Ryanair are making international headlines once again…

Ryanair Fires Pilot After TV Show Probes Safety Culture

Ryanair Holdings Plc (RYA) dismissed Captain John Goss and said it plans to pursue legal action against the pilot after he was featured on a U.K. television program this week that questioned the airline’s safety. “We will not allow a Ryanair employee to defame our safety on national television,” the airline said in an e-mailed statement. Pilots are wary of raising concerns and are encouraged to carry as little fuel as possible, the Channel 4 “Dispatches” program reported, citing a survey conducted by the Ryanair Pilots Group, which claims to represent more than half of the carrier’s pilots. The fuel issue arose when three jets declared emergencies before touching down in Valencia, Spain, after diversions from Madrid last year. The planes landed safely and in compliance with European regulations, the Irish Aviation Authority said.

Discussion of Ryanair’s policies had already been headline news in the UK following the Dispatches documentary Secrets of the Cockpit on Channel 4, which focused on whether Ryanair are carrying dangerously low amounts of fuel. Dispatches accused Ryanair of operating with a level of fuel that was ‘close to the minimum’ required.

The key conversation that I’m hearing which worries me is not whether Ryanair’s current actions are reasonable but whether or not the airline is safe.

Now, I won’t fly Ryanair as a passenger because I think their booking policies and customer service are atrocious. Their hiring policy is distinctly dubious. There are widespread reports of pilots being bullied within the company. I have no comment on the sacking of the pilot who spoke to the television show but it leaves a sour taste in my mouth. When it comes down to it, I really don’t like defending Ryanair as an airline. However, it is true that Ryanair have never had a fatal accident in one of its aircraft, despite it having one of the largest fleets in the world.

The documentary reported that three jets declared fuel emergencies flying into Valencia. There have actually been four incidents of Ryanair flights declaring low-fuel emergencies over Valencia. The first incident was in May 2010, when a Ryanair Boeing 737 en route from Stansted to Alicante diverted to Valencia. The three detailed in the documentary took place in July 2012 in an incident where seventeen airlines were diverted to Valencia from Madrid.

In order to better understand these incidents, lets start with the regulation. EU OPS 1.375 states that:

The commander shall declare an emergency when calculated usable fuel on landing, at the nearest adequate aerodrome where a safe landing can be performed, is less than final reserve fuel.

Ryanair’s procedures at the time were as follows:

– The Commander shall make an urgency call (Pan ×3) when he believes he will land with less than Final Reserve Fuel.

– The Commander shall make a Distress call (Mayday ×3) when he is committed to an approach from which he will not have enough fuel to conduct a Missed Approach.

Final reserve fuel is enough fuel to fly for 30 minutes at holding speed at 1,500 feet above aerodrome elevation. As a pilot, you should always land with final reserve fuel still in your tanks.

Now the clear problem here is that EU OPS state that an emergency should be declared where Ryanair consider it a situation of urgency, and only when the situation has escalated further are Ryanair pilots told to declare an emergency.

European Union regulation requires that the operator have a fuel policy for the purpose of flight planning to ensure that every flight carries sufficient fuel for the planned operation, as well as reserves to cover deviations from the planned operation.

The fuel requirements include :

Taxi fuel (for use on the ground)

Flight plan fuel

Alternate fuel (allowing the aircraft to get to furthest planned alternate airport if there is a diversion)

Extra fuel

Final reserve fuel

The extra fuel is added at the Captain’s discretion. Extra fuel is added based on weather conditions, experience of the route, expectation of a diversions en route due to NOTAMS, etc.

The Captain can choose to carry up to 300 kg extra fuel without explanation. Over 300 kg, the Captain has to note an explanation for why he requested the additional fuel. He does not have to get it approved or do anything other than justify his reasoning.

The more fuel the aircraft is carrying, the heavier it is, the more fuel it will burn. So yes, captains are absolutely expected to manage their fuel loads: a Captain who carries 299kg extra fuel on every flight “just in case” would swiftly find himself being taken to task. However, it is the Captain’s duty to ensure that his flight is safe and that includes carrying extra fuel if he believes it may be required.

Now onto the incidents: all of these were investigated and reported on by Spain’s Civil Aviation Accident and Incident Investigation Commission.

14 May 2010

RYR 9ZC, a Ryanair B737-800, departed Stansted for Alicante with 8,200 kg of fuel. The forecast weather conditions were good and there were no expected setbacks and delays for the flight. The Captain decided that the contingency fuel (minimum 5% of the fuel required to fly to Alicante), equivalent to about seven minutes of flight time, would suffice for any diversions they might encounter. Thus, he didn’t request any extra fuel.

When he arrived at Alicante, he discovered that the winds were highly variable. The flight crew attempted a landing on Runway 10 but broke off the approach just three feet above the runway. The crew checked the fuel requirement to divert to Valencia. They believed they had sufficient fuel to try one more approach at Alicante before diverting.

They requested Runway 28, which ATC initially confirmed as showing only calm winds. During this second approach, the wind was reported as beyond limits for Alicante Airport, so the flight crew aborted the approach and proceeded to Valencia.

Valencia was not actually the closest airport. The Captain stated, however, that he had noted the weather conditions at Valencia when they flew past en-route and he was familiar with the airport. He wasn’t sure if Murcia San Javier Airport was open to commercial traffic (it was). Ryanair’s operational flight plan did not make it clear that San Javier Airport required less fuel.

So RYR 9ZC diverted to Valencia. The fuel required for the diversion was 2,259 kg, with a final fuel reserve of 1,139kg.

The aircraft encountered a headwind which was nearly three times that predicted in the operational flight plan. The fuel levels, already low, continued to decrease.

12 minutes after they had initiated the second approach and then diverted, the fuel was down to 1,250 kg. The crew realised that they would land with a fuel amount below the final reserve fuel. In accordance with Ryanair policy, they declared an urgent situation.

18:30:02 RYR 9ZC: PAN PAN, PAN PAN, PAN PAN Ryanair 9 Zulu Charlie errr… fuel…requesting, ummm, vectors immediate to land runway one two. PAN PAN, PAN PAN, PAN PAN

It’s got to be said, that’s not the clearest declaration of urgency that I’ve heard. But we’ll get back to the ATC conversation at the end. For the moment, the point is that they followed their company policy to a tee, with 1,250 kg of fuel left on board.

As they turned onto short final, the fuel remaining was 1,140 kg on board. The company policy is that if they are committed to this approach, that is, they no longer have enough fuel to go around and try again, they must declare an emergency. As they are now on the final reserve that they should not be using, it has become urgent.

18:38:15 RYR 9ZC: MAYDAY, MAYDAY, MAYDAY, fuel emergency now.

The aircraft turned onto final and landed on Runway 12 with 956 kg of fuel remaining, 183 kg below the final reserve fuel.

From the official Spanish report:

The incident was caused by the crew’s inadequate decision-making process in opting to make a second approach, in the choice of alternate airport and in the flight parameters used en route to that airport, which resulted in the fuel amount dropping below the required minimum reserve fuel and in the crew declaring an emergency (MAYDAY). The company’s fuel savings policy, though it complies with the minimum legal requirements, tends to minimize the amount of fuel with which its airplanes operate and leaves none for contingencies below the legal minimums. This contributed to the amount of fuel used being improperly planned and to the amount of fuel onboard dropping below the required final fuel reserve. Another contributing factor was the wind information provided by ATC to the crew when preparing the approach to runway 28. This information, though accurate, did not give the crew a clear picture of the changing wind conditions, which would have facilitated their making more suitable decisions.

So, the point is that the aircraft was not at any time unsafe. The aircraft did not have enough fuel, absolutely clear. However, the report concluded that the primary issue was that the Captain decided to try one more approach at Alicante before continuing on, when he did not have enough fuel to do so safely.

This report is particularly important because the low fuel incidents of July 2012 were bundled into the same report. The investigators felt that the sequence of events was so similar that the conclusions and recommendations would all be exactly the same. Thus the incidents did not require a separate report, although they were all investigated separately.

26 July 2012

Around 20:00 UTC, seventeen aircraft were diverted from Madrid Airport because of hailstorms at the airfield. Twelve flights were diverted to Valencia and five were diverted to Alicante. Of those seventeen flights, four declared fuel emergencies. Let’s focus on the three Ryanair flights first.

RYR 2054 was a scheduled flight from Palma to Madrid. The aircraft departed with 613 kg of extra fuel, which was justified in the log report as due to weather forecast (storms).

They attempted an approach into Runway 18R at Madrid but at 20:08 the flight crew broke off and performed a go-around because of the hailstorm. They held northwest of the airport hoping to try a new approach but then at 20:19, they were diverted to Valencia. At 20:55 the flight crew contacted Terminal Area Control Center Valencia. At 20:59 TACC Valencia instructed the aircraft to hold.

The flight crew responded that they could not hold as they did not have enough fuel. Valencia Approach asked if they were declaring an emergency. At 21:00 the crew issued a MAYDAY.

The final reserve fuel for this flight was 1,104 kg. The aircraft arrived with 910 kg of fuel (1,029 kg on touchdown).

RYR 9VR was a scheduled flight from Stansted to Madrid. The aircraft departed with 283 kg of extra fuel, which was justified in the log report as due to delays in Madrid.

They also attempted an approach into Runway 18R at 20:11 and also had to perform a go-around. They were directed to hold northwest of the runway but en route to the hold point, they diverted to Valencia. When the crew first contacted Valencia ATC at 21:01, they were instructed to hold. The flight crew have reported that at that point, there were six aircraft on approach. As a result of the emergency declaration from another aircraft (presumably RYR 2054), their planned approach was delayed even more. at 21:04, the crew informed Valencia ATC that if they did not start their approach within 2-4 minutes, they would have to declare an emergency. At 21:11, the flight crew declared an emergency and at 21:12, the aircraft was cleared for Runway 30.

The final reserve fuel for this flight was 1,119 kg. The aircraft arrived with 1,130 kg (1,160 on touchdown). They landed without ever touching the final reserve.

RYR 5389 was a scheduled flight from Stockholm to Madrid. The aircraft departed with 892 kg of extra fuel which was justified in the log report as due to 20 minute delays expected in Madrid and due to change of the alternate airport.

The alternate airfields for this flight were Valladolid, Zaragoza, Vitoria and Valencia. Valencia, the fourth alternate, was the most distant. The most distant alternate airfield is the one which must be used for fuel calculations.

They performed a go-around at runway 18L at Madrid at 20:12 and also proceeded to the northwest hold. They diverted south by 14 nautical miles before reaching the hold point and then proceeded to another hold point also in the northwest. At about 20:30, the aircraft was diverted to Valencia.

At 21:14, when they still had not been given clearance to land at Valencia, the crew declared an emergency.

The final reserve fuel for this flight as 1,090 kg. The aircraft arrived with 1,120 kg (1,228 kg on touchdown). This flight also landed with a fuel amount that was above the final reserve.

In my opinion, the Dispatches documentary misrepresented these MAYDAY calls. A pilot on the television show says:

If you have to use a MAYDAY call during a flight, that indicates you are in imminent danger…you are saying help me, I’m in danger, I need to land now.

Whereas we know that the declaration of an emergency is required if you can’t land with a minimum of thirty minutes holding fuel in your tanks , even if you are absolutely sure you are going to land safely. It’s straight forward: you may not use the final reserve and if you realise that you are going to, you must declare an emergency.

If you want to get technical, for two of the three flights, the issue was not that the aircraft did not have enough fuel, but that they declared an emergency too early. A less generous soul might consider that they did not want to wait for their turn and jumped the queue by declaring low fuel. But realistically, the second two flights would have dipped into their final reserve fuel had they not declared an emergency.

There was another aircraft that declared an emergency that day: a LAN Chile flight flying from Frankfurt to Madrid. It was also diverted to Valencia. However, this flight declared an emergency due to the “loss of an engine”. The “engine stoppage” as they called it, was the number three engine which had stopped as a result of fuel starvation. I find that a lot scarier, don’t you?

Meanwhile, four other aircraft reported being low on fuel without declaring an emergency. The investigation does not state whether they landed with their final reserve fuel intact or not.

In every instance, Ryanair aircraft carried sufficient fuel for the flight and its alternate. In every instance except one, the Captain had chosen to take extra fuel on board. These flights were in line with regulations and cannot in themselves be considered unsafe.

The incident report discusses Ryanair’s fuel policy as a part of its analysis:

Ryanair’s fuel policy, as stated in its Operations Manual, is based quite specifically on minimizing the fuel load at the start of the flight. Since fuel consumption rises considerably with any additional weight that is transported, the goal of this policy must therefore be to reduce consumption by reducing the weight of the fuel transported as much as possible. As a result of this economic policy, Ryanair aircraft generally land with the minimum required fuel. This policy, which is in keeping with EU OPS 1.375, gives Ryanair a competitive advantage over other airlines that tend to fly with larger amounts of reserve fuel and that therefore use more fuel.

However, the investigators’ warning is not that such a policy is dangerous but that too many airlines might choose to follow it:

It is worth noting that market competition is forcing other airlines to reduce their costs by adopting fuel policies similar to Ryanair’s. This could make it commonplace for airplanes to arrive at their destinations with the minimum required fuel and without reserves in the event of a delay or, as in this case, to attempt a second approach after being given preferential treatment by ATC at the expense of other traffic yielding its approach priority. The arrival of several aircraft flying with minimum fuel at the same airport could give rise to several simultaneous emergency declarations for lack of fuel, especially if circumstances force deviating to the alternate airport.

The issue at Valencia was that every aircraft declaring an emergency delayed the other aircraft getting in and, if that trend continued, multiple declared fuel emergencies could swiftly turn into a disaster as they can only get in one flight at a time.

The report recommendation is that airports have specific “average delay times” based on local circumstances (for example that Valencia is limited to a single runway) so that airlines can correctly work out how much fuel they need to fly safely.

As a result of this report, ICAO amended their Procedures for Air Navigation Services to allow for a clear definition of minimum fuel and standard phraseology to be used “when it has been determined that the aircraft will infringe upon its final fuel reserves before landing.” As of November 2012, an aircraft must declare minimum fuel when “committed to land at a specific aerodrome and any change in the existing clearance may result in a landing with less than planned final reserve fuel” and must declare a fuel emergency using the phrase MAYDAY MAYDAY FUEL when the calculated fuel on landing at the nearest suitable aerodrome where a safe landing can be made will be less than the planned final reserve fuel.

These changes make the procedure clearer but all of the above aircraft would be expected to declare an emergency under the circumstances that they found themselves in.

Meanwhile, I mentioned the ATC exchange in the May 2010 incident. If you want to read something scary, then read this…

18:30:02 RYR 9ZC: PAN PAN, PAN PAN, PAN PAN Ryanair 9 Zulu Charlie

errr… fuel… Requesting, ummm, vectors immediate to land runway one two. PAN PAN, PAN PAN, PAN PAN

18:30:12 Valencia approach ask RYR 9ZC to repeat

18:30:13 RYR 9ZC: We would like to declare a pan due to errr… a pan

emergency due to fuel…urgency, PAN PAN, PAN PAN, PAN PAN Ryanair 9 Zulu Charlie.

18:30:21 Valencia Approach: Confirm you declare emergency?

18:30:23 RYR 9ZC: Urgency, PAN PAN, PAN PAN, PAN PAN, Ryanair 9 Zulu Charlie.

18:30:28 Valencia Approach: Copied, proceed own discretion to runway 12

18:32:00 Valencia Approach informs Valencia Tower in Spanish that the Ryanair flight is arriving at the airport without fuel and that it just declared PAN-PAN, telling them to be ready because he does not know what to do in those cases. Tower replies that it will report it to Coordination (CEOPS) and that they will know what to do.

18:32:04 RYR 9ZC calls Valencia Approach to ask for the latest weather report for Valencia using the abbreviation “met report”. The controller does not understand and asks him twice to repeat.

Finally RYR 9ZC says “we would like to request the weather at the field”. Valencia Approach replies: “OK, the weather is, the wind is 140/5 variable on direction from 110° 217° visibility 10 km or more, the cloud scattered 4,500 ft, QNH 1011. Temperature 16, point 06.”

18:33:49 Valencia Approach (in Spanish) to Tower: Hello, look, we’ve dropped the Ryanair down to 5,000 feet and it looks like he’s proceeding on final, ok? You’re ready, right?

Valencia Tower replies that it has notified Coordination. The planner controller at Valencia Approach reports that the aircraft said PAN-PAN. Tower asks what exactly that means as he has never heard it before. Approach then rectifies and says that what the aircraft said was TAM, TAM…TAM, TAM MEDICAL, which surprises the Tower controller who, while laughing, asks what that is and if the aircraft has really declared an emergency, which is not the same as PAN-PAN, to which Approach replies to stand by.

18:35:38 Approach contacts Tower again to confirm that “the aircraft definitely said just TAM, TAM.” A discussion ensues between them regarding whether it had reported airport in sight so as to initiate the emergency, since Approach had reported the emergency and the airport has to be notified to undo the start of the emergency.

Approach reports that the aircraft is declaring an urgency at that time, to which Tower insists that they have been told emergency, not urgency, and as a result have notified the airport. Approach contacts the aircraft to request information on emergency declaration. The Ryanair crew replies: “We declared urgency, not emergency, RYR9ZC”.

A minute later, Approach contacts again to request number of passengers onboard.

18:38:15 RYR 9ZC: MAYDAY, MAYDAY, MAYDAY, fuel emergency now.

18:38:40 Valencia Approach informs Tower that the aircraft just reported an emergency. Tower replies that the two things were not the same and that they had the airport “in chaos”.

18:38:02 RYR 9ZC reports turning onto final runway 12. Approach transfers the flight to the Tower frequency. The aircraft lands at 18:43 without incident.

Eurocontrol admitted that most of its controllers had no experience in handling serious emergencies and that, as a result of overall safety levels in commercial aviation, would probably not attain such experience on the job. They conceded that this lack of experience made it likely that, when faced with a real emergency, deficient performance could result.

Spain’s Civil Aviation Accident and Incident Investigation Commission recommended promoting the appropriate use of MAYDAY and PAN codes as well as checklists for controllers to better handle emergency situations.

I may not fly Ryanair because I dislike their commercial policies but I see nothing here that makes me believe that they are unsafe.