Legal, Safe or Wise?

Whenever an aircraft goes down, pilots immediately want to know “what went wrong?”

If the aircraft involved is similar to the type you happen to fly, the interest in possible causes takes on an even more personal imperative. The recent crash of the FlyDubai B738 at Rostov-on Don, Russia lead to much speculation – and as I fly the B738, I obviously took a personal interest in the crash.

The recent interim report by the Russian Authorities provides some insights into the situation leading up to the crash. This preliminary report clearly states that, in accordance with ICAO standards and practices its sole objective is to prevent aviation accidents and no blame or liability is apportioned. The Flight Data Recorder and Cockpit Voice Recorder are still being interpreted and that information will undoubtedly provide further insights into the factors involved.

What is insightful is the final paragraph, which reads:
“For the purpose of preventive measures the investigative team recommends to:”
And then adds 5 recommendations, all relating to the same issue – here summarised in their para.2: “Have additional training on elements of go-arounds in various conditions, in manual control mode with two engines operative from various heights and with insignificant flight weights”.

They also refer to the 2013 B735 crash at Kazan and the 2006 A320 crash near Sochi, stating that the safety recommendations issued by the investigation teams should be “repeatedly studied and analyzed”.

It would thus appear that, at this early stage no malfunctions are reported and that the second go-around ended in a loss of control situation. This led the investigative team to feel that they needed to publish immediate recommendations regarding training.

Just looking at the facts presented: There were 7 crew members and 55 passengers on board, which makes for a very light aircraft. Take-off weight is given as 68 tons. Just doing the simple maths, I would reckon that they had a zero-fuel weight of anywhere between 50 – 55 tons, depending on whether any freight was carried. That would mean that they could have carried anywhere between 13 to 18 tons of fuel. The report does not indicate how much they had, but they flew for just over four hours, made an approach and went around, then held for just over 1 hour and 40 minutes before requesting a second approach. Just using raw numbers, calculating conservatively they had probably used around 12 tons of fuel by then.

So on the second go-around the aircraft would have been very light and at TOGA thrust it would have climbed very rapidly – as indeed indicated in the report.

Both approaches were manually flown using the HUD system. FlyDubai’s B738 airframes are apparently not certified for dual channel approaches and auto-lands, so this would have been according to their SOP’s. (A number of operators prefer this option, probably because of the lower costs associated – pure speculation on my part).

Importantly though, the report states that both approaches were flown “without significant heading or altitude deviations” – in other words, these were well flown approaches.

So it appears to be the go-around that went wrong – and from a Human Factors perspective I would await the final report and CVR analysis with great interest.

I have no idea how long the crew had been on duty, but they had clearly flown for more than 5.5 hours at that stage and were conducting the second approach well after midnight. The report uses Z time, but the local time was just before 04h00. Needless to say, as we know from dire experience – humans are diurnal beings and we do not perform well nocturnally.

Neither do we perform well when tired or fatigued. I have just recently presented a CRM workshop at ICEM 2016 and the emergency medical fraternity were extremely aware of the dangers when humans are tasked to perform in demanding situations while fatigued.

While the preliminary report suggests that training for go-around manoeuvres is required, I sincerely hope that the CRM aspects will be thoroughly investigated when the final report is published.

My own experience in airline operations is that what may be completely legal may not necessarily be safe – nor wise.

 

 

 

 

 

Beware the Jabberwock, my son!

“It seems very pretty,” she said when she had finished it, “but it’s rather hard to understand!” (You see she didn’t like to confess, even to herself, that she couldn’t make it out at all.)
– From Through the Looking Glass and what Alice found There, by Lewis Carroll.

Earlier today I had a discussion with a journalist regarding a TV programme about decompression events in aircraft, for which he had done the research. This leads me to my blog’s musings for today: What influence does the crew have on passengers’ experience and their recollections after an incident? We’re not discussing serious accidents here, only the run-of-the-mill events such as go-arounds, diversions, technical problems and, yes – pressurisation problems.

“This is your captain speaking…”

You would hear these words on almost every commercial flight. It is probably the most quoted sentence when passengers discuss their experiences in the air. Yet very few people would be able to tell you what the captain, or the cabin crew for that matter, had actually said. Not always because the announcements sounded like some comedian’s rip off – simply because people do not pay attention.

I’ve discussed passengers’ behaviour during emergencies before (see my previous post Evacuate, Evacuate! Are you ready?) as well as the power of the media in Good News vs Bad News.

What concerns me here is the widely disparate perceptions passengers report after an incident. “Report” is the correct verb here – anyone with a cellphone becomes an instant reporter and social media allow immediate “reports” on events as they unfold.

Unfortunately, most passengers are not experts in matters aviation and, much like Alice we don’t want to confess that we simply have not the faintest idea of what is happening, has just happened or had happened. However, cellphones allow us to become instant and expert commentators.

Phrases such as “near death experience”, “hysterical cabin crew” or “terrified passengers” abound. Snippets of accurate, factual information are few and far between. “Facts” often prove to be completely wrong perceptions – in one recent event a passenger commented that “the person who tweeted this could not have been on the same aircraft!”.

The dangerous reality is that a perfectly safe airline can have its reputation in tatters and face bankruptcy as a result of 140 instant characters.

Most airlines, like most businesses have an online presence and a department dedicated to following social media. They hope to catch the complaints and negative comments, attempting to counter them – essentially damage control. Unfortunately modern humans have an incredibly short attention span and by the time your positive reply hits social media, we are already onto the next 140 characters of interest.

During the QF32 emergency social media declared that the A380 had crashed, even while Captain De Crespigny and his crew were working the problem and getting their passengers back safely. Fortunately the hysteria calmed down once the facts became clear.

Have a look at this YouTube Video clip from News24:

Despite the headline, I think the passengers do not look too concerned – very few are wearing their oxygen masks, most have the time and presence of mind to turn their cellphones on to film the goings-on.  (Just joking – they were on anyway…) There is the sound of a baby crying, understandable as infants cannot equalise quickly and their ears would hurt with any pressure differential.

So where did the reports of “terrified” passengers originate?

Other social media reports indicated trauma and high drama – clearly not everyone was as composed as the people visible in this clip. I saw reports of “oxygen not flowing” – probably from those who forgot the briefing to give a tug to start it flowing.

Which brings me to the role of the crew – all professionals, all trained to deal with these situations. However, although most airlines would provide standard announcements for various events – some pilots and cabin crew are simply better able to communicate and calm frayed nerves.

When United 232 lost all hydraulics and all controls when the no. 2 engine failed catastrophically over Iowa, passengers spoke afterwards about Captain Al Haynes being “firm, but soothing” while informing them via the PA system.

Similar complimentary comments were made about the way the crew of QF32 handled the PA announcements.

QF32 Fire engines

QF 32  (Pic: criticaluncertainties.com)

As pilots we make decisions in difficult situations based on the old A-N-C acronym – Aviate, Navigate, Communicate. Our primary task is to fly the aircraft, whatever the situation. Once the flight path is under control, we need to fly it somewhere – the navigate bit – whether it be to a diversion airfield or to a ditching. Then we tell people what we are doing – ATC, our crew, and when time allows, our passengers.

It would appear that we should improve that last little bit – keeping passengers informed and comforted could avoid most of the negative and destructive social media rants.

In fact, after Captain De Crespigny had debriefed the passengers of QF32, TV crews were eager to record the dramatic stories of survival which these passengers surely had to tell – to their dismay, most of the passengers had no complaints and only praise for the crew.

Pilots train exhaustively for any possible mishap. Dealing with incidents and problems is the easy part  – how you address the passengers when they feel like Alice is a major challenge. However, allowing them to make sense of our “inverted world”, reading in reverse in the mirror could allow them to slay their Jabberwocks and turn the negative experiences and comments into compliments.

 

 

 

2016 and the Future for Pilots

Elon Musk predicts that in a couple of years, we will only be driving cars for recreation – transport will be automated.

The RAeS (Royal Aeronautical Society) recently held an interesting debate in London about the future of pilots in aviation. I followed this with great interest and the proposal that we will have pilotless cockpits within forty years was carried with a large majority.

Read any commentary on the current state of commercial aviation, and while it is acknowledged that it is safer than ever before, the general consensus is that pilots have been lulled into complacency by automation and have lost their basic flying skills.

As we kick off 2016, there we have three propositions which, effectively, indicate that we – pilots – are an endangered species. Add to these the advent of drones, which, especially in the military environment can be controlled from thousands of miles away to devastating effect.

Commercial Aviation is safe. In fact, the recently published annual statistics by ASN (Aviation Safety Network) indicate that 2015 was the safest year ever for airliners.

A decade or so ago the major causal factor in commercial aviation accidents was CFIT (Controlled Flight into Terrain). Training and the advent of Enhanced Ground Proximity Warning Systems (EGPWS) countered that trend. During the last decade the major causal factor in airline accidents has proved to be Loss of Control in Flight (LOCI), a fact which supports the contention that pilots are losing their stick and rudder skills.

And now we see a new, worrying trend emerging – the 2015 statistics show that most fatalities were a result of only two accidents. 150 people died in the Germanwings disaster on the 24th March 2015 and on the 31st October last year 224 people died when the Metrojet A320 was shot down over Egypt. Both caused by human depravity – not the usual “pilot error” or mechanical failure. The previous year’s Malaysian disasters fit this trend as well – the one shot down and the other still a mystery, but probably downed by dark intentions.

About the shooting down of civilian airliners not much can be said. It is terrorism and depravity of the worst kind. But what about the deliberate crashing of an airliner by the very people who should ensure its safety?

About LOCI we can do something. We can enhance high altitude handling training, we can up the required standards, we can add extra warning systems.

But what can we do about the insidious potential danger of a pilot “losing it” and endangering the aircraft, passengers and fellow crew members?

There lies the challenge for airline managers and their HR departments – the days are gone where pilots would come up through the ranks via the Air Force or contract or charter flying – this would act as a natural sifting process and only the dedicated and flying fit would make it through.

My concern is that modern aviation trends would tend to allow pilots who lack experience or the required resilience into cockpits – perhaps causing more trauma than we would like to imagine.

Unless we can solve this new-found dilemma, the RAeS debate’s outcome could become our future reality.

But would you like to be a passenger on a pilotless aircraft?

One has to question whether a computer would have made the decision to land in the Hudson river, saving all on board. In the case of QF32, where the pilots had to land their overweight and crippled A380 on too short a runway the computers were so confused that they were providing false information.

Despite the fact that Artificial Intelligence is being developed apace, my prediction for 2016 is that we will not see that pilotless flight this year – and frankly, I would hope not for many a year!

Jet Upset: Not a Good Tabloid Headline…

wwi_plane_in_a_tree_small_poster

I think its time again to haul out this sad picture, which hangs in just about every flight school or ops office and which has served to warn generations of new pilots about the perils of flying with the wrong attitude.

The recent loss of an AirAsia Airbus A320 serves as an example: The accident investigation board cited a solder crack in a circuit board as a causal factor – it did indeed set off a number of events which clearly caught the pilots unaware, but the major cause was the pilots’ inability to recognise their aircraft’s departure from the intended flight path – and their “incapacity” to recover from that upset, potentially due to a mixture of “carelessness and neglect”.

Flight path management is the pilots’ primary task. There are obviously other tasks to be accomplished (navigation, weather avoidance, radio work and a myriad others) but controlling the aircraft’s current and projected trajectory by way of energy management remains the most important.

What the recent AirAsia crash and that of Air France 447 a while ago clearly illustrate, is that we need a different training approach to avoid pilots losing control in flight. LOCI (Loss of Control in Flight) has become the major cause of aircraft accidents. (Review the below graphic from Boeing’s latest annual Statistical Summary of Commercial Jet Aircraft):

CRM Acc Stats 15

It tells me that pilots would rather leave the flying to computers and autopilots, while they fiddle with circuit breakers and try to figure out “what this thing is doing now”.

It would appear that the captain of AirAsia 8501 was out of his seat to pull circuit breakers without consideration of the consequences and when the Airbus went into “alternate law” the FO could not accomplish the basic recovery from a stall event at altitude. (The same problem the pilots of AF447 had over the Atlantic Ocean).

High altitude flying comes with its own set of problems. I won’t bore you with the definitions of “coffin corner”, but at high altitude aircraft have three possible limitations: Certified altitude, Thrust Limit Altitude, and Buffet or Maneuvre Margin.

On the B738 I fly, thrust is usually the most limiting factor, as at altitude you may find that you have insufficient thrust for anything but relatively minor maneuvering. The Boeing FCTM (Flight Crew Training Manual) clearly states: “Flight crews intending to operate at or near the maximum operating altitude should be familiar with the performance characteristics of the airplane in these conditions.” 

The fancy FMC (Flight Management Computer) will provide you with a limited bank angle which won’t exceed the current available thrust limit, only if you’re operating in LNAV (Lateral Navigation) mode. In any other mode – and this is what many pilots miss – you need to maintain your own speed at least 10kts above the lower buffet limit and use a maximum of 10 degrees of bank. Should you run into the thrust limit, you can only reduce bank angle, increase thrust to max continuous, or descend (or all three).

Which all goes to show that at those altitudes the potential for control loss is very high.

In a recent blog, David Learmount ( http://www.Learmount.com ) stated that in 18 control loss accidents since the year 2000 almost 2000 people lost their lives. That is simply unacceptable. Crashing an aircraft which, despite some technical issues, is fully flyable, is an indictment of our pilots’ level of training and expertise.

It is not the jet that gets upset – it has no emotion in this regard. It is the pilots who should be the last barrier of redundancy, but who are failing by causing the jet upset.