Tag Archives: NTSB

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

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

Aviation Mishap Investigations: Other Conclusions

One of the subjects of this blog will be Major Commercial Aviation Mishap Investigations and others and alternative analyses, conclusions and recommendations that could be reached. The sole purpose of seeking and reaching these alternative analyses, conclusions and recommendations is to improve commercial aviation safety closer toward the point that it is mishap free.
Investigations can give us an insight into a mechanical chain of events. NTSB and other major mishap investigations often accomplish this goal. Yet investigations can also give us insight into human thinking, human nature and human factors. Human factors is just another expression for the human condition, and since mishaps are the subject, the part of the human condition most often observed is that of “human error.” This further, perhaps deeper insight might give us a window into ways to prevent mishaps from ever reoccurring.

It may be possible to reexamine the facts of major aviation mishap disasters for the purpose of drawing conclusions which would lead to recommendations which could make aviation closer to being mishap free than it is today. This may seem a daunting task, taking into account the complexities of aviation disasters. This may seem an unreachable task, taking into account all of the very talented people who even today pursue aviation mishap investigations formally for the NTSB and other groups. This may seem a redundant task considering the wide range of party status granted by the NTSB to interested groups.

But it may be possible that new analysis, conclusions and recommendations can be reached, though however daunting the task.

Essentially, that is the purpose of this blog. The free expression of ideas may lead the commercial aviation community towards a safer future.