Tag Archives: Human Error in Aviation

Air Asia 8501 Crash: Cause is No Mystery-Thunderstorms Can Kill

Captain Paul Miller in cockpit

Captain Paul Miller, Night Flight

In the 1931 novel “Night Flight” by Saint-Exupéry, we learn that even intrepid pioneering aviation heroes in the end are not match for thunderstorms in Patagonia.  We find out that thunderstorms can and will kill. We loose the wonderful hero of this timeless novel, a story of some of the earliest commercial night mail pilots. It is a book that professional pilots and readers the world over have kept popular for over 80 years.

Now we see the crash of Air Asia 8501 as the latest dreadful and inglorious chapter in the story of commercial aviation. Thunderstorms can kill.

Thunderstorms can kill with hail, turbulence, lightning and icing.

Hail will shred aluminum leading edges of the wing and tail. Hail will bend, dent and destroy the leading compressor blades of a turbine engine, components spinning at tens of thousand of revolution per minute. Hail will dislodge and destroy the multitude of radio antennae and necessary flight probes sticking out in the free airstream. Hail will pock-mark, crack and puncture flight deck windscreens, windscreens that protect the flight crew from 300 mph winds, minus 60 degree temperatures and air so thin humans can not inhale enough oxygen to live.

Turbulent vertical wind shears will load up a wing with positive two times the acceleration of gravity one moment and slam back in the opposite direction the next with an equal and negative acceleration, and keep doing this over and over again.100_3975

Lightning can burn holes in fiberglass, aluminum and composite components of an aircraft exterior and flight surfaces.

Clear icing can coat an aircraft with a slick covering, increasing its weight beyond the wings ability to sustain flight. Rime ice can build quickly on flight control leading edges, disrupting the airflow needed to sustain controlled flight, raising drag significantly above the engines ability to push forward and again adding weight.

Thunderstorms can and have destroyed numerous aircraft in the history of commercial flight.  The danger to commercial aircraft is so severe that US commercial pilots are required by the FAA and their companies to remain clear of thunderstorm cells and even the overhang of ice crystals, sometimes referred to as the anvil.

Are modern commercial passenger and cargo aircraft safe to operate inside of thunderstorms? This question has been asked numerous times in the week since Air Asia 8501 disappeared from radar screens.  Let’s examine the current FAA standard specifications for commercial transport category aircraft. Are commercial aircraft and engine building companies required to produce aircraft and engines capable of sustained flight in conditions of hail, lightning, icing and severe vertical turbulence?  If so, were any of the current transport category aircraft and engines now flying ever certified by such field tests? Data please?

Are any US certified commercial passenger or cargo airlines currently certified to operate inside thunderstorms in their operation specifications or OpSpecs? I know of none. Are  FAR Part 121 airline dispatchers required to demonstrate their knowledge of thunderstorm avoidance flight planning and flight following by the FAA in order to be certified to operate as a dispatcher?

Are any US certified commercial airmen trained and certified for sustained flight operations inside thunderstorms? Not that I am aware of.

Is FAA air traffic control required by their own regulations to vector commercial aircraft around thunderstorms? Is the national weather service required to keep FAA ATC informed of areas of thunderstorm activity?

So how is it that airlines around the world, operating commercial transport category aircraft, airlines such as Air Asia, in aircraft such as Airbus 320 family, under the direct supervision of a trained and certified dispatchers with access to current up-to-the-minute satellite photographs of, not only thunderstorm cells in the planned flight path of the airline’s flight, but areas and lines of thunderstorms, do not advise their own company flights of safer routes? How is it that the local and enroute air traffic controllers, whose ground-to-air radar is exceptionally good at depicting weather,  might deny a flight’s request to divert around or over a massive area of thunderstorms and then not offer some safe alternative assistance?

Where is the team work, the coordination, the combination of minds needed to improve commercial aviation flight safety?100_0306

Is any of this new information to any certified crew member, airline, ATC, regulator or manufacturer in commercial aviation? Have not thunderstorms been killing commercial flights and flight crew members since the beginning of manned flight. Don’t we find the first popular documentation in the 1931 book, “Night Flight” by Saint-Exupéry. Here our crew members operate aircraft with piston engines, wooden spars and canvas wings.

Now here is the airline industry, more than 80 years since Night Flight with turbine engines, steel spars and aluminum wings. Yet, thunderstorms are still killing commercial flights. Why was Air Asia 8501 the most recent to join the long list?

I wonder if  Saint-Exupéry  would say, “Imagine that? Nearly a century has passed since I wrote my book and this story is still timely in terms of flight safety!”

The chapters are new, the planes are new, the pilots are new, but the story is timeless: Thunderstorms can kill.

Early morning sun rising through clouds.

Early morning sun rising through clouds.

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

Human Error and Training

I certainly can see why airlines with good safety records have vigorous training programs, and in many if not in most cases of mishaps, if not in all cases, human error should be found as the cause of the mishap. Let’s examine the AF Toronto mishap. Human Error: crew continued approach and landing during adverse wind field encounter. Crew did not brief a runway that had failed to have been grooved by the national airport authority contractor, presuming dry runway – like stopping performance.
I would bet dollars to donuts that the Toronto AF flight crew training program DID NOT include a segment of approach briefing covering whether or not the runway was grooved, porous friction coated or not grooved. [by the way this information is on the 10-9A page]. And yet wet runway stopping and control performance degradation is a commonly known hazard. Yet look at the investigation and you will see virtually all the blame heaped upon the flight crew, with little or no mention of this severe training deficiency. Also if the crew was trained and certified upon dispatch by AF and French CAA, why did they continue their approach to land into an adverse wind field generated by convective weather occurring in the approach corridor? Were they acting in accordance to the procedures for which they had been trained and qualified? Yet no where in the investigation do you see any questions raised about AF convective weather avoidance procedure training and why is that?

For a safety investigation to have any merit, it must identify what went wrong and what steps can be taken that will prevent the mishap from recurring. Why do so many airlines have their pilots “practice to proficiency” the windshear go around procedure, auto and manual?
Why do so many airlines require their flight crew, by procedure to brief whether or not the landing runway is grooved or not? How could any airline operating be oblivious to the notes on 10-9A about grooving? How could any airline not make this information an element of the approach runway briefing?

How could the Canadian national airport authority contractor make a decision to not groove their main instrument runway in their biggest city, or any runway in the country for that matter, and ICAO and not one other global safety authority object? How is it that ATSB could complete their investigation and not cover these subject areas? Is it possible that the humans on the ATSB made an error? Of what use is their report? What steps did they recommend to prevent the re-occurrence of this same mishap?

Is it possible, just possible, that what the ATSB really did was conduct a legal and administrative investigation where they found fault and laid blame for the damage and injury, but never really found the cause and recommended the actions to prevent a re-occurrence?

Lastly, the purpose of training is to put a crew together, working as a team, using standard operating procedures, designed to give crew members a pretty comprehensive set of well practiced actions to deal with whatever is expected to be encountered. The argument that no one can not make no mistakes is irrelevant. When you look at any and all of the major airline mishaps, the crew made massive errors, the crew did not trap the error and correct each other (two heads are better than one theory of CRM.)

I am not arguing the academic argument of purity from error. Rather I am arguing the very practical argument that a crew well trained in well written procedures will be able to handle just about anything that it encounters.

In the mishap reports that I have read, not only did one crew member make an error, but moreover other crew members did little or nothing to trap and correct the procedures in use. Take the Amsterdam Turkish B737-800 mishap where the crew allowed the aircraft to stop in the air and fall out of the sky. What kind of procedures were those? Where was the training to proficiency program for that airline?