David Learmount: August 2008 Archives

Accident investigators have two tasks: one immediate, the other longer term.

The immediate task, following an accident, is to determine whether there is - or even might be - useful advice that should be disseminated to the operators of the type of aircraft that crashed. It's not necessary to be absolutely certain of facts before advising operators to check a component or a procedure if a risk might exist.

The Spanair Boeing MD-82 accident at Madrid is one of those for which the number of plausible causes is almost infinite, given the very sparse data being made available by the investigators. We have been told the aircraft got airborne, but clearly it was unable to stay airborne, and it impacted the ground with a very high nose-up attitude.

At this point, therefore, because of the lack of information provided, intelligent speculation about the possible causes by experts and interested parties - like MD-80 operators - can still include the following: incorrect take-off configuration; de-rated power selected despite Madrid's density altitude at the time and a tailwind of 9kt during the take-off run; incorrect speeds calculated or set;  engine failure or of loss of power; uncommanded thrust reverser deployment. Then there are all the potential combinations.

Two days ago Spanish investigators returned from their visit to the UK Air Accident Investigation Branch with the downloaded data in their possession. It is in their power by now, surely, at least to rule out some of that list, even if they are hesitant, at this point, about postulating the primary factors they believe might have contributed.

Accident investigators are public servants. They are paid by the public to serve the public. The information they hold does not belong to them, it belongs to the public. The public is not so stupid it would fail to understand information - even incomplete information - if it were provided.

One of the main problems here, as in most of the world's countries, is that the investigators are taking second place to the judiciary in the investigation, and lawyers do not seek knowledge with the aim of preventing a recurrence of this type of accident; they seek evidence to use to prosecute individuals. Hence the silence, and the lack of information provided to MD-80 operators who need it.

So Qantas had a sudden decompression a few weeks ago, and now a Ryanair Boeing 737-800 has just suffered one.

Sudden decompression is one of the two types of event that can occur on any passenger flight that are certain to scare the hell out of almost anybody on board, even though they normally contain little or no risk to life and limb.

The other frightening event is an unexpected go-around late on final approach to land. Both that and decompression are fairly rare, but either or both might reasonably happen at least once to anybody who does a lifetime of frequent flying.

The terror factor in these events is a result of their sheer suddenness, and the fact they are totally unexpected (even by the crew who are reacting fast to a situation not usually of their making), and both these types of incident make the pilots so busy for several minutes that they cannot safely take the time to explain what has happened and reassure the passengers there is no risk.

First, let's picture the go-around situation: the aircraft is getting so low  on its approach to the runway that the passengers are watching buildings and landscape zip past, and they are mentally preparing themselves for the touchdown; this is white-knuckle time for a high proportion of passengers on any flight. Suddenly the engines roar, the nose pitches up, and the aircraft is climbing fast, and the worrying whirrings and clunkings of the gear being retracted and the flaps adjusted can be heard loud in the cabin.

No explanations from the pilots are possible because they are concentrating hard on making the aircraft safe, and working with ATC to ensure there are no traffic conflicts caused by this sudden change of trajectory. The cabin crew have no idea why the go-around decision has been made, so they are just as surprised as the passengers. The reason can vary from the failure of an aircraft that landed ahead to clear the runway quickly, to the crew being unhappy with the stability of their approach in stormy weather.

Now sudden decompressions. These are terrifying because of the sheer drama.

Depending on what has caused the decompression (see the blog on the recent Qantas event) there may be a lound bang followed by a whooshing sound as the air rushes out of the cabin; instantly, the passengers' oxygen masks drop from the overhead racks, and fog forms in the cabin air because (remember your physics at school?) decompressing a gas causes a temperature drop, so the moisture in the air condenses into water droplets. The pressure drop will hurt everybody's ears badly, and anybody who has a serious cold may suffer ruptured eardrums (they will eventually heal, I am reliably informed).

As if that were not enough, the pilots, who have had also to don oxygen masks and suffer the same pain, have to put the aircraft into a rapid descent to get down into more dense air before the emergency oxygen supply runs out.

During this emergency descent they have to communicate closely with ATC who are trying to help them to avoid collision with all the aircraft at lower cruising levels; simultaneously they are having to control the aircraft's speed to ensure it does not exceed the allowable maximum, while navigating to ensure they don't hit any mountains buried beneath the cloud layer they are flying through.

That's not all. They also have to change their navigation plans to divert to an airport that's not the one they'd planned for, which also means checking their charts and reprogramming their flight computers for the approach to the diversion airport. Simultaneously they are trying to do a diagnostic job on what caused the decompression, because they have to assume it may have damaged the aircraft's structural integrity, even if it has not.

And you expect a reassuring message while that's going on? Forget it. Even if they gave you one you wouldn't believe them - you know you're going to die, and that's it.

But what about the cabin crew? They, too, have to don their oxygen masks and, because of the steep descent, they ought to strap into their seats - although some don't because they are trying to help the passengers. Unlike the pilots' oxygen masks the cabin crews' don't have microphones that connect to the cabin address system, and even if they did the cabin crew don't know what's gone wrong so they can't explain it, even if they do recognise that what's occurring is a controlled emergency descent. Some of them, like the passengers, also believe they are going to die.

Finally, about the emergency oxygen supply: it's a trickle of pure oxygen designed to increase the proportion of oxygen in the air the passenger breathes. It is not a rush of oxygen that fills the bladder on the supply tube.

I'll probably get murdered for telling you this, but even without donning an oxygen mask, a fit young person who doesn't smoke would probably not suffer unconsciousness during the brief period it takes for the aircraft to get down to below about 20,000ft. Anyone who did suffer unconsciousness would be unlikely to have brain damage, because they would still have been breathing air, even if at a pressure that did not sustain their brain at a fully functioning level, and the unconsciousness would have been so brief. 

Just get used to the reality. Go-arounds and sudden decompressions are seriously frightening, but hardly ever dangerous. The only people who love them are journalists.  

Not a lot.

It's a tragedy on a scale Western Europe hasn't seen for years. It was the sort of accident we thought we'd seen the last of in this part of the world.

But Boeing MD-80 series aircraft crashed fatally twice last year: once in September at Phuket killing 90 people, and the other at Isparta, Turkey in November killing 56.

Among aircraft of its design period it has a safety record which does not differ significantly from its peer airliners, but there is no doubt that it cannot match the safety record of the succeeding generations of narrobody, notably the Airbus A320 series and the Next Generation Boeing 737 series. Aircraft and flightdeck design have moved on, and the MD-80 series and its successor - the MD-90 later designated the Boeing 717 - have been out of production since 2006. The aircraft that crashed had been in service 15 years - not a long time for a jet airliner.

Referring to this accident, it occurred in daylight and good weather. The aeroplane was full or nearly so, and would have been heavy. Although that may turn out to have been a factor in the accident it would not have been the cause.

There is much talk of a No 1 (left) engine fire, but no official source has confirmed it. If a single engine power loss and engine fire were all that had occurred, the pilots would have been able to control the aircraft, so the investigators will be looking for more than that. They will also be looking for why the aircraft caught fire so fast and so completely that only a few passengers were able to survive.

If the flight data recorder and cockpit voice recorder have survived the fire, and yield good data, we will have information very soon. But the early information is likely only to be a series of facts. Using the data from the boxes, what happened in the accident is normally fairly easy to establish; why it happened will take longer.

Here is my video analysis of how the investigation such as this usually develops:

Few people understand the concept of a 'just culture' as it refers to aviation safety reporting. Or in any other industry for that matter. Most people don't know what it is or what it's for.

I'm not sure why Eurocontrol should be the first agency to carry out an analysis of why this ignorance exists, and of how societies and industry could be made better informed. But the agency has produced two readable, reasonably compact documents that I would commend to anyone who cares about aviation safety - but especially to air navigation service providers (ANSP) and national aviation authorities. They are downloadable, free, too.

Their titles are rather lugubrious, but don't let that put you off. The first is 'Just Culture Guidance Material for Interfacing with the Judicial System', the second 'Just Culture Guidance Material for Interfacing with the Media'.

I quote from the introduction to the first: "Setting up a Just Culture revolves around three questions: different States have so far tried, to a greater or lesser extent, to address the problems at the heart of a Just Culture in different ways. While they may differ considerably
in outward appearance, all these efforts actually centre on the reconciliation of three key questions:
1. Who in the State, ANSP or society gets to draw the line between acceptable and unacceptable behaviour?
2. What and where should the role of domain expertise be in judging whether behaviour is acceptable or unacceptable?
3. How protected against judicial interference are safety data (either the safety data from incidents inside of ANSPs or the safety data that come from formal accident investigations)"

The documents examine these issues, and propose ways in which States that don't have a just culture - but which recognise its potential benefits - could sow the seeds that would create a legal culture in which it might flourish. The second document deals extensively with the importance of the media in influencing the thinking of all people in society, from those in the government and the judiciary to ordinary air travellers. The industry does not do anything like enough, Eurocontrol proposes, to inform journalists about itself and its operations, so the journalistic ignorance that results in misreporting is largely laid at the industry's own door.

Naturally, Eurocontrol is concerned particularly to see a just culture working in the ATC and air traffic management sector.

I quote again: "In any type and level of communication [with the media], the approach should be based on honesty - journalists equate transparency of information with honesty. But being perceived as transparent is difficult for ATM, as the system's complexity has the effect of confusing those who do not understand it. Lack of comprehension can create misunderstanding, and since journalists are under intense pressure to deliver stories quickly, they often begin to construct a story before they fully understand the issues or the context. The resulting story can disappoint the ANSP, and a mutual mistrust can begin to develop."

The agency then explains the options for attempting to change that state of affairs.

This is an ambitious project, but full marks to Eurocontrol for doing something while other people are just wringing their hands about it.

Earlier this year, still under the heady influence of the sustained boom in global commercial air transport, the chief executive of Swiss Aviation Training Manfred Brennwald said he was worried about the prospect of a general acceptance that pilot quality would inevitably suffer as a result of the demand for sheer quantity.

The industry, he said, has a responsibility to "polish the image the pilot profession has" to ensure quality students are attracted to an airline career. He was worried that pilots are becoming regarded as just "a commodity".

Brennwald's absolutely right: the risk of many airlines hiring low quality pilots has always been there, but it is heightened at a time of high demand. The Flight Safety Foundation and the International Air Transport Association have voiced the same concern. It may all seem a bit surreal now that pilots are being laid off instead of hired, but the cycle will swing up again in a year or two and the industry will once again be scrabbling for a diminished supply of flightcrew.

Meanwhile, judging from the adversarial relationship significant numbers of airlines have with their pilot workforce, pilots are considered a commodity. It's also axiomatic that if that's how pilots are regarded and treated, it's how they will behave and perform, which reinforces the airline's conception of them as commodities. It's a self-fulfilling management behavioural pattern.

In the preceding blog I promised a look at alternatives to airline flying for aspiring pilots on the basis that the training cost leaves new pilots with a financial millstone around their neck for years, the job is unstable, it provides an appalling quality of life, and wrecks families.

I'd advise any aspiring pilot today to go for military flight training - during which you get paid well. It's obviously up to you whether you can square the job with your personal ideals, but if you can, you'll become far more versatile than an ab-initio airline pilot's training would ever make you. Then, when you exit, don't go for the airlines, get a job as a business or corporate pilot, or go into a training organisation. Either way you get paid well, but with corporate flying you get far more job variety and quality, and a more benign lifestyle. With training you get satisfying flying, but you also get to see your family.

Until airline boards and human resources departments actually take a serious look at what they expect and demand of their pilots, they will not attract the best, or if they occasionally do, they will not retain them. A few carriers do manage their pilots well, but most only think they do.

Incidentally, this sort of stuff is just one of the issues that will be analysed and debated at Flight International's Crew Management Conference in Dubai.

In fact, don't become one. Unless...

Anyone who wants to become a commercial pilot needs good health, certain aptitudes, considerable determination, and access to a lot of money for training.

But it's by no means all he/she needs. Pilots must have a gypsy soul to survive. That may not be new, but it's particularly true right now as the downturn bites.

Ideally, pilots should have no family ties beyond mum and dad. If they acquire a family en route, every member of it has to be incredibly tolerant of the pilot's chosen lifestyle.

Why the need for a gypsy soul? Well, for new young hours-builders, it helps to be prepared to go wherever in the world somebody will hire you as a bush pilot or night mail flyer. Your employer will pay you survival wages to do it. Small US operators have been known to charge the pilot for the privilege of working.

For the very young and unattached, bush/agricultural/night mail flying sounds exciting, but if you've just borrowed $100,000 from your mom and pop to train to CPL on the premise that you'll soon start paying them back, the stress can wreck the experience.

You are condemned to seek a relatively dull but steady airline job as soon as you can get one because your soul is owned by a bank.

Being a happy gypsy also helps when the economic downturn dumps you on the scrapheap with a load of other pilots. Along with all the others, you begin scanning the world's websites for jobs - prepared to go anywhere.

At times like this the airlines - bless their cotton socks - will charge you several thousand dollars for a simulator selection ride and the privilege of being inteviewed, followed by the $20,000 - $30,000 cost of a type rating if you need one. Heaven help your family life/love life.

The new multi-crew pilot licence (MPL), under which pilots train from scratch for a job in the right hand seat of a particular aircraft type with a particular airline, looked as if it had the potential to stablise training arrangements for the student pilots and deliver SOP-ready, type-rated pilots at a rate the partner airline had chosen.

But this also turns out to have been a mirage. The world's first nine MPLs were dumped during cutbacks at Sterling on the good old last-in, first-out basis. It's worse for them, because the MPL qualifies them only to fly as part of a crew, not as a single pilot in command, so they can't go for night freighting or bush flying in Cessna Caravans and the like unless they convert to the old CPL. More dollars please.

For what to do instead of flying for the airlines, read the next blog.

And now ... there's a Part 2 to this story...