Thursday, January 12, 2017

Captain's Authority, Captain's Responsibility

airline captains' authority has eroded
Should he run the entire show?

A recent incident on a JetBlue airplane where former Senator Al D'Amato was removed from the flight after causing a disturbance got me thinking about captain's authority. In this incident, some passengers needed to be relocated due to a weight and balance issue. When some of the passengers refused, Senator D'Amato apparently started a ruckus and blamed the captain stating "the captain needs to grow some balls", according to another passenger.

My first thought upon hearing this story was wondering why the captain allowed himself to become involved in a passenger dispute in the first place. That's almost always a no-win situation. Then I thought that Al D'amato is in his late 70s and probably still entertains the quaint notion that airline captains actually run the show.

In one sense they still do, but it is an extremely narrow writ. Federal regulations give airline captains absolute authority over everyone on a commercial airliner but only as it pertains to the safe conduct of the flight after departure. As the flight was still parked at the gate, the captain had no legal authority to order anyone to do anything, and my guess is that JetBlue policy states that pilots are not charged with moving customers. That is a customer service issue to be handled by customer service specialists.

And in case there is any doubt about that, pilots who still have old school ideas about injecting themselves into customer disputes can quickly find themselves with a few weeks of unpaid leave. I've seen it happen time and again. That, unfortunately, is the new reality of today's airline operations. Cost a guy a half a month's pay and he should eventually get the idea.

My guess is that the pilot was attempting to persuade some customers to voluntarily move, but I find it highly unlikely that he was empowered by JetBlue to order anyone to move. And I of course don't blame passengers who took the effort to get to the airport early to get in the first boarding group now being asked to sit in the back of the bus.

So what are your thoughts? Should we return to the old school days where pilots actually did run the whole show, or should they just stick to the mechanics of flying the plane as they are expected to today?

Thursday, January 05, 2017

I Feel Ok, But I Still Called in Sick

Flight doctors keep pilots flying
A visit to the flight doc might prevent this 

To be fair, I really do have a bit of a cold. It started the day before my trip with some sneezing and a headache. It's really nothing most workers would consider staying home for. A daytime Theraflu has got me feeling almost fine, but I still didn't go to work. Instead, I called scheduling to get myself pulled off my trip and replaced. Now I've got some extra time to write a blog post. Am I lazy or is this a good call?

You Don't Want Me Flying Your Plane

Though it may sound like I'm milking the system, trust me when I say that you do not want me anywhere near your airplane for a number of reasons. The first, obviously, is that I'm not 100%. Flying places enough physiological stress on a body as it is. Disrupted circadian rhythms, fatigue, dodgy airport food, and dehydration from hours in dry airplane air can all contribute to a degradation of the alertness which is needed to operate an airliner.

Throw in additional stressors such as congestion, or a headache and effectiveness in the cockpit can drop precipitously. My experience has been that no matter how you feel while sitting in your kitchen, you will always feel worse on an airplane, medically speaking. A bit of an itchy nose is guaranteed to become a non-stop sneezing fit on the airplane. So if I'm feeling a bit off at home, I don't go in. 

Almost as important as the underlying illness, the drugs taken to combat the symptoms of a cold or flu are themselves disqualifying for operating a commercial airliner. The FAA does not publish a list of medicines which pilots are allowed to take while operating an airliner, but would rather have each individual pilot with a medical complaint be evaluated by a doctor. Then a determination should be made as to whether the pilot should be flying with that medication. Some common ones are approved, while others are not.

For simple ailments such as a cold or the flu, pilots are expected to remove themselves from flying until they feel fit to fly. As far as the over the counter drugs for a cold are concerned, the FAA recommends a wait of five times the recommended dosing interval. This means that if the directions suggest a certain dose of say every six hours, a pilot should wait five times that, or 30 hours before operating an aircraft.

Pilots and Doctors: An Uneasy Relationship

All pilots, whether civilian or military, need the approval of a doctor to be able to fly. But because doctors can ground pilots, this means that pilots are never too comfortable around doctors. Airline copilots or first officers in the US are required to get an annual FAA Class II medical exam. Captains and international pilots need to have an FAA Class I medical exam every six months. All airline pilots require a Class I medical after age 60 and an electrocardiogram is required annually after age 40. 

The idea here is to catch any sort of medical problem before it manifests itself while the pilot is behind the controls. If something should be found that is disqualifying, such as say complete color blindness, there isn't much that a pilot can do. For many other ailments, however, a pilot can appeal their case to the FAA's Office of Aerospace Medicine for the issuance of a waiver, otherwise known as a Special Issuance.

In this case, a pilot would be able to continue to fly using a "Statement of Demonstrated Ability" which means that whatever ailment they have is considered to be static or non progressive. In plain speak this means it is not getting worse nor affecting the ability to fly.

The unease which pilots have around doctors stems from the perception of misaligned incentives. If something during a flight physical is found to be in a grey area, the pilot will naturally want to keep flying, while the doctor would rather err on the side of keeping the pilot grounded. There is good reason for this as the doctor could be held responsible for missing something which causes trouble later. Here's the text from the FAA's guide for aviation medical examiners (AMEs):

The consequences of a negligent or wrongful certification, which would permit an unqualified person to take the controls of an aircraft, can be serious for the public, for the Government, and for the Examiner. If the examination is cursory and the Examiner fails to find a disqualifying defect that should have been discovered in the course of a thorough and careful examination, a safety hazard may be created and the Examiner may bear the responsibility for the results of such action.

So of course this makes pilots naturally wary about reporting every little ache and pain during their flight physical. They don't want to lose their livelihood for what they might perceive as overreach on the part of an overly cautious doctor. Pilots also tend toward stoicism as a general rule, so keeping quite about a random ache, especially when it might ground them, suits them just fine.

A Flight Doc and a Real Doc

Most aviation medical examiners, or flight docs, do not work for the FAA. They are usually physicians in private practice who have volunteered and are designated and trained by the FAA to perform flight physicals. It seems to be a somewhat lucrative practice as the physical itself usually takes about a half hour with about ten minutes of that time actually being spent with the doctor. The cost is around $150 cash as many AMEs do not take insurance. I even know of some AMEs who have shut their general medicine practices and now perform only FAA physicals.

Of course it is now generally recognized that avoiding the doctor is not really a good long term health care strategy. Pilots (begrudgingly) accept this as well, but rather than confessing all their health issues to their AME, they engage another or "real" doctor to check things that aren't included in the FAA medical exam. This might include things like a prostate exam or perhaps a closer look at a discolored mole. 

Truth be told, the AMEs I've seen over the years have never seemed too thrilled to have these sorts of ancillary medical issues raised in an FAA examination. The idea is to check the things on the FAA list, collect their fee, and usher in the next pilot. They get it. Should a complaint which is ancillary to the flight physical be investigated and found to be nothing by the non-FAA doc, all the paperwork of having to deal with the FAA bureaucracy is also conveniently avoided. In fact, in the competition between AMEs, the word quickly gets out on the street about which docs just check the essentials and which ones are "tougher".

So do I mean to suggest that pilots or flight docs are somehow "cheating" the system? Absolutely not. Should a serious issue be found by a non-FAA doc, pilots are legally obligated to inform their AMEs of all medical care other than routine physicals, so even the FAA recognizes that their own exams are not all encompassing. It is the false alarms and paperwork that are being bypassed.

Went Peacefully

There's an old aviation joke that goes: "When it's my turn to go, I want to go out peacefully in my sleep like ol' Joe...not screaming in terror like his passengers".

Yes, macabre, but there have been a number of times that a pilot has died at the controls. The latest incident happened just over a year ago when the 57 year old captain of an American A-320 died while enroute from Phoenix to Boston. The pilot had had bypass surgery years earlier and likely suffered a heart attack even though he had been flying for years after the surgery. The first officer landed the plane without incident.

Keep 'em Flying

So even though there exists some measure of disaffection between pilots and doctors, I believe the system functions well to ensure that only healthy pilots are at the controls. For those pilots who end up with serious health issues such as heart problems, or cancer, the bureaucratic wheels at the FAA can turn slowly, but they do eventually turn and many pilots who have suffered these types of problems can get back into the cockpit once their problems have resolved. 

Flying airplanes demands complete attention from alert and healthy pilots. With all the negative physiological stresses on members of this profession, having someone keep an eye on the pilot's health while he or she keeps an eye on your airplane maintains the high integrity and safety of today's aviation system.

Monday, January 02, 2017

Don't Depend on the Kicker to Win the Game

LaMia 2933
If it routinely comes down to the kicker to win, the team has failed.

Last month I wrote about the crash of LaMia 2933 which resulted from fuel starvation. Post crash investigation revealed that the flight was planned beyond the range limits for the aircraft and no provisions were made for required reserve fuel. Thus, after encountering a slight delay for another aircraft, the LaMia airliner ran out of fuel and crashed killing 71 of the 77 passengers and crew aboard the aircraft.

Much opprobrium has (rightly) been placed upon the heads of the pilots who planned the trip to exceed the capabilities of the aircraft they were flying, but I'd like to take a closer look at the circumstances of the situation to try to understand why the pilots would make such a foolish mistake. It certainly wasn't made in a vacuum.

Cinderella Story

The trip was a charter flight for the staff and players of the Brazilian Chapecoense futbol squad along with some journalists to the Copa Sudamericana Finals in Medellín. They were scheduled to play against Atlético Nacional the day after their arrival in Medellin.

Chapecoense was the first Brazilian football team to make it to the final of the Copa Sudamericana finals in three years. Representing a city of about 200,000 in the state of Santa Catarina, Chapecoense had bested more highly favored teams to represent Brazil in the finals match. Thus, there was intense interest in the match including a significant amount of national pride.

Chapecoense had wished to charter LaMia to transport the team directly from Sao Paolo to Medellin but were prevented from doing so by international regulations. Any charter aircraft flying between Brazil and Colombia would have to be registered in one of those countries. LaMia, however was a Bolivian registered operator, so provisions were made to fly the team on a Bolivian commercial airline to Santa Cruz in Bolivia before transferring to LaMia for the leg to Medellin.

A delayed departure from Santa Cruz meant that a planned refueling stop in the Bolivian city of Cobija was not available as that airport closed at sunset due to lack of runway lighting. The LaMia pilot then filed a flight plan showing a refueling stop in Bogota, but did not make that stop as Bogota is just slightly closer than Medellin. A stop there for fuel would have raised awkward questions about inadequate fuel planning. Another possible refueling stop was available in Iquitos, Peru, but would involve a two hour notification for customs and prior permission to enter Peruvian airspace from the DGAC (Bolivia's Civil Aviation Authority).

A Roll of the Dice

We must remember that the captain of that doomed airliner did not get up that morning with any idea that his actions would end up killing himself and his passengers. His essential error was that of what safety experts call "expectation bias". Simply put, the human brain has an expectation that things will work out in the future as they have in the past. The result of succumbing to expectation bias is that it effectively masks the underlying risk of one's actions.

In the back of our minds all pilots "know" that the risk of screwing up badly is an untimely meeting with the grim reaper. Pilots are famous for making macabre jokes about death even as aviation has grown safer. But with such sentiments being always present throughout a career in aviation, it becomes ever easier to believe that bad stuff only happens to the other guy who got unlucky. The fact that any particular pilot is around to reflect on the demise of compatriots can actually reinforce the belief that he or she is doing it right.

Now contrast that omnipresent but dull sense of risk of a crash with the very clear and present fear of the consequences had these pilots not gotten the beloved Chapecoense football team to their championship match. The pilots likely thought that cancelling the flight was not an option as the match was scheduled for the next day. The captain, and the airline of which he was part owner, would have suffered tremendous enmity and a loss of future business when it was learned that they were the cause for the team to miss their game or to arrive without the needed rest to play the next day.

There is little doubt that the captain knew that fuel was going to be tight, but he conflated the risk of running out of fuel with the risk of not getting the team to the game. He rolled the dice without understanding how many chips were on the table.

The question is, how does one person get put into the position of making a decision between an uncomfortable outcome that is certain to happen (if the flight cancels) and a deadly outcome that might or might not happen (if the plane runs out of fuel)? Had the plane not run out of fuel 10 miles from the airport, no one would have been any the wiser.

Depending on the Kicker

Any organization depends on cooperation between individual team members to be successful. Success or failure should not, however, be dependent on the actions of one person. Like any complex machine, an organization must have redundancies for critical functions. Too much stress on a critical link in any chain guarantees eventual failure. If winning the game always depends on the kicker, the team has failed.

The captain of LaMia 2933 should not have been in the position to be able to trade safety for financial gain. This crash was due not only to a bad decision made by the captain, but also to the organization which allowed one actor to be pressured to make such a decision. So how should an organization insulate itself from this type of single point failure?

Culture of Safety

First, in any industrial setting, cultivating a "culture of safety" is paramount to a successful operation. What this means is that safety of the operation is first and foremost. This culture must be internalized by everyone from senior management to entry level and temporary employees.

Successfully installing such a culture is hard work and will not be accomplished through mere platitudes or safety posters hung in the workplace. There will need to be honest organizational support for safety initiatives and a reassurance from the C-Suite on down that the goals for a safe operation are embraced. This will include a robust safety reporting system and employees who are empowered to implement correctives for identified deficiencies.

Secondly, individual employees should not be put in a position of having to choose between a competing set of values. In the case of airline operations, the people in charge of financial results are probably the wrong people to be making operational decisions that impinge on safety. The bottom line must obviously be watched, but if an operation cannot be done safely, then it probably shouldn't be done at all. Management tools such as pay protection for line employees when operations are cancelled can help in the effort to make sure the correct decisions get made.

The Choice is Yours

Whether you find yourself as a manager or operator, you must understand that humans respond to incentives. Wrongly aligned incentives will eventually manifest themselves by coming back to bite the unwary. Is your organization optimized to be as safe as it can be? How will you know if it isn't?

Thursday, December 22, 2016

The Crash That Made Your Airplane Safer

Terrain is now displayed on primary flight displays
Enhanced GPWS display showing terrain (in green)

Any airplane crash is a tragedy, but in the investigation following a crash, it is always hoped that something can be learned which will aid in the prevention of a future crash. Commercial aviation is now one of the safest modes of transportation available, but it has only become this way through dogged investigation of aircraft accidents and the application of lessons learned. Such was the case of American 965.

On December 20, 1995, American 965, a 757-200, crashed in the mountains of Colombia while enroute to Cali. 151 passengers and eight crew were killed while five passengers survived the impact. The investigation into the crash concluded that the primary cause was a navigational error made by the flight crew resulting in terrain impact.

There were, however, some unique aspects of this accident which highlighted contributing factors. One of these was found to be several errors in the aircraft's navigational computer database which led the crew astray.  Also unique to this accident investigation was the method in which investigators were able to reconstruct the events which led to the crash. As it happened, one of the 757's flight navigation computers was found in the wreckage with its internal battery and volatile memory still intact. 

This allowed investigators to reconstruct electronically what the aircrew saw as they were descending through the mountainous terrain that night in Colombia. This finding revealed the true cause of the errors that were made by the flight crew which had until then eluded investigators. And this, in turn, directed investigators to the errors in the onboard database.

Increasing reliance on automation meant that aircrews were becoming more dependent on onboard electronic systems used for navigation rather than on the printed paper charts and radio beacons which had been the mainstay of airborne navigation since the dawn of aviation. Uncritical trust in this system, however, turned out to be deadly.

The aftermath of this crash resulted in new safety systems that are now installed on virtually all commercial airliners to aid in terrain avoidance as well as new procedures to be used with automated aircraft navigation systems.

Let's take a closer look at the causes of this accident and some of the changes resulting from the investigation.

Where is it Taking Us?

Alfonso Bonilla Aragón International Airport, which serves Cali, lies in a valley with mountainous terrain rising to over 12,000 ft on either side of the north-south running Cauca Valley. The arrival path of AA965 had the aircraft descending through this valley to pass over the airport and then reverse course to land to the north.

At some point though, the controller, who had no operable radar due to terrorist activity, offered the crew a straight-in approach to land to the south on the north-south runway. The crew accepted this clearance but were now high on profile without the turn around to lose the excess altitude. Thus they were expediting their descent with the aircraft's speed brakes being extended.

There was also some confusion in the instructions given to the crew by air traffic control with the aircrew finally asking to proceed directly to a radio beacon near the airport. This beacon, really just a radio transmitter, was named "Rozo NDB". It is here where a database error and a lack of situational awareness caused problems.

The paper charts which the crew was using listed the Rozo beacon by its identifier as the letter "R". That meant that typing that identifier into the computer should have caused the aircraft to fly to the Rozo beacon straight down the valley. The database installed in the aircraft, however, had an error and differed from the paper charts the crew was using, The identifier of the Rozo beacon in the electronic database was "ROZO" and not the letter "R" as the crew believed.

Thus when the crew typed in "R", the aircraft turned left towards another beacon located 130 miles to the east in Bogota named "Romeo". This beacon actually did have its identifier listed as "R" in the electronic database. This turn to the east took the aircraft directly into the mountains on the east side of the Cauca Valley.

Maintain Situational Awareness

If the above description is confusing for you to read, imagine what was going through the minds of those pilots as they tried to sort out where they were and why their airplane was mysteriously turning when it should've been going straight south to the runway. It took the crew about a minute to sort out that the airplane shouldn't be turning and another minute to start a turn back to safety. But even though they eventually got terrain warnings and had started an emergency climb, they had descended too far into the mountains and hit a ridge at an elevation of about 8900 ft.

One of the prime directives of aviation, drilled into all pilots from the beginning of their careers, is to maintain situational awareness. This means knowing what is going on around you at all times. It is a fundamental skill in aviation. This crew was set up by a database error, but should have had an idea that any turn off their course down the valley was ill advised. They should also have known that they had descended below the altitude of the mountains bordering the valley.

One of the luxuries that US based airlines enjoy is a first rate air traffic control system which is unparalleled in not only maintaining traffic separation, which is their main objective, but also in providing terrain avoidance. They're so good at it in fact, that it is easy for pilots to become complacent about the need to always be vigilant about terrain if for no other reason than they (and their passengers) will suffer the consequences of any such complacency.

The same, unfortunately, cannot be said for many countries without the superb infrastructure found in most first world countries. While most controllers are excellent at what they do, the Colombian controller had no radar with which to warn American 965 that they were in danger. It is the pilot's sole responsibility to maintain awareness of any terrain clearance problems.

Not in Vain

The story does not end here. The fallout from this accident was wide ranging. The database error which led the pilots to make a wrong turn into the mountains prompted a thorough review of the navigational databases which are used by commercial aircraft, including safeguards to ensure that the information printed on charts matches that in navigational databases. Flight crew procedures were also changed to ensure that a "common sense" check of any computer commands were made before those commands were executed in the navigation computers.

It also became apparent that faster and more capable computers coupled with GPS receivers would be able to provide a whole new level of protection against controlled flight into terrain (CFIT). Ever since the crash of Eastern Airlines 401 into the Florida everglades in 1972, commercial aircraft have had a system installed that is known as the Ground Proximity Warning System (GPWS). Pronounced "jip whiz", this system warns pilots of approaching terrain through a downward looking radio altimeter. 

GPWS is the source of the electronically generated "PULL UP" command you may have heard in movies or when the system is tested at the gate. The limitation of this system is that there is no way to reliably warn pilots of very rapidly rising terrain as the system can only look straight down at what is directly below the airplane. In fact, the GPWS system on American 965 did warn the pilots of danger but not until it was too late.

Enhanced GPWS

A new system called Enhanced GPWS has since been designed to use a database of all the terrain an aircraft is expected to encounter either regionally or globally. When coupled with GPS location, this system can give pilots enough warning to avoid any possible terrain conflicts well in advance of encountering any high terrain. It generates a terrain map on the primary flight display. This display looks somewhat like an old fashioned topographic map but terrain is displayed in green, yellow, or red depending on the height of the terrain in relation to aircraft altitude.

The system is proactive and will also generate cautions and warnings based on the current aircraft trajectory and any terrain that may be a danger. Pilots are warned well in advance of any projected terrain encounters. The system finally gives pilots real time feedback on exactly where they are in relation to high terrain, a problem which has always plagued aviation.

Aviation is safer now than at any time in history but this is no accident. Many accidents are caused by carelessness or complacency on the part of crews or maintainers, but occasionally something is learned that materially affects the safety of the entire industry. American Airlines 965 was a tragedy for everyone aboard that fated airliner as well as for their friends and families, but at least in this one case, real changes were made which will make a recurrence of this accident much less likely.

The next airplane trip you take will also be safer because of lessons learned from the crash of American 965.

Addendum: Counterfeit Parts and Aircraft Design

Two other issues were brought to light in the aftermath of American 965. One that was highlighted was the existence of an international network of counterfeit aircraft parts as some of the parts from the wreckage began to show up on the black market. Aircraft parts are built to exacting and expensive standards, so an incentive exists for unscrupulous actors to sell counterfeit and stolen parts. Parts with serial numbers from AA 965 did make their way into this network.

A second issue was that of cockpit design. When the pilots realized that they were near the terrain, they initiated an emergency climb, but neglected to retract the speedbrakes which they had been using to descend. Because the aircraft hit the ridge only a few hundred feet below the summit, speculation was made as to whether the speed brakes should automatically retract when the throttles are pushed up and whether doing so would have saved the aircraft. Some aircraft have this feature while others do not, but highlighting the issue should make pilots aware of the potential problem.

Friday, December 02, 2016

How Does an Airliner Run Out of Fuel?

LaMia 2933 ran out of fuel

While the investigation into the crash of the LaMia RJ-85 airliner in Columbia is still ongoing, it is becoming apparent that the aircraft ran out of fuel. Investigators at the crash site noted that there was no post-crash fire or fuel spillage. Other evidence suggesting fuel starvation is that photos of the fan blades on the engines appear to show them to be mostly intact. A spinning engine often throws its blades upon impact suggesting that the engines were not operating.

Other significant factors affecting this flight were the length of the leg, an arrival delay imposed due to another emergency aircraft, and the status of the pilot as a part owner of the charter airline. Also of note is that the first officer was on her first flight as a commercial pilot.

How Much Fuel Did They Need?

Any airline will be subject to the regulations of the country in which they are based, but most countries' rules conform to guidelines published by the International Civil Aviation Organization (ICAO). ICAO rules state that any aircraft must have enough fuel to travel to its destination and any alternate airport plus an additional 45 minutes for reserve. The investigation will determine if the LaMia aircraft departed with sufficient fuel.

Remember, though, that winds aloft, weather, payload, and even temperature can affect the fuel range of any airplane. There is no hard and fast mileage number to apply. The investigation will need to reconstruct all the planning data that the LaMia pilots had.

Two Ways to Run Dry

The first and perhaps most common way to run out of gas is due to simple human error. This can result in an aircraft being mis-fueled or having an erroneous fuel reading due to a bad gauge. Call it inadvertent...when it gets quiet while still airborne, the pilots may be surprised the most. This can take multiple errors by fuelers, mechanics, or pilots who can be extremely inventive in finding ways to circumvent procedures designed to catch fuel errors, but it has been known to happen.

The second way to run out of fuel is to have a lapse of judgement, or what we in aviation call airmanship.

This Has Happened Before

Part of the essence of being a pilot in command of a commercial aircraft means internalizing the fact that 1) you're on your own and 2) that everyone aboard is depending on you. Of course you aren't literally on your own as you have resources such as your first officer, air traffic control, and dispatch, but no one will be there to hold your hand or pull your chestnuts out of the fire if things go wrong. The nature of the job means that you will be made, in some way or another, to own the decisions you make.

Keeping your eye on your fuel state is one of those "Aviation 101" things that every pilot gets pounded into them from day one. Running out of gas is something you just don't do if you're aware of the two precepts above. It is rare but it happens.

In 1978, a United Airlines DC-8 crashed outside of Portland, Oregon after running out of fuel. The pilots had become preoccupied with a bad gear indication and flew around until the fuel ran out. The engineer was not assertive enough to communicate the plane's dire fuel state to a distracted captain. As the engines quit, the captain implored the engineer to "keep them running". He forgot that it was his job to land before the fuel ran out.

Again in 1990, an Avianca Boeing 707 crashed after running out of fuel on approach to New York's JFK airport killing 74 passengers and crew. The cause was determined to be a language barrier and misunderstanding by the crew in communicating their fuel state to air traffic control. Specifically, air traffic controllers will not give priority handling to any aircraft unless the word "emergency" is used. The Avianca crew did not use that term and ran out of fuel after extensive traffic delays.

In both of these cases, the pilot in command failed to take appropriate actions to land before the fuel ran out. It really doesn't matter what air traffic control says or what state the landing gear are in. It would've been better to belly in or to disregard controller instructions than to crash. Making uncomfortable choices between two potentially unpleasant options is a big part of being a pilot.

Was This Careless Flying?

While the investigation is far from complete, a picture is beginning to emerge. LaMia, which only owned this one aircraft, was known to be one of the cheapest charter operators available for hire in the region. A takeoff delay also meant that a potential refueling stop was not available due to the closure of that field. It also turns out that the pilot in command was a part owner of the company who may have let financial concerns cloud his judgement. 

Lastly, his copilot, Sisy Arias, was on her first ever commercial flight as a pilot. This is important because in her very inexperienced state, she may not have been aware of the fuel situation nor was she likely to intervene even if she was.

There's an old aviation aphorism floating around which states that the definition of a superior pilot is one who uses their superior judgement (proper fuel planning) to avoid situations requiring their superior skill (doing a night dead-stick landing into mountainous terrain). 

Aviation is a profession that calls for strict adherence to unmalleable rules. Behaving recklessly is bad enough, if that is indeed what happened here, but the real tragedy is in betraying the trust of your passengers and crew.

Monday, October 17, 2016

NTSB Attributes Design Flaw and Pilot Input for Crash at LaGuardia

Back in March of last year, a Delta MD-88 slid off the runway in a snow storm at LaGuardia. The aircraft was heavily damaged but there were no injuries. I wrote about that incident here.

To recap, the aircraft landed in really lousy visibility during a snowstorm and slid off the side of the runway and almost into Flushing Bay. While the approach and landing were normal, the aircraft drifted off the left side of the runway after landing, eventually hitting the airport perimeter fence and coming to a rest on the berm that borders the airport and the water.

Since the winds were not particularly strong, my first guess was that the problem might have been a braking problem, but that was not the case. The NTSB recently concluded their investigation of the incident and have blamed the accident on an obscure directional control characteristic of aircraft with tail mounted engines known as "rudder blanking" along with the pilot's reaction to that effect. The full accident report can be found here.

Design Flaw

Inherent in the design of turbine powered aircraft with tail mounted engines and thrust reversers is an effect known as rudder blanking. Shortly after touchdown, pilots command the thrust reversers open using levers located on the throttles. On the MD-88, the aircraft involved, baffles actually close over the exhaust of the engines and redirect the thrust to the sides and forward of the engine. This redirected thrust helps to slow the aircraft.

The problem with this configuration is the location of the engines on the rear fuselage near the tail of the aircraft. The redirected thrust also has the effect of reducing the relative wind over the vertical stabilizer and rudder. Reducing the air over the rudder reduces its effectiveness. The reduced rudder effectiveness combined with the crosswind allowed the aircraft to depart the left side of the runway and to hit the boundary fence.

Boeing (which purchased McDonnell Douglas, the manufacturer of the MD-88) was aware of the flaw and recommended that reverse thrust was not to be used at full power during landing. Boeing recommended a further restricted use of reverse thrust when landing on a runway "contaminated by clutter" which is aviation-speak to mean a buildup of snow or slush.

Here's an excerpt from the Flight Operations Bulletin published by Boeing:

Due to the geometry of the MD-80 thrust reversers, the exhaust gas efflux pattern will, at certain rollout speeds and EPR settings, interfere with the free-stream airflow across the rudder surfaces. This will result in partial “rudder blanking”; with a resultant reduction in directional control authority. As rudder effectiveness is more critical on wet or slippery surfaces, “rudder blanking” becomes a concern above a reverse thrust level of 1.3 EPR. Normal dry runway maximum reverse thrust power is 1.6 EPR [emphasis in original].

Will the Brakes Stop the Airplane on the Runway?

Another concern of the crew was the "braking action" on the runway. This is also aviation-speak to mean the slipperiness of the pavement. The crew had heard reports that the braking had been reported as "fair" which meant that they would not have been able to stop the aircraft on the runway and would have needed to divert. Later on in the flight, the braking action had been reported as "good" by another airliner and the crew made the decision to continue.

The problem with braking action reports by other aircraft is that they are highly subjective. Some pilots make the determination by how many times their anti-skid cycles during a landing. Others use different criteria and each aircraft can respond differently to the same conditions. One pilot's "fair" report can easily be another's "good".

Weather and runway reports from the airport itself indicated that the runway was covered with 1/4 inch of wet snow. The runway had recently been swept, but by the time Delta 1086 landed, it was already white in appearance from new snowfall.

So you can see that as a minimum, this crew was concerned that they didn't have much room for error on this landing.

The Friction Measuring Trucks Were Parked

As far as the actual condition of the pavement, airport authorities have been using friction measuring equipment for decades. So what was the actual friction measurement at the time Delta 1086 landed? No one knows. Due to bureaucratic ambiguity and confusion between FAA directives and the New York Port Authority, the Port Authority elected to not use either of the two trucks it had available to measure runway surface friction.

From a bureaucratic point of view this makes perfect sense as you can be held liable for inaccurate or missing reports if your policy was to collect them. Change your policy to keep the trucks parked and you're off the hook. This works best for bureaucrats sitting in heated offices, but not so well for passengers landing in a snowstorm. But it's completely legal.

On the Edge of Safe

So in essence, the story so far is that the aircraft landed in 1/4 mile of visibility in a snowstorm on an extremely short runway bounded on three sides by water with an essentially unknown slickness of the pavement.

As a reminder, a quarter mile of visibility is 1320 feet and a touchdown speed of 140 kts is about 236 feet per second. This gave the pilot about five and a half seconds of time between seeing the runway and landing on it. And according to the flight recorder, the touchdown was well within the landing zone and on speed.

What happened next was measured in seconds. Here's the synopsis from the NTSB report:

During a postaccident interview, the captain stated that, as he was lowering the airplane’s
nose to the ground after main gear touchdown, he moved the thrust reversers to idle and then “one knob width on the reverser handle” to obtain Delta’s target setting of 1.3 engine pressure ratio (EPR).16 FDR data showed that engine reverse thrust exceeded 1.3 EPR between 3 and 4 seconds after main gear touchdown (with the left engine exceeding 1.3 EPR before the right engine) and was advancing through 1.6 EPR immediately after the nose gear touched down. FDR data showed that the EPR value exceeded 1.6 for 5 seconds, reaching maximum EPR values of 2.07 on the left engine and 1.91 on the right engine between 6 and 7 seconds after main gear touchdown. Engine power decreased after this point, and the thrust reversers were stowed at 1102:25 (7.5 seconds after deployment, 9 seconds after main gear touchdown, and 2,500 feet from the runway threshold) at an EPR value of 1.8 on the left engine and 1.6 on the right engine. At that time, the airplane’s groundspeed was 93 knots. 

In plain-speak, the pilot used reverse thrust in excess of the recommended amount for a total of five seconds and then stowed the reversers. The aircraft started to drift left at six seconds after touchdown, or three seconds before the reversers were stowed. This meant that it was in the three seconds between the time the aircraft started to drift and the time the reversers were stowed that the problem occurred.

To further complicate the landing, the aircraft by this time had slowed to 93 knots. At this speed the rudder itself loses effectiveness as there is not enough air moving over the surface to keep the aircraft on the runway. Other than the rudder, directional control of an aircraft on the ground is obtained through the use of nosewheel steering and differential braking. Both of these were used but were not effective enough to get the aircraft under control.

No Win Situation

Pilots are goal oriented people. We like to get the job done. But we are also called upon to get the job done correctly and are tasked with being the final arbiters of safety. To this end, we are given the tools and the criteria to use those tools correctly. But when some of the supposedly objective information we have turns out to be highly subjective and incomplete, the process becomes a crapshoot.

In my view, these guys were set up. They were told that if the braking was "good" they could land, but if it was "fair" they'd go for a swim. So for a few seconds the pilot overcompensates with too much reverse thrust and they nearly go swimming anyway. Another MD-88 had landed minutes before and had no problem while also exceeding reverse thrust limits. These guys just got hit with an unlucky gust of wind.

The whole idea of risk management is to make sure that the operation does not become a crapshoot. Had these pilots diverted when the "system" said they could make it safely and other airplanes were landing, they'd be questioned by their chief pilot and ridiculed by their passengers. Now they're probably wishing they had diverted. A three second and immediately corrected deviation from SOP during extreme conditions should not result in a major accident.

In the appendix to the accident report, board member Robert Sumwalt, himself a retired airline pilot, had this to say about the situation facing the captain:

As a former airline pilot for over 20 years, I’m confident saying that having to limit reverse thrust on a relatively short, slippery runway is counter-intuitive: When you need it the most, you have to use it the least.

So the next time your pilot diverts or goes around when others are landing, you will be frustrated or angry that you don't get to your meeting or home on time. Don't be. The guy or gal up front is trying to get you where you're going, but also trying to keep you alive.

Addendum: A Few Words about the The NTSB

I'm going to take a moment to say a few words about the NTSB. Good words. The NTSB in my view is a national treasure. They are staffed with a group of smart and thoughtful professionals who take the time to get to the bottom of the accidents they investigate. And while they don't have any real regulatory power to force changes, nor do they make economic cost-benefit assessments of their various proposals, their recommendations often serve as signposts to be disregarded by industry and regulators at their peril.

Delta is the Best!

Here's an amusing comparison from a Delta captain of block hours, revenue, and profits at the big four carriers that I found on a pilot forum...

Delta is THE BEST...

...Just ask them! A Delta Pilot's perspective on how the big 4 measure up.


Hello all, me again, with more numbers to share. As of late we've been all up in arms
about the status of negotiations. And somewhat displeased and confused by the rumors of
what's happening inside the MEC and perhaps even in a panic by the NMB parking us. No
doubt these are all depressing things for the average line pilots.

Well, relax a second. I'd like to take a moment of your time to give you some numbers
that will lift up your spirits and make you proud to be a DELTA pilot working for a truly
good company. Ironically, my numbers will also expose a number of lies our boss, the
company and DALPA are trying to sell us.

The Steve Dickson LIE - If you have attended a meeting recently in which our boss, a good
guy by most accounts, has briefed us about the status of the company - you will have
heard him say that the company needs improved productivity from the pilots. He has said
to me directly, that we are the least productive pilots in the industry. That our average
block hours per pilot per month are well below our competitors and that we must make
improvements to remain competitive. If you look at the data from MIT, at first, his
statement appears to have some validity.


Let's look at the big three and half airlines for comparison. They are American, United,
Delta and Southwest. The first three are similar in size and SW is about 60 percent of
the other's size. According to MTI, the average pilot flies...

> 46.9 hours per month at American
> 40.2 hours per month at United
> 43.1 hours per month at Delta

And - those energizer bunny guys at SWA...

> they fly 57.8 hours per month (Whooah!)

[data based on 2015 total annual block hours flown, divided by total pilots, divided by
twelve months]

Okay - first little lie. We're not the least productive, by the above data we are number
three and United is dead last. Clearly lazy bastards with too much quality of life
(remember this statement). But - geeze, those SWA boys and girls are kicking everyone
else's asses in productivity. How do they do it? I can see Management is dying to ramp us
to that level of efficiency... but is it really?

Block hours flown is not a complete picture. A better picture is how much revenue each
company pulls in with their annual block hours. So - let's compare annual block hour
generation first. In 2015...

> American with 12,363 pilots flew 3,478,489 total block hours
> Delta with 11,476 pilots flew 2,966,095 total block block hours
> United with 11,128 pilots flew 2,687,068 total block hours

Again - American, averaging 46.9 per month seems to have a clear lead among the big
three, but fucking SWA, wow...

> Southwest with a mere 7,457 pilots flew 2,587,191 block hours (almost equal to
united) - [could it be their taxi speeds?]

Clearly the Managements of the bigger three want to know SWA's secret and salivate over
the thought of driving us to such high levels of productivity. Look at SWA, you guys can
do just as good!

On a side note, Dickson's least productive guys delivered the second highest amount of
block hours to their company last year.
But - this is a rather meaningless number without looking at the revenue the block hours
generated. Revenue generated per block hour is important because it is an excellent
indicator of comparative fleet capacity effects on money generation. And of the big
three, Delta has the least wide bodies, and SWA has none.


In 2015 the big three and half generated the following total revenues:

> American's 3.478 million block hours delivered 41.084 billion $.
> Delta's 2.966 million block hours delivered 40.704 billion $.
> United's 2.687 million block hours delivered 37.864 billion $.
> And SWA's 2.587 million block hours only got 19.820 billion $.

Stated another way - as in dollars per block hour, a measure of efficiency of the
operation, it looks like this.

> SWA earned $7,661 per block hour flown.
> American earned $11,811 per block hour flown.
> United earned a whopping $14,091 per block hour flown.

Wait a minute, weren't those United guys the lazy goofs who only flew 40.2 hours per
month? Aren't they less productive than everyone else? Why isn't this lining up with
Steve Dickson's accusations? Liar... Oh, and what about Delta.

> Delta earned $13,723 per block hour flown.

Hey! Don't we have the second lowest average block hours flown per month per pilot? Yet
we produced the second highest amount of revenue per block hour of all the airlines.
Could that mean that there is less a correlation of block hours flown to revenue than
fleet capacity per hour flown to revenue? And doesn't more hours mean less quality of
life? Those poor rabbits at SWA are running hither and dither working way harder than
anyone else yet barely generating half the total revenue. Could there be a problem with
an all narrow-body fleet mix. Could there be a correlation with United having the most
wide bodies being able to produce the most revenue with the least effort, perhaps even
having a better QOL than us Delta guys? I'd say yes.

The good news fellow Delta pilots, by this measure we are in second place among the
airlines. But wait...there's more. Revenue is just one measure of a company's
productivity. Each airline is unique for its expenses, so let's look at how good they are
making money, not in terms of revenue, but in terms of profits.


You have revenue and then expenses and what's left is profit. This is the REAL measure of
pilot productivity. Not total work generated but rather total profits generated by equal
work. Since each company is different in size and make up, and in it's total block hours
flown, we have to go one step further and look at how much profit each pilot generates
for its company per year, all things being equal, that means per block hour. Alright -
let's see who has the best business model going.

In 2015...

> SWA generated 3.479 billion in profits. That works out to $1,344 and 70 cents per
block hour flown. As it takes two pilots to fly a block hour, each pilot at SWA generates
$672.35 in profits per block hour flown.

> American generated 4.668 billion in profits. That is $1,341.96 per block hour and
$670.98 in profits per pilot per block hour.

> United generated 4.219 billion in profits. That is $1,570.12 per block hour and
$785.06 per United pilot per block hour.

And what about the home team? Dickson's "least productive" pilots in the
industry? The ones who are third in average block hours flown and only second in revenue
generated? The one's Management MUST have become more productive lest the competition
bury us? The one's DALPA is bending over backwards to rob QOL from in order to meet the
company's needs???

Yeah, what about us Delta line guys and gals?

> Delta generated an amazing 7.157 billion in profits last year.

That is $2,412 and 94 cents per block hour, which is 53.7 percent better than the
powerhouse United gang and almost double the others.

THAT - is a whopping $1,206.47 in profits per pilot per block hour flown.


Ladies and gentlemen, fellow Delta pilots, esteemed comrades, despite our in fighting,
our fears, and management's lies and distortions...


Take pride - wear your orange, fight for what you deserve!

(Mr. Dickson - take your lack of productivity message and ditch it. DALPA, negotiate us
what we are truly worth).

J.D. Webster
7ER Capt. C4

Thursday, September 22, 2016

What's Up with the Rollercoaster Takeoffs from Orange County?

If you've ever had the pleasure (or perhaps the terror) of taking off in a commercial plane from Orange County's John Wayne airport, you'll know that it is a takeoff unlike any other. Just seconds after liftoff, you will feel your stomach drop as the airplane does a very abrupt pushover. This pushover, similar to what you might feel on a rollercoaster or perhaps a hilly backcountry road, will make you light in your seat. You might even feel yourself being restrained by your seatbelt.

The next thing that you will notice is that the sounds in the cabin will change. Specifically, they will get much quieter. The roar of the engines that accompanies all takeoffs will diminish dramatically. You will sense that the nose of the aircraft has dropped significantly. The incline, or what pilots call the "deck angle" will have gone from the usually steep angle used for most takeoffs, to one that is barely distinguishable from level flight. And all this will seem to be happening much too close to the ground.

Finally, you may become aware of an annoying thumping that you feel in your chest. Don't worry, that's only your heart pounding.

You may think that this is over...and wonder if there's enough time to squeeze a goodbye text to your loved ones before plunging into the Pacific ocean. But you should rest easy. You are not going to die (at least not today). What you have just experienced is known as a noise abatement takeoff. They occur hundreds of times weekly at John Wayne and are an FAA approved and in fact government mandated maneuver. That's right; pilots and airlines will be fined if they don't perform this type of takeoff.

So why, you may ask, are you being subjected to an experience that should probably be featured at the nearby Disney theme park? Well, as I mentioned above, noise. Noise and of course politics. For John Wayne airport is the only airport which mandates such a drastic noise reduction profile. And as legend has it, the Duke himself, the airport's namesake, had a hand in getting those restrictions put in place.

The departure path from John Wayne airport flies almost directly over Newport Beach. And as you may know, Newport Beach is a very well-heeled community. And while I'm not going to make judgements on wealth accumulation, one thing wealthy people are good at is getting things done. Starting with the arrival of the first turboprops and jets in the 1970s, community activism followed soon thereafter. Eventually lawsuits were filed and the restrictions were put in place.

Why Orange County?

John Wayne Airport dates back to 1923 when a landing strip was first opened by a man named Eddie Martin to host a flying school. Then known as Martin Field, Orange County assumed ownership in 1939 with the airport becoming to be known as Orange County Airport. The name was changed to John Wayne Airport in 1979 in honor of actor John Wayne, a nearby resident, upon his death.

Noise restrictions at the airport date back to 1985 when a local group representing residents who lived under the departure path sued the county. The resulting settlement implemented noise regulations and curfew requirements which remain in force today. Noise meters are deployed along the departure path to measure the sound footprint of each departing aircraft. Those restrictions are unique in being some of the first of their kind, and also just about the only of their kind.

In 1990, Congress, fearing that many localities could eventually hamstring the growth of aviation by implementing their own patchwork of noise restrictions, passed the Airport Noise and Capacity Act which outlawed curfews at airports. John Wayne was grandfathered in, however, due to the original lawsuit being filed in 1985.

Why the Rollercoaster?

So knowing why airplanes have to fly quietly, you may be wondering about the "how". And specifically, you might be wondering why airliners don't just use less thrust from the get-go instead of the roar followed by the pushover and silence. Without getting too technical about takeoff performance, much of it comes down to the runway length at John Wayne airport, or to be more specific, the lack of runway length.

The longest runway at John Wayne is less than 6000 feet long. At a scant 5701 feet to be precise, it is one of the shortest runways if not the shortest runway in the nation from which large commercial aircraft fly.

It is the nature of gaining flying airspeed in a very short distance which necessitates the full power takeoff. Once airborne, but before the flaps are retracted, the aircraft reaches a "cutback" altitude of about 800 ft. It is here where the engines are throttled back either manually or by the auto-throttles to a thrust which meets the minimum required climb gradient of about 2.5%. Less thrust also means a shallower climb angle, hence the pushover.

Once beyond the noise sensitive area, or about six miles after takeoff, the aircraft resumes its normal climb profile using full climb thrust.

Is It Dangerous?

I suppose that depends on your definition of the word dangerous. Any time you monkey around with large power changes on a turbine engine, you increase the odds of something going wrong. In fact, many engine failures occur not on initial thrust application such as takeoff, but rather on a large thrust reduction. That said, the odds of that ever happening are infinitesimal. Still, it isn't unknown for engines to fail as was dramatically illustrated by the uncontained engine failure on a Southwest Airlines 737 several weeks ago. Infinitesimal odds, but not zero.

So no, it isn't dangerous in the conventional sense of the word. Avoiding flights out of Orange County to avoid takeoffs using this procedure would be silly. And likely more dangerous as a longer commute up the freeway to LAX would definitely expose you to more absolute danger in your car. Of course, the safest course of action is to hide under the bed which still won't protect you from meteorites...or dust bunnies.

So when you do get on that airplane leaving the OC, be sure to get a window seat on the left side of the airplane which gives the best views of Catalina, relax and enjoy the ride. But don't put your arms in the air and scream as if on a real rollercoaster. People will stare.

Monday, September 19, 2016

Flying to Cuba on One Engine

Flying to Cuba on One Engine
Brian Hall (center) and his Bonanza in Havana

This past August saw an important landmark in aviation history with the first scheduled commercial flight between the US and Cuba taking place in nearly fifty years. On August 31st, a JetBlue Airbus flew from Ft Lauderdale to Santa Clara, Cuba with 150 passengers, journalists, and dignitaries. JetBlue is one of six US airlines which won approval to fly direct routes from the US to Cuba.

As historic as that occasion was, an equally historic flight took place earlier in 2015. Scooping the first scheduled commercial flight by over a year, was the first flight of a private civilian aircraft to Cuba from the US. On January 15 of last year former Air Force C-130 pilot and businessman Brian Hall flew his Beech Bonanza from Fort Myers, Florida to Havana. Flying under the rules of Part 91, Hall's flight was the first flight of this type in over fifty years.

Hall is hoping to start a new ferry service called CubaKat between Florida and Cuba. He flew to Havana to discuss business details with his Cuban employees and government officials. He might be considered a serial entrepreneur as he is currently the CEO of a marine engineering company and has had a hand in starting or running everything from ferry services to an airline to an energy services company and consultant services.

Flying to Cuba on One EngineWhile travel to Cuba for tourism is still not permitted under current rules, other reasons for travel such as cultural exchange are permitted. In addition to his proposed ferry service, Hall also spoke to Cuban officials during his visit about starting airline service between cities in Cuba itself. There is apparently a need for intra-island air transportation and Hall seems to be in the right place at the right time to capitalize on business opportunities in Cuba. He is proposing to start service using Cessna Caravans to deliver passengers and cargo.

Well as it turns out, Hall was a student pilot in my flight at the 98th Flying Training Squadron at Williams AFB in Phoenix, Az, nearly thirty years ago. The 98th trained students to fly the T-37 primary jet trainer while on their way to become Air Force pilots. After graduation from undergraduate pilot training, Hall went on to pilot C-130 Hurricane Hunter aircraft before leaving the service to start his career as a businessman.

The Road to Cuba

I was able to catch up with him about a week ago and ask him how his path led him to make history flying a single engine aircraft to Cuba.

He told me that his fascination with Cuba came from his grandparents who had often vacationed on the island. They would tell stories of their travels which captivated him. Many years later, he was able to arrange a retreat to Cuba for some family members and from that point on was hooked. He has since been back to Cuba many times on cultural exchange trips, though always having to travel by chartered aircraft.

In December of 2014, President Obama announced a restoration of full relations with Cuba thus ending decades of stalemate and embargo with the island nation. Hall knew that this was his opportunity to get in on the ground floor with the establishment of ferry service between Cuba and Florida. His CubaKat venture, which will use large catamaran ferries carrying up to 200 passengers, is still awaiting final government approval to begin operations.

In the meantime, Hall saw an opportunity to make a historical flight. He actually owns two aircraft, a single engine Bonanza and a twin engine Baron. And while the general rule for overwater flying is that more engines are better, Hall said he had insurance problems with taking the Baron to Cuba. As a result, he had to take his single engine 1953 Bonanza for the 217 mile journey to Havana.

While many pilots fly single engine aircraft to the Caribbean islands, Hall said that the one concession he made was to wear his life vest rather than to just have it available. The last thing a pilot wants to be doing if forced to ditch in a small aircraft, is to simultaneously fly the plane and make a distress call while figuring out how to don a life vest.

While planning for his flight, he did contact the US Immigration and Customs service who for some bureaucratic reason or another informed him that he couldn't make the flight as he had planned. It had something to do with Miami being the only approved airport for flights from Cuba. Being steeped in the culture of entrepreneurial risk taking, he found that it was in fact easier to beg forgiveness than to ask permission and had no trouble upon his return to the states.

Lacking the Basics

Hall told me that the actual mechanics of flying to Cuba were rather routine. The Cuban controllers were all perfectly gracious, spoke good English and his flight to Havana was uneventful. It was upon arrival that he realized that Cuba has a ways to go as far as aviation infrastructure is concerned. Routine expectations such as tie-downs and chocks, available at most US airports, were notably lacking. They also didn't have fuel, which might have been a problem had he not had the foresight to carry enough fuel for a round trip.

Since his first trip, Hall has been back to Cuba in his own plane three times. He says that the lack of overall infrastructure to handle the tsunami of Americans expecting to visit the island will be a brake on the tourism industry once the tourism ban is eventually lifted. Hall told me that one of his employees requested that he bring a toilet seat along on his next visit. It took two visits as the first one he brought was oval when a circular one was required.

Hall also mentioned that travellers to Cuba should not forget to bring enough cash to cover their expenses while visiting as there are almost no ATMs on the island. The Cubans, for their part, seem to be catching on that there is money coming along with their new island visitors. On one of his latest trips, a new $40 departure tax was levied which hadn't been mentioned or collected before. Of course you must pay if you wish to take off.

Cuba is His Passion

Even though the regulatory hurdles Hall faces to get his CubaKat venture going can be a real headache, he doesn't plan on quitting the island anytime soon. He's there to stay in one fashion or another. His motto is that if a businessman isn't earning, then he's learning. And Brian Hall, Air Force pilot turned entrepreneur turned Cuba evangelist seems to have enough passion and energy to do plenty of both.

Thursday, September 08, 2016

Is Aviation Automation Killing Us?

Is Aviation Automation killing us?

"When we design our systems, we need to assign appropriate roles to the human and technological components. It is best for humans to be the doers and technology to be the monitors, providing decision aids and safeguards."

 - Captain Sully Sullenberger

The past week has seen several high profile aviation incidents come to light. The first one was a preliminary accident report on the crash and fire which destroyed an Emirates Boeing 777 in Dubai last August. The second was the release of the final report by the Australian Transport Safety Bureau (ATSB) regarding an AirAsia Airbus A330-300 enroute from Sydney to Malaysia last year which suffered navigation and other system failures as the result of erroneous input by the pilots during preflight.

The Emirates crash tragically took the life of a responding fireman, while the AirAsia incident caused no injuries but did result in a diversion. Each incident had the potential for great loss of life, though. The improper use of automation can be implicated in both the Emirates and AirAsia events. Let's take a look at each of these and see if we can draw some parallels.

Emirates 521

The crash report on the Emirates flight, released by the General Civil Aviation Authority (GCAA) of the UAE details that the approach was flown by the captain. The autopilot was disconnected for the landing while the autothrottles remained engaged. The aircraft experienced a longitudinal wind component which changed from a headwind of 8 kts to a tailwind of 16 kts during the approach. As a result of the decreasing performance wind shift, the aircraft made a long touchdown.

An automatic system on the Boeing warned the crew about the long touchdown, and a decision was made to go around. So far so good. Going around rather than accepting a long landing due to shifting winds is the correct decision.

What happened next wasn't so good. The nose was raised, the flaps were reset and the gear were retracted, but go-around power was not added until three seconds before the aircraft impacted the runway with the gear partially retracted. The post crash fire destroyed the aircraft entirely.

Adding power during a go-around is...or should be, instinctual. It's considered aviation 101, or rather it used to be. Today's highly automated aircraft, however, all employ autothrottles which automatically advance themselves when the "Takeoff-go-around" or TOGA button is pushed. This is how go-arounds are performed on automated aircraft.

The 777, however, has a feature which disables the TOGA button after touchdown. This makes sense as you don't want the throttles to advance after landing in case of accidentally touching the TOGA button. After a normal landing, that is. There are times when a rejected landing, or go-around, occurs after touchdown. The reasons vary, but a landing can be rejected any time until the thrust reversers are deployed, even after the gear touch down.

This is what happened to the Emirates 777. It touched down, and then attempted a go-around without adding power. Questions remain as to whether or not the captain actually engaged the TOGA button but in any case, the captain should have manually pushed up the throttles for the go-around or ensured that the autothrottles automatically advanced.

Why would he not do that? Easy. It's called negative conditioning or negative training. Go-arounds are routinely practiced in all airline simulator training programs, but go-arounds after touchdown are practiced much less frequently. Over time, muscle memory will expect the autothrottles to advance themselves during a normal go-around as they always do.

Put a pilot in a highly dynamic situation such as a windshear landing, and then perhaps throw in a non-routine distraction such as the automatic runway length warning, and voila, muscle memory takes over and the throttles don't get pushed up. Automation, which is supposed to make flying easier and safer, might have helped make a crash such as this inevitable.

AirAsia X 223

On March 15 last year, an AirAsia A330 suffered multiple inflight malfunctions of  its navigational display systems rendering the aircraft incapable of either continuing to its destination in Malaysia, nor of returning to its origination point of Sydney due to low ceilings. The aircraft eventually landed uneventfully in Melbourne, which had clear weather.

Subsequent investigation revealed that the pilots made a data entry error during their pre-flight checks consisting of a single digit error in programming the aircraft's location.

Modern navigation systems on today's commercial aircraft are capable of guiding an airplane to a spot on the other side of the globe with accuracy down to several feet. But in order to know where to go, the computers on the airplane first have to know where they are. 

Part of the preflight process is to enter in the aircraft's current location in the form of a latitude and longitude. The pilot entering this data made some sort of fat finger error which resulted in the actually entered position being thousands of miles away from the Sydney airport. So after the aircraft departed, discrepancies between where it actually was and where it believed it was caused the computers to crash resulting in a nearly complete failure of the navigational system.

After identifying  and while attempting to fix the problems with the navigation systems, the crew compounded their problem by cycling two of their three flight computers to off and back on. This incorrect procedure resulted in the loss of other primary flight displays and rendered the aircraft incapable of flying even a simple approach back to Sydney necessitating the diversion to Melbourne.

Even after arrival at Melbourne, the aircraft had to make several attempts at a completely manual landing without the benefit of either the autopilot nor autothrottles. There is little doubt that flying a highly automated aircraft left the pilot's manual flying skills in a somewhat rusty state, which is completely expected.

Automation: Friend or Foe?

Automation of commercial airliners is with us to stay. It provides many benefits and economies but there are problems with its deployment which contributes to accidents and incidents such as these. The old aphorism which states that computers just allow humans to make mistakes faster and with more efficiency certainly applies here. 

Over reliance on automation is also well known to cause a deterioration in manual stick and rudder piloting skills, which go unmissed until they are needed. The crash of Asiana 214 in San Francisco several years ago was a perfect example of this.

But as Captain Sully warned in the quote above, automation is best deployed as an enhanced decision making tool, not something which a bored human being should be tasked to sit and watch, as it is today.