Flying blind

The Tatastan Air crash at Kazan is yet another piece of evidence that the kind of risk airlines face is changing. Perfectly serviceable aeroplanes are crashing because of pilot misjudgements or ignorance, and taking their crew and passengers to an unnecessary death.

This may seem a harsh judgement to make only days after the event, but unless the flight data recorder is lying or the investigator – Russia’s highly competent MAK – is misinterpreting the data, the Boeing 737-500 had nothing wrong with it, but the crew became disorientated while carrying out the nighttime go-around and pushed the aircraft over the apex of the manoeuvre into a 75deg nose-down dive to impact.

Once thought of as a routine manoeuvre, entire dissertations at operations conferences are now given over to analysing the dangers associated with go-arounds. There have now been at least five such fatal accidents and many more near-disaster go-arounds in the last 20 years. The previously sacred diktat that crews should not land from unstable approaches is, itself, being de-stabilised by figures that suggest the greater risk is encouraging crews to abandon bad approaches and carry out a go-around.

The Kazan missed approach, like all the other  fatal ones and at least one of the near-disasters, occurred at night. Add these to other night loss of control accidents like Air France 447 and the evidence becomes overwhelming: many pilots who hold an instrument rating can no longer fly on instruments. They probably didn’t know they could no longer do it, but if their employers didn’t ensure their competence, that is negligence. Maybe not gross negligence, but the result is gross.

In 2010 I attended a Flight Safety Foundation conference in Milan, Italy, in which Boeing and Airbus presented on how pilots needed to be re-taught basics like stall recovery, and Air France’s head of corporate safety Capt Bertrand de Courville presented on the go-around dilemma.

Meanwhile at the same conference Dr Kathy Abbott revealed the early results of a study she was leading for the US FAA, revealing the evidence about how pilots are not trained effectively for modern flightdecks and modern flying.

That FAA report didn’t emerge when it was expected to, and everything went quiet for three years. Now it is rumoured that the FAA is about to publish it. What took them so long? Is the industry afraid of what it has discovered?

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One Response to Flying blind

  1. MJ 27 November, 2013 at 5:06 pm #

    Today I read an article “Do you really understand how your trim works” written by Alex Fisher (GAPAN) and originally published in UKFSC’s Focus Magazine (issue 77), available here: http://www.ukfsc.co.uk/files/FOCUS%20-%20Past%20Issues/Focus%2077.pdf

    In the context of this accident it is quite striking and I think it is well worth a read. It describes the difference between the trim system in an aircraft like a 737 – which has an “all trimming tailplane” – and the type found in a basic training aircraft such as the PA28 or C150. The crucial distinction is that the in the 737 the stick must return to the neutral position after re-trimming in order to prevent over-controlling and a potential departure from the normal flight envelope.

    Could it be the case that during this go around in night IMC with the trim set to a value suitable for the approach (possibly even increased nose up setting used in the advanced stages of a fail passive approach), the pilot flying pushed forward to prevent excessive nose-up in the go around manoeuvre, and simultaneously trimmed forward, believing (incorrectly) that the nose-forward trim would relieve the load on the control wheel? Combined with disorientation, task saturation in the go around, and fatigue, it is not hard to imagine that this situation went unchecked and the combined forward stick force and forward trimming sent the aircraft into an undesired nose down pitch attitude.

    The article cited above mentions that, at the time of writing, there were no known accidents caused by this lack of full understanding between the differences in trimming a conventional stabilizer vs an all moving tailplane. Could this be one such accident?

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