MH370-Were there Hazardous Materials Loaded into the Cargo Hold?

The question of hazardous materials being carried on passenger aircraft has arisen in the quest to determine what happened to MH370. But very little information has surfaced concerning the cargo that was loaded by Malaysian Airlines into MH370.

So the question remains unanswered: “Were hazardous materials loaded into the cargo hold of MH370?”

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Problem Solving Skills Training a Factor in Fort Hood Shootings?

Captain Paul Miller preparing for a coming storm.

Captain Paul Miller preparing for a coming storm.

Solving the mystery of shootings at military activities may involve how the force is trained. First, my sincere condolences to all who have suffered a loss in this and other similar tragedies. Second, my hat  is off to the Army Training Command for doing a great job of training soldiers for today’s force.

Now in the case of certain individuals, if their problem resolution skill set is not broad based by the time they enter training, there may be a small sub set of individuals who acquire the only elements to the skill set in military training. However if all of the significant training (in their mind) involves some type of gun, bomb or other type of violence and destruction, at the end of training, this might possibly be the only tool in their problem solving skill set.

In combat, as well as civilian life, that actually can be a very big weakness. In civilian life, we can see that violence is most often the worst choice of action. But in combat operations, there may be many times where the most powerful weapon a soldier has is his or her ability to out-think their enemy.

In summary, I would encourage Army training policy makers to consider two steps:

1. Do initial problem solving assessment for new members of the force

2. Train soldiers to develop a wide spectrum of problem solving skills to add to their skill set, to use in combat and then use outside of combat as adults in a challenging world.

If the only adult problem solving skill that a soldier acquires in formal training is to attack with deadly force, then that can be a problem. And that problem may well become a severe liability on base and off base.

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MH370 Solved?: Did Antenna Bracket Failure Rip Open Fuselage Hole?

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Did an unfinished FAA/Boeing Air Safety Directive or AD doom MH370? Reinforcement to the fuselage mounting bracket for certain radio antennae on B777 aircraft may have been required by a recent FAA AD. However completion was allowed for an extended period. Metal fatigue and other cracking failure modes common on aluminum cyclically pressurized fuselages could lead to pressure vessel failure in the uncorrected configuration. In the event of a pressure vessel failure through metal rupture, normal pressurization differential by engine bleed air could then exacerbate the rupture further, as could high dynamic pressure from the high speed descent initiated by flight crew members in response to a rapid depressurization. If an antenna was connected to the ships ACARS or the transponder system, loss of the antenna would render the unit nonfunctional in terms of how the ground stations were reading that data.

A second B777 AD relating to  emergency oxygen plumbing, if it had gone unfinished by maintenance could have rendered some oxygen backup systems ineffective. The work completion was not immediate and could have been deferred.

Combining this B777 AD information with the disappearance of MH370 may give investigators and others interested in the fate of this flight something to consider. A loss of comm, a rapid decompression, a divert and emergency descent all seem to fit what we know so far. The transponder and the ACARS might not have been “switched off.” Instead, if either or both of their antennae were rendered inoperative by a metallurgical fatigue or other similar material failure, to the outside observer, these various electrical devices would appear inoperative. Why? Because it is the exchange of their radio signals that we use to determine their operation from the ground. In a like manner, a small fire in baggage area from a stowage of lithium batteries or even a small explosive of a criminal nature might again cause a similar system failure.

 

 

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Battery Cargo Lobbyists Victorious over Commercial Aviation Safety? What Happened to MH370?

100_0306Though ticketed passengers did not suspect, battery lobbyists had been victorious over the very best commercial aviation safety advocates. Through private meetings, where financial benefits of shipping dangerous lithium batteries to the battery industry by air freight are fostered, did lobbyists convince passenger airline executives to allow carriage onboard passenger commercial flights?

Many commercial aviation safety groups opposed the shipping by air freight, even cargo pilot groups and passenger pilot groups, who by the way hold identical commercial FAA flight ratings. ALPA, CAPA and other pilot industry safety groups have opposed the carriage of lithium batteries as air freight because passenger aircraft carry air freight in their cargo holds. That is correct, there is more than luggage in the cargo hold of passenger flights. There are live animals, mail, company maintenance items and air freight, to include lithium batteries, in these cargo holds. But hundreds of reported lithium battery related fires in flight related incidents have prompted safety groups to advocate regulations prohibiting these shipments.

Now comes along MH370 and Kuala Lumpur  and Malaysia and 500 pounds of lithium batteries and 239 ticketed passengers and flight crew and cabin crew. Why did they all come together? Were not the warnings of commercial aviation safety experts sufficient to prevent this confluence of danger? Have the battery lobbyists been victorious in over riding all of the Safety Purpose?  We may never know what happened to MH370. But we do know that publicly released statements from Malaysian Airlines document that about 500 pounds of lithium batteries were onboard MH370.

Has there been  a victory celebration in the halls of the Lithium Battery Cargo Lobbyists and Battery Industry? Do they consider the defeat of the very best efforts of commercial aviation safety experts to influence government safety regulators in the US and apparently in Malaysia a victory for business over commercial aviation safety?

Will it now be time for the defeated to spend time mourning the loss of family, friends and colleagues who were aboard MH 370, UPS 6, Asiana 991 and other similar tragic disaster flights? How has it become that paid lawyers and public relations experts who are battery industry lobbyists can prevail over the very best efforts of hundreds of commercial aviation safety advocates?

Early morning sun rising through clouds.

Early morning sun rising through clouds.

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MH 370 and UPS 6 near Dubai, 2010: Same Mishap Repeated?

100_3975When UPS 6 crashed near Dubai in the evening of September 3, 2010,  (www.gcaa.gov.ae/…/2010-Interim%20R.) (http://en.wikipedia.org/wiki/UPS_Airlines_Flight_6) the crew had been in a battle for their lives for about 20 minutes. Upon first realizing cargo area temperatures were rising and that smoke and fumes were entering the cockpit, the crew made a turn towards a divert field, began a descent to landing, put on their oxygen masks and attempted to quell the fire.  The crew was overcome by the smoke and heat, despite their best efforts and the plane crashed while the crew was attempting an approach to land. Communications with air traffic control were immediately effected by both the use of oxygen masks and the growing smoke and heat in the cockpit. Navigation and aviation back to the divert field were effected by the fire destroying electronic navigation components and flight control components. In essence, the crew was overcome and the plane was overcome by the fire in the cargo compartment. In the end, the plane crashed into the desert sand in the descent the crew had initiated.  The investigation revealed that a fire most likely caused by lithium batteries

About twenty minutes after MH 370 began its flight, the aviation, navigation and communication changed dramatically. Was it due to a fire caused by lithium batteries carried in the cargo hold? Was it due to an explosion or fire related to material brought aboard by terrorists? Though this may be unknown at this point of the investigation, the flight path of the flight, the changes in navigation and changes in communication both verbal and those by automated reporting systems seem to indicate high levels of similarities between these two mishaps.

Does failure of regulatory authorities to comprehend that a cargo aircraft mishap caused by a fire from hazardous cargo could one day lead to the loss of a passenger aircraft hauling the same cargo reveal a fallacy in regulatory logic?  Do regulators reason that until a loss occurs, there is no reason to restrict commerce? But what if the loss of an aircraft due to lithium battery caused fire is a cargo aircraft? Do regulators reason that only cargo aircraft should be restricted from carrying lithium batteries? Should regulators reason that passenger aircraft should also be restricted from carrying lithium batteries?

Are we looking at what is called regulatory two levels of safety, one for cargo flights and one for passenger flights? Is the great fallacy in regulation that passenger flights also haul massive amounts of air freight, and the attempt to create two levels of safety to carve out an exemption for cargo flights in reality results in no level of safety when it comes to carrying hazardous cargo?

Are MH 370 and UPS 6 essentially the same mishap recurring all over again? Was in fact MH 370 a preventable mishap?

Captain Paul Miller in cockpit

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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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The Injury of Pilot Fatigue: Is Fatigue a Stress or a Strain ?

Early morning sun rising through clouds.

Early morning sun rising through clouds.

Fatigue: Is It a Stress or a Strain, that is, an injury? Is fatigue an injury to the human body from which we need time to recover? Or is fatigue just being tired or over tired, a stress for which a good night’s sleep is the common remedy?

That is the question: is fatigue just a stress on the body and mind and as such something from which the body and mind can bounce back without any damage? Or is fatigue rather something more insidious and injurious than just a stress? Is it possible that fatigue is actually a strain, that is to say,  an injury, damage to the body and mind? If fatigue is an injury to the body and mind, an overstress resulting in a strain, does the body and mind need time to heal back to health from this injury? Is the time of a “good night’s sleep enough time to heal from this injury?

Does repeated stress lead to more damaging strain? Can the road to recovery from the strain of fatigue to the body and mind be a lot longer than just one good night’s sleep? Is the body and mind being damaged beyond the ability to recover in a day or a weeken

Human beings who has spent many nights and days working multiple shift hours far in excess of any reasonable eight or ten hour schedule can be over tired, falling asleep at the switch as the saying goes from fatigue. Yet they are there trying to do a good job, a necessary job and trying to have a life outside of work at the same time. The one thing that has not been discussed is does recovery from fatigue take much more time than just one good night’s sleep. If so, why? Is a person somehow injured in my mind and body to the extent that they need to heal? If so, where was the injury, how can a person feel it and how can they measure it? How much time is needed for full physiological recovery of body and mind? Is sacrificing the health of body and mind for a job well understood? If so, are people being separately compensated for both the work done and the sacrificing of the health of body and mind?

There are two issues to working at night and working extended hours repeatedly, the issue of compensation for the work and compensation for the hours past any reasonable shift.

But there are often more questions about fatigue than answers.  What is the pineal gland anyway and how does it work? Does the brain need oxygen and sugar to function? Why does worry have the same affect as caffeine? Why is a hot shower so refreshing when tired? Why do kids fall asleep when tired wherever they sit down? Why do older folks struggle often with sleep?  Why do flight crew often feel so tired on weekends that they just want to relax and do nothing stressful, just recover and hope for restful sleep? How and why does fatigue knock your brain out like a light switch turning off, even when you are not lying down in bed? How does it know to do that? What else do we not know about fatigue?

So, in my curiosity I harkened back to my university days studying metallurgy. We studied the physical relationship between stress and strain on a metal sample and on samples of wood, plastic, ceramics and other material. Stress is the force that is applied to the metal sample and strain is the amount of deformation that occurred to the sample piece as a result of the stress.

As students we found was that for the most part, metals deform elastically under lower levels of stress and essentially return to their original shape, size and strength. This means that the stress is bourne by the material and it springs back into its original being.

In physiology terms, we might say that one all-nighter isn’t so bad; just get a good night’s sleep and you will bounce back, good as new and be ready to go just fine. Probably all true, especially so for lab studies of human being subjects.

Now back to the metal samples. As we continued to add stress to the metal samples, somewhere down the line we got strain that is no longer elastic. The sample no longer bounces back. The sample now begins to deform. It is still strong and has some of its original strength, but it has become bent, stretched and weakened.  The stress that was put on the sample past the elastic strain point damaged the sample. It is deformed plasticaly, that is, it will no longer spring back into it’s original size, shape and strength. It is deformed into a new shape. It is still one piece, but deformed. It will not now nor ever go back into its original shape. Moreover, if the stress is continually applied, not only does the strain result in a deformation in size, shape and strength, the sample will eventually break, fail and just come apart, often with a very loud bang.

Now, back to the human physiology story. Again does the human body and mind react in a similar manner, that is to say, that the body and mind can take some stress, some sleeplessness, and bounce back elastically with just a good night’s sleep. But what happens to the human body and mind when the stress of sleeplessness is applied continuously and applied over the ability to take this stress undamaged?

Can the stress eventually cause a strain, that is, damage to the body and mind, damage that one good night’s sleep is insufficient in time and regenerative power to cause or allow a recovery? Can we over stress the body and mind with fatigue? Can fatigue be damage that affects the body and mind such that it is injured and needs time to recover from the injury? Is fatigue more than a stress? Can fatigue cause a strain or injury?

The answers to all of these questions is neither clear nor well known. But these questions need to be asked. Is fatigue more of a strain at some point than just a stress? Can we do injury to our bodies and minds by stressing them with fatigue to the point that they are damaged in some manner and no longer function well? Can this damage be such that one good night’s sleep is insufficient time in which to recover? Have we broken something that needs mending? Have we injured something in ourselves which needs recovery?

Is fatigue more of a strain than a stress?

 

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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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Is the Study of Accidents the Same as Mishap Prevention? Are the Two Related or Is Mishap Prevention More?

Recent publications of the Boeing Statistical Summary of Commercial Airplane Accidents, The ICAO Safety Review,  The EASA Annual Safety Review and the UK CAA Global Fatal Accident Review cause me to react this way: These are documents of failures, of human failures, of failures despite the best efforts of many government and commercial organizations.

100_3975I understand that the logic is mainly deductive reasoning, let’s discover what went wrong and study it. Then let’s use our logic to try to figure out why what went wrong and let everyone know.

Then let’s take a break and hope that someone can tell us how to keep this from re-occurring.

Is reviewing previous mishaps events, the same thing as coming up with procedures to prevent mishaps from ever occurring in the first place? Is there some sort of bizarre human logic that says until people die in a mishap, there is no reason to make change?

Do we have a tendency to focus on the failures and try to figure out who was at fault?  To promote safety, could we rather be spending our time and energy trying to look ahead and see the hazards that are present in our operations right now?  could we present ourselves with resolutions these same hazards before, yes before, not after we have another crash?

How many of you reading this, believe that this is possible? How many of you think that perhaps you can play some role in that effort?IMG_6024 If so, I would encourage you to work in that effort with all your imagination and resourcefulness. You may well have a favorable outcome.

Remember that every time you resolve a safety hazard to your operation, you prevent an incident or possibly an accident or mishap.  The quicker you work, the sooner the hazard becomes resolved and the fewer operations occur with the hazard in place.

Be imaginative.

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