Another outcome of the R. Fortunately one advantage of data in digital form is that it lends itself readily to handling by computer. A schematic of the pneumatic deice system and cross section of the deice boot is presented in figures 2 and 3, respectively. Code, Annotated are exempt from both the immunity and confidentiality provisions of the ASRS program. The ASRS program managers made an early decision to use the services of a civilian contractor to assist in the design and management of the ASRS program.

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Si pour une raison quelconque, vous êtes satisfait de notre produit ou un service, veuillez nous contacter avant de laisser vos commentaires afin que nous puissions résoudre le problème. The others were strongly oriented toward design a subject which was not covered by the symposium: To this end the possibilities of recording operational data on some civil helicopters is being actively pursued. In addition to its ability to fulfill the role of a disinterested intermediary, NASA saw a unique benefit to its research capability deriving from ongoing access to the human factors data generated by an incident reporting system. As a result, aviators encounter flight problems from which they cannot recover, e.

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The content of this publication has been reproduced directly from material supplied by AGARD or the authors. This explains a continuous activity of this panel devoted to the lessons from operational experience on flight mechanics and design of aircraft and systems.

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This subject is covered by symposia at regular intervals, the first of which took place in in Baden-Baden, Federal Republic of Germany. The following tianium were covered: The second symposium was arranged in in Sandefjord, Norway, with the following title: Again a first session was devoted to methods for accident statistics and analysis. The others were strongly oriented toward design a subject which was not covered by the symposium: Then a small session was devoted to aircrew considerations.

It can be seen from the description of the above two meetings that the second one put strong emphasis on the design aspect with little consideration of the man-machine interface. From the major change which has occurred in the design of aircraft is the general use of electrical controls in combat aircraft fly-by-wire together with sophisticated systems used to provide man-machine interfaces, enabling an increase of efficiency of the crew, together with an increase of safety.

Thus the periodic review of the lessons from experience which it was decided would be the subject for the spring meeting of the Flight Mechanics Panel was arranged in order to put some emphasis on these two major subjects. The first session, titanum devoted to the progress made in recording techniques, was reoriented toward the reporting systems used in various countries which exert influence on operations and design; the second session to adverse environment including rotorcraft icing, operation from high altitude airfields, windshear, atmospheric electricity.

The third session was devoted to survivability after failure. Examples were given of new electrical control systems. The last session, the largest one with seven papers, was devoted to the man-machine interface. Much has been learned from the discussions held after each presentation; it is hardly possible to sum up in a few words what could be the conclusions and recommendations about such a broad area covered recroder this symposium.

Nevertheless the following remarks can be made: This is well shown by Session I with a special mention of the papers on incident reporting systems by NASA, and Air France which illustrate this point quite well. Ui 3 the most controversial subject is that of the man-machine interface; great advances have been made in that area with the new head-up and head-down display and new control systems.

But crews are always discussing the best means to use, the training needed to make proper use of new systems, the proving of new information systems. In conclusion, it can be said that such symposia are very useful as they provide a unique opportunity for discussion between aircraft designers and users.

Thus, it is appropriate that another meeting of this type be arranged in a few years, when the emphasis could be on the subject of man-machine interface and the increasing use of digital computers and associated controls and displays, as they could influence the design of aircraft from an operational viewpoint.


Le titanijm eut lieu en a Baden-Baden, Allemagne Federate, sous le titre: Les sujets suivants furent traites: Le second fut organise en a Sandefjord, Norvege; son titre etait: Les autres furent principalement orientees vers la conception sujet non traite au symposium de Une petite session fut consacree au probleme de ‘equipage. A partir deune revolution titainum la conception de Fa6ronef: La troisteme session est consacree k la survie apres panne et illustree par des exemples des nouveaux systemes de commandes eiectriques.

Les discussions apres chaque presentation ont ete riches d’enseignements; il est difficile de resumer en quelques mots ce que peuvent etre les conclusions et recommandations concemant le vaste sujet de ce symposium. Cependant, on peut faire les remarques suivantes: Ceci est bien demontre par la Session I et en recorer par les communications sur le NASA Reporting System et sur le systeme employe par Air France, qui illustrent bien ce point de vue. Apres lecture de ce texte, le lecteur ne pourra faire autrement que de lire entierement la Session IV.

En conclusion finale, on peut dire que de tels symposiums titsnium tres utiles en donnant au constructed une occasion unique de discuter avec les utilisateurs.

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From fiscal year FY the Army has experienced an average of 91 major aircraft accidents per year. Figure 1 shows the cause factors of these accidents and it can be seen that human error is by far the largest. The problem for the safety community is to identify sources uadio these cause factors in the Army system, take corrective action and thereby make the system more efficient and effective. In the accident model presented in Figure 2 there are 12 Items outlined which are basic elements of the Army system.

When one or more of these elements Is out of ttanium, an overload Item 13 is placed on the system role of personnel, materiel or the environment item Host titanijm errors, materiel failures and environmental factors do not lead to accidents item However, when circumstances operate unfavorably accidents occur item Table 1 shows this 3W approach. It requires each investigator to answer what happened, what caused it to happen, and what to do about it with respect to man, machine and environmental cause factors.

It can be seen that accident cause factors originate from inadequacies in the system. When remedies are applied which correct these system inadequacies, then human errors, materiel failures and the environment’s affect on man and machine are reduced.

As a result, fewer accidents occur and a more efficient and effective system is produced. Both reports are based on an OH accident. Table recodrer rspresents the type of informat on reported before implementation of the 3W approach. Particular attention should be focused on the proper use of the landing light.

Table 3 shows the type of information reported using the 3W approach. It can be seen that the critical question of why the pilot did titnaium use the landing light is answered titnaium the identification of system inadequacies. Consequently, remedial measures In the third column address system Inadequacies which are the root causes of the pilot error. He failed to use landing light to determine suitability of area for precautionary landing The landing light recordef glare and obstructed vision of the pilot.

Because of inadequate unit training. Pilot had not received sufficient training in execution of emergency procedures at night due to the unit being without an OH IP for 3 months.

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The remaining 22 accidents were investigated by field accident boards. The 3W information from reports of these accidents was then formatted into lessons learned and grouped by Aircrew Training Manual Tasks. Utility, observation and attack helicopters accounted for of the lessons learned and 76Z the cost. It can be seen that Inadequate supervision and inadequate self-discipline account for most of the system inadequacies.

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Examples of lessons learned are appended. This enabled the identification of lessons learned with respect to cost, type aircraft, flight tasks, cause factors and system inadequacies 6.02 produced the human error and materiel failure cause factors. The lessons learned identified human error as the primary cause factor, regardless of type reecorder, and these errors showed up mainly in emergency or landing and approach tasks.


The most frequent system inadequacies leading to human error were inadequate self-discipline and Inadequate supervision. The unit conaander is in the best position to take actions that will correct these Inadequacies within the unit.

Therefore, all lessons learned from FY 82 have been compiled recorcer a single report and tltanium to commanders of aviation units. Additionally, the lessons learned report has been provided to major commands and higher staff levels for actions to correct system problems that are beyond the purview of unit commanders. Aviators who Intentionally violate written guidelines and verbal orders governing requirements of low level flight increase the probability of wire strikes.

Because of excessive self-motivation or Improper motivation, avlatots intentionally fly their aircraft at low level altitudes and airspeeds that violate oral and written guidelines. As a result, aviators encounter flight problems from which they cannot recover, e.

Unit Commander take positive command action to Insure aviators understand and comply with oral and written guidelines governing low-level flight altitudes and airspeeds and that these guidelines are not violated to enhance mission accomplishment.

Inadequate self-discipline of aviators adversely affects their ability to make sound decisions regarding by-the-book flight and safe aircraft operations during approach. AH-1S Class C accident: PIC’s inadequate self-discipline improper attitude encouraged pilot to fly unautorized maneuvers which exceeded the pilot’s and aircraft’s abilities. Pilot was in a hurry to return to the heliport because of deteriorating weather conditions. In his haste the pilot reduced the throttle below necessary RPM in contravention of TMtiitanium causing him to land tall low.

Recommend Unit Commander inform personnel of .60.2 and remedies associated with these accidents. Include titahium discussion of the adverse affect « haste » can have on job performance. A Unit Hitanium who fails to establish a crew rest policy in accordance with TableAR lncreasesthe probability of having fatigued aviators making critical errors. The lack of unit guidance regarding crew rest requirements for aviators promotes abuses in the assignment of work tasks for aviators, e.

Unit Commander take positive comnand action to insure crew rest polices are established.

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ARTablemay be used as a guide in this effort. Failure to Insure TM OH provides adequate instructions for describing tall rotor malfunctions and the correct emergency procedures for coping with them increases the probability of an aviator improperly handling this type of emergency. OH 2 Fatal Injuries: Tall rotor malfunctions and loss of tall rotor effectiveness has become a concern in OH aircraft. However, about two pages of TM are delegated to a description of tail rotor rcorder and emergency procedures.

The terminology used is vague and the procedures described conflict from one paragraph to the next such that the reader is confused as to the required corrective actlon s. DARCOM revise procedures in TM B, Chapter rceorder, concerning tail rotor malfunctions such that corrective actions for each set of circumstances are expressed explicitly and without conflict.

Techniques for rapid dissemination rceorder the information to investigators are illustrated.

Future developments in the design of voice and data recorders are discussed. Their unparalleled ability to provide detailed information on the events leading up to a mishap can rapidly indicate the areas in which the investigators should focus their activities.

In Canada, our experience with flight recorders has been confined mainly to transport aircraft. The Centre is responsible for playback and analysis of information from all accidents and incidents as requested by the investigating authorities.

The centre is required to process fourteen different basic recorders and a number of minor variants. The civil systems involve separate voice and data recorders armoured and insulated to protect them in the crash environment. The voice recorders are designed to retain the last 30 minutes of information and the data recorders the last 15 to 25 hours.

The recorder retains the last 30 minutes of both voice and data. In this paper, I will attempt to summarise some of our subsequent efforts and comment on the future development of recording systems.