) • Certification means that a manufacturer must demonstrate that his product meets a minimum level of safety, as defined (ultimately) by the Aviation Community. • The minimum level of safety is defined in the Certification Specifications – For small aircraft, it is called CS 23. 19

Technical. • AAIU(be) is currently investigating on: – Instrument Board lay-out design. – Electrical System design. – Emergency Parachute. Why is it that (for the last cases) parachute did not save lifes ? • Late decision ? • Handle easy to grab ? • Safety pin not removed before flight ? 20

Same ULM Type, instrument panel somewhat different. Difference in Ergonomy. Parachute handle – on pilot’s side, or on passenger’s side ? 21

Regulation: certification: CS 23. 671 General (b) Controls must be arranged and identified to provide for convenience in operation and to prevent the possibility of confusion and subsequent inadvertent operation. For ULM, CS 23 is not applicable. Each designer has his own solution, and they will be challenged only by YOUR experience. 22

Other example The passenger door opens in flight, causing the pilot to take appropriate actions, that eventually force him to an emergency landing. • Door lock (simple – crude). Plexy flexible. Once opened in flight, difficult to close. CS 23. 783 (1) There must be means to lock and safeguard the door against inadvertent opening during flight by persons, by cargo, or as a result of mechanical failure. 23

The problem • Once we determine a technical problem, we can define recommendations to improve the product, but: What do we do with the recommendation ? – We can not improve the Standard, there’s no standard. – We can not address more than one manufacturer, – What about retrofit ? 24

ULM and Engine failures 25

Fly Synthesis Storch Summer 2009 • After propeller replacement, and subsequent engine ground tests, the pilot took off for a flight test. • He encountered heavy engine vibration, that forced him to an emergency landing. • Airplane was slightly damaged. Cause was identified as Vapor Lock. 26

1/5/2010 – FK 9 Emergency landing after in-flight engine failure. • Lots of corrosion found in carburettor. Corrosion comes from water condensation in fuel system (tank, lines, pump, …- MOGAS) during long immobilisation periods. - how to prevent ? Filling up, draining ? • Fuel system was modified in-service, by addition of a pressure regulator. 27

France 20/5/2010 – Mistral 23/5/2010 – CT Short Wing Mistral: Engine failure in flight. Emergency landing in field; terrain was very soft, airplane severely damaged. CT Short Wing: In short final, the engine suddenly stops The pilot attempts to land, but hit trees, and crashes – wings ripped off. RH wing tank empty, 15 -25 l fuel remaining in LH tank. During LH turn, fuel system unprimed, engine stopped by fuel starvation. 28

4 /6/2010: SG Rally Damaged during landing • Due to engine problems (heavy vibrations), the pilot performed emergency landing on EBHN. Coming in too fast, the landing was brutal, and Nose Landing Gear collapsed. 29

Conclusion • Engine in-flight failure are not exceptional. – Use of MOGAS (water content, flash point, . . ) – Local modifications, – Other specific to the configuration of the specific airplane. And. . – Traditional causes (engine starvation, . . ) 30

Solutions • In this case, we can design some generic recommendations: – Human Factors; ULM pilots should be more prepared to react to engine failures at any time (awareness, briefing, training, …) – Generic technical solutions; impact on the use of MOGAS. • Protection of the equipment during winter, • Risk of Vapour lock. 31

• Designing stop-gaps, accident after accidents may not be satisfactory; What can we do we make sure ULM flying improves up to an acceptable level and, more important, remains at that level ? • More Regulation ? 32

Aviation Regulation and the ULM • No significant changes in Regulation. – ULM defined by capacity, weight, structural and stall speed limitation. – => Extensive use of carbon fiber, Flaps, etc • CS-VLA. – 750 kg. – “light” CS-23. – Expensive. • Lower Requirements for licencing, – What about competence ? – Human Factors training • National requirements in Europe. – EASA Flight Permit per Part 21 A. 701. 33

Evolution: new EU Regulation on Accident Investigation. * Every civil aviation accident or serious incident involving aircraft other than specified in Annex II to the Regulation (EC) No 216/2008 of the European Parliament and of the Council shall be the subject of a safety investigation ( = No obligation of enquiry for ULMs) • Safety investigation authorities may decide to investigate incidents other than those referred to in paragraph 1 as well as accidents or serious incidents to other types of aircraft, in accordance with the national legislation of the Member States, when they expect to draw safety lessons from them. 34

• US. NTSB; no enquiry for ULM crashes. • To-day already, in some EU countries, ULM crash investigations are given a low priority, unless the Public determines otherwise. • Common sense dictates that the initiative to improve safety must come from the ULM community itself. 35

Reason Model • aviation is a complex socio-technical system, where safety is ensured by a series of defense barriers. • Each barrier may present flaws (latent or active) whose combination can lead to an accident. • An usafe act (active failure) alone would not cause an accident. • Latent failures are more easily detected and corrected that human errors, which are (globally) inevitable. 36

• The ULM community should reinforce its Defense Barriers. • Organisation: Federation and Clubs. Create a Safety Climate - Norms and rules - Safety Programs - To define a Safety Climate, we need to assess the potential risk, and for that we need data: YOUR experience. 37

Pyramid of Heinrich • If a fatal accident is caused by a specific combination of events, an uncomplete series of events causes INCIDENTS. • If we identify all potentially dangerous events AND with that information, build-up the defenses, we can avoid ACCIDENTS. 38

SHARING EXPERIENCE • By informing the Federation of the small events and incidents that spoiled one of your flights, you allow the Community to understand the potential dangers and act upon. (and respect confidentiality) “Learn from mistakes of others; you won’t live long enough to make them all by yourself” 39

Human Factors • To err is human. • Human life (and flying) is full of decisions. • It is therefore more important to know yourself than to know how to fly your aircraft. – Get-home-itis, Distraction, Communication, . . • Understanding human factors is a very important step in improving your defenses. 40

Competence and Readiness • You hold a pilot licence; but are you a competent flyer ? • How will you react when faced with a potential dangerous situation? • Assessing your competences with an instructor is an opportunity to improve. • When flying, be ready. 41

What is the Authority doing for you ? 42

A series of work groups within EASA are thinking about how to improve flight safety. (ESSI) One of them is about General Aviation (EGAST). Initiative includes a leaflet On Collision Avoidance, and has been relayed to you by the Federation. There are technical Work Groups dealing with MOGAS 43 and

An initiative to develop Posters with comic strips On high risk topics. The first goes about taking The right decision when the Weather is below minimum. They are expected in the Coming months. 44

For Belgium, Accident reports are made public on the SPF/FOD website. Recent reports (from 1 st May 2007) are directly available through hyperlinks. Reports are written in English. Information Notes are also available in order to highlight specific danger area: Nr 2010 is about engine cold start. We would like to develop more Notes, for ULM in collaboration with the Federation. Historical reports: currently a list is posted. The list is fairly complete from 1972. 2 ancient reports (1936 and 1965). The reports (Fr /Nl) are desidentified and available on request. The list will be completed as we go along in reviewing archives. 45

Thank you for your attention, and AAIU (Belgium) wishes you many happy landings Photos credit: MRA / KLM 46