Category Archives: Safety Investigations

Alternative Analysis Recommendations, Conclusions Aviation Disasters

MH 370: Probable Location for Search Malaysian Airlines Flight 370, Missing B777 Was Hazardous Cargo Aboard?

MH 370: Probable Location for Search

Malaysian Airlines Flight 370, Missing B777

Was Hazardous Cargo Aboard?

Are Cargo Safety Regulations Important for PASSENGER Aircraft Flights?  Two Levels of Safety May Mean No Level of Safety

 

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MH 370 flight crew members witnessing an overheat in the large cargo compartments of their Boeing 777, would most likely do the following steps:

1. Don oxygen full face masks, check for full oxygen flow for breathing and clearing of smoke from eyes and reestablish communications via the mask microphones

2. Run fire suppression checklists

3. Begin divert to nearest available airport and begin descent for landing, with the goal of landing as soon as possible, certainly less than 20 minutes. But after the turn to divert, if the crew becomes incapacitated by smoke and fumes, the aircraft would continue to fly on whatever heading was established. Considering natural static and dynamic stability of many transport category airliners, such as the Boeing 777, the aircraft would remain flying while the nose of the aircraft oscillates slowly up and down to maintain  stability.

Looking at what is known about the flight path of MH370, the crew appears to make a sudden turn directly towards a very long 13,000 ft long runway airport. Communications by radio cease.  Fishermen at sea in the area of the 13,000 ft runway reported witnessing a large aircraft flying low during the time frame consistent with the flight parameters possible arrival in that area. This scenario is consistent with smoke and fumes in the aircraft for whatever reason may have been occurring on the flight.

The captain was an experienced international captain. The first officer was an experienced flight crew member [albeit reportedly with a tendency to invite friends and acquaintances  to the cockpit, although whether that was on the ground at terminal only has not been established].  The captain was resourceful by creating his own flight simulator at home, most likely for the purpose of training himself to perform the hundreds of standard operating procedures (SOP) required of B777 flight crew members during semi-annual regulatory checkrides. It is also quite probable that the captain invited  other crew members to join him in these SOP procedure training sessions. A check of the software companies who sell flight simulator software world wide reveals that tens of thousands of people own these same home simulators, some for professional training, some for entertainment. More than half a dozen vendors make this type of software  and it is globally available on the commercial software market.

Personal history of the flight crew members appears stable.  As with many flight crew members they have been long engaged in their profession and are dedicated to always learning more.

So where could investigators look next in their investigation? How about the known or unknown hazardous material that was loaded as cargo or baggage? Is not the cargo hold of  MH 370, a B777 is capable of hauling large weights of cargo? Was any cargo or baggage trans-shipped, that is, loaded aboard MH 370 from flights connecting booked passengers to Beijing? Who checked all of the cargo and baggage that was loaded onto MH 370? Who was supposed to check for hazardous material to ensure documentation or restriction of prohibited items from passenger flights? Who may have shipped cargo or baggage of prohibited items and why? Should not this more likely scenario be at a higher level of priority than looking at the captain’s personal flight simulator?

Hazardous cargo can catch fire and spread quickly. See the mishaps of the 1996 ValuJet crash in The Everglades outside of Miami, Florida or UPS 6, September,2010 in Dubai for substantiation. The Swiss Air 111 inflight fire again substantiates that time is very limited when a crew is dealing with this emergency.

Lobbyists for the airline passenger and for the cargo business side have long argued against comprehensive commercial airline hazardous cargo regs, convincing legislators and regulators that more regs are unnecessary as is enforcement. At the same time they haul for profit as much cargo as they can get their hands on, plus luggage containing uninspected material, shipped as innocent personal belongings. Two levels of safety may mean no level of safety.

My guess is that the aircraft is in the water not far from where the fishermen said it was, or flew in the direction that the fishermen said it headed and is located out that vector.

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UPS 1354, Birmingham Runway 18, August 14, 2013: Is FAA Policy vs Procedures Inconsistency Causing A Severe Safety Risk in Commercial Aviation? “Is the Tail Wagging the Dog ?”

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In the last 40 years the US FAA has spent hundreds of billions of taxpayer dollars engineering safety into the nation’s commercial aviation infrastructure. This policy at the FAA has led to great success in achieving an astonishing low commercial aviation mishap rate in the US.  Moreover it has provided an example for Western Europe, Pacrim Asia and the rest of the world to match in building and outfitting highly standardized, major international commercial all-weather airports. Birmingham International Airport in Birmingham, Alabama is one of these airports.

But on the early morning hours of August 14, 2013 at Birmingham International, all of the latest and greatest in hundreds of billions of dollars of technology and engineering was put aside, so that an airfield electrician could change out a few dozen fifteen dollar light bulbs.  When UPS 1354 arrived at Birmingham in the cloudy, dark soup of early morning, the pilots’ heads were swimming in night time induced fatigue.  All that they hoped for was that the local FAA area Air Traffic Control approach controller would vector them onto the final approach course for the amazingly technical all weather runway. They hoped to couple up their fantastically sophisticated jet’s autoflight system to the airfield’s highly accurate electronic glide slope and precision path localizer. They planned to comply with FAA all weather approach procedures and bring their huge  jumbo jet down to the runway along an approach path well clear of trees, mountains and towers. They hoped to land on a well light, precision marked, sharply cut grooved and crowned runway.

But instead, someone at Birmingham, we don’t know who yet, made a decision to invoke a local procedure, a procedure that did not support the most sophisticated FAA instrument approach procedures nor the FAA policy of providing the latest and greatest engineering and technology to commercial flight crew landing huge jumbo jets at Birmingham Airport.

Someone at Birmingham took it upon themselves to take all of this engineering and technology out of service, to shut down all of these highly sophisticated procedures and do so for a considerable amount of time. They did so knowing full well that UPS 1354 would be scheduled to arrive at just this time and in fact was arriving in the area as scheduled. They also knew that the weather at the field held low lying clouds. Additionally, they knew full well that the runway that they would offer UPS 1354 on which to land held only antiquated technology dating back to the dawn of commercial aviation, literally into the 1930’s. Finally, they knew that the descent path for the approach to that runway was directly over hilly and irregular terrain north of the airport, an area unsuited for the installation of any ATC approach modern technology and engineering.

Who was it locally at Birmingham that approved such a procedure that clearly was inconsistent with official FAA all weather commercial operations policy and procedure, and especially so for a cloudy runway at night in the mountains, all while a fully instrumented and safely engineered runway was available and would be consistent  with current FAA safety policy? Where is that procedure written down?

Additionally, how did this conflict between local procedure and FAA policy and procedure for all weather commercial operations come to exist at Birmingham? For that matter how did it come to exist at any international FAA airport? Why didn’t someone either in Birmingham FAA Air Traffic Control Office or the Washington FAA Headquarters Air Traffic Control Directorate or the Commercial Air Safety Directorate question this apparent policy versus procedures inconsistency? Was this an FAA managerial snafu or in fact is this a widespread FAA organizational inconsistency and thus a severe commercial aviation safety hazard?

Was not a very similar commercial aviation safety policy versus all weather procedures conflict involved in the Asiana crash in San Francisco just a few months earlier? In that case, instead of an electrician changing out light bulbs, the airfield’s multi billion dollar engineering and technology instrument approach system was set aside so that bull dozers could move dirt around to build a taxiway.

How is it that such inconsistencies exist at FAA? Is this a case of the tail wagging the dog? How is it that the maintenance of light bulbs and airfield construction take precedence over the safe operation of commercial flight? Who at the Washington FAA Headquarters Safety Policy Directorate and the Air Traffic Control Directorate is supposed to be ensuring that local airfield FAA managers are employing procedures that are supportive and consistent with the FAA safety policy? Why are US taxpayers spending hundreds of billions of dollars on commercial airfield infrastructure and operational safety only to have that safety compromised by maintenance and construction and local procedures?

Are we really expecting our international jumbo jet flight crew members to make up for this FAA policy vs procedures failure, at 4am in the morning, in the dark, in the clouds and in the mountains by resorting to 1930’s technology and procedures? Really?

How many more similar commercial airline crashes must occur before the FAA is able to determine that they have policy vs procedures safety inconsistency?

In my opinion, the US National Transportation Safety Board needs to investigate this safety inconsistency, this very severe FAA commercial aviation safety hazard, this severe risk to the US taxpaying public and make a recommendation for corrective action to the FAA before the next similar commercial aviation mishap occurs. In my opinion, they should do so quickly.

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Titan B733, Chambery France, Loss of Control, Human Factors,14 April 2012: Is Flawed Aerodynamics in UK AAIB Investigation Report?

 

Captain Paul Miller preparing for a coming storm.

Captain Paul Miller preparing for a coming storm.

I believe that there is a basic flaw in the mishap investigation report by the UK AAIB. The flaw is a lack of inclusion of important take off aerodynamics procedures in the investigation, due to referencing solely the events surrounding EFB procedure errors. [Did the board seek the Safety Purpose or the Legal Purpose? See the end of the article for more on that argument.]

Here is the basic flaw in the investigation. The tail scrape occurred because the crew raised the deck angle to take off climb attitude instead of raising the deck angle to lift off angle. This is a mishap due to a misunderstanding of aerodynamics, rather than the entry error in the weight and balance procedure. If pilots reading this article remember this very important point, they will be able to prevent tail scrapes or tail strikes even in the circumstances where there has been an underweight error made in the weight and balance procedure.  Understanding the aerodynamics going on during the take off procedure will allow a flight crew member to easily overcome these errors and not damage the aircraft. Remember any damage on take off could lead to a compromise of the pressure vessel, which could lead to pressurization failures and even structural failure. So in my opinion it is very important that the UK AAIB considers reopening the investigation and delve into take off aerodynamics. In lieu of that happening, I have written this article to cover the important aerodynamics involved.

Take off really requires several steps. The first is the lift off rotation and the second is the rotation to take off climb. With our very powerful engines today, these two steps most often blend into one smooth step since the aircraft accelerates so quickly, even at heavier weights.

But in fact there are two separate steps and if flight crew member understands this, they will be able to both recognize that the lift off attitude, that is the deck angle read on the EADI, will be the same at any weight. By setting this deck angle and waiting for the wing to develop lift equal to weight at the correct speed for the weight, the crew will never drag the tail on the concrete. It is critical to recall that the wing lift is what raises the aircraft off of the runway. The thrust from the jet engines seems like the exhaust from a rocket, but if crew tries to raise the nose to “launch the aircraft into the air” with jet engine exhaust, much like a rocket takes off and if the wing needs more lift to raise the weight into the air, the rotation will not produce lift, but rather only drag the tail. Remember that raising the nose or deck angle up to the climb angle should never be done until the aircraft is airborne, that is wing borne, is lifted off the runway, hence my terminology “the lift off angle.”  So, let us look again at a wing trying to produce lift with an aircraft heavier that it was thought to be.

The wing of the aircraft, any aircraft, flies when it attains the correct lift, a product of  coefficient of lift and indicated airspeed creating a pressure differential spread over the wing’s surface area.  The coefficient of lift itself is based on the shape of the wing and the angle of attack of the wing in the airflow. When the coefficient of lift combined with the indicated airspeed spread over the wing surface is sufficient, the wing will produce a lifting force equal to the aircraft weight, the aircraft will rise up off the wheels and onto the wing and flight will be achieved. This is the lift off rotation from the wheels and onto the wing.

Just pulling the nose up at any speed, thereby creating angle of attack above optimal, is therefore never the correct procedure for lifting off of the runway into the first flight on the wing. The angle of attack is created by the deck angle setting the wing angle of attack when the indicated airspeed is achieved. You can not yank the nose up at a slower indicated airspeed to get lift because the angle of attack will be excessive and lift will be less than aircraft weight.  Therefore just pulling the nose up high past rotate angle and into climb angle is never the correct take off procedure. The weight will not yet be lifted onto the wing and therefore further rotation will just drop the tail to the runway and scrape it along at a very fast speed and with a very strong force. This is not good and may do a great deal of damage. This may be hard for crew members to remember especially if their previous training has been on smaller longitudinal axis aircraft such as a trainer. Since transport aircraft tend to be long bodied, the initial lift off rotation and take off climb procedures based on separate deck angles is so important to learn and remember.

The error that this crew made was pulling the plane into the air early at a lower than required indicated airspeed, to a deck angle well above the initial take off angle and up to the higher take off climb angle.

The lift off angle is often low, around 5-8  degrees. Then after the wing is producing lift and lifting the aircraft off the wheels and initially into the air, raising the nose slowly up, further to 15-20 degrees sets the climb angle and the take off climb. There rotation brings the entire aircraft into the air, not just the nose off the ground and the tail into the concrete.

Why was the mishap crew procedure an error? Was it because they may have been “trained” with incorrect practices? Moreover was there another error that this airline made either by teaching or allowing their flight crew to use incorrect and unwritten and unapproved “practices” (set by who knows who), instead of employing the correct, approved and published procedures? In my opinion written Procedures, not generally accepted Practice, is the key to safety and success.

Remember that there is a separate and lower lift off deck angle, the first-part-of-rotation angle, an angle meant purely for lift off of the aircraft from its landing gear and up onto its wing. Once this flight has been achieved, through the production of lift equal to weight by the wing, the aircraft can next accelerate and then climb upward on the wing. These two steps, initial lift off rotation from the wheels and onto the wing and take off climb on the wing, are all really separate aerodynamic events, even if we blend them into one smooth take off rotation procedure due to the rapid take off acceleration of powerful high bypass ration turbo fan engines.
In my opinion, it is a major flaw in aerodynamics to assume that raising the nose at any speed will be sufficient to achieve flight through lift. It appears that this flaw was not identified in the mishap investigation report. If it was in there, I did not find it. The flaw of the airline or the crew members is not uncommon. However, wouldn’t this information from the mishap board investigation identifying the procedural flaw, be of value to other pilots? In my opinion this a major mistake of omission and I believe  a correct accounting of the correct take off procedures should be offered here.

Every flight crew member flying all transport aircraft would be better off if they knew the basics of aerodynamics related to take off, so that they could prevent scraping the tail on takeoff, even in the hazardous event the take off weights are given wrong, calculated wrong or entered in the flight management computers wrong.

Here is the correct procedure in my opinion and in my opinion it is the same or very similar for all transport aircraft:
1. After application of whatever takeoff power  is chosen and as the aircraft approaches rotate speed, the crew should rotate to and then stop the rotation at the lift off deck attitude and do not go any higher. Stop here, hesitate here, be ready to remain here in the event that the aircraft is not yet at the correct lift off speed. If you do this, you will never ever drag the tail of the aircraft even if the weight and balance are wrong.  The speed will continue to accelerate and momentarily will be traveling fast enough for lift off to occur on the wing. If the take off data, the rotate speeds and take off speeds are correct and if the wing camber (flap setting) is correct, the wing will achieve the take off coefficient of lift at take off speed,  as the angle of attack lowers to the lift off angle of attack and the aircraft will lift off the wheels and onto the wing through the production of lift. Again, if the speeds are slow, it will be only by 15 to 20 knots at the most, and with large turbo fan engines, this 15-20 acceleration will take place within a few seconds, in my experience.

2. At that point the wing will lift the aircraft off the ground, because the lift is generated at the correct angle of attack and camber creating the take off coefficient of lift, at the correct indicated air speed. (This is not what is called ground effect, wherein the downwash angle is reduced by close proximity to the ground, thereby reducing induced drag and allowing acceleration and more lift from the aerodynamic force.)

Rather, this is actually the wing producing lift to get the weight of the aircraft up and off the ground. This is a very important step to recognize as a separate event, a separate and distinct part of the lift off take off procedure. It may very well occur at an indicated airspeed above what you may have expected, but not to worry. When the lift is being produced to lift the aircraft into the air, it will occur due to the wing flying at the proper speed and angle of attack. This is how you can overcome a weight entry error and not drag the tail. This is critical training information that every transport pilot should know and be trained on.

3. As the wing lifts the aircraft off the ground and out of ground effect, the feel of pitch control movement will demonstrate an increase in lift as pitch is increased. This is really important and critical to understand. If the aircraft is flying in ground effect and is not at the take off coefficient of lift, any increase in pitch will only result in aircraft longitudinal axis rotation but no increase in lift and will not result in any upward movement of the aircraft due to lift. This is the tell-tale indication that the indicated airspeed is too low for the actual total weight of the aircraft in my opinion and experience. This is trouble and the best thing to do is hold the stick steady, hold the rotation angle steady and wait for more speed.  Many pilots refer to a feeling of a mushy control column in this situation.  Be very careful here and be patient for the aircraft to accelerate to a higher speed. Patience and a light touch on the controls will serve you well at this point. Do not panic and do not yank the nose up, but rather wait, wait for the continuation of acceleration by the engines. Remember that the wing can fly at a range of speeds and weight, but only at the correct angle of attack needed to create sufficient coefficient of lift when the speed is at the minimum for flight and then decreasing angle of attack as the speed increases. So, wait for that correct angle of attack to lower onto the wing before moving the stick back any further.

4. If the situation occurs that the aircraft is airborne solely in ground effect, no further rotation should be attempted until an additional increase of 15-20 knots of indicated airspeed has been achieved. Wait, wait for more speed. At that point the aircraft should be going fast enough at the correct angle of attack to begin to rise from the runway, to lift off out of ground effect. Another take off rotation attempt can now be made. This 15-20 knot increase should move the aircraft closer towards the correct take off speed, the correct angle of attack, the correct coefficient of lift and the correct lift from the wing for flight. Remember that at this point you are not sure what kind of weight error has been made, but you do not need to worry about that at that moment. Just wait for the angle of attack to lower to climb angle of attack, then you can gently raise the nose.

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In my professional opinion, the mishap crew just over rotated the nose of the aircraft up to the climb deck angle and into ground effect by not hesitating long enough at the lift off rotation deck angle. The coefficient of lift was too low for flight because the speed was too slow for flight and the angle of attack was too high. Therefore the lift being generated was too low to climb, even though it was sufficient to allow rotation of the nose up and the tail down, with the main gear as the fulcrum of the lever.  When the crew rotated the nose up to a higher angle of attack to attempt raise the coefficient of lift and lift, it appears that the crew did not understand the basic aerodynamics related to take off flight in that lift off angle of attack was not yet achieved.

Did not knowing what to do next, when faced with incorrect rotate speeds and take off  speeds at rotation result from the use of “common practices”  in lieu of standard operating procedures? Is scraping the tail the result of rotation to lift off angle or to climb angle?

If the crew had rotated the deck angle to the correct lift off deck angle and then waited for whatever indicated airspeed was needed to produce lift at whatever weight the aircraft was actually at, and not tried to raise the aircraft into the air to climb, by rotating above that deck angle, this mishap could have been avoided, it would have never happened and the data error would have been the only problem the airline needed to deal with. In the same manner future take off over rotation mishaps can be avoided, even when the incorrect take off weight is entered in the EFB or other weight and balance calculation error occurs during preflight procedures.

My guess is that during a career in commercial aviation, many crew members are going to be faced with an incorrect, over-weights or other weight and balance issues due to human error, human factors. But by knowing how to deal with the aerodynamics of take off, and not by just doing a rote “this is how we do it here” practice, they will have the keys to success in any circumstance. In my opinion, during a 40 plus year flying career, you are likely going to see just about one of everything. But if you are prepared by training, you can overcome the hazard and continue to fly safely.

In my opinion this crew and perhaps crew members at other airlines need more takeoff training. This company and perhaps other companies needs more detailed take off procedures. In my opinion this mishap board needs to redo the investigation with a much more detailed investigation of the basic aerodynamics related to take off. I believe that an investigation of errors in the calculation or entry of take off data in the Electronic Flight Book was insufficient to both explain this mishap and explain how to avoid the occurrence of this mishap again, anywhere.

If you were to ask me, this mishap board sought to answer the legal question, who was at fault for the damage and who is to pay. In so doing they failed to answer the Safety Question, “How did this mishap happen and what can be done to keep this mishap from happening again?”  In my opinion, Mishap Investigation Boards,  Accident Investigation Boards should be called upon to serve the Safety Purpose of making commercial aviation safer, and not served the Legal Purpose of finding blame and determining who pays?

Feel free to question any of my arguments. I’d be happy to respond. It is critical that we all learn something from these mishaps through the mishap investigation reports and the Safety Purpose.

You can send me an email: paulmiller@safetyforecast.com. I look forward to your correspondence.

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UPS Safety Program: Prevention or Mishap Investigation? What are the Financial Consequences of a Failed Safety Program?

Captain Paul Miller preparing for a coming storm.

Is UPS Airlines now joining the ranks of so many previously safe FAR Part 121 airlines whose safety program looks good on paper, but in the field is no longer functioning to prevent fatal mishaps?

Since 1982, UPS has run UPS Airlines free of fatal mishaps. In fact the few mishaps that have occurred in the operation by and large have not been attributed to flight crew error at all. This has been a substantially safe operation, most markedly from the pilots’ seat. In my opinion, this is a valid reflection of the training program and the safety program that have been working hand in hand successfully.

Now, however, in the space of 3 years, two fatal mishap events have occurred. The two events involved the deaths of four pilots. Additionally the events involved the total destruction of two jumbo jets fully laden with cargo and express packages have brought tragedy and disaster to the front door of this fairly large global shipping company. Has the airline safety program, a program that had been working so well, now failed to prevent two major financial disasters in three years? Are top UPS executives asking the question, “Does the safety program look good on paper but then fail to prevent aviation disasters and the accompanying hundreds of millions of dollars in financial losses?”

The airlines and the pilot union have just completed a three year process involving the GCAA (Dubai civil aviation authority) mishap investigation of the September 2010 fatal air tragedy of UPS Flight 6, a B747-400 freighter, that caught fire inside the cargo area and crashed after takeoff in Dubai, despite the heroic efforts of the crew. (See the article below concerning the report recently released on UPS 6 by GCAA.)

Now UPS once again is visited by tragedy and disaster in Birmingham, Alabama, with the crash of UPS 1354. By all early and outward reports this mishap appears to have been completely preventable. Many people may ask both, “Why and why now?”

Here is the most difficult questions of all for UPS Airlines and its Joint Safety Program with the FAA and its pilot union: Has the safety program been working to prevent mishaps from occurring? Has the Safety Program been serving the safety purpose? Or has the Joint Safety Program become a legal avenue to find blame for the tragedies and losses that are now occurring regularly, without really delineating concrete steps to prevent the mishap from recurring? Is the safety program now serving the legal purpose instead of the safety purpose?”

UPS, its pilot union and its FAA partners are now party to another massive NTSB investigation that will attempt to answer the safety question, “How did the UPS Flight 1354 tragedy at Birmingham’s airport happen and what can UPS, the FAA and its pilot union do jointly to prevent this mishap from occurring again?”

But then the line flight crew member may ask these questions: “Wasn’t the purpose of the Safety Program originally, to prevent this mishap from ever occurring in the first place? Why did that program not work, where was the failure and what can be done now to prevent another fatal mishap from occurring?”

So again the crew member may be wondering, “Has the Safety Program now shifted towards reacting to tragedy and disaster instead of preventing tragedy and disaster? What good is all this attention to the disasters, when at the end of the day two fellow crew members are once again dead?”

Airline operations had been safe between 1982 and 2010. Now losses are occurring. Where has the safety program failed, if in fact it has, and how does UPS return to safe operations?

Perhaps a safety forecast may be useful now in order to develop a new safety plan? Perhaps looking ahead to the safety hazards that the airline faces in the future will allow the airline safety department to create a safety plan to return the airline to mishap free operations.

Mishaps are terribly costly in both human terms and financial terms. The losses from these two mishaps at this time have most likely surpassed half a billion dollars. From a financial perspective alone, a safety forecast and a safety plan would be a wise strategy.

Winter Storm

Asiana 214, Fatigue and In-Flight Crew Meals: Postprandial somnolence, or getting sleepy after you eat.

The more factors I consider, the fewer seem likely until I consider the human factor of fatigue. Automation? He was flying a B747 prior, plenty of automation there. San Francisco? Not all that different from dozens of international airports in the Pac Rim. CRM? Things didn’t go bad until the last few miles. New captain, new instructor? Happens everyday at every airline. Cultural paralysis? What? These airlines fly safely all around the world daily. Airmanship? The guys have thousands of hours flying the heavy machinery. Sure, the B777 is different from a B747, but the pilot monitoring was a B777 instructor, trained and qualified.

So why did they just stop flying, lose situational awareness, lose internal communications and CRM all at once? It seemed. like someone had whacked them in the head with a stick, like they ‘d had been incapacitated,  like they were barely conscious?

What is the one factor that would interrupt motor skills,cloud judgment and block action? Only one common factor comes to mind, the human factor of fatigue.

If culture was cause, then every flight operated by this culture would crash. But that is not what the facts tell us, since pilots from this culture operate hundreds of flights safely everyday, everyweek, everymonth, everyyear. Therefore logic tells us that culture is NOT THE CAUSE.

Since most commercial aviation mishaps are related to human factors, such as fatigue, which is highly incapacitating to all humans, regardless of culture, flight crew fatigue would be one of the first places to investigate in my opinion.

If we look at the many aircraft mishaps over the years, the demographics of flight crews involved cuts squarely across every cultural line. Any attempt to “culture-bait” this investigation in my mind is an attempt to divert us from the truth. And I personnaly do not like looking in the wrong direction for truth.

Let me ask any of you who are non-flight crew persons, how many of you who are office type persons spend 14-16 hours at your desk each day? Consider this hypothetical situation  because probably you have at least once spent 16 hours at your desk.
At the end of this theoretical 16 hr day, how good were your decisions, how clear was your judgment, how swift were your actions and how clear were your communications?

Fatigue can shut down the best parts of our brains. Why do we have such a hard time understanding that putting pilots in charge of a flight with 38 or more computer modes after a 14 hr day and 200+ peoples lives is not such a great idea?

And one further question, when did the crew eat their last meal before reassuming their duties on the flight deck? Did the after meal fatigue, the tendency for many of us to nod off as our digestive systems go to work, put the crew members into a food induced fatigue?

This is just my hunch, I have no facts to check this out.
Sometimes, when a crew grabs some rest, after they arise, they may eat a meal.
If after eating, they moved up to the flight deck and took over flight duties for the last 1 1/2 to 2 hrs, it is possible that the crew got hit with very human post meal drowsiness. Even with a few cups of strong coffee, many if not most people I flew with  were certainly affected.
I have never seen this addressed in any FAA reg, SOP or safety note. But it is certainly very common. I know of at least one B747 incident on record where the crew ate and fell asleep, the autopilot disconnected and the plane went out of control.
We will see, again this is  100% speculation.

I just ate my lunch. I think I will take a nap now.

 

Asiana 214: Cultural Issues, Fatigue or a need for better Stabilized Approach and Go Around Procedures?

IMG_0922_2Culture issues, fatigue and other human factors of every type are and will continue to be amongst the most serious safety hazards, risks or challenges for the foreseeable future in commercial aviation.

In the very open cultures of North America there may be a tendency to see cultural issues not only as a non-typical factor, but one that affects flight crew members in other regions of the world. Previous mishap investigations have shown this human factor issue for the most part affecting flight crew members not from North America. But I would argue from a safety viewpoint, where communications is the key to success, we in North America are vulnerable and have to remain alert for cultural issues in our operations. Why? I would argue that our demographics are far from homogeneous. Culturally we have on the flight deck old and young, male and female, military and civilian, conservative and liberal, uptight and loosey goosey and many other opposites on various cultural scales.  There is often a cultural demographic out there that could trip up our communications.

Now let’s look at fatigue. Fatigue is highly dangerous, much more so than even the most ardent and zealous safety advocates realize. Fatigue can cripple the parts of even the most mature, well trained and seasoned brains of our most experienced flight crew members and catch everyone by surprise. Furthermore, as Murphy’s Law tells us, fatigue will affect us at the worst possible time. The night express package delivery and the international segments of our industry are a fatigue prone operation. Long haul flights over many time zones, all week long-all night operations are knitted into these human factors. It doesn’t take much more in life to toss even the best of us off our planned sleep-rest schedules. Typical life events such as family harmony issues, health of aged parents, the teen years of our kids-who knows what will affect us next week? We are all vulnerable. But because of our humanity we are also our own worst judges of how we are doing. The person in the mirror can not always judge the right thing to do when tired.

The whole spectrum of other human factors, such as crew communications, ATC comm, being caught by surprise with an unusual circumstance, all of the other Human Factors out there, we are all very liable to be exposed because as flight crew members, our group is very human. Yes, the typical flight crew is very polite and diplomatic but at the same time very dynamic, very capable and are mostly well rounded people. I never ceased to be impressed with what a fine group of people I have had the pleasure to know and fly with around the world. But that means that we are VERY HUMAN, and thus very vulnerable. The great success of our superb FAA ASAP program, the wonderful reactions of our crew members to the insightful FOQA data reports and the success of our flight training is dependent upon us all being good and open communicators. Good communicators tend to be involved with people on and off duty: it is our strength but at times may be our weakness.

Having said that, in my opinion, three things, all interrelated, are the best approach to our most typical human factors safety risks: procedures (SOP), training based on procedures for operational competency and lastly good communications.  This is where Asiana is going to have to go to get well from this tragic mishap, in my humble opinion.

The recent Flight Safety Foundation European Advisory Committee Go Around Safety Conference was three years in the planning and preparation. Unstable approaches turned out to be the main topic of the conference. I was very happy to have been a participant in the steering committee at EAC that brought this conference to fruition. But now we and the airlines all over the globe will have to roll up our sleeves and work hard on this safety issue. We have to get stabilized approach procedures written and better trained. We have to make a Go Around part of the approach procedure when we do not achieve and maintain the stabilized approach procedure.  Let me repeat by saying this has to be a written SOP, not a criteria or policy, and we have to train to this procedure.

What was learned in the remarkable seven papers researched for, written for and presented at the Go Around Conference, was how poorly flight crew members globally react to unstable approaches. Researchers found that only 3-4 per cent of the time do flight crew members who were flying unstable approaches, employ the go around procedure. The rest, that is right, the other 97% of pilots continued to fly the approach to a landing. Out of these landings is where we have the runway excursions off the end and side and as we saw with Asiana 214, a landing short of the runway.

There are plenty of other stats about how many approaches are unstable and how many mishaps resulted from all this flying in the following references published on Eurocontrol’s Skybrary: see  http://www.skybrary.aero/index.php/Portal:Go-Around_Safety for the many details.

But for us, we involved in the safety business, the most important thing for us to get behind and to make changes globally, everywhere that there is a commercial aviation operation, is that only 3-4% of crew flying unstable approaches Go Around.  Our great success in safety so far I have no doubt is related to the idea of a stabilized approach procedure (SOP). Notice I did not use the term policy. It is a procedure, this is a critical term here. Now we must integrate the Go Around as part of the stabilized approach  procedure when we do not achieve the stabilized approach.

Remember that ‘cultural issues’ are a very common human factor everywhere, but the safety risk is the inteference to communications and the interuption of the achievment of procedures (SOP). My recommendation continues to be SOP, training and communications as a common approach to human factors safety risks. Train, train and train until flight crew are as well rehearsed as any professional should be. We have done so well globally in commercial aviation safety. But now we must make a change that will improve safety to an even higher level. I know that each safety manager at each airline knows where to go now with this safety effort. We are the fortunate ones to be in a position to make this important safety change.

Good luck and let’s get to work. Best wishes, your friend in safety, Paul Miller

Asiana 214 Mishap, SFO, July 6, 2013: Stable Approaches & Go Around Procedures

Captain Paul Miller in cockpit

Captain Paul Miller

Stabilized Approaches must be part of an Standard Operating Procedure (SOP) and not just a criteria, policy or even best practice.  Procedure means that it is a written set of steps and explanatory notes. Procedures are trained by the airline, checked by the FAA and continually verified, reviewed and updated by the FAA and the airline. Part of a stabilized approach procedure must include a verbalized communication of the aircraft state and progress at several points in the approach and a verbal command to continue the approach or to Go Around as the aircraft passes these points, if the procedural steps are not achieved.

One of the most important things we learned in the recent June 18, 2013 Flight Safety Foundation (FSF) Go-Around Safety Conference, sponsored jointly by EuroControl, European Regions Airline  Association (ERAA) and the European Advisory Committee and the International Advisory Committee (EAC and IAC) of the FSF, in Brussels, addressed the idea of a criteria, policy or best practice as opposed to an SOP.

See the conference link at http://www.skybrary.aero/index.php/Portal:Go-Around_Safety  for more details.

It is one thing to have a 500ft or even a 1000 ft stabilized approach criteria.  It is quite another thing to have an SOP to which all flight crew members are trained, a procedure  that says if the crew does not accomplish a stabilized approach by 1000 ft or even 500 ft, the pilot monitoring, the flight crew member not flying, shall say verbally “GO AROUND,  APPROACH UNSTABLE.”  Then, as written in the SOP, the pilot flying (PF) procedurally initiates the Go Around (GA), as per trained, as briefed and published as well  as cleared by air traffic management procedures.
Even now, even with a stabilized approach criteria or policy at 500ft or 1000 ft and a even with a no fault GA policy, wherein the crews’ motive for going around is not called into question, air lines still need to have an SOP, a written operating procedure. The SOP must require crew members to verbalize, “1000 feet, APPROACH STABLE, CONTINUE,” or “1000 feet, APPROACH UNSTABLE, GO AROUND.” The SOP must define action, not just policy or criteria. It must require prescribed actions for the flight crew to do at that point of decision. This is not a talking point, a time for discussion or observation-this is a time for action.

Why is this important now? So, it has actually always been important.  However, now we need to understand what happened to Asiana 214 and learn from it. Having seen the video of Asiana 214 approaching San Francisco International (SFO) runway 28 Left, one thing is quite noticeable. The approach appears very flat and very low in altitude at a considerable distance from the stone wall at the waters edge. In lieu of the standard three degree glide slope, the aircraft appears to have essentially leveled off at 100 or 150 feet 1/4 to 1/2 mile from the seawall. This is not good, but also this did not happen in the blink of an eye. This was a developing situation, to which the crew did not report their state nor did they take action.

Keep in mind that the designated normal landing area on any runway is between 500 feet and 1500 feet down the runway. Add onto that, the stone wall at the waters edge appears to be approximately 1000 feet from the end of the runway.  So the aircraft landed approximately 2000 feet short of the intended point of landing, that is, the normal landing area on the runway. This means that the aircraft had descended approximately 50ft and 100ft  below the normal 3 degree glide slope. This deviation did not occur 4 or 7 seconds from landing, but possibly 1/2 mile or more from the end of the runway. This very large deviation was neither reported nor reacted to initially as it occurred, but only just a few seconds prior to impact. By apparently not having a reporting and Go Around procedurally ingrained by training, the crew was left to determine where they were by their own criteria or judgment and then decide on a course of action and then to take that action: too much to think about in too little time and space, in my opinion.

If and when the aircraft passed 1000 feet in altitude or even 500 feet in altitude during the final approach, this would have still been a considerable distance from the runway. In this mishap the aircraft had to have been well below glide slope and thus very unstable at that point, a factor observable from the flightdeck and measurable against the requirement for a stable approach.

So did the airline have a procedure (SOP) that required the crew to verbalized stable or unstable and continue or go around? If so, why did the crew continue the unstable approach? Did the crew notice the unstable approach? Why was there a hesitation to act? Was there a procedure in place to which the crew had been trained? Or rather was there merely a criteria and a policy only in place? Can you see the difference between having a a trained GA SOP and having only a policy or only a criteria? A policy or a criteria gives talking points.  An SOP gives action required.

Early reports from the NTSB identified that the airspeed decreased from a landing target of 137 knots down to about 109 knots. Remember that normal target speed is 130% of the stall speed at that weight or 1.3 times the stall speed. So this decrease of 28 knots is a considerable change. But remembering the laws of aerodynamics, the aircraft nose attitude had to slowly pitch upward as the speed decreased. This means that the plane went from a normal landing attitude to a very high nose up attitude, again something very noticeable from the flight deck, another clue that the speed is unstable.

Rounding off for argument sake, a stall speed of 100 knots, with a 30% buffer gives a landing speed of 130 knots. The stall warning stick shaker come on 5-8 knots above stall speed (or more correctly stall angle of attack).  So the crew was not flying the aircraft just a little slow; the crew was flying substantially slow, dangerously slow and into the region of rapidly rising induced drag.  The crew appeared to be unaware of the rapid decay from 137 knots to 109 knots right into the stall. I wonder if the subject of the region of reverse command in swept winged aircraft was part of the Asiana B777 training program? Again, there may be a reliance on subjective values such as airmanship, in lieu of a set of written procedures, approved, trained and checked. But all flight crew of swept wing aircraft must have a very good understanding of the region of reverse command and the grave consequences of allowing the aircraft to enter into that part of the flight envelope. Yet, how many commercial pilots can recount the danger of the region of reverse command? Does the FAA require it?

Remember it is not uncommon for many crew to add 5-7 knots to give a margin above the minimum target speed. So that would mean many pilots would be flying at about 142 knots. The aircraft landed 30 or more knots slow. This would require a significant increase in angle of attack and nose up position, which was seen in the video at the last moments. This high pitch attitude rapid change is another major deviation from a stabilized approach procedure.  This deceleration should have been recognized immediately as it occurred initially below 137 knots and the nose high attitude should have been corrected by the crew or the crew should have commanded a Go Around. The GA SOP should have been initiated as soon as the airspeed fell below the target speed. The correction would have been to add substantial power and lower the nose slightly.  The value of a written stabilized procedure is that this procedure is trained over and over again until the crew is exceptionally skilled in close to the hand eye coordination needed when a lot is going on.

As it happened the aircraft was well below glide slope and very slow below landing target speed. Both of these serious deviations from the stabilized approach requirements occurred well before the aircraft arrived at the sea wall. The deviations began more than a half mile out and increased as the flight approached the sea wall. The crew began a discussion during this period, but did not take action during this period. This is the danger of having a criteria and/or a policy in lieu of a well trained GA SOP.

Not having a well trained Go Around SOP based on deviations from Stabilized Approach is a severe risk to safety. Not having a training program that covers the aerodynamic principle of the region of rising induced drag and does not address corrections is a severe risk to safety as well.

Concerning the Instrument Landing System (ILS) electronic glide slope for runway 28 left being inoperative, I would ask very serious questions of the FAA and the airport authority as to why they chose to temporarily decommission this system and why the decommissioning lasted for such a long period of time. This puts a burden on the crew members in the cockpit. This is what many people call the tail wagging the dog. Why have all this expensive ILS technology, engineering, equipment and training, if in the end all of it is deferred to a construction company that is laying concrete? Whose decision is that? Either the ILS is important and we had better damn well keep the system up and operating, or it is not important and we should train pilots to do visual landings. But the FAA and airport authorities want the argument to go both ways and always be in their favor. I do not agree with this tail wagging the dog theory. If the runway is “under construction,” then close the runway and allow the construction crews to do what has to be done. Do not close all of the vital instrumentation and just keep the concrete portion of the runway open for revenue generating purposes. This is not fair to the flight crew and this is most certainly not fair nor safe to the flying public, which by the way is also the paying public. Again the least of all parties in this case is the concrete construction company. Therefore it ought to be they who accommodates the operation, not the operation that accommodates the concrete company.

Decommissioning the ILS  requires the crew to build an artificial glide slope in the flight management system, using runway data and alternate procedures. This would have been a good training opportunity for the crew to build that approach within the aircraft flight management system. This could have been done as part of the preparation for the approach. Again though, was this Asiana SOP?

This is a standard and written procedure in the B777 flight manual. If that procedure was not done, the next guide to a usable runway glide slope would have been the precision approach path indicators known as PAPI mounted along side the runway. The PAPI  will indicate to the crew when they are below the glide slope, an illumination of four red lights to the left side of the landing area of the runway. We are not sure from reports that the crew was using the PAPI to assist them in the landing.

One last thing, as the initial operating experience instructor pilot sitting in the right seat should have said when things got far out of hand, “Okay, I’ve got it,” and flown the aircraft back into safety, again as a procedure for being the person in command. But the actions taken were to order a Go Around to the pilot flying, but too late for any reasonable reaction from the pilot flying. He should have taken the plane and done the Go Around when he saw that things were out of hand.

A lot going on here to discuss, no? I think so. We all would be better off tomorrow if we all tried to understand what happened to Asiana 214 today. We should see many ways on how our own airline could be made safer from the discussion of the mishap of Asiana 214.

Stabilized Approach Procedures, Go Around Procedures and substitutes for ILS procedures all must be part of the skills sets of B777 crew members and for that matter all commercial flight crew members no matter what aircraft they are operating.

Lithium-Ion Aircraft Batteries as a Passenger and Cargo Smoke/Fire Risk

100_3975In fact three aircraft have been destroyed by fires caused by lithium ion batteries, one in 2006, two in 2010. But the FAA, NTSB and other government and official agencies categorize safety as related to passenger safety or a cargo acft only hazard and of no interest to passenger airline safety, such as the current FAA and EASA Cargo Carve-out Exemption of new Flight Duty and Rest Regulations. However, by summarily ignoring the distinct ties in safety that nevertheless may validly exist between cargo airlines, passenger airlines and their respective pilots safety, FAA, EASA and others may have gravely missed the most valuable of all safety principles, that of early warning.

The early warning evidence in this case was the two cargo fires caused by lithium-ion batteries.  The fire dangers of lithium ion batteries have been amply noted, the information on this hazard has been widely available and mishap reports by FAA and EASA have identified a clear and present danger since at least 2006.

Instead of keeping lithium-ion batteries away from commercial aviation however, FAA, EASA and others have made a clear choice to allow industry lobbyist lawyers to influence safety decisions when it came to lithium ion battery carriage regulation and by that same process, have kept the safety experts themselves at arms length.

No greater illustration of inverted safety logic is present in aviation government regulatory administration today than this example.

When will the FAA, EASA and other government aviation safety agencies place aviation safety experts in charge of making important public safety and industry regulatory safety decisions?

When will the direct, clear connection in commercial aviation safety between passenger and cargo airline operations be recognized by FAA, EASA and others? It is obvious that attorneys themselves appear unable to make that connection. Wouldn’t the industry be better served by placing safety experts in charge of safety decisions and regulations?

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Are “Passenger Lithium-ion Batteries” the same as “Cargo Lithium-ion Batteries?”

Captain Paul Miller preparing for a coming storm.

Captain Paul Miller preparing for a coming storm.

Recent passenger jet fires involving B787 Dreamliner have made news, but is it really new news? FAA and other regulators have dismissed the dangers of lithium-ion batteries when carried on cargo aircraft because. Why? Well, perhaps it is because fires on on cargo airline aircraft result in “no significant loss of life?” Isn’t this the legal reasoning offered by aviation officials when safety issues concerned cargo airline flights and not passenger airlines? That is right, cargo companies are called cargo airlines and operate under much the same rules as passenger carrying airlines.

But when a recent fatigue law was ruled not applicable to cargo airlines, thus cargo pilots, again by these same aviation officials, cargo pilots cried out, “Not fair to us!”

What they should have cried out should have been, “Not fair to the flying public!”

Yes, this ruling carved out an exemption from all sorts of safety rules for cargo airlines by aviation officials, from the same rules that will govern passenger carrying airlines. What I am arguing is this “carving out”process by aviation officials could well be seen as quite unfair to the flying public. How so you might ask?

Here are several examples. In 2006, lithium-ion batteries carried as cargo on a cargo airline caught fire in the air. A crew was hospitalized after they barely got the jet on the ground, that same aircraft finally being total destroyed by that fire.  The crew had to jump out of  cockpit windows to escape a burning smoke-filled aircraft.  Then again, four years later two cargo airline crews were not so lucky. In both of those cases in 2010 the fires were so quick moving and so intense, that despite their best efforts,  the crews of both aircraft perished in the fires while still in the air and then the cargo aircraft crashed.

Once again however, aviation officials, in a show of unprecedented irony, ascribed the events to cargo airlines and therefore not a passenger airline issue. Strangely enough however, the one common thread in these three stories are the batteries, the lithium-ion batteries. In each case, the batteries carried as cargo caught fire in the air and then caused massive fires inside the airplanes.  Despite the three known fires investigated by aviation officials, despite warnings going back to 2006 that these lithium-ion batteries can be very unsafe to carry in the air, these same aviation officials approved the use of these same batteries on the B787 Dreamliner. Not only was the approval for carriage of the batteries, but the approval was to hook up the batteries to the aircraft electrical system as electrical power sources, meaning that on every flight of a B787, there would be large lithium-ion batteries aboard and connected.

Many people would ask why this was done and why it was allowed to be done? My guess, and it is only a guess is that most likely, battery manufacturing experts explained to some aviation official lawyers, that these are somehow different batteries and different battery applications than those involved in the three cargo aircraft destructive mishaps. On paper, on a slide presentation in front of a room of officials, that argument probably, and obviously,  played well.

But in the end, the question remains now in the front of the minds of the public and press, “Are ‘Passenger Airline Lithium-ion Batteries’ the same as ‘Cargo Airline Lithium-ion Batteries’?” The events surrounding recent B787 lithium-ion battery related fires seems to raise serious questions about that question.

Maybe time and science and engineering will show us that this gendre of lithium-ion batteries can be made safe for the skies. That would be preferable for the future of the battery industry and the airline industry. But for right now, the question seems to be that they are similar enough in their fire catching characteristics to make all us in safety quite concerned?

Maybe these same aviation official lawyers can reconsider whether cargo pilots are somehow less susceptible to fatigue than passenger pilots and rescind the cargo carve out of the most recent fatigue rulings.100_3985 For it is in this transgression of logic that B787 Dreamliners took to the skies with lithium-ion batteries that may be the same type of batteries that brought the first of three cargo airline aircraft to destruction more that six years ago.

More on AF 447 LOC: Stability, Vg/Vn Diagram and Recovery

There is another very important aerodynamic engineering issue that needs to be discussed when Loss of Control is the subject, and that is Stability, as it relates to high angle of attack flight. Transport category aircraft may not have the same “forgiving” stability as training aircraft, when it comes to bringing the aircraft back into the flight envelope, in the event that Loss of Control has taken the aircraft outside of the flight envelope.
Training aircraft are designed for students, so that they are designed to be easily recoverable from high angle of attack flight and out of controlled flight and flight outside of the flight envelope. The center of gravity, the aerodynamic center, the moment arms of the wings and fuselage, the control surfaces size, types, deploy-ability and locations, the aerodynamic and geometric wing twist, the wings’ angle of incidence on the fuselage and additional itens such as stall strips or other early stall initiation devices, are all assembled so as to make recovery from stalls, post stall gyrations and spins possible for students. This however is not how transport category aircraft are designed and assembled.

Rather, transport aircraft are commercial competitive aircraft, and as such, are optimized for L/D max  (lift/drag max) in cruise, that is the best lift for the cost of drag, for high coefficient of lift devices for take off and landing performance and for relatively good stability (In my opinion, slots, slats and similar devices are incorrectly called high-lift devices. Why? Because you really just want to get the same lift but at lower angles of attack.  They might be more properly be called high “coefficient of lift devices” where the coefficient of lift is maximized by camber and air channels, where the angle of attack is lowered).

But with long wings and long fuselages, when there are very long moment arms with large weights such as passenger/cargo payloads and massive engines, transport aircraft may not perform in the same docile manner as trainer aircraft, acrobatic aircraft and military tactical jets. For line crew members to expect transport aircraft to be as nimble and recoverable as trainers would not be realistic.

Stability is more challenging to engineer when the moment arms and weights get larger.  Recovery from the edge of the flight envelope, that is the Vg/Vn diagram or the Velocity vs G Loading diagram, is possible and quite satisfactory with most transport category aircraft.

But when a flight’s excursion goes well outside of the flight envelope, of the Vg/Vn diagram, when the transition is larger and the aircraft passes well through and past the edge of the envelope, then recovery back into the flight envelop, may not be as easy.

It may still be possible, but testing during development may not have been investigated or engineered. Recovery from outside the envelope may require much more aerodynamic knowledge than a pilot that is qualified just by the requirements of training by regulation may posses.

And if crew members do not possess that knowledge, then there is a problem, because the plane is outside the advertised limits of operation and they may be at a loss on what procedures to use next. So, now what?

Early morning sun rising through clouds.

Early morning sun rising through clouds.

In my opinion, when flight crew members get into the seat of a transport category aircraft, an aircraft  with dozens of people seated behind or into the captain’s seat of a jumbo transport category aircraft with hundreds of people seated behind, flight crew members should be prepared to focus 110% of their attention for the next eight to twelve hours on nothing but flying. Forget about casual conversation. Forget about big meals, you will not starve in 8-12 hours, a sandwich and coffee will do. Forget about all sorts of distractions. Flight crew members need to be focused on keeping the aircraft in the flight envelope by procedures and purely by procedures.

Flight crew members have to know the Vg.Vn diagram and know how to stay well inside of the envelop. Why? That reason is because it may be difficult, very challenging and for some and in some cases, impossible to get back into the envelope once having left the envelope! Is that what happened to Air France 447? I just don’t know, but many of the clues seem to point in that direction.

Flight crew members need to definitely keep the aircraft out of thunderstorms and out of harm’s way for any threat to control and stability. The commercial transport plane is not a trainer, it is not a jet fighter and it is not an acrobatic plane and it is most certainly not a test and development aircraft. It is a massive piece of machinery that has been designed to do one thing extremely well and that is carry large payloads over long distances at exceptionally efficient fuel costs. Attempting to do anything other than that with the aircraft just does not seem “like a good idea.”

As far as members of various boards of investigations are concerned, if board members do not know the aerodynamic principles and physics of large transport plane flight, then it would behoove the board to bring in people who do know these things, such as pilots. Investigations that do not cover this subject area, when part of the flight, especially the fatal last few minutes, occurs outside of the VgVn diagram, are incomplete and therefore as of yet,  little safety value.

These investigations in my opinion are not for the purpose of assigning blame and forming the basis for further legal actions such as dismissal, monetary damages and fines. Lawyers and courts do that kind of work and the case history for lawyer based investigations and court awarded compensation in the Western world goes back hundreds of years.

Instead, these safety investigations are supposed to be about what went wrong and how do we keep this from happening again. They should be about safety.

Whatever the SOP, whatever the aircraft hand-book, whatever the company training program, something was not right in this case and it was up to the board to find that out. But did they find out what was wrong and did they inform everyone else who conduct flight ops with this equipment, on these routes, with these aircraft, how to do so safely? Or did they leave more questions unanswered? Why is the interest in this subject still so high?

How many times have we been given reports of aircraft mishap board investigations stating that something went wrong, and then that they advise someone else, such as the operator, the regulator or the manufacturer to figure it out?

This is incorrect safety investigation theory and procedure. In my opinion it is the duty of the board to find out what went wrong first and then to recommend actions to correct that situation, those SOPs, the aircraft handbook and the training process.

So, to proceed, would not the board need to understand “what went wrong?”

To understand “what went wrong”, investigators would have to know the aerodynamics of high angle of attack flight, the subject of aerodynamic stability, the idea of the Vg Vn diagram  and flight envelop and the entire concept of controlled flight for jumbo transport aircraft.  They also would have to reaffirm that all flight crew members need to know this information through training with their report of the mishap.

Again, JMHO. What do you think? Hey, we are pilots, we have to know this stuff. Shouldn’t the investigators be required to know this stuff as well? How else can they unravel the mystery of a mishap investigation? How else can we move forward to make commercial aviation as safe as possible? How else can we climb into the captain’s seat and take on the responsibility of being a commercial airline captain?100_0306