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G-YMMM: could the crew have done any more?

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After an accident, pilots always discuss whether a crew could have done more even if they appear to have done a good job. It's not usually vicious or critical, it normally feels more like pilots experimenting with ideas about how they might handle a situation like it if they were to meet one themselves.

 

The crew of flight BA 038, a Boeing 777-200ER on short final approach to Heathrow's runway 27L after a flight direct from Beijing, were suddenly faced with a technical problem that has never happened before. Not in the effects it had anyway. So any suggestion that they should have been better prepared for it is somewhat wide of the mark.

 

The presence of some ice in fuel is a known issue, but systems are designed to cope with it. On this day, however, the ice behaved in a unique way, a function, investigators believe, of the particular combination of a long flight in lower than usual outside air temperatures and low average power settings throughout.

 

The problem showed itself when - on short final approach - the autothrottle system demanded power following many hours at low power settings. As the fuel flow tried to increase, "sticky" ice that had accumulated on the fuel pipe walls was suddenly dislodged and washed downstream, accumulating in a mushy mass on the front face of the fuel/oil heat exchangers which are just upstream of the engines. This restricted fuel flow, denying first the autothrottle and then the pilots the power they were demanding. The engines settled at a setting not far above idle power.

 

Here's an account of what happened from that point. Heights are above ground level, times are seconds to go to G-YMMM's actual touchdown short of the runway, and autopilot and autothrottle are both engaged. The problems begin at 720ft AGL according to the flight data recorder, but it is a few seconds more before they become apparent to the crew:

 

  • 800ft: Copilot takes control according to BA standard operating procedures;
  • 720ft agl/57sec: Right engine fails to respond, then rolls back power to 1.03 EPR;
  • 50sec: Left engine retards to 1.02EPR, but both engines remain above idle;
  • 600ft/48sec: Copilot becomes aware of a split in power lever positions and, distracted by this, he fails to trip out the autopilot as he had briefed he would do at 600ft;
  • 34sec: Crew recognise low speed and that there is a problem maintaining glideslope. They apply manual power but there is no engine response. Airspeed drops further below reference speed and aircraft descends below the ILS glideslop, but the autopilot continues to raise the nose;
  • 240ft: captain reduces flap from 30deg to 25deg, which AAIB says stretched the glide by about 50m
  • 200ft: Stickshaker operates, copilot pushes stick forward to prevent stall. AIRSPEED LOW master caution warning operates;
  • 150ft: Autopilot is disconnected by copilot's action in pushing on the control column;
  • 3sec: Capt makes Mayday call;
  • 0sec: Aircraft hits ground at a 1,400ft/min (25m/s) rate of descent, 330m short of runway 27L, and slid 372m before coming to rest. Peak touchdown vertical acceleration 2.9g.

 So what more could the pilots have done?

 

The only thing the investigators reveal, from their tests reproducing fuel system ice behaviour, is that if the crew had reduced the low power settings actually to idle, the ice blockage would have dissipated. The trouble is that reducing power at a time when your problem is not having enough thrust is totally counter-intuitive.

 

So forget that option.

 

They could have pulled the gear up to reduce drag. Yes, but when the gear broke off at touchdown because of the very high rate of descent, it absorbed some of that vertical energy. Without it, the hull impact would have been harder, the tail would have impacted well before the front fuselage, raising the risk of a fuselage breach. And the aircraft still wouldn't have made it to the runway anyway.

 

What about the captain's decision to raise the flap from 30deg to 25deg? The AAIB says it stretched the glide by 51m. Raising it further would risk a stall. Not changing the setting would still have seen the aircraft make it "over the hedge" into Heathrow, and maybe just about clearing the ILS localiser aerial array as well. So doing nothing was an option, but what the captain chose to do definitely reduced the risk.

 

I couldn't have done better, and I would be pretty pleased if I could have done as well as Capt Peter Burkill and SFO John Coward did on that day in January 2008.

 

 

 

 

 

 

 

 

Nailing the Concorde "criminals"

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Today in Pontoise, north of Paris, the French judiciary began to examine who, if anyone, was criminally guilty of causing the Air France Concorde crash.

There is no obligation under French law to launch a criminal prosecution following an aviation accident. An accident could be presumed to be just that: an unintended, unforseen occurrence.

This compulsion to prosecute following aviation accidents in France seems to be embedded in the way the establishment works in the country, but it's about time somebody in authority questioned the procedure. The trouble is that it seems to be considered sacrilege to criticise or interfere with the French judicial system. The judiciary's independence is sacred to the extent that they can write their own rules. So that's what they do.

In this blog about 18 months ago I reported an encounter with a senior French lawyer who specialises in aviation, and she gave me a cryptic insight into why the French judiciary act as they do. I quote briefly from that report: "The French judiciary are not obliged to prosecute following accidents, any more than the British judiciary are, but in France they always choose to go for prosecution, while in the UK they hardly ever do."

Let's look at what this Pontoise court has to do if it is to convict any of the five accused of manslaughter.

For the charge against the Aerospatiale engineers/designers to stand, the prosecution has to be able to prove that Concorde was designed negligently, that the design's vulnerability to wing fuel tank damage was known, and it could have been forseen that there was a risk that this vulnerability could lead to the loss of the aircraft so as to cause harm to those on board.

That will be difficult to prove.

The Continental Airlines mechanics are alleged to have departed from proper engineering procedures when they prepared a titanium strip to carry out a repair to the DC-10 that took off from the same runway shortly before Concorde began its take-off roll, and that the strip detached from the aircraft during the roll. The accident investigators' report says the probable cause of the accident is that the titanium strip on the runway cut one of the Concorde's tyres in such a way that a large chunk of the exploding tyre pierced the wing skin and released a stream of fuel that caught fire, causing the crash.

It may be that the alleged departure from standard engineering procedures could be established, but whether a connection between the engineering procedure and the accident can be proven is not certain. The technical investigation does not deal in legal proof, its purpose is to establish a "probable cause" for an accident purely so that future events of the same type can be prevented. A probable cause is not a proof. The court may be unable to prove the connection.

This court case is pointless. Concorde itself will never fly again, and in the unlikely event that any new technical facts emerge that had not already been examined by the accident investigators, they are unlikely to provide lessons that are transferable to in-service types because so much about Concorde's design is unique. If the argument is that the prosecution is being pursued "pour encourager les autres", or to see justice served by jailing some individuals on the grounds they are guilty of manslaughter through criminal negligence, which group of people will welcome this judicial revenge against five individuals? There has been no baying for blood over this accident, merely sadness.

In previous cases where a prosecution was mounted following air accidents in France, the normal outcome has been the acquittal of all involved. On the rare occasion that a person has been found guilty, the sentence has been suspended.

What makes the Concorde case particularly distasteful is how much time and money have been wasted on preparing it for court over the nine years since the accident, and how much more is going to be wasted in court during the next four months. Add to that the harm and delay always imposed on the technical investigation by the French judiciary's meddling which, in this case, drove the UK Air Accident Investigation Branch - a partner in the investigation - to distraction while they were trying to get on with the job.

The French judiciary in this case are acting like a peculiar sect with strange beliefs pursuing an eccentric ritual that has no relevance to anyone except the participants.  

As usual, this case will be won or lost on legal technicalities. It is certainly not about aviation, it is more about legal egos, if my French lawyer friend is to be believed. And about lining their pockets. 

The curse of the flight director

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Despite all the recent talk in this blog, at the FAA, at Airbus, and now at US ALPA about loss of piloting skills as a result of operating with high levels of automation for a long time, there is a danger that some people are getting confused between the loss of hand-flying skills and the loss of mental skills.

Hand flying skill rarely gets terminally rusty, and if it does you can pick it up again fast. Once you've learned to ride a bike you never lose that ability.

It's the mental ability to fly and to navigate using raw flight and navigation data that gets lost if it is not used. If you have to hand-fly the aircraft at the same time as using raw flight and navigation data when you are not used to either, that's quite a workload.

That mental ability can also be restored quite quickly with a bit of training, but its return is not instant.

Raw-data handling is manual flying without the flight director. It's having to choose a pitch attitude and a bank angle that will provide the performance you want at the power setting you have selected, instead of having both of those chosen for you. If you unquestioningly follow the crossbars out of sheer habit, you may stop noticing what your pitch and bank actually are, or at least not with any precision.

All pilots learn early on that a chosen flight path is the result of a combination of a selected pitch attitude, bank angle (or wings level) and power setting. If you stop having to choose the attitudes and power settings that give you the result you want because you can choose the performance directly by dialling the numbers into the autopilot, that is not flying, it's trajectory management. So if, one day, you have to go back to flying when the autopilot trips out because two or more air data computers disagree and so do your airspeed indicators, you are not in practice for the situation you face.

So the recurrent training today's pilots need to be given must entail a couple of hours with the autopilot, authothrottle and the flight director tripped out, and compass rose mode selected on both navigation displays.

All pilots can do this. They wouldn't have their licence if they couldn't. But they can't do it well if they never practice it.

Does it matter? Yes it does. The FAA-quoted Colgan accident is not the only example of why it does.

 

Another one in the sea at night

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With the loss of the Ethiopian Airlines Boeing 737-800 offshore from Beirut on 25 January, the phenomenon of fundamentally serviceable aircraft - and all their passengers - being lost over the sea at night is becoming frightening.

I have put this issue under the spotlight before.

Here's a list of the main airline losses in this category since 2000. There have been seven such accidents, and together they have killed 976 people:

2010 Ethiopian Airlines 737-800, Mediterranean Sea near Beirut

2009 Yemenia Airbus A310-300, Indian Ocean near the Comoros Islands

2009 Air France A330-200, South Atlantic

2007 Adam Air 737-400, Java Sea near Sulawesi

2006 Armavia A320, Black Sea near Sochi 

2004 Flash Airlines 737-300, Red Sea near Sharm el-Sheikh

2000 Gulf Air A320, Arabian Gulf near Bahrain 

In some of them the cause has been established officially.  Gulf Air, Armavia, Flash and Adam Air were all caused by a combination of total or partial pilot disorientation followed by a failure to control an aircraft that could have been controlled.

Yemenia is known to have hit the sea having stalled at quite low level during an attempted circling approach at night, so that could be put in the loss of control/loss of situational awareness category.

Air France was known to have suffered some specific technical anomalies, but in the absence of new information indicating the the aircraft was physically uncontrollable, the crew should have been able to maintain control but failed to do so.

And now Ethiopian Airlines. It sounds distressingly like several of the others, particularly the Flash Airlines event. In the latter, the captain was carrying out a slow turn over the sea at night, and from what he said to the copilot, he clearly had the "leans". The aircraft went into a spiral descent and crashed. The copilot could see what was happening but left intervention too late.

We have learned from Beirut air traffic control that the aircraft was on a northerly heading soon after take-off from runway 21. We believe it was heading to a coastal way point north of Beirut, possibly with the intent of crossing Lebanon eastward, bound for Syrian airspace. There it would, presumably, have turned south toward its destination, Addis Ababa.

But the flight, still in its early northward climb, was told to turn left onto 270deg to avoid traffic inbound to land on 16. The aircraft's left turn continued through 270deg around to 140deg, despite warnings from ATC. The crew did not respond, and radar contact was lost.

There were thunderstorms in the area, and this may turn out to be a contributory factor in what happened. But right now it looks terribly like another case of pilot disorientation over the sea at night.

This is an undeniable phenomenon now, but no-one is recognising it as such. Whenever it is finally recognised, determining more appropriate pilot training would be a priority internationally. Maybe the aviation insurance industry should start lobbying, but it's a pity they should need to.

What is "piloting best practice" these days?

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If you are on the ops side of an airline or fractional ownership fleet, and you want to find out what currently constitutes piloting best practice, we can still take last minute bookings for Flight International's Crew Management Conference in London staring 0900 on Monday next week.

Pilot Best Practice, the theme for the CMC this year, is not about Top Gun attributes. But  stick-and-rudder skills are part of it, even today. Do you know how to save fuel and stay safe?

If you want to learn the latest on that, and a load of other ways of being a dream pilot in the eyes of your airline, your passengers, the insurance industry, and even Friends of the Earth, you'd better be there with other like minded people.

Visit http://www.flightglobalevents.com/crewmanagement09 to find out what you'll be missing if you don't come.

Talk about cost/effective....!

Will the A400M fly, then?

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A400M engine run.jpgThe A400M's first all-engine, on-wing engine-run 

 

Now here's a real aeroplane. It has propellers.

And yes, it will fly because we need this machine. At present there's no military airlifter between the C-130 and the C-17 unless you are in the USAF. The maiden flight is programmed some time before the end of the year. But, if it doesn't meet that deadline, patience!

At Toulouse a few months ago I "flew" one of the test simulators for it.

A400M simulators_copyright Airbus.JPGA400M fixed-base simulators, wired up to the "Iron Bird "

test rig for the  new aircraft 

For an ex Herc driver like me, getting your head around this machine takes some doing, and I'm not there yet. It's a sidestick aircraft (which I have no problems with), and FBW, but flight envelope protection is invisible. You wanna do a barrel roll? Feel free.

I didn't do a barrel roll, but I did roll 110deg into a mock evasive descent manoeuvre (much good may it have done me in real life).

But just like the A400M's Europrop International TP400-D6 engines - which have been giving problems that have extended the programme's spectacular delays - especially their FADECs, its avionics suite and mission systems need some work yet.

 

Cockpit_AC-1_A400M.jpgAlso, the sims need a lot of shaking down before they deliver. But the engines are the most powerful turboprops the Western world has ever attempted, and the avionics are incredibly ambitious.

Problems? Surprise, surprise! Remember how long the C-130J took to shake down? And that was just a simple Herc with digital avionics and upgraded engines/prop systems.

Since when did military procurement go smoothly?

Anyway, the delays associated with this programme have enabled the "Iron Bird" systems mockup of the A400M to go through many more cycles than it would otherwise have achieved before first flight.

The picture of the "bird" is below. Just so you understand what you are seeing, it's the complete hydraulic, electrical and control surface actuator rig that represents the systems on the real A400M, laid out in a hangar and powered. Imagine the layout you see as being the aeroplane flying in a direction that's laterally 2 o'clock compared with your view of the scene. The wings are against the far wall, and they continue around the corners for lack of lateral space to get all the systems in. The red objects are the control surfaces (spoilers etc), weighted to represent real inertia. The walkway down the centre is the rig for the hydraulics/electrics that follow the fuselage line, and on the left, high up, is the horizontal stabiliser with the screw-jack acuator ahead of its leading edge, and the red units representing the elevators where the trailing edge would be. 

A400M iron bird_copyright Airbus.JPGIt may be rigged to one of the simulators (there's one with motion systems as well), but the systems and control surfaces are constantly being flexed just to test their durability.

South Africa may have cancelled its A400M orders, but unless they have changed their defence strategy (quite probable) they'll be back. If you need an airlifter in the A400M size/performance category, there's no alternative on the horizon.


How to burn 18.4% less fuel and live. Really.

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Courtesy of Oxford Aviation Academy and SAS at OAA's Stockholm base, I have just flown an A320 twice from Gothenburg to Copenhagen, with identical weights in identical conditions both times.

But, by adopting a few modified procedures the second time, we used 18.4% less fuel.

Don't try all these tricks on your next trip without having a word with your ops and training standards people, because even SAS, which has been working for a few years with OAA to develop "Eco-Piloting" techniques and training, has only just got there, and has not yet begun the process of transferring the new tricks onto the line.

If you want to learn about the techniques SAS/OAA have been trialling, register for Flight International's Pilot Best Practice/Crew Management Conference in London at the end of this month and you can talk to Per de la Motte, OAA's Director of Training, Nordic region about his secrets.

Back to my two short trips.

Given that, on the first trip, my mentor in the right hand seat, OAA's fuel-efficiency guru Peter Fogtmann, ensured that we used normal SAS/A320 SOPs and standard routeing with absolutely no shilly-shallying, I wouldn't have thought a fuel saving of 18.4% was possible. But its what we did. Since it's only a 25min hop, 18.4% translates as a 320kg fuel saving, which may not sound much - but what a percentage! Save that every trip for a year and you're talking big bucks and dramatically reduced emissions.

Of course Peter and I are in a simulator, but it's a Level D FFS, so the figures we get should represent the truth, as near as dammit.

The first trip was done the way any good line pilot would do it, so I won't bore you with that. But here are the differences applied on the second trip:

  • Reduced the cost index from 30 to 7 in the FMS;
  • Chose Malmo instead of Gothenburg as the alternate, which meant we could carry 450kg less fuel;
  • APU was started only moments before pushback;
  • Single-engine taxi (using No 1 engine). APU was shut down once No 1 was established and checked;
  • No 2 was started with 3min to go to line-up for take-off;
  • Take-off was carried out with flap/slat 1 instead of 2, and packs off;
  • Power levers retarded to "climb" detent at 800ft (instead of 1,500-3,000ft), and acceleration initiated at that point;
  • Request for optimum speed below 10,000ft accepted, and continued at 305kt (opt) instead of sticking to standard 250kt;
  • Request direct routeing at every opportunity (in this case the routeing was almost direct anyway, so there were no benefits there);
  • Input forecast or actual winds rather than standard seasonal;
  • Initiate descent at a carefully estimated point beyond normal TOD because continuous descent approach was likely to be available;
  • Flap 1 selected at glideslope intercept; flap 2 at 2,000ft; gear down just before 1,000ft; flap 3 selected just before 500ft (would be 1,000ft in IMC); land with flap 3 instead of 4;
  • Idle reverse during landing run;
  • 3min after touchdown, No 2 engine shut down; single-engine taxi to stand.

Yes I know you wouldn't be able to do all those things on many regular trips, and hardly any of them in busy terminal areas during the winter, but just doing some of them when you can provides a benefit that makes a difference. Yes I know you have to consider icing procedures in unkind weather, but sometimes the sun shines.

SAS and OAA, who are making this kind of expertise a speciality, say it's about a mindset. A mindset that hasn't been examined critically for a long time, with the result that there are lots of treasured beliefs out there that are effectively urban myths.

Come and listen to Per, and find out what he has found out.

 

Opening cabin doors onto the Hudson River

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It was Capt Chesley Sullenberger and First Officer Jeff Skiles that put the US Airways Airbus A320 safely down on the Hudson River, but it was the cabin crew that faced the job of getting the passengers out.

I spoke to two of Sullenberger's cabin crew, Donna Dent and Sheila Dail, at the Guildhall in the City of London, just before the Guild of Air Pilots and Air Navigators annual awards banquet on 29 October.

The third cabin crew member, Doreen Welsh, could not attend that evening but she, seated as she was at the aft end of the cabin on that winter's day as the aircraft came to rest on the river, watched as the damaged tail slowly dipped, and the dark, freezing water began to flow into the cabin ahead of her. Dent and Dail were near the forward doors, and I will let them tell their story:

 

Flight 1549 crew

 

Why Sully succeeds

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If you read Capt Chesley Sullenberger's just-published book "Highest Duty", you will understand that the success of his Hudson River ditching was no fluke.

Sullenberger is a thoughtful man. Everything he does is considered. He identifies objectives and works resolutely toward them, checking his progress as he goes. It's the way he approaches life and flying.

If that makes him sound like a cold fish, you'll find it's not so. His quiet love of flying and his clear recognition of what's important in life - and what's not - shine through the unfussy prose and the downplayed narrative of events. He treats people, colleagues and family alike, with respect.

He knows he is good at what he does and is proud of that, but he also knows he's good because he has worked hard at it. He may enjoy flying, but he takes the task seriously.

Being a really good aircraft commander and pilot is not something many people can achieve, so if you want to know what it takes, check here.

A few days ago, at the Guildhall in the City of London, just before the Guild of Air Pilots and Air Navigators' awards banquet, I asked Capt Sullenberger briefly to describe what it was like when his Airbus A320's engines were stopped by a massive birdstrike (see video).

 

 

Listen to the detail of what he says, and you'll understand why this ditching worked and everybody survived. It was no accident.

Later that evening Capt Sullengberger, accompanied by two of his cabin crew on the day of the ditching, Donna Dent and Sheila Dail, accepted the Guild's Master's Medal on behalf of the Crew of Flight 1549.

You can find out what the cabin crew had to say about their experience of the event in my next blog entry.

This blog has, several times, addressed the subject of the contamination of bleed air supplied to aircraft cabins by toxic organophosphates. Now Susan Michaelis, already the author of the Contaminated Air Reference Manual, is appealing for those who have suffered - or believe they have done - from illness related to cabin air contamination, to get in touch with her. I'll leave the request in her hands:

 

"I am currently in the process of completing a PhD on the health and safety implications of  contaminated cabin air at the University of New South Wales in Sydney. As part of this I am undertaking 3 health surveys. While I have obtained considerable data I am keen to hear directly from pilots from around the globe falling into the following 3 categories: 1) BAe 146/ 146 RJ pilots both past and present; 2) medically retired or pilots who are/have suffered long-term ill health (permanently or for a period of time) after flying the B757; 3) pilots (colleagues or family may respond) who have experienced brain tumors, particularly those having flow short haul or aircraft up to B767 during their careers.

 

To date my research of past and present UK BAe 146 pilots has shown the following preliminary results: Out of approximately 300 pilots contacted, 87% were aware of the contaminated air; 59% had experienced some adverse symptoms that are commonly seen with such exposures; 27% reported medium to long-term 'Aerotoxic' type symptoms and approximately 10% appear to have been either ill health retired, suffered long-term ill health or were deceased appearing to be related to what many call 'Aerotoxic Syndrome'. A similar pattern is being seen internationally  and is supported by published literature from around the globe.

 

The data will all be de-identified and should contribute significant data to the knowledge we have on the cabin air issue. Anyone willing to participate in the basic survey should contact me as soon as possible at: susan@susanmichaelis.com."