Is More Emphasis Needed on Commercial Aviation ‘Go-Around’ Procedures & Is More Training Needed to Improve Safety? : A Report of the Flight Safety Foundation European and International Advisory Committee June 2013 ‘Go-Around Safety Forum’

IMG_6024Commercial pilots do not often go around when an approach has gone bad. As a matter of fact about 97%  of the time, pilots have tried to salvage a good landing out of a bad approach. From that segment of attempted landings out of bad approaches comes nearly all of the fatal commercial aviation landing disasters. At least that is what seven separate groups of commercial aviation safety researchers have discovered.

Those seven separate and independent research groups presented their papers at the recent Go Around Safety Forum, June 18, 2013 held at EuroControl Headquarters in Brussels, Belgium. The Go Around Safety Forum was organized by the European Advisory Committee and the International Advisory Committee of the Flight Safety Foundation and co-sponsored by the European Regions Airline Association and EuroControl. EuroControl is the European Organization for the Safety of Air Navigation, with 39 member nations. See http://www.eurocontrol.int/ .  After working on this joint EAC-IAC project for three years, which included international meetings and a great deal of correspondence, I am pleased to say that all of the formative work, persuading our safety community that we need to look deeper into the issue of go arounds has proven to be well worth the effort manifested today in this highly unique conference. The work of EAC. has been to look ahead and find new ways to dramatically improve commercial aviation safety.

IMG_6033

 

 

All of the papers presented are now supported by EuroControl Skybrary, an on line reference web site open to all. See http://www.skybrary.aero/index.php/Portal:Go-Around_Safety and http://www.skybrary.aero/index.php/Portal:Go-Around_Safety_Forum_Presentations.

I would like to recommend the articles concerning flight crew Go Around Procedures Training to all commercial airline safety and training managers to determine how the syllabus at your organization compares. See http://www.skybrary.aero/index.php/Go-around_Training

IMG_6030_2Author and member of European Advisory Committee (EAC) Captain Paul Miller with long time committee member Jean-Jacques Speyer VUB University and current EAC chairman and Eurocontrol Safety Manager Tzvetomir Blajev at the June 18, 2013 Go Around Safety Forum.

 

IMG_5985Independent Pilot Association representative Captain Cris Simmons (middle) with chairman of the International Advisory Committee Captain Bill Curtis (left) and Captain Martin Smith, PhD, aviation safety researcher, Presage Group (right).

 

IMG_6025Author with Zeljko Oreski, Executive VP, Int’l Federation of Air Traffic Controllers’ Assns (IFATCA).

 

 

When airlines write Go Around procedures and then train their flight crew members on how to use them, somehow a disconnect may be happening.  What have here may be a failure to communicate. If only 3 out of 100 pilots is use the going around procedure when the approach goes wrong or as it is referred to in industry terms as “unstable,”  then statistics show that in that pool of the 97% of pilots who try to land, virtually all of the landing mishaps occur that involve runway over runs, excursions off of the side of the runway, short landings into terrain and other structures occur.

In safety terms, this is an area where industry wide, a great improvement in safety can be achieved if flight crew members execute a go around 100% of the time out of an unstable approach and come back around. Why there is a large disparity between what is trained and what done by line pilots is up to each airline to determine and remedy.  The Go Around Safety Forum was intended to bring the issue to the attention of the global commercial aviation community and in that regard it was a successful three year effort, capped off by the successful one day seminar. Now all of the papers, the data and discussion is available to all airlines and it now is up to the local safety managers at each airline to put this information to good use and improve safety.

IMG_6035Flags of the 39 European nations of Eurocontrol.

 

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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

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UPS 6 Sept 2010 Dubai Crash GCAA Final Report: What Is the Cost of the Mishap? What Recommended Corrective Actions Will Prevent this Mishap from Occurring all over again?

100_4203What is not written in the just released GCAA Final Report of the September 2010 crash of UPS Flight 6? Was the report written for legal purposes or safety purposes? What wasn’t learned from the reading of the report? Was anything learned from the report that would have prevented this mishap, that wasn ‘t already known before the mishap? How does the line pilot become more safe as a result of this three year long exercise in investigatory procedure?

Is it possible that many people may ask these questions and feel that the report did not answer these questions? Here are a set of questions that may be on the minds of many people:

1. How did the cargo get on the plane, who put it there?

2.  How did it catch fire?

3. Why was this situation allowed to occur?

4. Were not all of the elements of this mishap known well ahead of time; did this accident happen once before and didn’t an investigation look into all of the essential elements of this mishap once before? Were not all these questions asked once before?

5. Why is it that this mishap happened again?

Again, these may be questions on the minds of many people who have read the GCAA Report and did not find all the answers to questions related to this mishap.  To look deeper let’s unwrap a few layers of information about the events related to this mishap.

First, the business of UPS is the main concern. According to their own published and filed financial reports, UPS created approximately $3.5 billion in operating income based on revenues of about $50 billion in 2010.  That is a return of about 7% or seven cents on the dollar for 2010 and about eight cents for 2011. So, this is good business return in this industry and appears consistent year after year.

Let’s consider the costs associated with crashing a fully laden B747-400 freighter and killing two crew. The plane is about $200 million. The cargo onboard guestimate is variable, but a fair estimate is between $50 million to $600 million, so let’s round off to $100 million. The crew death costs together all told about $2 million. The costs of a thorough three year investigation is about $5-6 million. Add this all together and the number is somewhere in the neighborhood of $308 million, and again since these are only estimates, the numbers could vary by plus or minus 10%.

Okay, now let’s figure based on seven cents to the dollar, how much business UPS has to conduct in order to have $308 million created as an operating income. The number is about $4.4 billion. Worth repeating: in order for this company to have enough money to go out and buy a B747, load it up with cargo, crash it, kill the crew and pay for a three year investigation, about $4.4 billion worth of business has to be conducted that results in $308 million in operating profits.

So what is the costs of a crash? How many people do you have to have out there working, selling service, moving packages, maintaining the operation, making things happen, so that at the end of the year they have all created $4.4 billion in revenue?

Asked another way, what is the comparison between the $4.4 billion and the annual revenue created by the entire company working the entire year of 2010, the year of the mishap? Comparing $4.4 with 2010 revenue of $50 billion, gives a number of about 9%. What does this mean? It means the mishap squandered the work of about 9% of the company’s entire work for one year. Again this is worth repeating. The UPS 6 mishap squandered about 9% of all the work done by all the UPS employees for the entire year.  That is a pretty big number in scale to any management goal and certainly a number acceptable by few responsible managers.

Put in another way, a company with 330,000 employees, where the work of 9% is wasted in a mishap, that would calculate to the work of about 29,700 employees wasted for one year.

While this is what happened, that set of numbers is not to be found in the GCAA report of UPS 6, nor is there any similar accounting of the costs of the mishap.

What was learned from the GCAA report that was not already known? The report identifies batteries of the lithium group carried as cargo to have been the source of the fire on board UPS 6.  But it was already known that lithium group batteries may initiate fires in cargo. It is already known that few methods of extinguishing are available to crews operating cargo aircraft and since there are no additional fire fighting crew members on board, any fire extinguishing that is going to be done, has to be done by flight crew members only. This means that either the crew keeps flying and no one fights the fire, or someone fighting the fire is not flying the airplane. But again, this was already known.  I am not sure what is in the GCAA report of the UPS 6 mishap, that was not already known? The report delineates the progress of the fire, the inability of the crew to complete a return to land, wherein the fire either diminished the systems needed to complete the flight or disabled or even destroyed them. Humans need oxygen to breath, the fire both filled the cockpit with smoke and caused the oxygen system to fail, just when it was needed most.

What was new in the report of the UPS 6 mishap that we learned? I am not sure that I found any thing new, anything that was not already known before. A cargo fire may render the cables controlling flight controls inoperable and do so rather quickly. That was not known, but is now. This is interesting because this aircraft is used for long overwater crossings regularly, wherein there is no divert field available without a transit time of two or three hours, meaning an immediate ditching, a ditching within 20 minutes of fire indication would be needed to complete any overwater ditching under controlled flight.

How is the line pilot safer as a result of the GCAA report? That appears open to discussion and to be determined. More fire suppression is good. Smoke hoods are good. All this is good, but preventing the event from recurring is the actual goal of the GCAA three year investigation. Other than chronicling the event per se, what else did the report do for safety of the line pilot? It is not really that clear.

Will the actions recommended in the GCAA report, if taken, prevent another similar mishap? If so, how would they? Will the actions keep Li group batteries off of aircraft? If so, how so? How much time will the next crew to experience a fire airborne have before they are overcome? Does this GCAA serve the safety of the line flight crew member? Did the report serve the safety purpose of mishap prevention for the benefit of the line pilot and the company or did the report serve the legal purpose of collecting the evidence for lawyers, regulators and administrators?

You are invited to read the report one more time and determine these answers for yourself. What additional questions come to your mind? What recommended corrective actions do you think need to be enacted in order to keep this same mishap from happening all over again? How can this mishap be prevented?

Captain Paul Miller preparing for a coming storm.

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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.

 

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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

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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.

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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.

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US Passengers at Risk by FAA Fatigue Rule

Passengers on domestic US airlines are now at an increased risk of being  crashed into by sleepy cargo pilots. Lawyers at the FAA used case law, negligence reasoning and other historically based legal records to reach a regulatory milestone, aligning witIMG_0922_2h lawyers at   large US based package express and airborne freight haulers. The FAA pointed out that so far, when cargo pilots have had fatal crashes, they have only killed themselves. But is the regulation a millstone around the necks of cargo pilots? Industry safety experts say the risk to the passenger flying public is very real. Fatigue caused human errors can lead to massive passenger casualties. Take for instance one of the worst commercial aviation passenger disasters in history. 583 people were killed when two heavily laden B747s collided in Tenerife in 1977.   It is believed that some of the crew members who may have been on duty in excess of 15 hours, in my opinion, misunderstood ATC communications. The KLM captain was very near the end of his official duty day, but believed that if he could get airborne before the end of his duty day, that he could complete the flight to Amsterdam with his load of passengers. A good man, a man dedicated to his company, a man with a great record at the company as a captain, under the fatigue caused misconception that he had been cleared to take off, although he had not, began his takeoff roll, colliding just moments later with a Pan Am jet on a fog shrouded runway.

Now imagine hundreds of fatigued cargo pilots operating around the clock due to this FAA ruling. Imagine a sleepy cargo crew misunderstanding an ATC radio call and ramming 850,000 pounds of plane, cargo and fuel into your family in a passenger plane innocently waiting to takeoff, albeit by accident, while seated on a passenger jet, one tightly regulated by the FAA. One thing will be for sure. The lawyers from the FAA and the cargo industry will be saying, “We need to do something about this.”

So, we have a chance right now to “do something about this,” and we ought to do it before we witness another tragedy such as Tenerife. The FAA should let the law of the people speak for the people. After all, it is their safety that is really the first priority, is it not? Cargo carriers have prospered under FAA safety regulations, countering the claims by their lawyers that safety would cost them business losses. Check their financial records. Now check the FAA and NTSB accident records. In fact the records show that  many if not most of the cargo crashes were the result of fatigue and other human factors, and not safety regulations. The ruinous losses of these accidents is in the hundreds of millions of dollars. And these are fully  documented losses of property and lives, they are not suppositions, arguments or cases put together in a law office.

This other “study” of potential business losses due to safety regulations is purely speculative, oppositional and entirely hypothetical. There doesn’t appear to be a shred of real evidence in the entire argument. So, I think that it is time that we base our decisions of safety, of life and death on reality, on data, on facts and on history and not on the unsubstantiated claims of lawyers, accountants and other business professionals.100_3975

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Safety versus Everything Else not SMS

Safety Managers can sort through legalities by remembering what safety is and what safety is not. Safety is about prevention, human factors, reporting and investigating, fixing the problem, communicating and looking forward.

Safety is not about criminal law, civil law, administrative law or regulatory law; it is not about public administration or zoning around airports. It is not about public relations, disaster preparedness and actually, much to the surprise of many, it is not about accident investigation.

All of these subject areas may involve commercial aviation and we have to be about the business of managing all of these areas, but they are not safety management.

Safety management is now going through the SMS phase and that is mostly good. But there is a mystic which may confuse some, turn off others or gray the black and white lines of aviation safety.

Safety must foremost be prevention, prevention of hazards from becoming mishaps. Strong leadership in safety is needed to make prevention happen; it does not come naturally to us humans to prevent mishaps, we tend to trip and skin our knees, we do not always seem ready to prevent the trip and fall. But prevention is cheaper. Straightening a rug by a door is cheaper that sending a guest to the hospital with a trip caused broken bone.

Safety is really all about human factors or what we really know as human error. There is no mishap on record that did not hold human error to account. So prevention really does seem to be a human error issue, what can we do as flight crew to improve our human performance. Training comes to mind, procedures and checklists as part of that.

Safety is all about the reporter finding a hazard and yelling out loud, “Hey, here is a problem everyone!” Those of us gifted to see thing may see more, but everyone sees something. Encourage reporting.

Fixing the problem is critical, don’t just report the hazard. There is no one other than the safety manager who is more in charge at this point; this is your time to shine. Do the work corporately or by your own imagination- but get the work done to find the solution and pronto. Remember that the flight on which the hazard was found will be repeated in an hour, a day or a week. No time for waiting for “the system to work.” The system didn’t work and now is the time to step in and take action, work with others to take action, manage others who are taking action or foster the action takers to hurry up.

Communicating is how safety works. Remember that you both speak for the pilots and to the pilots. They speak to you. Keep those channels open and flowing. Do whatever is needed in your organizations culture to encourage communications. Remember also that Tweets, emails, Facebook, IM’s and every new electronic media is whats happening now.

Lastly, safety is all about looking forward to mishap free operations.  Consider everything you do as influencing a safer tomorrow. You will be one of the few who do.

Remember, do not get involved, sidetracked or distracted by what safety is not. As the safety manager, you are the only one doing those six safety goals leading you to the now SMS.

Alone in the sky with the sunrise.

Alone in the sky with the sunrise.

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