Instead of a journey to Mexico City lasting an hour or more, Aeromexico Flight 2431 was in the air for less than a minute after rolling down the runway at General Guadalupe Victoria International Airport at Durango. The airplane rotated to climb and then settled hard onto the earth within a half-mile of the tarmac’s end. Fortunately, all 103 people aboard the 31 July flight survived (some with serious injuries).
The pilots will be available for interview by crash investigators. The flight data and cockpit voice recorders were pulled intact from the wreckage. Crash investigators have a fortuitous wealth of information.
Not how the flight was supposed to end
The 99 passengers are owed an explanation. Others who fly commercial also merit assurances that the crash will not be repeated again anytime soon.
Bad weather, specifically a gust of wind, is attributed to the crash, but much, much more merits airplane investigation by investigators. This appears to be an accident caused by bad judgment — specifically by the pilots but also by air traffic controllers in the airport tower.
Let’s pose the salient questions in sequence as the airplane left the departure gate and positioned itself for takeoff.
Was the airplane behind schedule? If so, the pilots may have been under subtle pressure by the airline to depart. The culture of Aeromexico merits review. Was the number one goal to meet schedule or to meet safety?
On what basis did the tower controller advise Flight 2431’s pilots they were cleared for takeoff? The tower controllers had access to weather radar. They could see the runway right out the tower’s panoramic windows. If gusty, dangerous winds prevailed, the folks in the tower would have seen them.
Were jetliners landing or taking off immediately preceding Flight 2431? Were these airplanes being noticeably bounced around by wind gusts? Did the pilots of these planes report to the tower that the conditions were dicey, if not dangerous?
In the cockpit of Flight 2431, the crew had access to their weather radar; what was on the scope that led them to believe a safe takeoff could be made? The Reverend Esequiel Sanchez, a window seat passenger, recalled that at the time it was raining so hard all appeared blackness outside his window. The same view would have appeared through the cockpit windscreen. Did either the captain or first officer voice any concerns? The essence of what’s called Crew Resource Management (CRM) is for the pilot monitoring to advise the pilot flying that the situation appears unsafe. The tower may have issued clearance to take off, but the flight crew was staring into wind borne and rain splattered blackness.
The pilots could have waited 10 or 15 minutes for the storm to pass, yet Captain Carlos Meyron released the brakes and shoved the throttles of the Embraer 190 twinjet to takeoff thrust. How long had he and the first officer been awake? This was not their first flight of the day. Had they been awake since dawn and were afflicted with sleep-deprived fatigue by the afternoon? Fatigue clouds judgment and can lead to a fixation on carrying out the flight schedule.
The takeoff roll into the windy darkness — the degree of crosswind is one of the significant as-yet-unknown details here — was described by passengers as incredibly bumpy from the start.
The airplane may have been pushed by the down gust back onto the runway three times before finally getting airborne. One assumes here that the airplane was properly configured for takeoff (e.g., flaps set) and that engines were putting out full power (e.g., more than a reduced-power takeoff).
The jet was climbing into an increasing downpour and was being buffeted by downdrafts. The jet smacked onto the earth within sight of the runway’s end.
It is not clear whether or not the order to evacuate came from the cockpit, but flight attendants barked, “Get out of the airplane!”
Passengers were screaming; the airplane was in flames — probably from fuel spilled by the fractured wing tanks which was ignited by the hot engines.
The airport firefighters, ambulances and whatnot arrived at the scene and evacuated all to hospitals. More than 60 people were released quickly, with only minor cuts and abrasions. It is fortunate that the airplane was unable to climb higher or accelerate to a greater speed, as either could have resulted in a greater impact with the ground, with more serious injuries or deaths.
The crash investigators will have to wrestle with a salient question: Why was takeoff under those conditions even attempted?
The final descent and landing is, statistically, the most dangerous segment of an airline flight. In recent years, the number of such plane accidents have been high, accounting for hundreds of passenger and aircrew deaths. Bad weather is often a contributing factor, as is poor pilot training.
The latest crash during the landing phase involves a FlyDubai B737-800 with 55 passengers and seven crew aboard on 19 March 2016 at the city of Rostov-on-Don in Russia. Everyone died as flight FZ981 dove right onto the runway, smashing the airplane and its occupants into bits. It was the pilots’ second landing attempt, aborted at the last second but too late to avoid a fiery crash during the heavy winds that prevailed. Severe turbulence and wind sheer may well have violently tossed about the airplane in the last moments of flight.
All that’s left of FlyDubai flight FZ981
From what is known about the airline, founded in 2008, poor pilot decision-making was involved, although details remain to be fleshed out in coming weeks and months by Russia’s Interstate Aviation Committee. However, enough details have surfaced to allow some informed commentary.
Task fixation. When aircrews are fatigued, there is a human tendency to focus on the task at hand, repeatedly, even if these actions are revealed by the investigation to be questionable. A great contributor to task fixation is fatigue; an operator who is significantly rest-deprived will tend to focus on one task, to the exclusion of other actions.
News reports assert that both pilots may have been experiencing fatigue late in the day of the crash. The pilot-in-command of the flight, 38-year old Captain Aristos Socratous of Cyprus, had filed paperwork with the carrier to leave because of the unbearable schedule. A former colleague and captain with the airline said, “The reason that the captain was resigning is because of the schedules. He just couldn’t do it anymore. He was too tired, going to work fatigued, and that is why he had resigned.”
The co-pilot, 37-year old First Officer Alejandro Álava, a Spanish national, had worked 11 days with only one day off before the fatal flight. According to his flight log, he had been transferred from daytime to nighttime flights without being given adequate transition time to adjust his sleep pattern.
“There is no doubt has was fatigued and exhausted for this flight,” the former FlyDubai captain asserted. “That definitely was a contributing factor, no matter how [FlyDubai] may try to deny it.”
In cases of chronic fatigue, pilot behavior becomes more erratic. Thinking is foggy, instruments are not monitored, and errors go unmissed or not acted upon. Task fixation is one of the many insidious effects of fatigue.
FlyDubai is the low-cost sister of Emirates Airline. Its lower cost may be the result of packing more seats aboard and flying a demanding schedule with fewer aircrews. There are only a few ways a low-cost operation can trim expenses. Flight FZ981 departed from Dubai International Airport for the nighttime flight to Rostov-on-Don Airport, one of the airline’s 11 destinations in Russia. Upon nearing the airport, air traffic control warned the crew about “severe turbulence and moderate wind shear.” Wind speed was approximately 30 mph gusting to 40 mph. Wind shear involved …..
Broken cumulonimbus clouds scudded by at 3,600 feet.
Two airliners successfully landed immediately before flight FZ981 made its descent to land. The crew aborted the landing at 1,700 ft above and 4 miles from the runway because of the windy conditions. They put their B737-800 into a holding pattern.
Soon after, an Aeroflot airliner made three failed attempts to land and diverted to nearby Krasnodar Airport.
FluDubai flight FZ981 orbited for approximately two hours, the pilots hoping the weather would improve. It is not publicly known what the pilots discussed during their time in the holding pattern, or what communications, if any, were held with the dispatcher at FlyDubai’s operations center. Surely, the possibility of diverting to Krasnodar, or elsewhere, was discussed. While the B737-800 was consuming fuel, after the four hour flight from Dubai it still had substantial fuel to divert — the airplane took off with eight hours fuel pumped aboard.
The aircrew decided to make a second landing attempt at Rostov-on-Don. Here was task fixation with a vengeance. The airplane got within 3.4 miles of the runway threshold, but the crew decided to abort the landing for the second time because of the gusty wind conditions.
Vasily Golubev, the governor of the Rostov region, and the home of most of the 55 passengers, said, “In all likelihood, the cause of the air crash was heavy winds approaching hurricane strength.”
It is probable, but not known with certainty, that Captain Socratous was the handling pilot; in which case First Officer Álava would have assumed the duties of pilot monitoring. According to one report, either Socratous or Álava turned off the autopilot and activated the take off/go around (TOGA) button. (See https://www.rt.com/news/
337400-pilots-conflict-boeing-rostov/) In any event, the airplane was put into a steep climb with speed declining.
“Wait! Where are you flying? Stop! Stop!” a voice on the cockpit voice recorder apparently shrieked.
By the time crew actions were coordinated, it was too late. The airplane was plummeting downward at nearly 200 mph at an angle of approximately 45 degrees, then 60 degrees Immediately off the approach end of Runway 22 a mighty explosion marked the impact point.
Would a well rested aircrew not functioning in the window of circadian low (when the body’s demand for sleep is most pronounced) even attempted landing under these conditions? Probably not. The fatal wages of task fixation.
Both pilots had received their training on Western-built aircraft.
Reacting wrongly to instruments. There are other cases where the pilots have momentarily misread their instruments — especially if they received training and gained experience on Russian-designed aircraft.
Case in point: the fatal crash in 2008 of Aeroflot-Nord flight SU821 while descending to land at Perm Airport, Russia, killing all 88 of the occupants. The domestic flight originated at Moscow. The Russian pilots were flying a Boeing B737-500. In the late afternoon, the weather at Perm was cloudy.
The air traffic controller radioed the pilots that the aircraft was too far to the right of the glide slope, and shortly thereafter the aircraft was viewed on the ground radar as climbing.
“Roger, we are descending,” the aircrew radioed. However, the pilots failed to comply and the air traffic controller ordered a go-around.
The report by Russia’s Air Accident Investigation Commission of the Interstate Aviation Committee noted, “After the base turn, approaching the landing course at 600 m with both autopilot and autothrottle disengaged, the aircraft started climbing up to 1,300 meters, rolled 360° over the left wing and collided with the ground.”
The final investigation report cited the following reasons for the crash: the loss of spatial orientation by the crew (Captain Rodion Medvedev was the pilot flying; First Officer Rustam Allaberdin was the pilot monitoring) and chiefly by the captain who was the handling pilot during the landing phase. The plane banked left, rotated onto its back and went into a rapid descent from an altitude of 600 meters. The loss of spatial orientation in the night, while flying in the clouds, with autopilot and autothrottle switched off led to the crash. Poor crew resource management and insufficient training for using the Western type of attitude indicators contributed to the accident, the report said.
Both pilots had previously flown Tupolov Tu-134 and Antonov An-2 aircraft, which featured Russian designed instruments. In the Russian design of the primary flight display (PFD) the airplane’s bank angle is shown by a moving aircraft symbol, while the horizon remains fixed.
In the Western design of the PFD, the airplane symbol is fixed and the artificial horizon moves. A pilot trained and accustomed to the Russian-designed PFD must be constantly conscious of the difference; a lapse while looking at the Western PFD and momentarily assuming the Russian convention can lead to loss of control of the aircraft. At an altitude of just 600 meters — 1,968 feet — and in an extreme attitude, there was insufficient height to regain control.
Captain Medvedev had only 452 hours in the B737; First Officer Allabertin had just 219 hours in the B737. In the waning hours of the day, in clouds, and a momentary confusion over what the PFD was displaying could easily lead to incorrect control inputs and an unrecoverable attitude. Add in the “inadequate practices” by Aeroflot-Nord regarding the operation of the B737 and the “mild intoxication” of Captain Medvedev, according to the investigation, and the set-up for disaster is complete.
It was not the first time, and probably not the last, where the difference between the Russian-designed PFD and the Western-engineered counterpart played a role in an accident.
The Western-designed primary flight display for aircraft attitude has the airplane fixed, with the horizon moving as the airplane maneuvers (on left). The Russian design (center) has a fixed horizon with the airplane symbol moving. A new design (at right) features both moving horizon and airplane symbol
In other cases, the wholly Western design and pilot training in its use may lead to fatal consequences. The case of the fatal August 2000 crash of a Gulf Air A320 while attempting a nighttime landing at Bahrain comes to mind. On the first approach the airplane was descending much too fast. The captain declared a go-around, but he did not perform a standard go-around. Instead, he circled at 500 ft. altitude, with flaps not adjusted and a positive rate of climb not established.
Coming out of the orbit, the jet was not properly configured for a second approach. The captain applied TOGA thrust but only 5° nose-up pitch, instead of the requisite15° nose-up pitch. As a result of the 5° nose-up pitch, the airplane at TOGA thrust accelerated rapidly.
This rapid acceleration can lead to a phenomenon known as false climb or “pitch up” illusion. The pilot’s brain misinterprets the stimuli, perceiving incorrectly that the airplane is climbing. Consciously or subconsciously, the pilot experiencing this illusion might apply forward side stick to correct his perceived nose-high attitude. This causes the aircraft to accelerate even more, causing a worsening of the illusion. The pilot suffering false climb illusion can rapidly “correct” his way right into the ground or, in this case, the inky dark waters below.
Then the master warning sounded, indicating a flap overspeed condition. The so-called “barber pole” would appear in the speed portion of the PFD. At the time the overspeed warning occurred, the airspeed was 191 knots. The maximum speed for the “flaps three” configuration was 185 knots.
Indicated airspeed is shown on the left with red “barber pole” descending to show an overspeed condition
Two seconds after the warning, the captain pushed forward on the side stick controller, thus pushing the nose down and increasing airspeed even further. He held the side stick forward for the next 11 seconds, pushing the nose down -15°. At low altitude, it was positively the worst response. The airplane struck the Persian Gulf waters at a point three miles northeast of Bahrain International Airport. All 143 aboard the A320 were killed.
Why did the captain push the side stick forward to drop the nose? With an overspeed — especially at low altitude — the correct response would have been to pull back on the side stick to increase pitch, hence angle of attack, and thereby decrease the airplane’s speed. At fixed TOGA thrust, speed is controlled by pitch.
But to increase pitch would have meant moving into the descending “barber pole” on the speed tape. By dropping the nose, in a direction away from the barber pole, the pilot actually increased airspeed during the overspeed condition. The captain pushed when he should have pulled back on the side stick.
As a general precept, people are accustomed to “move away from the red.” For example, the correct response when the needle on an automobile tachometer goes into the red is to back off on the accelerator. However, this situation required the pilot to fly into the red in order to bleed off excess airspeed.
One surmises that the barber pole is moving in the wrong direction, inviting the wrong response from the pilot who may have lost situational awareness (the infamous “pitch up” illusion).
To be sure, it is difficult to believe that this seasoned captain would pay less attention to the primary attitude display while attempting, incorrectly, to deal with the slow moving “barber pole” warning on the adjacent speed tape display and its insistent “ding, ding, ding” aural warning.
This writer suspects that the barber pole, instead of descending, should have been rising. The pilot then would have been induced to increase pitch, not decrease it.
From these examples of landing catastrophes, two succinct observations come to mind:
Fatigue and its attendant symptom of “task fixation” can rob an aircrew of all available options. They’ll keep trying to land when prudence dictates a diversion.
Different instrument designs can, in the moment of confusion, lead pilots into irrevocable loss of control mistakes.
Both problems emanate from complacency. The FlyDubai pilots were operating under a perfectly legal schedule, albeit one at the limits of permissibility. The Aeroflot-Nord and the Gulf Air pilots were set up to fail by non-standard and pernicious instrument designs.
Jetliners frequently fly above foul weather. But to safely get back on the ground, everything should be done to ensure the crew is well-rested for critical decision making, and the instruments on which they rely should be standardized and intuitively logical.
It is that time of year when the agency responsible for conducting aviation accidents reveals its utter impotence at influencing real change. On 13 January 2016 the National Transportation Safety Board (NTSB) held its annual press conference announcing its “Most Wanted” list of aviation safety improvements. Since the NTSB issues recommendations, the “Most Wanted” list, as in years past, is likely to be slow-rolled, ignored or rejected outright by the Federal Aviation Administration (FAA).
It is time to consider an approach that would put real heat on the FAA.
The NTSB declares its “Most Wanted” list features “critical changes needed to reduce transportation accidents and save lives.” Note use of the word “critical”. The NTSB really wants its “Most Wanted” recommendations translated into regulatory action that would compel long overdue changes.
As NTSB Chairman Christopher Hart said at the press conference: “For more than 25 years, we have issued our Most Wanted List to help spur action on these unimplemented recommendations. Our Most Wanted List is our roadmap from lessons learned to lives saved.” (See http://www.ntsb.gov/news/speeches/CHart/Pages/hart_20160113.aspx)
NTSB Chairman Christopher Hart
But, given the frustrating history of Most Wanted recommendations — either languishing in the bureaucratic backwaters of the FAA or rejected outright — the “roadmap” delineates for the NTSB the triumph of hope over experience. Each year the NTSB issues its Most Wanted list of transportation safety improvements, and each year the regulators continue their stately deliberations and inaction. (NTSB Unveils 2016 Most Wanted List, Stresses Technology, see www.ntsb.gov/Safety/MWL/Pages/default.aspx)
For 2016, the Most Wanted recommendations for aviation include:
Reduce Fatigue-Related Accidents
The NTSB said:
“Human fatigue affects the safety of the traveling public in all modes of transportation. Twenty percent of the 182 major NTSB investigations completed between 2001 and 2012 identified fatigue as a probably cause, contributing factor, or a finding. Combating fatigue requires a comprehensive approach focused on research, education and training, technologies, treatment of sleep disorders, hours-of-service regulations, and on- and off-duty scheduling policies and practices.” (See www.ntsb.gov/mostwanted)
Not said is that pilot commuting from home to the base station does not factor into hours of service. Yet such commuting can include a fatiguing cross-country trip prior to the assumption of duty.
Fatigue remains a major issue
The NTSB has a whopping total of 29 aviation-related recommendations in this category of “Most Wanted” items. Here are a few recommendations with, so far, an unacceptable response from the FAA:
“Require all … Part 121, 135, and 91 subpart K operators [scheduled airline, non-scheduled transport category, and general aviation] to address fatigue risks associated with commuting [to the departure airfield], including identifying pilots who commute, establishing policy and guidance to mitigate fatigue risks … and developing or identifying rest facilities for commuting pilots.” (Under current regulations, pilots can commute across the country and assume their flying duty without rest.)
“Establish duty-time regulations for maintenance personnel working under … Parts 121, 135, 145 and 91 subpart K that take into consideration factors such as start time, workload, shift changes, adequate rest time, and other factors …” (Under current regulations, there is nothing to prevent an aircraft mechanic from undertaking two back-to-back 8 hour shifts.)
“Expedite rule-making which would make flight time and duty time limitations, and rest requirements for commuter air carriers the same as those specified for domestic air carrier crew members under [Part] 121 [the scheduled airlines].” (This is an especially galling loophole given that commuter airlines are often painted in the livery of the scheduled airlines with home they are partnered, with only a small sign on the fuselage denoting the commuter airline with which the passenger is actually flying.)
“Expedite the development and implementation of the air traffic controller performance assessment program … to detect and alleviate stress and fatigue among controllers.”
Maybe the FAA would have responded positively if senior FAA managers were required to put in the allowable hours now permitted for pilots, mechanics and air traffic controllers.
Disconnect From Deadly Distractions
The NTSB declared:
“Since 2003, the NTSB has found PED [personal electronic device] distraction as a cause or contributing factor in accidents across all modes of transportation. A cultural change is needed for drivers and operators to disconnect from deadly distractions. In regulated transportation [such as aviation], the strict rules minimizing the threat of distraction must be embraced by every operator on every trip. Removing unnecessary distractions is the first step in safely operating any vehicle.”
The NTSB has five recommendations in “Most Wanted” status. Below, a recommendation that is typical of the lot and is in “unacceptable response” limbo:
“Require … operators to incorporate explicit guidance to pilots, including checklist reminders as appropriate, prohibiting the use of personal portable electronic devices on the flight deck.”
Prevent Loss of Control in Flight for General Aviation
The NTSB lamented that:
“While airline accidents have become relatively rare in the United States, pilots and passengers involved in general aviation still die at alarming rates. Between 2008 and 2014, about 47 percent of fatal fixed-wing GA accidents in the U.S. involved pilots losing control of their aircraft in flight, resulting in 1,210 fatalities. Pilots can reduce these accidents through education, technologies, flight currency, self-assessment, and vigilant self-awareness in the cockpit.”
It should be noted that “self-assessment” and “vigilant self-awareness” are notoriously unreliable means for a pilot to avoid loss of airplane control. Involvement in unusual attitude recovery training can help sensitize a pilot to the subtle indicators of imminent loss of control, but such training in recovery from unusual attitudes is not required.
To be sure, the difference between accident rates for scheduled airlines (where the piloting is performed by company employees) and non-scheduled general aviation (in which aircraft owners do their own piloting) is truly shocking. According to the latest NTSB statistics, general aviation accidents occur in the U.S. at an average rate of three per day in 2013 — the most recent year for which the NTSB has compiled statistics. Fatal accidents occur in general aviation on average about once every two days, totaling nearly 400 deaths in 2013.
On average, one person is killed every single day in general aviation (Part 91)
In contrast, commercial airline accidents occurred in 2013 at an average rate of one every two weeks. The table below summarizes the stark difference:
Accident Summary 2013
Part 121, scheduled airlines
18 million flight hours
Part 91, general aviation
20 million flight hours
Source: NTSB Aviation Data & Stats, www.ntsb.gov/investigations/data/Pages/AviationDataStats.aspx
The difference between Part 121 and Part 91 accidents is no anomaly for 2013. Year after year, the same difference — 50 times more accidents in Part 91, same roughly comparable flying hours — reflects unbelievable mayhem in general aviation.
Despite the continuing bloodshed, the FAA has been sluggish in responding to 14 NTSB “Most Wanted” recommendations. The examples below indicate the NTSB recommendations have been paid in blood, are modest and implementable, but the FAA remained unmoved. Thirteen of the 14 recommendations remain in an “Open” classification , in many cases “Open — Unacceptable Response”, while the 14th recommendation is classified as “Closed — Unacceptable Action”. The FAA’s record in this area is frankly unbelievable:
“Revise airman knowledge tests to include questions regarding electronic flight and navigation displays … and the interpretation of malfunctions and aircraft attitudes.”
“For pilots holding a private, commercial, or airline transport pilot certificate in the airplane category who do not receive recurrent instrument training, add a specific requirement that the biennial flight review include a demonstration of control and maneuvering of an aircraft solely by reference to instruments, including straight and level flight, constant airspeed climbs and descents, turns to a heading, and recovery from unusual flight attitudes.”
“(I)nclude a certification standard that will ensure safe handling qualities in the yaw axis throughout the flight envelope, including limits for rudder pedal sensitivity.”
End Substance Impairment in Transportation
Alcohol and drugs affect one’s ability to drive a truck or pilot an airliner. According to the NTSB, more and better data will contribute to understanding the scope of the problem and the effectiveness of countermeasures.
In this category, the NTSB has 11 aviation-related recommendations in which the FAA response has been to slow-roll implementation or reject the idea outright.
Among the NTSB’s modest proposals:
“Require commercial operators to collect … toxicological specimens from surviving crewmembers involved in … aircraft incidents or accidents.”
“Review the research and literature on the potential effects on pilot performance of both licit and illicit drugs, in both therapeutic and abnormal levels, and use that to develop and actively disseminate to pilots usable guidelines on potential drug interactions with piloting ability.”
Require Medical Fitness for Duty
When safety-critical personnel have untreated or undiagnosed medical conditions preventing them from doing their job safely, people can be injured or die. The NTSB wants comprehensive medical certification to ensure that safety-critical personnel are medically fit for their duty.
Safety-critical personnel must be certifiably fit for duty
The NTSB has nine specific aviation-related recommendations in the “Most Wanted” category regarding medical fitness for duty. These recommendations are “open” or “closed” with either an unacceptable response from the FAA or no response has been received from the FAA. Among the NTSB recommendations:
“Develop a standard battery of tests … that would prevent applicants with color vision deficiencies that could impair their ability to perform color-related critical aviation tasks from being certificated without limitations.”
“Implement a program to identify pilots at high risk for obstructive sleep apnea and require those pilots provide evidence … of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification.”
“Revise the current … guidance on issuance of medical certification subsequent to ischemic stroke or intracerebral hemorrhage to ensure that it is … includes specific requirements for a neuropsychological evaluation and the appropriate assessment of the risk of recurrence or other adverse consequences subsequent to such events.”
Strengthen Occupant Protection
The NTSB declared that improved occupant protection could have saved lives and reduced injuries. Needed improvements include increased use of restraint systems and better design of occupant protection that preserves survivable space while ensuring speedy evacuation.
The worst way to ensure the safety of infants, holding them in a parent’s lap
The NTSB has a total of 16 aviation-related “Most Wanted” recommendations in this category. One of these recommendations concerns unrestrained “lap infants” and the need for these occupants to be in their own safety seats. This initiative has been supported by independent child safety experts for years, but the recommendation languishes in the bureaucratic swamp of inaction. Improved occupant protection involves modest costs, the methods of accomplishing it are well understood, yet the FAA does nothing.
Below, a sampling of unrequited NTSB “Most Wanted” recommendations:
“Amend … Parts 121 [scheduled airlines] and 135 [nonscheduled airlines] to require each person who is less than 2 years of age to be restrained in a separate seat position by an appropriate child restraint system during takeoff, landing, and turbulence.” (It should be noted that the FAA currently requires all galley equipment to be secured during these periods of flight. Coffee pots are restrained; infants are not.)
“Explore the feasibility of requiring, on a retrofit basis, non-injurious handholds on the back risers of aisle seats in order to provide an immediate form of restraint for standing persons.”
“Require operators of transport-category helicopters to equip all passenger seats with restraints that have an appropriate release mechanism that can be released with minimal difficulty under emergency conditions.”
The NTSB recommendations regarding occupant protection are modest, doable and affordable, yet the FAA rejects them.
Expand Use of Recorders to Enhance Transportation Safety
Investigators must have an accurate picture of an accident in order to help prevent future catastrophes. No tool has been more helpful at determining what went wrong than recorders, yet certain categories of aircraft are still not equipped with these critical technologies.
The ‘black box’ is actually orange
The NTSB has an astonishing 49 outstanding aviation-related recommendations in this category. Most are classified “unacceptable response” from the FAA. Below, a sampling of the NTSB’s frustration:
“(R)equire all turbine-powered, non-experimental, non-restricted-category aircraft that have the capability of seating six or more passengers to be equipped with an approved 2-hour cockpit voice recorder that is operated continuously from the start of the use of the checklist (before starting engines for the purpose of flight), to completion of the final checklist at the termination of the flight.”
“Do not permit exemptions or exceptions to the flight recorder regulations that allow transport-category rotorcraft to operate without flight recorders, and withdraw the current exemptions and exceptions that allow transport-category rotorcraft to operate without flight recorders.”
“Require all existing turbine-powered … aircraft that are not equipped with a flight data recorders … to be retrofitted with a crash-resistant flight recorder system. The … recorder system should record cockpit audio C197, ‘Information Collection and Monitoring Systems’.” (This recommendation requires the installation of cockpit imaging systems, which the FAA and its industry allies have stoutly resisted.)
“Require that all aircraft used in extended overwater operations and operating under … Part 121 or Part 135 … be equipped with a tamper resistant method to broadcast to a ground station sufficient information to establish the location where an aircraft terminates flight as the result of an accident within 6 nautical miles of the point of impact.” (This recommendation is a direct result of the disappearance of Malaysian Airlines flight MH370 in March 2014.)
The NTSB is not the only investigative agency frustrated at the lack of progress in implementing necessary, modest and well within state-of-the-art recommendations. For example, in its January 2016 report on the fatal fertilizer explosion in West, Texas in 2013, the Chemical Safety and Hazard Investigation Board (CSB) recalled an earlier recommendation:
” ‘Revise the Accidental Release Prevention Requirements … to explicitly cover catastrophic reactive hazards [specifically, fertilizer grade ammonium nitrate storage practices] that have the potential to seriously impact the public, including those resulting from self-reactive chemicals …’ ”
“Unfortunately, EPA has not issued rulemaking consistent with CSB’s recommendation more than 10 years since its issuance. Therefore, CSB has categorized the status of this recommendation as ‘Open — Unacceptable Response’ “. (CSB Investigation Report, West Fertilizer Company Fire and Explosion, Report 2013-02-I-TX, page 192; see www.csb.gov/assets/1/7/West_Fertilizer_FINAL_Report_for_website.pdf)
The NTSB is not alone in facing foot-dragging and excuse-prone resistance from agencies responsible for assuring the safety of the public.
In the case of the NTSB’s yet-to-be-enacted transportation safety recommendations, the course outlined below seems reasonable and overdue:
The NTSB forwards its 2016 “Most Wanted” safety recommendations — 133 for aviation alone — to the Transportation & Infrastructure Committee of the U.S. House of Representatives.
Committee Chairman Bill Shuster (PA-R) convenes a hearing.
At the hearing, NTSB officials testify as to why recommendations are on the “Most Wanted” list.
At the hearing, FAA officials must explain their languid activity, under oath.
Where explanations are wanting, Congress enacts legislation requiring the FAA to act.
Follow-up hearings would be held to document FAA compliance with the Congressional directives. Where reasonable progress is lacking, Congress votes “no confidence” in the head of the FAA and his immediate subordinates. These individuals would be denied performance bonuses. The list of said persons to be forwarded to the White House with a statement that such persons will not be approved by Congress for re-appointment or promotion.
Guaranteed, in this regime, the “Most Wanted” safety recommendations would receive positive attention in a suddenly fully-attentive FAA.
Pilots are so accustomed to relying on cockpit automation that their basic airmanship skills to fly manually are eroded. The result? When automation fails, pilots cope with the situation either with misguided and distracting attempts to restore the automation or with inappropriate and ham-fisted techniques when suddenly forced to hand-fly the airplane.
The reliance on automation, and some airlines’ encouragement in its use, has led to a situation in which the airplane is probably on autopilot even before the seat-belt sign is turned off after takeoff.
Although this is not one of the latest “glass” cockpits, automation can lead to complacency, dependency and ennui (ennui: a feeling of listlessness and dissatisfaction arising from a lack of occupation or excitement)
A recent report by the Inspector General of the Department of Transportation (DOT/IG) comes to this glum conclusion:
“FAA [Federal Aviation Administration] does not have a sufficient process to assess a pilot’s ability to monitor flight deck automation systems and manual flying skills, both of which are important for identifying and handling unexpected events.”
The title of the report is revealing: “Enhanced FAA Oversight Could Reduce Hazards Association With Increased Use of Flight Deck Automation” (see https://www.oig.dot.gov/sites/default/files/FAA%20Flight%20Deck%20Automation_Final%20Report%5E1-7-16.pdf). The FAA has overseen, and approved, cockpit automation which has led to a degradation in piloting skills. Now, the same kind of “oversight” is necessary to reverse the trend. Perhaps something more basic is needed.
The trained, professional airman sitting in front may be confused by what his state-of-the-art instruments and displays are, or are not, telling him. Many pilots are so reliant on automation they are reluctant to switch it off, and too many pilots are not confident in their basic hand-flying skills. Recent accidents have proved over-reliance on automation to be a recipe for failure. As demonstrated by the Asiana Airlines B777 accident in 2013 at San Francisco, a pilot may even construct an airplane accident scenario through mishandling the automation — and be quite unaware of what he’s done. (See Aircraft Accident Report, www.ntsb.gov/investigations/AccidentReports/Reports/AAR1401.pdf)
The DOT/IG notes that the FAA has developed new simulator requirements for hand-flying the airplane, which take effect in 2019:
New Simulator Requirements for 2019
Upset prevention and recovery
Aircraft upset is an unsafe condition which may result in loss of control. Training should focus on the pilot’s manual handling skills to prevent upset, as well as training to recover from this condition.
Manually-controlled arrival and departure
Pilots will be both trained and evaluated on their ability to manually fly a departure sequence and arrival into an airport.
Pilots will be trained to understand the performance of the aircraft and the way it handles at airspeeds just above the stall warning.
Loss of reliable airspeed
Training will focus on the recognition and appropriate response to a system malfunction which results in a loss of reliable airspeed [display] which increases risk of aircraft stall and/or upset.
Recovery from stall/stickpusher activation
Training will provide pilots with the knowledge and skills to avoid undesired aircraft conditions which increase the risk of encountering a stall or, if not avoided, to respond correctly and promptly.
Recovery from bounced landing
A poorly executed approach and touchdown can generate a shallow bounce (skip) or a high, hard bounce that can quickly develop into a hard landing accident.
The DOT/IG observed that the FAA is “developing guidance for implementing the new training requirements” but that “a completion date has not been determined.”
The DOT/IG did not indicate that the FAA’s glacial rate of progress is indicative of the low priority accorded the new training protocols.
If pilots cannot confidently and smoothly hand-fly the airplane through all phases of flight, and deal with upsets, unusual attitudes, loss of engine power, loss of electrics/hydraulics/pneumatics, etc. through all phases of flight, the notion of professionalism has been degraded to that of systems monitor. Yet there are situations in which the pilot’s basic skills at the controls will determine the fate of the airplane.
Below is a menu of correctives which will improve pilots’ handling skills:
At No Cost
Every chief pilot and fleet manager should declare the following policies:
— During cruise, aircrew to be strapped in snug, with at least one pilot’s feet within reach of the rudder pedals.
— During approach and landing, pilots strapped in tight, with the flying pilot’s feet resting lightly on the rudder pedals. The feet of the pilot monitoring should be easily within reach of the rudder pedals.
Incorporate the push-power-rudder-roll mantra in ground training for unusual attitude recovery:
— Push the yoke or side stick forward.
— Power, as in increase power to the engines.
— Rudder is applied. The rudder movement induces a yaw. That yawing motion causes the lower wing to move faster than the opposite, upper wing. The downside wing thus generates more lift. To be sure, whenever advocating rudder to be used in this manner, recall the lessons learned from the 2001 crash of American Airlines Flight 587, where the first officer was taught to use the rudder enthusiastically when experiencing attitude excursions. (See Aircraft Accident Report, In-Flight Separation of Vertical Stabilizer, www.ntsb.gov/investigations/AccidentReports/Reports/AAR0404.pdf)
— Roll to wings level.
Include an operating flight strength diagram in aircraft flight manuals, particularly in the “performance limitations” section, so that aircrews better understand the G loadings which result from full deflection of the elevator at a given airspeed.
Aircrews should keep their hands on the flap control lever until deployment is complete (asymmetric deployment can lead to an unusual attitude, which can be more quickly countered if the hand of the pilot flying is still on that secondary control lever).
At Modest Added Cost
Incorporate unusual attitude recovery techniques in initial flight training. Roll angles to 110° can be demonstrated airborne in a light trainer aircraft.
Send a cadre of check pilots and simulator instructor pilots through advanced in-flight unusual attitude recovery training. Thus exposed, they will be loathe to teach pulling the yoke full aft, losing altitude while increasing angle-of-attack, speed and G’s which can exceed the structural limits of the airplane.
Add a real-time G readout at the instructor position in all simulators so that instructors will be better equipped to advise students when they have pulled the wings off of the aircraft.
Perform fully developed stalls in the simulator at low altitude and at cruising altitude to show that with the correct techniques (push-power-rudder-roll) less altitude will be lost at low altitude, and to reinforce that one cannot fly out of an inadvertent stall at high altitude without losing some height.
At Greater Cost
Incorporate an angle of attack (AOA) indicator in the pilot’s primary line of sight, as an integral part of the attitude director indicator/primary flight display (ADI/PFD). Providing AOA information to the pilots provides an added margin of safety. An increasing AOA can warn of icing. Even with a “clean” (uncontaminated by ice) wing, the additional wing loading of a turn at low airspeed can put an airplane into a stall in the blink of an eye. An AOA indicator with a distinctive aural alerter and stick shaker would provide an essential warning to the pilots.
Expand simulator capabilities to present high-fidelity, real-world unusual attitude recovery situations. The goal is to inculcate familiarity, recognition and an instinctive avoidance response.
Ensure adequate tactile feedback, such as moving throttle levers when engine power changes, trim wheels that move when trim changes, and yokes/side sticks with increasing-force feedback to pilot inputs. In the 2009 crash of Air France Flight 447 in the Atlantic, and the 2008 A320 accident off Perpignan, France, the pilots were so unfamiliar with the manual trim wheel that they never even thought about it, let alone used it to extricate themselves from a dire, developing situation. (See Final Report on the Accident on June 1, 2009, to the Airbus A330-203 … Operated by Air France, www.bea.aero/docspa/2009/f-cp090601.en/pdf/f-cp090601.en.pdf. For the Perpignan accident, see Report on Accident off the coast of Canet-Plage at www.bea.aero/docspa/2008/d-la081127.en/pdf/d-la081127.en.pdf)
Train all pilots, in the air, in unusual attitude recovery techniques. Airlines need not maintain expensive trainer aircraft but can, instead, contract out this vital training to certified providers. Actual flight is necessary to reinforce the contrast with simulators. Stall recovery at both low altitude and at cruising altitude must be part of such training to reinforce the contrast. In both the AF 447 and the Perpignan accidents, both airplanes were super-stalled (i.e. they entered a stall condition due to an extreme and unsustainable pilot-induced nose-high pitch attitude selection). AF447 was inadvertently driven nose-high into the so-called “coffin corner” of the flight envelope at altitude The stunned first officer kept his A330’s side-stick aft (sight unseen by his opposite number) in a confused attempt to control the drastic post-stall height-loss In the Perpignan accident, the A320 entered its nose-high extreme stall attitude due to a misguided attempt to mode-change and complete a hectic air-test schedule at a much lower height than was safely appropriate. This distinctive stall onset is very different from any stall entered subtly via inadvertent speed reduction at a virtually constant pitch attitude at lower altitudes. A low level stall onset arrives with very noticeable buffeting and airframe vibration. In a super-stall entered at or near cruising height, the wing’s AOA is so high that turbulent airflows off the wing pass above the tailplane, so there is no attention-getting warning buffet at either the incipient or fully developed stage. The super-stalled airplane has the aerodynamics of a brick, thus the “locked-in” extremely high rates of descent and stable post-stall attitudes seen in those accidents. Moreover, the two airplanes were auto-trimmed into the stall; thus the trimmable horizontal stabilizer was fully deflected and sustained the stall. Manual pitch-trim was available but unused. The underslung engines, at full power, added to this overall pitch-up moment and thus the stalled condition was increasingly stabilized and self-sustained as more height was lost and as thrust increased. All airline pilots should be trained in these inter-relationships and how to recover from a super-stall.
At least once a year, train airline pilots in the air, moving beyond the simulator experience to actually experience the G-forces, visual stimuli and interactive ergonomics of actual flight
Not only is this menu of actions (and their rationale) more comprehensive than that published by the FAA, it also is far more likely to restore airmanship and professionalism among airline pilots.
In the Asiana accident discussed at length in the DOT/IG report, three “trained” pilots sat on their hands and allowed their jet to slam into a sea-wall well short of the runway on a beautiful July day in 2015. Afterwards, they were quite bereft, bewildered and clueless as to why the accident could have happened. This was a real wake-up call. The profession has been slowly hollowed out by automation and relentless cost cutting. It is time to reflect soberly that the best guarantor of a safe flight is a well-trained and alert pilot skilled in the manipulative nuances of airmanship in extremis.
To minimize press exposure, while simultaneously asserting one is on top of the issue, is a unique form of bureaucratic art. It has been mastered by the Federal Aviation Administration (FAA), as evidenced by its latest media minimization effort. Specifically, it issued a press release on December 22nd, giving the appearance of candor with four pages of text, all couched in blandishments, vague assurances and promises of internal audits. The date of issue, just two days before Christmas Eve, coincided with many reporters being on holiday leave, and the avoidance of certain expressions — such as “threats to safety” — assured scant coverage.
From the FAA’s perspective, the timing was perfect. The subject of the press release was relegated to a brief mention in the financial pages, if that. It was not covered by the network news, with Transportation Secretary Anthony Foxx having to sit under the sweat-inducing klieg lights and answer probing questions.
The press release was titled “Boeing Agrees to Pay $12 Million and Enhance its Compliance Systems to Settle Enforcement Cases”. (See www.faa.gov/news/
press_releases/news_story.cfm?newsId=19875) Whose “compliance systems” and “enforcement cases” are under discussion? Why, the FAA’s, of course. Boeing, it seems, had been blithely derelict for years, so the FAA wrapped up all $38 million in proposed penalties, and settled with Boeing Commercial Airplanes at approximately 31 cents on the dollar in exchange for Boeing’s fervent promises to do better in the future.
Press accounts described the deal as the “second highest enforcement settlement” achieved by the FAA, suggesting the agency has suddenly found its manhood and is truly acting as a regulator.
Look just a little deeper, though, and it’s business-as-usual for the FAA: take no action for years in the face of egregious behavior, propose paltry monetary penalties, then negotiate with the perpetrator to reduce those penalties to a minor fraction.
Of course, Boeing said in a statement that the $12 million penalty “fairly” addresses the matter. Given the sheer number of deficiencies cited in the FAA’s press release, the penalty goes beyond “fair” and into the realm of “token”.
Among the issues covered by this settlement was fuel tank safety. Boeing was required by the FAA to develop instructions for installing systems to reduce the likelihood of fuel tanks exploding which would lead to an aircraft crash. Remember, the FAA’s settlement announcement was in December 2015.
This issue goes back almost 20 years to July 17, 1996, when electrical arcing caused the center in-fuselage fuel tank on TWA Flight 800 to blow up shortly after the B747 departed New York City’s JFK Airport with 230 passengers and crew aboard. The force of the explosion blew the nose section — including the cockpit — off the airplane. The B747 struck the water in two sections, killing everybody on board.
A center fuel tank explosion destroyed TWA Flight 800
The National Transportation Safety Board (NTSB) investigated and determined that errant electrical energy found its way into the fuel measuring circuit in the center tank. The tiny spark in the dark confines of the tank was sufficient to ignite fuel-air vapors.
The NTSB concluded that all airliner fuel tanks needed to be protected with an on-board inerting system. In other words, flood the empty space in the fuel tank with an inert gas to preclude the possibility of explosion.
The NTSB recommendation was contained in its final investigative report on the TWA Flight 800 accident, issued in August 2000. Additionally, the NTSB said:
“Pending implementation of design modifications, require modifications in operational procedures to reduce the potential for explosive fuel/air mixtures in the fuel tanks of transport-category aircraft.” (Recommendation A-96-175, p. 310 of final report at www.ntsb.gov/investigations/AccidentReports/Reports/AAR0003.pdf)
It was not until 2008 that the FAA published regulations that required manufacturers to develop design changes and service instructions to reduce fuel tank explosiveness. The FAA was culpable of gross regulatory delay, and then compounded the tardiness by granting the manufacturers until 2010 to submit their implementation plans. It is not evident that recommendation A-96-175 has ever been issued to the airlines; none of them has modified procedures.
Boeing did not submit its plans to the FAA for inerting fuel tanks in the existing fleet or for modifying fueling procedures until 2011, more than 300 days after the deadline for submission to the FAA. Eleven years elapsed before plans were developed, not equipment and procedures modified. Someone at FAA headquarters should have been monitoring progress on a monthly basis; reports of progress, and lack thereof, should have been sent up the chain of command. Industry action should have been spurred; it obviously was not done.
The FAA should join Boeing in the docket for benign regulatory neglect and utter passivity given the threat of another fuel tank explosion right under the passengers’ seats.
Another major problem involved fasteners used to rivet together sections of Boeing’s 777 long-range jet. Boeing received a shipment of fasteners that did not conform to required specifications. The incorrect fasteners were used until 2010, even though the discovery of out-of-conformance parts was made in 2008. It is not clear if airplanes that left the factory with the incorrect parts were ever returned for correction and replacement, or if in-service inspections of these aircraft were mandated to assure that no long-term structural durability problems were being missed.
Quality control problems in the manufacturing of new Boeing airplanes
As in the case of fuel-tank issues, the FAA seems grossly derelict in assuring the structural integrity of B777 airliners. Some questions come to mind, such as:
How long had Boeing been receiving bad fasteners? The bad shipments were not discovered until 2008, but does the FAA know when the first shipment of bad parts was received?
How many airplanes were affected by the installation of out-of-conformance parts?
What testing on samples was done to assess degradation of durability?
These are questions to which answers are sought. Unfortunately, they are nowhere to be found in the FAA’s December 22nd press release. It is apparent, however, from the matters it does discuss — generically — that Boeing’s manufacturing process was shot through with poor management, absent quality control, and inadequate “process specifications” (15 in all) to ensure that aircraft production and supervision of same was of the highest order.
For all of these shortcomings, evasions and late compliance, Boeing negotiated a $12 million penalty to be paid the FAA. To put this puny penalty into perspective, Boeing in 2014 reaped approximately $5.45 billion in profit. The fine represents a miniscule .002% of the mighty Boeing’s profits. Ten times the $12 million penalty seems to at least be in the realm of appropriate, given the magnitude of the lassitude and outright incompetence suggested by the FAA’s press release.
Not even mentioned is the possibility of shutting down the production line until all deficiencies are corrected. The mere threat of such action from the regulator would bring massive media attention to the problem. Congress might even be energized to query the FAA on its suddenly proactive stance (causing some soporific Congressmen to jolt awake). The Administration might be forced to implement changes at the Transportation Department which would bring a halt to “feel-good” press releases that don’t increase the safety of the flying public. Indeed, the press release appears to preserve the jobs of those officials on whose watch the violations occurred, and to which they are fully and belatedly culpable.
A new ultra-lightweight material promises to save weight in aircraft structural applications. Its proponents are not very forthcoming about the downsides of the new material. For now, be wary of heady promises until independent testing results are compiled and made public.
“We are revolutionizing lightweight materials,” proclaimed Dr. Bill Carter, a materials manager at HRL Laboratories in Malibu, CA.
The material is said to be the world’s lightest, approximately 100 times lighter than the Styrofoam used in disposable coffee cups. According to HRL, the material is a nickel-phosphorous alloy that is coated onto an open polymer structure. The polymer is then removed, leaving a “microlattice” metallic structure that is mostly 99.99% air. In many respects, it is similar to bone in the human body, very rigid on the outside and very lightweight on the inside.
According to HRL, the approach “combines ultra-stiff and ultra-strong materials (such as nanocrystalline metals) that provide higher strength than conventional materials with highly optimized truss architectures that enable unprecedented degree of freedom to tailor the mechanical performance.” (See HRL press release at http://www.hrl.com/news/
2015/1005) The trick is to fabricate a lattice of interconnected hollow tubes with a wall thickness of 100 nanometers, or 1,000 times thinner than a human hair. (See HRL press release at http://www.hrl.com/hrlDocs/pressreleases/2011/prsRls_111117.html)
A sample of the new ‘microlattice’ structure is shown balanced atop a dandelion puffball. Large panels of the ultra-lightweight material are envisioned for airliners
Boeing owns HRL and is looking at the new lightweight material for both space and aviation applications. For airliners, the material is being considered for floor, side and ceiling panels to save considerable weight.
The new material would be sandwiched between carbon fiber composite facesheets. Before application to airliner cabins, the “microlattice” structure must be scaled up to achieve realistically-sized panels. This year a core panel of just 12″ by 12″ is the development goal. If successful, a follow-on effort will attempt a 2′ by 2′ panel, for a fourfold increase in size. Then the process will be expanded further to develop a 10′ by 11′ core panel of the ultra-lightweight material — 110 square feet. This larger panel is necessary to determine if the material can be produced in large enough pieces to use as structure in the cabin of an airliner. In other words, a 100-fold increase from the 1-square-foot panel attempted this year is necessary to determine if the new material is practical.
The ultra-lightweight material can be fabricated into a variety of shapes; the sample shown in the middle suggests its usage in cabin floors and sidewalls
The material is promised to hold its shape under pressure. For example, if used as cabin flooring, the “microlattice” will not bend and give a “bouncy” feel to the floor.
Note that initial application is not envisioned for flight-critical assemblies, such as engine pylons, flaps or wings. A healthy respect for a conservative approach is evident.
Note also that this development is not to improve safety, but to save weight. The last great initiative to improve structural safety was the “damage tolerant” ethic, in which added strength had to be added to account for the worst possible fatigue crack imparted on the structure during the manufacturing process (See http://www.efatigue.com/training/Chapter_2.pdf).
Many questions come to mind about full-scale application of the ultra-lightweight material in airliners. Here are a few items for which answers are presently unavailable:
How will the sandwich panels incorporating the super-lightweight materials be attached to underlying structural members, such as stringers and ribs? Whole chapters have been written about various fasteners used in production.
Will the interaction of markedly different materials, such as bending, compression, tension, create new problems that are not anticipated at this early stage in “microlattice” development?
What is the durability of this new ultra-lightweight material when exposed for extended periods to high levels of humidity, especially a salt water atmosphere associated with operations in tropical climates? Recall that current composites must be painted/protected against moisture intrusion.
How resistant is the new material to spilled fuel that pools and catches on fire?
Is the new material immune to the intense heat of electrical arcing, which may occur in circuits routed nearby?
How resistant is the new material to maintenance mishaps, such as damage from a dropped tool or a technician stepping on it?
How will damaged ultra-lightweight material be repaired?
Above all, complicated systems, such as this material with its ultralight metallic latices which are too small for flaws to be detected visually, have a tendency to produce unexpected outcomes. Be wary of the heady promises of this new ultra-lightweight material; much is promised but in-service experience is presently lacking.
On the afternoon of 10 November, with low clouds, mists and fog obscuring the ground, the silence was broken by the roar of the jet’s engines. The airplane was way too low for its landing at Akron Fulton International Airport, Ohio, and it slammed into a multi-family home. The force was like an eggshell hitting a brick wall, the shell being the structure of the airplane and the yolk inside comparable to the nine occupants. Shell and yolk were consumed by the fuel-fed fire. No one who resides in the building was there at the time. Damage from the impact and resulting fireball was substantial.
The airplane plowed straight into a building that was fortunately empty; note the overcast sky
The National Transportation Safety Board (NTSB) dispatched investigators to the horrific scene the next day. The NTSB will conduct a thorough analysis taking months to complete. But one acronym seems sure to feature prominently in the final report: CFIT. The abbreviation stands for Controlled Flight Into Terrain. If all the landing accidents in the country were laid out on one common display, most would be clustered short of the runway along an extended centerline, with the remainder shown left and right of the centerline, decreasing in frequency farther from the centerline. The display would represent a grim “CFIT cemetery”.
CFIT has been a big killer, and it spurred development in the 1970s of a preventive technology: a cockpit warning of looming terrain ahead. It is known by various monikers, but TAWS is the most common. TAWS compares the airplane’s position in three-dimensional airspace with an onboard digitized map. The system features a “look ahead” function to provide sufficient advanced warning for pilots to gain altitude. Generally, the system will sound an aural alarm in the cockpit: “Terrain. Terrain. Pull Up.” If a moving map display is part of the cockpit instrumentation, TAWS will color-code dangerous terrain ahead in red. Terrain well below the aircraft’s altitude will be shown in green. (See www.skybrary.aero/index.php/Terrain_Avoidance_and_Warning_System_(TAWS))
TAWS has proven to be a real life saver, helping airline pilots avoid skirting too low to terrain, especially on landing. All airliners weighing more than 12,500 pounds and having a passenger capacity of more than nine are required to be outfitted with TAWS. Charter airplanes powered by turbine engines and having 6-9 passenger seats are required to have a simpler TAWS-B system, which has everything but the moving map display. (See TAWS Buyer’s Guide, www.aeapilotsguide.com/pdf/05-06_Archive/TAWSPG05.pdf) As the runway threshold is approached, TAWS essentially snaps off, as landing configuration is attained and encounter with the runway tarmac is planned. In the Akron accident, the airplane was four miles from its destination — so if it was equipped with TAWS, the system should have provided an aural alert to the pilots that the airplane was too close to the ground.
The accident airplane in better days
The accident airplane was a Hawker 125-700. The airplane features a maximum weight of about 25,000 pounds and can be configured to carry 8-14 passengers. Owned by ExecuFlight of Ft. Lauderdale, FL, this particular aircraft had ten passenger seats. As a Part 135 charter operator, the aircraft was required to be equipped with TAWS.
“We are no less shocked than anybody else,” said ExecuFlight CEO Augusto Lewkowicz. “Planes just generally don’t fall out of the sky.”
He added that both pilots were experienced and had been ExecuFlight employees for about a year.
In skimming the ground before the plane crash, the airplane struck an electric power pole, causing a temporary blackout in the area.
If the airplane was not downed by a system malfunction, the role of TAWS — and the crew’s reaction to “Pull Up” announcements — will be scrutinized. Were such automated admonishments ignored as the crew attempted to skirt beneath the low hanging clouds and land the airplane?
The pilots in the airplane following Dynamic International Airways flight 405 on the taxiway radioed a warning, “Hey, yeah, Dynamic, the left engine looks like it’s leaking, I don’t know, a lot of fuel. There is fluid leaking out of the left engine.”
Shortly thereafter, the leaking fuel caught fire on the B767. The airplane halted and the slides inflated for the 101 occupants to conduct an emergency evacuation while Ft. Lauderdale fire trucks rushed to the scene.
Photo taken from a passenger window in a following airliner
Flames engulfed the left side of the airplane and black clouds of billowing smoke erupted skyward. Some of the thick smoke wafted through the doors and into the stricken airplane, no doubt adding to the anxiety of passengers now crammed into the aisle shuffling towards the emergency exits.
All thoughts of the flight to Venezuela on the charter airline were forgotten in the press to get out. “I was terrified, so I started pushing people,” recalled passenger Daniela Magro.”
“It was a real scare,” said passenger Luis Campagna. “As we were getting out of the plane down the chute, the smoke was beginning to enter and the engine was in flames.”
Not all emergency slides were used; the investigators will determine why
After the accident, Dynamic issued a statement that said, in part, “Safety of our passengers and crew members is the first priority of Dynamic International Airways.”
Dynamic Airways, founded in 2009, is headquartered in Greensboro, N.C., and had begun charter flights in July between Ft. Lauderdale and Caracas.
After the fire was quenched, the airplane was towed off the taxiway and parked. The National Transportation Safety Board (NTSB) dispatched four investigators to the scene. On 3 November 2015 the NTSB issued a preliminary statement on the 29 October fire:
“Examination of the left engine revealed no evidence of an engine [sic] uncontainment or other failure.”
“…[T]he main fuel supply coupling assembly had disconnected in the wing-to-engine strut above and behind the left engine. This coupling has been retained for further examination.”
The fuel connector is known as a ‘wiggins coupling’
“The lower inboard portion of the left wing, left engine cowling, and left fuselage center section sustained thermal damage. The fire did not penetrate the fuselage.” Note the NTSB’s use of dry, formulaic language to describe severe scorching, charring and blackening; note also the declaration that fire had not penetrated the fuselage while ignoring reports of smoke getting in to the passenger cabin
The maximum temperature in the wing fuel tank will be an indicator of how close true disaster was averted
“The NTSB is reviewing the airplane maintenance records … According to the aircraft records, the accident airplane was in dry storage for approximately 29 months until September 2015 when Dynamic International Airways leased the airplane. Dynamic International Airways has operated the airplane for about 240 hours under the present lease.” The airplane appears to have been a “boneyard bargain”; it had an astounding13 operators before being acquired by Dynamic. The airplane was nearly 30 years old. The integrity and thoroughness of the maintenance records — with so many operators — should be a major focus of investigation.
“An initial review of the airplane onboard logbook revealed there was no entry of maintenance action having been performed in the area of the fuel coupling prior to the accident flight while in [Ft. Lauderdale].” One of the areas of inquiry ought to be the maintenance requirements for an aircraft brought out of storage and engaged in active revenue service.
“Dynamic International Airways has issued a Fleet Campaign Directive to inspect the remainder of their aircraft to ensure proper installation of the fuel line coupling assemblies.” In other words, hasty action after a fire, not before. Again, the issue is post-storage inspection of the airplane, and any maintenance conducted. An item like the fuel coupling to the engine is critically important and requires a maintenance supervisor to inspect any work thereon and to sign maintenance paperwork attesting to the rigor and completeness of any action. Maintenance records on file at corporate headquarters should be thoroughly examined.
There is at least one other major issue that bears on this case. Fuel leaks to a screwed-on fitting do not suddenly appear. They manifest themselves in a slow, worsening leak beforehand. On the repeated trips to South America, did pilots notice a disparity in fuel consumption between the left and right engine? If they had no means of determining a disparate fuel consumption rate, was total fuel consumption greater than expected? If so, what was done about it, if anything?
The basic premise here is that anything loose will only get looser. Fittings for fuel line couplings do not get tighter, only looser without corrective maintenance action. As the saying goes, a coupling is only as good as the torque applied to it. In this case, the connective fitting may have been under-torqued — loose — for quite some time. Improperly connected fuel lines to engines have occurred before. The case of Canadian airline Air Transat flight 236 comes to mind. On a 2001 trans-Atlantic flight from Toronto to Lisbon, with 293 passengers and 13 crew aboard, the airplane exhausted all fuel and made a successful unpowered landing at Lajes airfield in the Azores — gliding some 65 miles to the landing.
Subsequent investigation by the Portuguese authorities — the Aviation Accidents Prevention and Investigation Department — found fuel had dribbled out a ruptured line, and that the flight crew was totally unaware of this leak. The #2 engine had been replaced before the flight, but without adequate clearance between the fuel line and an hydraulic line. Vibration in the inadequately-separated hydraulic line ruptured the fuel line. (For the full Portuguese report, see www.fss.aero/accident-reports/dvdfiles/PT/2001-08-24-PT.pdf)
Maintenance personnel had “force fit” the fuel and hydraulic lines where they run together in the engine pylon.
In the case of Dynamic Airways flight 405, the connection of the fuel line to the engine doubtless features a fitting that must be tightened to a certain tolerance, which requires a tool called a torque wrench to ensure that the fitting is neither under- nor over-tightened. Does the nut require periodic and measured adjustment? Was a torque wrench used, or just a plain old wrench? Was this maintenance performed on schedule, or had it been deferred until a more convenient opportunity?
For transport-category aircraft overall, the Dynamic Airways accident reveal a larger design issue. An airliner should not, ultimately, depend for safety on one connection that can vibrate free over a mere 240 hours of service since the airplane was pulled from storage.
The cockpit of a modern jet gives the impression of the soul of rationality and safety. Glowing instrument displays, rows of softly illuminated knobs and dials.
What’s not evident to a boarding passenger passing by the open cockpit door is the absence of built-in fire detection and suppression. A search for the round disks found on the ceilings of office spaces — indicating the presence of built-in fire extinguishers, will be in vain. A close look will reveal that a small, hand-held extinguisher is located in the cockpit; it is a testament to futility, as there is no way to inject its chemical agent behind panels to get to where a fire is going to be found, adjacent to the miles of electrical cables and fittings. Chafed wire or, worse, the presence of electrical arcing in the vicinity of emergency oxygen lines can lead to extremely dangerous oxygen-stoked fires.
At least two sure fires in recent times illustrate the extreme danger. One such conflagration occurred in July 2011. An EgyptAir B777-200 experienced a ravaging cockpit fire while on the ground Cairo, before the airplane was to depart with passengers (307 occupants, passengers plus crew). The fire, started in an oxygen line, scorched the cockpit and blowtorched a hole in the fuselage. The fire was caused by an electrical short circuit to the helically wound internal stiffener wire that provided rigidity, preventing hose-kinking and flow restrictions leading to the first officer’s oxygen regulator. The stiffener wire unfortunately was electrically conductive.
From the Egyptian investigation, the fire-ravaged remains in the cockpit. The full report by the Egyptian Aircraft Accident Investigation Central Directorate may be viewed at www.skybrary.aero/bookshelf/books/2394.pdf
From the Egyptian investigation, the burn-through of the aluminum skin
Fueled by 100% oxygen in the pilots’ emergency supply conduits, the fire might be described as an “oxygen flare fire.”
If an oxygen flare fire occurred in the cockpit during flight, as opposed to on the ground, a hand-held extinguisher would be of little use; there is no way to direct the extinguishing agent at the base of the fire, which is behind panels and other surface coverings.
At altitude, an oxygen flare fire would feature instantly high temperatures, lowering quickly as the oxygen was consumed. Many electrical circuits and associated avionics would be destroyed by the heat’s effect on flare-exposed plastic push buttons, LED screens, keypads and other plastic components that have replaced metal fixtures in earlier generation cockpits.
The following justification to this scenario follows:
Oxygen flare fire
Initiated by a wiring insulation flaw. Flare-up of 10-15 seconds duration (25-30 seconds at most) until oxygen depleted, hull rupture or leak blocked by melting material at the leak.
Loss of the aircraft.
Effect on cockpit instruments, displays and flight controls
The high heat of an oxygen-fed flare fire would melt/distort plastic switches and buttons in relation to their dissimilar plastic housings.
Although modern aircraft feature multiple back-up redundancies, those redundancies would be compromised by melting plastic buttons and switches and/or their latching solenoids, and it is possible to kill individual systems.
Explosive decompression due to an oxygen flare fire and its blowtorch effect on the adjacent hull skin.
Such a fire at cruise altitude would be quickly extinguished by hull burn-through and instant oxygen depletion via consequent depressurization outflows. Prior to hull rupture, the pressurization differential would assist the blowtorch weakening on the inside hull skin, speeding up the resulting skin rupture. Once the hull is holed, the oxygen-rich atmosphere is quickly lost and the flare fire quickly gives way to a very cold, dark and windy cavern, sporting just a few residual lights on consoles and panels. All else would be covered by a veneer of soot.
Effects upon pilots
Instinctively averting one’s face from the source of the flash fire might avoid instant incapacitation for the pilot on the opposite side of the cockpit, but once the hull was breached and emergency oxygen was burned away, hypoxia would have been inevitable.
It is instructive that when the Apollo capsule experienced a fire in the 100% oxygen atmosphere used at the time, the last astronaut communication from inside the capsule, in which procedures were being ground tested, came 27 seconds after the fire was reported. Not much time. In an airliner, any simultaneous attempt to don an oxygen mask would be in vain, as both pilots’ emergency oxygen supplies are from the source, unprotected by non-return valves. The intense fire would sear the pilots’ lungs.
In May 2014 the Federal Aviation Administration (FAA) issued an airworthiness directive for the B777 aircraft. This AD was one of a number issued in recent years by the FAA covering cockpit vulnerability to fire in a number of different models of transport-category aircraft. This particular AD required the replacement of oxygen hoses in the cockpit. AD 2014-09-06 explained:
“We are adopting a new airworthiness directive (AD) for certain Boeing Company Model 777F series airplanes. This AD was prompted by a report of a fire that originated near the first officer’s seat and caused extensive damage to the flight deck. This AD requires replacing the low-pressure oxygen hoses with non-conductive low-pressure oxygen hoses … We are issuing this AD to prevent electrical current from passing through an internal, anti-collapse spring of the low-pressure oxygen hose, which can cause the low-pressure oxygen hose to melt or burn and lead to an oxygen-fed fire near the flight deck.”
As usual, the FAA seems blind to the larger problem: the lack of fire detection and suppression in the cockpit. Sure, pilots have access to a small hand-held fire extinguisher, but they have no means for inserting the nozzle behind panels, where the fire is most likely to be located. The cockpit, locus of all things electrical, with emergency oxygen lines running in immediate proximity, remains woefully unprotected.
The military has lost aircraft due to fire in the cockpit. At least three cockpit fires in the Navy’s P-3 antisubmarine patrol aircraft resulted in “total loss” of the airplanes on the ground. All three fires occurred in the check valves that were part of the crew’s oxygen system. The military’s sad experience — and corrective actions — have never passed the unseen barrier between the military and civilian communities (see http://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20080026076.pdf).
There would appear to have never been any imaginative interpretations or prognostications of what might occur when a chafed wiring-initiated oxygen flash-fire should occur in flight. Such a detailed analysis, with effective corrective action, seems long overdue. The FAA Technical Center at Atlantic City, NJ, seems eminently staffed and equipped to undertake such a review.
Alternatively, a university engineering department or separate laboratory could be contracted to perform a fire-vulnerability study of current-generation airliners, to include burn trials of cockpit instruments, knobs, dials, fittings, hoses, lines, display screens, and other equipment, panels and accoutrements found in cockpits. Following component testing, a full-scale cockpit should be subject to fire vulnerability tests to assess the interrelationships of components. Having a university or laboratory conduct such a review would further assure independence.
The findings should lead to wholesale hardening of the cockpit against in-flight fire.
What is needed is a built-in fire detection and suppression system for the cockpit, in which chemical agent is stored in bottles behind panels, with output vents directed to likely sources of conflagration in hidden areas. Until such equipment is installed, the highly-electrified and most-flammable area of the airplane — the cockpit — will remain a flying firetrap.
Air traffic controller fatigue remains a significant issue, made worse by controllers squeezing five eight-hour shifts into four days. The result is controllers fighting sleep while they stare at radar consoles.
FAA air traffic controller at work
There are ample reports of controllers not responding to pilots’ radio queries because they had nodded off, of other controllers having to respond to the pilots, and the most scandalous case to get public notice: the controller who reportedly made a bed on the floor of the control room, complete with blanket and pillows.
“We’re trying to get a hold of Knoxville approach or Knoxville departure,” radioed one pilot as he vainly attempted to reach the snoozing controller.
In Washington, DC, two airplanes landed at Reagan Airport after the controller fell asleep and was unable to radio the requisite landing clearance. This kind of situation could have easily resulted in a plane crash.
The Federal Aviation Administration (FAA) asked the National Aeronautics and Space Administration (NASA) to study the issue, then it squelched the results. Repeated requests for the study resulted in its being belatedly made public 18 July. The FAA poor-mouthed the study, claiming, “Concerns remain that the academic approach used by NASA did not sufficiently integrate an understanding of the air traffic 24-7 operational environment with a scientific approach.” A plain reading of the paper reveals just the opposite (see ‘Controller Alertness and Fatigue Monitoring Study’, report DOT/FAA/HFD-13/001; see www.faa.gov/data_research/research/media/NASA_Controller_Fatigue_Assessment_Report.pdf). The results — cutting through the dry bureaucratic language — are troubling.
Media reaction to the survey got right to the point
The study found that nearly a fifth of controllers blamed fatigue for committing “significant errors” in their duties. Controllers averaged less than six hours of sleep, with less time sleeping before working at odd hours.
Scheduling practices allowed controllers to work five 8-hour shifts over 88 consecutive hours. In contrast, the average non-controller worker will undertake the same duty over 104 hours.
One popular work shift, dubbed the “rattler”, enabled controllers to squeeze five 8-hour shifts into four 24-hour periods. This schedule allows controllers to enjoy a three-day weekend. In the “rattler” schedule, a controller ends an 8-hour shift at 2 p.m., and then returns to duty at 10 p.m. the same day.
Here is a typical work schedule that includes the “rattler”:
Hours between shifts
Between 74-81 hours off during the preceding weekend, depending on previous week’s watch schedule
15 hours off from 11 p.m. Monday
7 a.m. – 3 p.m.
9 hours off from 10 p.m. Tuesday
6 a.m. – 2 p.m.
15 hours off from 3 p.m. Wednesday
10 p.m. – 6 a.m.
8 hours off from 2 p.m. Thursday
Off duty as of 6 a.m.
Note that this schedule guarantees maximum circadian disruption; that is, it requires alertness during the hours from midnight to dawn when the body is programmed — through millennia of evolution — to sleep. As the NASA study noted, “This circadian challenge is compounded by the fact that it is commonly difficult to sleep during the day before the midnight shift, when humans are biologically conditioned to be alert and awake.”
In addition, controllers often work overtime, either as extra hours tacked on to a regular watch or as extra days. As the NASA study observed, “This yields a 6-day schedule with potentially one day off before the next week’s schedule begins.”
The controllers’ response to a survey item was revealing about trust in leadership. Instead of “usually”, the overwhelming response was “sometimes” to the statement, “When I am fatigued at work, I feel comfortable asking for a break or rotation.”
There are obvious solutions to the supposed “dilemma” of controller scheduling and fatigue:
Instead of scheduling five 8-hour shifts over 88 hours, spread these shifts over 104 hours. Yes, the controller workforce of about 18,000 will have to be expanded. That is the price of establishing a more reasonable relationship between shift work and recuperative time.
Eliminate the “rattler”. Yes, such a move would cut into the three-day weekend, but the weekend is already short by six hours, when the controller is on watch until 6 a.m. Friday morning.
We are long past the point where schedules should be dictated by convenience instead of science. The FAA’s pooh-poohing and dismissing the NASA study for its “academic approach” is simply an admission that other factors than what is known about circadian rhythm drive the controllers’ work schedule. Life-critical decisions are entrusted to people too often fighting off sleep.