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Flight Safety Information

FOURTH QUARTER 2004

INSIDE THIS ISSUE


Safety Management Systems Threat Error Management Model
ISASI Seminar 2005
Major Accidents/Incidents

FSI

To FSI Subscribers:

Safety Management Systems


(SMS)
3

Threat Error Management


Model
7

Welcome to the Flight Safety


Information Fourth Quarter
Journal. The journal is produced in order to create safety
awareness, provide timely and
valuable safety information,
and to ultimately prevent accidents. I welcome contributing input, articles, and photos
from the readers.
Curt L. Lewis P.E., CSP

Flight Safety
Information Journal
ISASI Seminar 2005
9

Published by
www.fsinfo.org
Managing Editor
Curt Lewis P.E., CSP
Curt.Lewis@fsinfo.org
Associate Editor
Sylvia Hughes
sylviah013@hotmail.com

Major Accidents / Incidents


10

Webmaster
Randy Enberg
Randy.Enberg@fsinfo.org

Flight Safety Information Quarterly Journal is a service of:


Curt Lewis, P.E., CSP
Lewis Engineering & Associates
www.Curt-Lewis.com

FSI

Safety Management Systems


Safety has always be a main design concern
in the Aviation industry. The need for Safety
Management is a legal requirement for Air
Navigation Service Providers, but it is also a
business necessity.
A Safety Management System (SMS) is an
integrated set of work practices, beliefs and procedures
for monitoring and improving safety. SMS can be defined as a formal framework
for integrating safety into day
to day operation and includes safety goals and performance targets, risk assessments, responsibilities and authorities, rules
and procedures, and monitoring and evaluation processes. It recognizes the potential for
errors and establishes defenses to ensure that
errors do not result in incidents or accidents.
Effective SMS generally have five key elex
x
x
x
x

Clear policies.
Effective organization.
Systematic planning.
Performance measurement.
Audit and review process.

The foundation of SMS is the implementation of a safety policy with in a company, in


which it expresses its commitment to
achieve the highest levels of safety.
Safety Management Systems make economic sense
Not only do SMSs guard against
mishaps, but they also provide
economic benefits in helping the
company:
x Market the safety standards
of your operation.
x Guard against the direct and
indirect costs of incidents and
accidents.
x Improve communication, morale and
productivity.
x Meet your legal responsibilities to manage safety.
Costs associated with an accident/incidents
are direct, indirect and industry/social
costs.
Direct costs:
Are easily measured on-the-spot; mostly related to physical damage; employee injuries
and aircraft equipment damage as well as
property damage.
Indirect costs:
Indirect costs are usually higher and less
obvious, causing delays.

Fig 1 Safety Management Cycle

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Indirect costs include:


Loss of business and
damage to the reputation
of the organization
x Legal and damages claims
x Surplus spares, tools and
training: If you have a
spares inventory and people trained for a one-of-akind aircraft that is involved in an accident, the
spares and training become surplus overnight.
In many cases, the sale
value of the spares is below the purchase cost.

Components of a Safety
Management System

x

For each component of an


SMS where specific procedures and processes are necessary, check lists or flow

x

x

The requirement for a


Safety Management System
Every organization needs a
functioning management
system that has continuity
throughout the organization
and provides positive control
of the operation. The system
must have the accountability
to ensue the effectiveness
and integrity of the operational management and control system.
The organization needs to
identify and assign responsibility within the management
system for ensuring compliance with regulatory requirements and established internal standards.

Policy: A policy statement regarding the company safety


goals should:

x

charts need to be developed


to facilitate implementation.
All components of an SMS
should be reviewed on a
regular basis to ensure that
they remain current and relevant to the organization.
All policies must be complemented with clearly defined
procedures and processes
detailing how the policy is to
be implement and managed.
The following components,
as a minimum, should be
included in an SMS:

x
x

x

Contain a senior management commitment to


safety as a fundamental
priority throughout the
organization and be signed
by the accountable executive;
Contain a clear statement
of objectives indicating the
organization's safety requirements and the principles and measures necessary to conform to state
and local safety regulations;
Promote a safety culture
embracing a non-punitive
reporting procedure;
Be relevant to the organization's operations;
Identify clearly that the
safety principles outlined
in the SMS policy statement applies to employees, agents and other contracted parties; and
The SMS should cover
procedures for reporting
and coordinating events
and activities performed
by other organizations that
are subject to their own
safety management systems, between the relevant
systems.

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Accountabilities: Ultimate responsibility


for the SMS remains at all times with the
accountable executive; however, responsibility for the implementation of the SMS
may be delegated to an identified responsible person. The safety responsibilities of
managers and employees at different levels in the organization should be clearly
defined and documented. Effective deputation of responsibilities should be established for operationally critical areas of
the operation when principal office holders are absent.

x

x

x

x

Flight Safety Program: The Flight Safety


Program should have:
x

A responsible manager having the appropriate qualifications, significant authority


and independence from operational and
line management responsibilities.

A flight safety management plan that


describes the philosophy, structure,
responsibilities, resources and processes in place to prevent accidents
and achieve safe operations.
x A process for setting safety goals as a
means of establishing an indication of
flight safety performance.

x

Accident Prevention Program: The accident prevention program should include:


x A process to ensure the capture and
analysis of information that can be
used to identify operational hazards.
x A process for the investigation of aircraft accidents and serious incidents.
The process should include procedures for an interface with relevant
government regulatory and investigative agencies, as well as other entities,
including original equipment manufacturers.

x

A process for identifying and investigating internal events, occurrences and irregularities that might be precursors to
an accident or serious incident.
A process to ensure the implementation
of action by appropriate operational
managers to correct and prevent nonconformities that affect flight operations.
A process to ensure regular and periodic
management reviews of significant and
relevant safety issues arising from the accident prevention and flight safety program.
A safety reporting system that permits
feedback from personnel regarding hazards and safety related concerns, and includes analysis and action by management as appropriate to identify and address safety deficiencies.
A process to ensure dissemination of
flight safety information to appropriate
operational and other personnel to promote continuing education and interest.

Risk Management Program: Risk management is the cornerstone of an SMS, and comprises three essential elements: hazard identification, risk assessment and risk control.
x Proactive processes to collect and analyze
data from routine monitoring processes,
incidents, inspections and audits to assist
in hazard identification are required.
x Hazards identified from data analysis and
trending need further assessment to determine any potentially adverse consequences in terms of risk exposure.
x Based on the risk assessment process,
risks may be categorized with a degree of
acceptability and control measures introduced to deal with those deemed undesirable or unacceptable.

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Emergency Response Program: An SMS


should include contingency plans to ensure
the proper response demanded of different
parts of an organization when an emergency arises. The emergency response plan
must be assigned to a responsible manager
and reviewed as part of an SMS periodic
review, and also following any change to
key safety personnel, or any change to the
organization's operation that may affect
safety. The organization must have procedures in place to ensure the effective communication of the emergency response plan
to all personnel, including sub-contractors
and visitors.
Audits and Inspections: The accountable
executive is responsible for periodic reviews
of the SMS to confirm that the system remains effective. The reviews may be performed by persons within the organization
or by external means. Persons whose role
and reporting relationships are independent of the tasks, functions or operations
being evaluated should, to the maximum
extent possible, perform the reviews.
IATA Operational Safety Audit (IOSA):
Section 1 of the IOSA Standards Manual
(ISM) and the associated Guidance Notes
incorporates all of the requirements of an
airline management system, including both
Safety and Quality Management Systems. It
follows that compliance with the IOSA requirements achieves the necessary standards in SMS.
*

References
Civil Aviation Authority Australia (2002)
Safety management systems: What's
in it for you? Http://www.casa.gov.
au/avreg/business/sms/guidance.
htm
Transport Canada Civil Aviation (2004) Safety
management Systems for small
aviation operations- A practical guide to
implementation. http://www.tc.
gc.ca/civilaviation/general/
Flttrain/SMS/TP14135-1/ menu.htm

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Threat Error Management Model


It is inevitable that error will occur within a
system no matter how strenuously it was engineered out. Threat error management (TEM)
is a framework for understanding operational
performance in complex environments. It focuses simultaneously on the operating environment and the humans working in it. The TEM
model proposes that threats and errors are an
integral part of daily flight operations and that
they must be managed by the flight crews to
ensure the safe outcome of flights. Threats are
events that are external to the flight deck and
must be managed by flight crew during normal
everyday flights.
In the model of threat and error management,
external threats are defined as situations, events
or errors that originate outside of the cockpit,
i.e. high terrain, poor weather, aircraft system
malfunction, errors made by the crew or maintenance, and Air Traffic Controllers (ATCO).
Such events increase operational complexity
and pose a potential safety risk to the mission.
Threats are to be expected by the crew and
briefed in advance. They may also be unexpected, appearing without warning or possibility of briefing.

Some threats are minor (a slight discrepancy in dispatch papers) or major (an incorrect altitude assignment).
Threat management is the act of minimizing the potential for the threat to occur.
Errors are actions or inactions by the crew
that lead to deviations from organizational
or flight crew intentions or expectations.
Errors in the operational context tend to
reduce the margin of safety and pose
a potential risk to the flight.

Threat & Error Management Model

Fig 2 ICAO November 2004

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Errors may be minor (selecting the
wrong altitude into the mode control panel,
but catching it quickly) or major
(forgetting to do an essential checklist). The TEM model provides a
quantifiable framework to collect
and categorize safety data.
To be effective in establishing a
safety culture in an organization, it
must be established based on data
regarding the organizations practices and the threats inherent in
the operational context.
Multiple sources are used, one of
which is the Line Operations
Safety Audit (LOSA) in which expert observers collect data in the
cockpit during
normal operations. In
LOSA, trained
observers record
and code potential threats to
safety and how
the threats are
addressed during
the flight. They
also record and
code the errors
such threats generate, and how
flight crews manage these
errors. The TEM model has been
successfully incorporated into airline training programs and, in some
cases, has replaced crew resource
management (CRM) training.

8
The Air Traffic Services (ATS)
equivalent of CRM training is called
team resource management (TRM)
training. The integration of the
TEM model in TRM training may
lay the foundations for future operations safety monitoring in ATS.
*
To be effective in
establishing a safety
culture in an organization, it must
be established based
on data regarding
the organizations
practices and the
threats inherent in
the operational
context.

References
Helmreich, R. L., Klinect, J. R., &
Wilhelm, J. A. (2004). Models
of threat, error, & CRM in flight
operations. The University of
Texas at Austin.
Http://homepage.psy.utexas.edu
/homepage/group/Hemrich
LAB/Publications/pubfiles/
Pub240.pdf
Helmreich, R. L., Klinect, J. R., &
Wilhelm, J.A. (2004). Threat
& Error Management: Data
from line operations safety audits.
The University of Texas at
Austin.
Threat & Error Management Model (Doc
9803). (2004).
www.eurocontrol.int/safety/galle
ry/ content/public/library/
TEM%20&%20NOSS

FSI

10

Accident / Incident Overview


Fourth Quarter 2004

DATE

AIRCRAFT

REGISTRATION

OPERATOR

FATALITIES

LOCATION

Sept 23

Cessna 208

N7392B

Eagle Air Cargo

USA

Substantially damaged during an in-flight collision with terrain

Sept 25

Ford Tri-Motor

N750RW

private

USA

The Bushmaster, a Ford Tri-Motor replica plane, took part in an air show
at Fullerton. As it was attempting to takeoff, it departed runway 24. The
pilot pulled up to avoid ramp personnel. It just missed the control tower
and slammed onto a street, sideswiping a car. The plane broke apart on
impact and erupted in flames.
Oct 3

Howard 250

N6371C

American Airpower

USA

The Howard 250, a converted Lockheed L-18, was prepared for takeoff from Midland following the conclusion of the Fina-CAF AirSho.
The aircraft was cleared for a runway 34L departure with winds at
140 deg. /9 kts. Shortly after starting the takeoff roll the airplane began to swerve to the right. Using the rudder the captain was able to
correct back to the centerline. The airplane then swerved to the left
and using full right rudder the captain reported that he could not arrest the left turn. By the time the airplane reached the left side of the
runway, the airplane had not reached the V2 speed (minimum takeoff
safety speed) of 110 knots. The airplane departed the left side of the
runway, became airborne and shortly thereafter, the right wing
dipped and contacted the ground. The airplane then spun 180 degrees, impacted the terrain, and slid backwards coming to rest in an
upright position.
Oct 5

Antonov 12

ST-SAF?

Sarit Airlines

Sudan

The Antonov, piloted by four Russian crew members, reportedly


left El Obeid around 11:35 for a flight to Juba. Weather circumstances forced the crew to divert to Higlig. The aircraft crashed,
killing al aboard. The identity of the plane has not been confirmed.

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11

DATE

AIRCRAFT

REGISTRATION

OPERATOR

FATALITIES

LOCATION

Oct 08

Fokker F-28

S2-ACH

Biman Bangladesh

Bangladesh

Biman flight 601 touched down far down Sylhet's 9000-feet runway 11/29.
The airplane overran the wet runway by 150 feet and ended up in a 20 ft
wide canal. The cockpit sustained serious damage. The crew members
were rescued from the wreckage after several hours. It had not yet been
confirmed that the plane is damaged beyond repair. Damage to the forward fuselage is serious.
Oct 14

Boeing 747

9G-MKJ

MK Airlines

Canada

At 00:03 local time MK Airlines flight 1602 departed Windsor LocksBradley International Airport for a flight to Zaragoza, Spain with a cargo
of lawn tractors. Take-off clearance was then given at 03:52 and the
crew conducted rolling take-off from near the end of Runway 24. The
Boeing 747 accelerated down the runway, but was unable to pick up
enough speed. The tail contacted the runway and at a speed of about
130 kts, 30 kts below take-off speed, the aircraft overran the runway.
The tail smashed against a berm, causing it to separate from the main
fuselage. The airplane skidded into a wooded area and began to break
up. The wings separated and a fire started, which consumed the fuselage.
Oct 14

Canadair Regional Jet

N8396A

Pinnacle Airlines

USA

At 22:08, the flight crew stated that they had a double engine failure and
that they wanted a direct route to any airport. Kansas City ARTCC directed the flight to Jefferson City Airport. At about 22:13, the flight crew
stated that they had the runway approach end in sight. The airplane did
not make it to the airport and crashed and broke up in a residential
area. about two miles from the airport. A large fire erupted.
Oct 15

Douglas DC-3

HK-1503

Aerovanguardia

Columbia

Douglas DC-3 HK-1503 departed Villavicencio at 06:30 in the morning


for a cargo flight to Medelln- Jos Mara Crdova Airport. At 07:35
the air traffic controller radioed that weather conditions at the airport
were poor due to fog. The captain then decided to divert to MedillinEnrique Olaya Herrera Airport. While descending, the airplane struck
electricity wires and crashed into wooded area.

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12

DATE

AIRCRAFT

REGISTRATION

OPERATOR

FATALITIES

LOCATION

Oct 19

Jetstream 31

N875JX

Corporate Airlines

13

USA

Crashed in a wooded area on approach to Kirksville. Eight people are


reported dead, five people were missing and there were two known survivors. METAR around the time of the accident (ca 00:33Z):
KIRK 192355Z AUTO 03007KT 6SM BR OVC007 09/09 A2995 RMK AO2
CIG 004V009 SLP1486//// T00940089 53011 TSNO=
KIRK 200019Z AUTO 04005KT 3SM BR OVC003 09/09 A2995 RMK AO2
TSNO=
Oct 24

Learjet 35

N30DK

Med Flight Air


Ambulance

USA

The flight departed Brown Field's runway 8 at 00:23 after dropping a


medical patient off, and was returning to Albuquerque. It climbed
straight ahead and the SoCAL TRACON controller instructed the pilots
to turn to a heading of 020 degrees, maintain VFR (visual flight rules),
and expect their IFR clearance above 5,000 feet. The aircraft then entered a broken-to-overcast layer of clouds and crashed into the Otay
Mountain at an altitude of 2300 feet. Crashed in an isolated, mountainous area approximately two minutes after takeoff.
Nov 07

Boeing 747

TF-ARR

Air Atlanta Cargo

U.A.E.

The aircraft was substantially damaged after overrunning runway 30/12 (4060 meters long). The aircraft had aborted the
takeoff and could not be brought to a halt on the runway. Reportedly, some tires burst, the undercarriage collapsed and
the left wing as well as fuselage received substantial structural damage.
Nov 18

Jetstream 31

YV-1083C

Venezolana

Venezuela

While attempting to land on runway 09, the Jetstream collided


with the fire station to the right of the runway. The METAR
around the time of the accident read: SVMI 181700Z 29005KT
9999 -DZ BKN013 26/26 Q1013= (wind 290 degrees at 5kts, visibility >10000m, light drizzle, 5-7 oktas cloud at 1300ft, temperature 26C dewpoint 26C QNH 1013hPa). A heavy thunderstorm
was approaching the airport containing 3-4 oktas cloud at
1200ft.

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13

DATE

AIRCRAFT

REGISTRATION

OPERATOR

FATALITIES

LOCATION

Nov 21

Canadair
Regional Jet

B-3072

China Yunnan

53

China

Crashed into a frozen lake in Nanhai Park just two kilometers past the
runway. Reportedly the aircraft struck a park ticket office, killing a park
employee, before it crashed into the water.
Nov 22

Gulfstream

N85VT

Jet Place Inc.

USA

Crashed short of the runway in foggy conditions after one of the wings
clipped a light pole. The METAR around the time of the accident read:
KHOU 221253Z 12005KT 1/8SM BR BKN001 BKN006 OVC050 22/22
A3002 (wind 120 degrees at 5kts, visibility 1/8nm/230 m, mist 5-7 oktas
cloud at 100ft, 5-7 oktas cloud at 600ft, 8 oktas overcast cloud at 5000ft,
temperature 22C, dewpoint 22C, QNH 30.02in)
Nov 27

CASA 212

N960BW

USAF

Afghanistan

The CASA 212 was contracted by the US Air Force to supply American forces deployed in remote areas of Afghanistan. En route to
Shindbad the airplane struck the top of Baba Mountain, in the heart of
the Hindu Kush mountains, at an altitude of 16,600 feet. Probably the
aircraft had been caught in a narrow valley and crashed as the pilot
tried to make a steep turn.
Nov 28

Canadair
Challenger

N873G

Air Castle

USA

The aircraft crashed on takeoff. It reportedly skidded sideways off


the runway, went though a fence and brush before hitting a roadway that ripped the cockpit from the fuselage. The aircraft attempted to depart from Montrose's 7500 feet long runway 31. The
airport reported light snow and mist at the time of the accident.

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14

DATE

AIRCRAFT

REGISTRATION

OPERATOR

FATALITIES

LOCATION

Nov 30

MD-80

PK-LMN

Lion Airlines

26

Indonesia

The MD-82 skidded off the rain-slicked runway on landing. Solo has a
single 8530ft / 2600m runway (08/26).

Nov 30

HFB-320
Hansa Jet

N604GA

Grand Aire
Express

USA

The aircraft, carrying Grand Aire's president and chief executive,


crashed shortly after takeoff from Saint Louis. METAR at the time of the
accident read: KSUS 301354Z 03003KT 3SM -RA BR OVC005 05/04
A3006 RMK AO2 SFC VIS 5 SLP183 P0001 T00500044=
Dec 04

Convair CV-340

N41626

Miami Air Lease

USA

The plane departed Opa-Locka at 08:39 carrying a load consisting of


electronics, toys and furniture. About four miles offshore, the pilot
felt the plane vibrating and he saw smoke coming from the nr.1 engine. The crew were unable to feather the nr.1 propeller and the
plane began to lose altitude. The pilot then turned and ditched the
plane in the Maule Lake Marina in Miami.
Dec 06

Cessna 208

N25SA

Salmon Air

USA

Crashed while on an RNAV approach to runway 31

Dec 10

Antonov 28

GN-97121

Venezuela ANG

16

Venezuela

The M-28 departed Puerto Ayacucho at 09:12 for a flight to La


Carlota. It crashed in mountainous terrain at an altitude of
FL115.

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15

DATE

AIRCRAFT

REGISTRATION

OPERATOR

FATALITIES

LOCATION

Dec 11

Embraer 110

PT-WAK

NHR Taxi-Aereo

Brazil

The Bandeirante departed So Paulo on an early morning mail flight


on behalf of TOTAL Linhas Areas. It crashed onto a house in the Rua
Uirapuru, killing one person inside.

Curt Lewis P.E., C.S.P.


Lewis Engineering & Associates
Office:817-303-9096
Cell: 817-845-3983
E-mail: Curt@Curt-Lewis.com
Web: Curt-Lewis.com
Lewis-Engineering.com
P.O. Box 120243
Arlington, TX 76012
USA

W H O W E A R E Lewis Engineering & Associates is a multidiscipline engineering


and scientific consulting firm. Our personnel are qualified in the fields of:
Residential/Light Commercial Engineering, Forensic Engineering,
Product Safety, System Safety, ISO 9001 Certification,
Accident Investigation/Reconstruction, Automotive Crash Worthiness,
Railroad Crossing Collisions

INDUSTRY STANDARDS
All work is accomplished by or under supervision of a registered Professional EnWe are highly familiar with the industry gineer (PE) and Certified Safety Professional (CSP).
standards used to regulate industry
Engineering Services
practices and procedures along with
those used to protect your employees
and customers from harm. We can
i Accident Investigation/
i Forensic Engineering
thoroughly examine your business prac- i Structural Safety
Reconstruction
tices to ensure standards, laws and
i Industrial Safety
i Industrial Safety
codes are being followed appropriately.
i Fire Cause & Origin Analysis
i Safety Engineering
Some of the more common standards
i Pre-OSHA Compliance Audits
i Product Safety
include:
i OSHA Industry Outreach Training
i Marine Safety
ANSI
OPEI
i Expert Witnesses
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i Railroad Accidents
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UL
NIST
i Product Testing
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CSA
MIL
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VDE
AWS
i ISO 9000 Compliance and Auditing
ASTM
API
SAE

HFS

ICBO

IEEE

NFPA

ISO

FAR

ASAE

NEC

OSHA

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16

Curt Lewis P.E., CSP


Lewis Engineering & Associates
Aviation Safety Engineering
& Accident Investigation
Aviation Safety Program
Lewis Engineering & Associates can assist your company in
developing an effective aviation safety program tailored
x

Safety Education and


Training

x

Accident and Incident


Investigation

x

Internal Reporting System

x

Safety Information Distribution

x

Aviation Safety Commitx


tee

x

Safety Audits and Inspections

x

Safety Program Analysis


Safety Awards

Other Safety Areas


Aviation Safety Engineering goes beyond looking at aircraft and making sure they are well maintained. Aviation safety engineering looks at
the big picture. It takes into account every aspect of your business
plus those that might impose risk to your employees or customers.
These areas include:
x

Airport Facilities and Airfields

x

Fuel Storage and Services

x

Airport and Aircraft Security

x

Ramp/Gate Operations

Office: 817-303-9096 Cell: 817-845-3983 E-mail: Curt@Curt-Lewis.com


Web: Curt-Lewis.com or Lewis-Engineering.com P.O. Box: 120243
Arlington, TX 76012 USA

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17

1 Process

6 Phases

7 Systems

15 Subsystems

105 Categories

2000
2262

Letter Of Compliance
Required Entries

CAVOK

3934

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world.
*

FARs
Specific Regulatory
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10000

SAI/EPI
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CAVOK folks know ATOS. We have developed tools,
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