You are browsing category: Accidents and Incidents
10 October 2014

Bit of a Fender Bender at Dublin Airport

You may remember my post about a previous incident at Dublin Airport, also involving Ryanair: Fear of Landing – “Where’s that Guy Going?” Runway Incursion at Dublin

That was the case where a Monarch crew took a wrong turn and blundered onto the active runway — right into the path of a Ryanair 737 on its take-off run. The Ryanair Captain initiated a high speed rejected take-off at 124 knots. By the time the Air Traffic Controller realised what was happening and shouted at the Ryanair to stop, the First Officer responded, we’re stopped. The Ryanair flight returned to the stand to have its brakes inspected. Meanwhile, the Monarch flight continued on its way, taking off three minutes later. That’s probably the first time ever I’ve felt sorry for a Ryanair flight for being late.

Anyway, Dublin airport has hit the news again, this time for two Ryanair aircraft damaged during taxi.

The Daily Mail ran the story with a typically staid headline:

Passengers watch in horror as two Ryanair planes collide on Dublin Airport runway

The Evening Standard followed suit:

Passengers watched in terror as two Ryanair planes crashed into each other on the runway at Dublin airport.

Quick point: neither aircraft was actually on a runway. The first aircraft was holding short of the runway and the second aircraft was behind it.

Ryanair, on the other hand, referred to the ground incident as a “scrape”. A notice was posted onto their website that afternoon with the following statement:

Two of our aircraft were taxiing slowly to the runway at Dublin Airport this morning. The winglet of one aircraft appears to have scraped the tail of the other. Both aircraft were under the instruction of Dublin Airport Air Traffic Control at the time.

There was no impact on customers on board and Ryanair contacted the IAA and worked with them to return both aircraft to stand. Affected customers disembarked, were provided with refreshment vouchers and boarded two replacement aircraft, which departed to Brussels Charleroi and Edinburgh later this morning.

The notice has since been deleted from the site.

The winglet or sharklet extends above and more recently also below the wing at the wingtip. They increase the performance for jets by reducing drag, which can mean a higher cruise speed or more commonly, better fuel efficiency.

How Things Work: Winglets | Flight Today | Air & Space Magazine

Winglets reduce wingtip vortices, the twin tornados formed by the difference between the pressure on the upper surface of an airplane’s wing and that on the lower surface. High pressure on the lower surface creates a natural airflow that makes its way to the wingtip and curls upward around it. When flow around the wingtips streams out behind the airplane, a vortex is formed. These twisters represent an energy loss and are strong enough to flip airplanes that blunder into them.

But obviously the winglet isn’t going to survive impact with another aircraft’s tail. This photo taken by Niall Carson makes it look a bit more than a scrape, I have to admit.

Irish newspaper accounts of the passengers show that they were somewhat bemused but not actually watching in horror or terror.

Dramatic picture shows wing tip embedded in plane after two Ryanair jets collide – Independent.ie

Andrea Cunningham, from Drogheda, was due to fly to Edinburgh for a job interview this morning and was a passenger on one of the Ryanair aircraft.

Speaking on RTE’s Morning Ireland programme, Ms Cunningham said the impact was minimal, but the plane shook.

“We just kind of turned a corner and hit into another plane.

“It wasn’t a huge impact to be honest but you could see the plane shook and then it kind of just stopped.

“We were on the plane for about an hour, maybe short of an hour.

“We were just waiting to go back into the airport terminal,” she said.

It seems that visibility was poor and one aircraft was passing behind without quite enough space there. The ATC recordings make it clear that the flight crews involved were really not sure what happened in the moment. Note: if you are reading this from the mailing list, you may need to click through to get the audio file.

This photo, which I was unable to find an attribution for, gives good context for how it happened.

According to a poster on the Professional Pilots Rumour Network, this was an accident waiting to happen.

Dublin: 2 x RYR in contact during taxi. Both damaged.

I retired some years ago from 50 years of professional (accident free) flying and I was very familiar with Dublin Airport.

I am quite sure that dozens of us were aware that the south east corner of that airfield, after they built runway 28, was an accident waiting to happen. To say that this little corner, even on a CAVOK day, is busy, is an understatement.

In fact, I have just downloaded an IAA Aerodrome Chart (EIDW AD 2.24-1) which has, at the top left hand corner, an insert diagram entitled (in red) “Runway Incursion Hot Spots”. This shows the problem beautifully.

In the morning nowadays, departures are made from runway 28 and 34 simultaneously so that part of the airfield can get quite congested. If you want my opinion (and you probably don’t) my guess is that the aircraft holding short of 28 was being super-safe and holding back a bit further than normal. The aircraft heading for 34 tried to taxi past but mis-judged his wing tip clearance by about 10 feet.

Now, as an ex-DC-10 captain, I need to tell the great unwashed on this thread that it is quite impossible from the flight deck to judge where your wing tip is within 30 feet or so (see BA 744 at JNB).

My car beeps loudly when I’m backing up into something else, maybe the wing tips need similar sensors? It would at least make for some amusement.

26 September 2014

Hypoxia on Kalitta 66

This video is making the rounds again and it chills me as much to listen to it now as it did the first time I heard it.

The video features actual audio from Air Traffic Control dealing with a hypoxic pilot. Here are the details of what happened.

Kalitta flight KFS-66 was a cargo flight flying from Manassas, Virginia to Ypsilanti Airport, Minnesota.

Kalitta Air is a cargo airline headquartered in Ypsilanti. Conrad Kalitta started carrying car parts in his twin-engine Cessna 310 in 1967. His business, originally called American International Airways. Kalitta retired in 1997 but in 2000, the company ceased operations and Kalitta came out of retirement to rescue it. He called the new airline Kalitta Air. In 2007 Kalitta received the FAA’s Diamond Award – the highest honor for maintenance training. Kalitta Air is still owned by Conrad Kalitta.

Kalitta flight KFS-66 departed Manassas normally and was en-route flying at FL320: 32,000 feet over the sea. The flight crew had just been handed off to Cleveland’s Air Route Traffic Control Center when air traffic controller Jay McCombs noticed that the aircraft had a “stuck mike” – that is, the Push-to-talk microphone was being pressed , keeping the transmission open.

What was actually happening was that the First Officer was already unconscious and his arm was flailing violently and uncontrollably, disengaging the autopilot and forcing the Captain was trying to hand-fly the aircraft. The air traffic controller can’t understand the Captain and a second pilot in a different plane helps to get the message across.

This transcript is from the National Air Traffic Controllers Association.

Controller Jay McCombs: Kalitta sixty six how do you hear?
Captain: Kalitta six six … (unintelligible)
McCombs: Kalitta sixty six roger. You’re keying your mike and it’s staying on there frequently so please be careful.
Captain: Kalitta six six, declaring emergency.
Second Pilot (in another aircraft): Sir, he’s declaring an emergency with his flight controls.
Captain: Affirmative!
Second Pilot: Yes, sir, he said affirmative on that.
McCombs: All right Kalitta sixty six, roger. What are your intentions?
Captain: Request vectors Ypsilanti.
Second Pilot: Sir, he’s looking for vectors.
McCombs: Alright, Kalitta sixty six, I understand an emergency, you want a vector to
Cincinnati. Is that correct?
Captain: Negative. Vectors Ypsilanti.
Second Pilot: Ypsilanti.
McCombs: Ah, Kalitta sixty six are you able to maintain altitude. What assistance can I give you other than that vector?
Captain: Unable to control altitude. Unable to control airspeed. Unable to control heading. Kalitta six six. Other than that, everything A-OK.
McCombs: OK, Kalitta sixty six understand you’re not able to control the aircraft. Is that correct?
Captain: That is correct.
McCombs: Kalitta sixty six are you able to land at an airport that is closer to your position? Pittsburgh approximately five zero miles southwest of your position, Cleveland about eight zero miles northwest of your position.
Captain: Prefer to land aircraft at destination airport as the aircraft is (unintelligible). No possible damage to any part of the aircraft (unintelligible). So we’re slowly, ever so slowly, regaining control the airspeed and the aircraft if we are given the time to slowly reengage.

Meanwhile, follow controller Stephanie Bevins tunes into the frequency so she can hear the pilot. She concludes that he must be suffering from hypoxia. Hypoxia is where effectively your body is starved of oxygen. The onset of hypoxia is often masked by the euphoria – you have a general sense of well-being and can be apathetic to the fact that something has gone wrong. You will feel confused and disoriented. Your time of useful consciousness is limited – the time in which you remain capable of making sensible decisions and correcting the issue.

Bevins knows that they need to get the aircraft down from FL32 to a level where the oxygen is sufficient for the pilots, and quickly before the Captain loses consciousness. At this stage, the Captain appears to only be able to respond to direct commands. McCombs tells Kalitta to descend.

McCombs: Kalitta sixty six if able descend and maintain flight level two six zero.
Captain: Descending now to flight level two six zero, Kalitta six six.
McCombs: Ah, Kalitta sixty six, are you still requesting a vector for Ypsilanti?
Captain: Affirmative. We sure are. Got the aircraft back under control.

The Captain couldn’t turn on the autopilot as his First Officer kept switching it off, which probably saved his life. His focus on hand-flying the aircraft kept him conscious through-out; otherwise they almost certainly would have continued on autopilot at 32,000 feet until the aircraft ran out of fuel and fell out of the sky.

As Kalitta 66 descends, the Captain’s voice changes. Slowly, his words become more understandable and his reactions more professional. By 11,000 feet, he and his First Officer have recovered.

McCombs (to someone else inside Cleveland Center) Kalitta sixty six can I vector him to the right? Try and hold on, we think he has hypoxia.
Unidentified voice: All right, to the right is approved.
McCombs: All right thank you.
McCombs: Kalitta sixty six if able fly heading of three three zero.
Captain: Three three zero.
McCombs: Kalitta sixty six, area of precipitation 11 o’clock and one five miles extends approximately three zero miles along the route of flight.
Captain: OK, we see that. Looks like it’s (unintelligible).
First Officer: And roger, at eleven thousand Kalitta sixty six.
McCombs: Kalitta sixty six roger say intentions.
First Officer: And Kalitta sixty six. Destination Ypsilanti.
McCombs: Kalitta sixty six roger. Cleared to Ypsilanti via direct. Maintain one one
thousand.
Captain: OK … proceed direct Ypsilanti, Kalitta six six.
First Officer: And Kalitta sixty six, the aircraft is stable at this time.
McCombs: Kalitta sixty six roger. Again, maintain one one thousand. You are cleared direct Ypsilanti. Contact Cleveland Center one two zero, point seven seven.
First Officer: Twenty seven seven direct. Yip, Kalitta sixty six.

Stephanie Bevins and Marvin McCombs were awarded the Archie for the Great Lakes region, the National Air Traffic Controllers Association annual safety award.

Great Lakes Region Award Winner

Without Bevins and McCombs, there is no telling what would have happened. Bevins’ diagnosis made all the difference to the fate of the passengers, and without McCombs, the necessary actions to solve the problem would not have been taken to get the aircraft down safely. Various individuals were involved in the assistance of KFS66, clearly stated by McCombs who says that “the entire area (Area 5) worked extremely well as a team.”

I agree with NATCA that this is an amazing story which really shows off air traffic controllers at their best. It’s also well worth a listen for all pilots to remind them just how insidious and deadly hypoxia can be.

19 September 2014

Pilot Suicides: Fact vs Fiction

There’s been a lot of news reports about Ewan Wilson’s “breakthrough” that the disappearance of Malaysia Airlines flight 370 must have been a case of pilot suicide, specifically the Captain. The arguments in favour of this are poorly justified and Malaysia Airlines have already responded with a harsh rebuttal.

Malaysia Airlines slams authors for lies, falsehoods in book on MH370 – The Malaysian Insider

There is no evidence to support any of the claims made in the book, which is a product of pure conjecture for the purposes of profit by the authors and publishers.

Neither Wilson nor Taylor were involved in the investigation into the disappearance of MH370, yet they have offered an analysis beyond their knowledge and abilities.

They should both be ashamed of themselves for what is nothing more than a cheap and maligned publicity stunt.

One of the claims by Ewan Wilson which is making headlines is that he “found” five flights which he believes were also caused by suicidal pilots.

To clarify, to “find” these cases, you just need to go to the Aviation Safety Network, where there is a list of aircraft accidents caused by pilot suicide. ASN lists nine cases there but Wilson is clearly talking about commercial pilots carrying passengers. That leaves us with five cases, all totally documented.

Each of these five commercial pilots flying a scheduled passenger service is believed (by some investigating bodies, although not all) to have committed suicide, taking their aircraft and their passengers with them: an especially horrifying type of mass murder.

I considered this theory in The Mystery of Malaysia Airlines Flight 370 but as this is currently in the headlines, I decided take a better look at the five cases in question.

1982: Japan Airlines Flight 350

The first example is at best a failed suicide although I’m not sure it’s fair to say that the Captain intended to kill himself or his passengers.

On the 9th of February in 1982, Japan Airlines Flight 350 departed nine minutes late for its scheduled domestic flight from Fukuoka to Tokyo. The aircraft, registered as JA8061, was a DC-8-61 with 166 passengers and 8 crew on board. The flight crew consisted of the 35-year-old Captain, the First Officer and the Flight Engineer.

The flight proceeded normally from there until the final approach.

08:35 Flight 350 was given clearance to land and the wheels were dropped and flaps set ready for landing.

08:44:01 At about two hundred feet above the ground, the Captain suddenly turned the autopilot off, pressed his controls forward and deliberately engaged the thrust reversers of two of the engines.

These means that he reversed the flow of the engines so that the exhaust is directed forward, which is used in combination with the brakes to slow the aircraft upon landing. Reverse thrust on a jet is always selected manually, usually immediately after touchdown. They are not normally ever used in flight and many modern commercial aircraft cannot use reverse thrust in flight.

The DC-8 was one of few aircraft designed to allow for reverse thrust in the air — some military aircraft have also been able to safely deploy thrust reversers in flight in order to increase manoeuvrability, however the Concorde and the DC-8 may have been the only commercial jets to allow this. On the DC-8, the thrust reversers could be fully engaged on engines 2 and 3 in flight once the gear was down but many (most?) airlines prohibit the use of in-flight reverse even when the aircraft is certified for it. The effect would be rapid deceleration and a rapid loss of altitude.

Passengers reported that the aircraft nose dropped suddenly.

The First Officer immediately pulled back on the stick and the flight engineer struggled to pull the Captain away from the controls. Japanese television reported that the First Officer shouted “Captain, what are you doing?” while the engineer fought to gain control of the thrust control lever. However, the lack of thrust put the aircraft into a nose dive and they were too close to the ground to regain control. Eight seconds later, the aircraft hit the water.

08:44:07 The aircraft crashed into Tokyo Bay 510 metres short of the runway threshold.

Twenty-four passengers died in the crash. Initially, it was reported that the Captain had been killed in the impact. However, soon after they discovered that he had discarded his uniform and had been picked up in one of the first rescue boats, telling rescuers that he was an office worker.

The news soon came out that he had been suffering from mental issues and had been put on leave for a year for for mental (“psychosomatic”) issues. After the event, his flight crew from the previous day reported that he had been acting oddly.

Troubled Pilot – TIME

The revelations that appeared in the Japanese press last week painted a chilling portrait of a pilot with a troubled psyche. There were claims that Seiji Katagiri had been suffering from hallucinations and feelings of depression. He once summoned police to his two-story house near Tokyo because he was convinced it was bugged, but a thorough search turned up no eavesdropping devices. On three occasions, his employers had urged him to see a psychiatrist.

The Captain was arrested for “professional negligence resulting in deaths” but was found to be not guilty by reason of insanity.

1994: Royal Air Maroc Flight 630

This was the most difficult of the cases to research as there is very little information online.

On the 21st of August in 1994, Royal Air Maroc flight 630 departed Agadir Al Massira Airport on a scheduled domestic flight to Casablanca. The ATR 42/72 twin turboprop, registration CN-CDT, held 40 passengers and 4 crew.

The aircraft departed at 19:00 local time and began its climb. About ten minutes after the departure at 11,480 feet feet, the aircraft suddenly entered a steep dive and crashed into the Atlas Mountains about 30 kilometres (20 miles) north of the airfield.

The investigation concluded that the pilot disconnected the autopilot and then deliberately flew towards the ground. The First Officer made an immediate call on the radio, screaming “Help, help, the Captain is…” but her call was cut off as the aircraft impacted the ground.

A statement at the time by the Transport Minister stated that the accident was “due to the deliberate will of the pilot who wished to end his life.”

The Moroccan Pilot’s Union originally disputed the suicide explanation stating that there was no evidence that the pilot was disturbed or had any grounds to kill himself. The cockpit voice recorder was published in France and apparently confirms the initial reports of the sequence of events. The final investigation report was meant to explain this more thoroughly but there is no copy of the report online. However, the union did not make any further arguments after their initial statement and there appears to be no remaining doubt that the Captain of the flight deliberately took control of the aircraft in order to kill himself and everyone on board.

1997 SilkAir Flight 185

The next case has been the subject of two investigations and considerable controversy. The timeline below is taken from the official report released by the Indonesian National Transportation Safety Committee.

On the 19th December in 1997, SilkAir flight 185 departed for its scheduled flight from Jakarta, Indonesia to Singapore with 97 passengers and 7 crew members on board. The aircraft was a Boeing 737-300 registered as 9V-TRF. It was less than a year old and the newest aircraft in SilkAir’s fleet.

08:37 UTC (15:37 local time) SilkAir flight 185 departed Soekarno-Hatta airport in Jakarta for an 80-minute flight to Singapore and began its climb out. The Captain was the Pilot Flying.

08:53 The aircraft reached its cruising altitude of FL350 (35,000 feet) and the flight crew was cleared direct to waypoint PARDI and told to report when abeam Palembang.

09:04:57 The Captain stated that he was going to go to the passenger cabin. Several metallic snapping sounds were recorded, which the NTSB believe were sounds made by the seatbelt buckle.

09:05:15 The cockpit voice recorder stopped recording

09:10:18 ATC informed SilkAir flight 185 that they were abeam Palembang and to contact Singapore Control when at waypoint PARDI.

09:10:26 The First Officer acknowledged this call. This means we have confirmation that the First Officer was in the cockpit at this time. No distress call was ever made or any sign given that there might be an issue with the aircraft.

09:11:33 The Flight Data Recorder stopped recording.

This was 6 minutes and 18 seconds after the CVR stoppage and approximately 35.5 seconds before the aircraft started its descent. Up to the point at which it shut down, the FDR showed no indications of unusual disturbance or other events affecting the flight.

09:12:09 Jakarta ATC radar recording showed the aircraft still in the cruise at FL350

09:12:17 Jakarta ATC radar recording showed that the aircraft had descended by 400 feet. The aircraft then went into a nearly vertical dive.

09:12:41 Jakarta ATC radar recording showed the aircraft passing through FL195 – in less than thirty seconds, the aircraft had descended 15,500 feet. That averages to 645 feet per second or 38,750 feet per minute.

A normal descent in a Boeing 737 would be around 1,500-2,500 feet per minute. After twenty four seconds, the aircraft began to disintegrate.

In less than a minute, the aircraft crashed into the Musi River. In the final seconds before impact it was travelling faster than the speed of sound.

There was no evidence of any malfunction which would explain why the recorders stopped recording nor why the aircraft would go into such a steep and fast descent. The radio continued to work, showing that there was not a general power failure in the cockpit. However, without the Flight Data Recorder, we have no definitive proof of what happened on the aircraft.

The Indonesian National Transportation Safety Committee reported that it could not determine a cause of the crash due to inconclusive evidence.

The NTSB held its own unofficial investigation. US investigators concluded that the recorders were intentionally disabled to hide a deliberate action to crash the aircraft, most likely by the captain who left the cockpit to disable the circuit breakers and then returned and manually held down the control inputs for nose-down flight at full speed.

1999: EgyptAir Flight 990

EgyptAir flight 990 was a regularly scheduled flight from Los Angeles to Cairo with a stopover in New York. The aircraft was a Boeing 767-300ER, registration SU-GAP, with 203 passengers and 14 crew on board.

On the 31st of October 1999, the flight departed JFK airport in New York at 01:22 local time as a scheduled international flight.

Again, the situation on this flight is convoluted and there were two investigations. Initially the Egyptian Civil Aviation Authority, who had jurisdiction over the accident, delegated the investigation to the NTSB in the US. The NTSB began their investigation but then proposed handing the investigation to the Federal Bureau of Investigation, as their evidence suggested the aircraft crash was intentional rather than accidental. The Egyptian Civil Aviation Authority refused and the NTSB continued their investigation which continued to point to a deliberate action by a crew member. However, the Egyptian Civil Aviation Authority believed that the NTSB was not sharing information and stated that they often learned of the NTSB’s views in the press. The Egyptian investigators had access to the data collected by the NTSB and launched their own investigation which concluded that the crash was caused by mechanical failure.

This is the first accident ever where I’ve been unsure as to which report is the official investigation.

The general sequence of events on the flight is agreed by both parties and I have used both reports for reference.

01:26:35 EgyptAir flight 990 contacted New York Centre and continued to climb to FL230 as they flew out over the Atlantic.

01:35:52 EgyptAir flight 990 was cleared for a cruising altitude of FL330, roughly 33,000 feet above sea level.

01:40 The Relief First Officer suggested that he relieve the Command First Officer at the controls, stating “I’m not going to sleep at all. I might come and sit for two hours, and then…” that is, offering to fly his portion of the trip at that time. After some discussion and catty comments, they agreed that the Relief First Officer would get some food and then start his shift. The Relief Officer appeared to have taken the First Officer seat within the next few minutes.

01:41:52 An oceanic clearance was issued and acknowledged by the flight crew.

01:47:18 New York Centre requested that EgyptAir flight 990 change frequencies.

01:47:39 EgyptAir flight 990 changed frequencies and the Captain reported in with “EgyptAir ah, nine nine zero heavy, good morning” on the new frequency. This was the last transmission to ATC from the aircraft.

01:48:03 The Captain said to the Relief First Officer, “Excuse me [RFO nickname], while I take a quick trip to the toilet.” The Relief First Officer responded with “Go ahead please.”

After the Captain left the cockpit, sound was recorded in the cockpit which included human speech but it was not possible to identify who was speaking or what the words were.

01:48:34 A click and a thump was reported, followed by the Relief First Officer saying “I rely on God.”

10:49:45 EgyptAir flight 990 was cruising on a heading of 080 at 33,000 feet when the autopilot was disengaged, almost certainly manually and intentionally, as there was no aural warning. The aircraft remained in level flight for about eight seconds when the Relief First Officer said again, “I rely on God”.

01:49:53 The throttle levers were moved from cruise power to idle and an abrupt nose-down elevator movement was recorded. The aircraft pitched nose down and began a fast descent. The Relief First Officer repeated his statement of “I rely on God” another seven times.

01:50:06 The Captain returned to the cockpit and said “What’s happening? What’s happening?” The elevator movements continued and the aircraft began to pitch down.

01:50:08 The aircraft exceeded its maximum operating airspeed. The Relief Officer repeated again “I rely on God” and the Captain, “What’s happening?”

01:50:20 The aircraft descended to 21,000 feet and the elevator movements changed to a nose up direction, which the NTSB believes were the result of the captain making nose-up flight control inputs. The aircraft’s rate of descent began to decrease. That’s when the left and right elevator surfaces began to move in opposite directions. The aircraft’s elevator had split.

Up until this time, the elevator surface movements were slightly offset but consistent (that is, both were moved in the same direction at the same time). This is where the reports diverge: the Egyptian report concludes that the mechanical failure already existed before the aircraft left New York for Cairo and eventually caused the aircraft to go out of control. They state that the Relief First Officer disconnected the autopilot after observing some unusual movement of the column and throughout was trying to regain level flight. The US report concludes that the dive was initiated by the Relief First Officer and the resulting stresses on the aircraft, specifically the two pilots applying force on the control column in opposite directions, caused the elevator split.

01:50:35 At 16,000 feet, the Flight Data Recorder and the Cockpit Voice Recorder ceased recording. Radar recordings showed that the aircraft climbed again, this time to approx 24,000 feet and then entered a final dive into the ocean. During the dive, the aircraft reached an estimated airspeed of 0.99 Mach and experienced g-forces from +0.98 to -0.227 before it crashed into the ocean.

2013: Mozambique Airlines Flight 470

On the 29th of November in 2013, the regularly scheduled Mozambique Airlines flight departed from Maputo International Airport to Luanda, Angola with 6 crew and 28 passengers onboard. The flight progressed normally and the aircraft was in contact with Gaborone Area Air Traffic Control and cruising at 38,000 feet. Radar showed that the aircraft, an Embraer EMB-190, suddenly started descending at 6,000 feet per minute and then disappeared. The aircraft did not arrive at Luanda, where it was scheduled to arrive about 90 minutes later and there were no reports of unscheduled landings anywhere in the region of the route.

Search and Rescue teams found the wreckage in the Mbwabwata National Park the following day and recovered the black box with the flight data recorder and the cockpit voice recorder. The Flight Data Recorder revealed that the aircraft had no mechanical faults. However, it also showed unexpected configuration changes in the cockpit.

A few minutes before the crash, the First Officer left the cockpit and went to the washroom.

The captain, alone in the cockpit, manually selected the aircraft flight altitude three times. He changed the flight altitude from their cruising altitude of 38,000 feet to 592 feet. The elevation around this time was over 3,000 feet, making the final flight altitude selection below ground level.

Then the auto-throttle was re-engaged. With the steep descent, the throttle level automatically retarded, setting the power to idle. The Captain manually selected the airspeed and set it to the maximum operating speed of the aircraft.

There was no evidence of accidental configuration. All of these actions displayed a clear understanding of how the automatic flight systems worked and with clear intent.

The autopilot was on and the aircraft hurtled to the ground. During this time, various warnings and alarm chimes could be heard sounding in the cockpit but the Captain did not appear to take any notice of them. Then there was the loud sound of banging on the cockpit door with demands to be let into the cockpit. The spoilers were deployed and held until the end of the recordings, proving that the aircraft was under human control as it descended at 6,000 feet per minute.

From the preliminary report:

All action observed from the recorders requires knowledge of the aircraft’s automatic flight systems as the entire descent was performed with the autopilot engaged. This displays a clear intent. The reason for all these actions is unknown and the investigation is still ongoing.

The aircraft crashed into the border area between Botswana and Namibia at high speed. There were no survivors.

The final report has not yet been published but if it is not complete by the one year anniversary of the accident, an interim report should be released with updates as to their progress.

Conclusion

Note that in every instance, if we accept that each of these was in fact an intentional suicide, the pilot chose to take control of the aircraft and crash it immediately. This is a huge contrast to Wilson’s theory:

‘Suicidal pilots killed 600 people’ says expert ahead of Birmingham event – Birmingham Mail

Mr Wilson believes that pilot Shah shut his co-pilot, Fariq Hamid, out of the cockpit on flight MH370, then shut off all communication and turned the aircraft around, veering off course.

He then depressurised the plane, and once the cabin crew and passengers’ oxygen had run out, they died from hypoxia.
The accident investigator believes that the pilot then made eight different course changes before finally allowing MH370 to fly on auto-pilot for the last few hours of its journey into the southern Indian Ocean.

The Australian Transport Safety Board published a report which is referenced as a part of the theory, because they stated that the final period of the flight appeared to fit the characteristics of an unresponsive crew/hypoxia event. However, the idea that the Captain was in control and deliberately disabled the passengers and crew in order to fly on autopilot until the aircraft ran out of fuel is quite a step beyond that and certainly not a theory that the ATSB, or any other investigating body, has put forward as viable.

The five pilot suicide/murder cases cited all show a clear course of action by the pilots: gain control of the aircraft and crash it as quickly as possible.

In no instance has a pilot ever tried to disable flight crew, cabin crew and hundreds of passengers and then fly the aircraft on autopilot until it ran out of fuel before gently guiding it into the water. It makes for a lovely Hollywood ending but in a real-world tragedy, it’s all plot and not enough facts.


If you found this interesting, you might like to pick up my books:

12 September 2014

UPS 1354 and the unforgiving nature of flight

On the 14th of August in 2013, UPS Airlines Flight 1354 departed Louisville International Airport at 05:04 EDT on a cargo flight delivering to Birmingham-Shuttlesworth International Airport in Alabama.

The captain was the pilot flying and the first officer was the pilot monitoring.

The aircraft was N155UP, a ten year old Airbus A300F4-622R. Its first flight was in November 2003 and it was delivered to UPS on the 13th of February, 2004.

Birmingham-Shuttlesworth International Airport’s main runway, 06/24 with a precision approach, was closed from 0400-0500 local time.

UPS flight 1354 was due at 04:51, which meant that only the shorter runway 18 was available for the inbound flight.

The weather forecast was for variable low clouds which could require the flight to divert to an alternate airport.

The dispatcher did not warn the flight crew of UPS flight 1354 about the low clouds or the single-approach option to the airport. Neither did dispatch bring up the fact that runway 06/24 would reopen at 05:00. At no point during the flight did the crew receive any of the variable forecast information.

This has been referred to as “the fatigue flight” as a result of the cockpit conversation before the flight, which was released in February. The Captain and his First Officer clearly discuss fatigue and over-work as they wait for to be cleared for their flight.

03:42:53 Captain We have two extra hours today in Birmingham.
03:41:58 Captain Rockford is only fourteen hours and * minutes rest. So you figure a thirty minute ride to-for hotel…
03:42:04 First Officer I know by the time you…
03:42:06 Captain …fourteen hours…
03:42:08 First Officer …by the time you go to sleep you are down to about twelve. (wow).
03:42:14 Captain This is where ah the passenger side you know the new rules they’re gonna make out.
03:42:17 First Officer They’re gonna make out
03:42:18 Captain Yeah. We need that too.
03:42:20 Captain I mean I [stammer] don’t get that. You know it should be one level of safety for everybody
03:42:23 First Officer It makes no sense at all.
03:42:24 Captain No, It doesn’t at all
03:42:24 First Officer I know. I know.
03:42:26 Captain Nope.
03:42:27 Captain Which means that you know * real pilot.
03:42:32 First Officer You know.
03:42:32 First Officer And to be honest. [stammer] It should be across the board. To be honest in my opinion whether you are flying passengers or cargo or you know box of chocolates at night. If you’re flying this time of day…
03:42:36 Captain Mm hmm. Yup (We work).
03:42:49 First Officer …The, you know [stammer] fatigue is definitely…**
03:42:32 Captain Yeah…yeah…yeah…**
03:42:54 First Officer I was out and I slept today. I slept in Rockford. I slept good.
03:42:59 Captain Me too
03:43:00 First Officer And I was out in that sleep room and when my alarm went off I mean I’m thinkin’ I’m so tired…
03:43:06 Captain I know.
03:43:06 First Officer …and I slept today.
03:43:07 Captain Exactly.
03:43:08 First Officer I know you know and we just are goin’ to Birmingham. What if I was goin’ to Burbank?
03:43:10 Captain and these people—
03:43:11 Captain Really God, I know these people have no clue. I know.
03:43:14 First Officer and I just don’t understand what they…
03:43:17 Captain And they you know they talk about cost. Well on the passenger side it just costs just as much. The same thing. You know, I mean give me a break. And these companies are the ones that are really making the money. They got a lot of nerve.
03:43:22 First Officer Exactly. Exactly. Making the money. I know.
03:43:30 Captain Yeah they do that [stammering] * says [stammering] a lot about what they how they think about you
03:43:34 First Officer * says a lot *.

The Captain was off duty from the 5th to the 12th of August. The hearing found that he took steps to mitigate the effects of fatigue:

  • August 12: Napped at home and acquired sleep room in Louisville
  • August 13: Adequate opportunity to rest in Rockford
  • August 14: Acquired sleep room in Louisville

The First Officer was off duty from the 10th to the 12th, however the hearing was less impressed with her sleep patterns and stated that she mismanaged her off-duty time.

  • August 12: returned to duty with about 9-hour sleep debt
  • August 13: less than 5½-hour sleep opportunity
  • August 14: acquired sleep room in Louisville

The NTSB felt that she was aware of her fatigued state and also expressed concern in the hearing that the final approach of the flight was during the window of circadian low.

The FAA defines three types of fatigue: transient, cumulative and circadian. Transient fatigue is acute fatigue by extreme sleep restriction – that is, being awake too long or having very little sleep over one or two days. Cumulative fatigue is mild sleep restriction or extended hours awake across a series of days, which is what seems to be described for the first officer. Circadian fatigue is the reduced performance during nighttime hours.

The window of circadian low is the lowest point of performance, alertness and body temperature. It is considered the hours between 02:00 and 06:00 on the home-base time zone for flight crew who are on a standard day-wake/night-sleep schedule.

The symptoms of fatigue include:

  • Measurable reduction in speed and accuracy of performance,
  • Lapses of attention and vigilance,
  • Delayed reactions,
  • Impaired logical reasoning and decisionmaking, including a reduced ability to assess risk or appreciate consequences of actions,
  • Reduced situational awareness, and
  • Low motivation.

The Captain and his First Officer seemed fine during the flight but as they reached the final stages of the flight, they began to make mistakes.

At 04:20 they listened to the Birmingham ATIS for airfield information.

Birmingham Airport information Papa zero eight five three Zulu observation wind calm visibility one zero. sky condition ceiling one thousand broken. seven thousand five hundred overcast. temperature two three. dewpoint two two. altimeter two niner niner seven. localizer runway one eight in use. landing and departing runway one eight. notice to airmen runway six two-four closed. all departing aircraft contact tower one one niner point niner for clearance taxi and takeoff. advise controller on initial contact you have Papa.

This appears to have been the first notification the crew had that runway 6/24 was closed.

With still half an hour to run, the Captain briefed his first officer for the non-precision approach into runway 18. The First Officer entered the approach into the flight management computer.

This “profile approach” means that the flight management computer can set up a glidepath for the crew to follow from the final approach fix to the decision altitude. For runway 18 at BHM, the flight crew follow the vertical path guidance to 1,200 feet above sea level, as opposed to step-downs, staggered descents where the crew must constantly monitor the minimum altitude for each step.

The aircraft was cleared for the localizer 18 approach, however, the flight management computer wasn’t set up correctly.

…although the flight plan for the approach had already been entered in the FMC, the captain did not request and the first officer did not verify that the flight plan reflected only the approach fixes; therefore, the direct-to-KBHM leg that had been set up during the flight from Louisville remained in the FMC. This caused a flight plan discontinuity message to remain in the FMC, which rendered the glideslope generated for the profile approach meaningless.

The key information here is that the flight management computer wasn’t set up correctly, neither of the flight crew noticed and, as a result, the glideslope information was meaningless for the approach that they were conducting. There was a clear error message which neither crew member paid any attention to.

If the flight management computer had been set up correctly, then the autopilot would have engaged the profile approach and the aircraft would have descended on the glidepath to the runway.

At the final approach fix, they were at 2,500 foot above sea level, instead of the expected altitude of 2,300.

Neither pilot realised that the flight plan was not verified. Nor did they notice that the vertical deviation indicator was pegged at the top because the aircraft was showing as over 200 feet below its (meaningless) flight path. The crew knew they were above, not below, the glidepath at the final approach fix. Yet they still somehow did not realise that the flight management computer was wrong.

The Captain did notice that the autopilot did not engage at which point he changed the autopilot to vertical speed mode, as one would use for a step-down approach. He didn’t mention changing the mode and they continued their descent without proper monitoring.

The decision altitude for runway 18 is 1,200 feet above sea level. If the runway is not in sight, the flight crew must stop descending. If they can not see the runway then they cannot continue the approach but must break off and go-around.

During the “Before Landing” checklist, the First Officer noticed that the autopilot was in vertical speed mode. The Captain then increased the vertical descent rate to 1,500 feet per minute. This means that not only do they have the heavy workload at a point when their bodies are at a circadian low, but he’s just significantly increased the pace.

04:47:02 First Officer There’s a thousand feet, instruments crossed checked, no flags.
04:47:05 Captain Alright, ah, DA is twelve ah hundred.
04:47:02 First Officer Twelve hundred yeah….

DA is decision altitude. To confirm to the UPS stabilized approach criteria, they should not be at a descent rate greater than 1,000 feet per minute. An unstabilized approach requires a go-around. And yet, they continued to descend.

The ATIS information stated that the cloud ceiling was at 1,000 feet so they expected clear skies once they descended below that. However, the weather information was incomplete and didn’t mention the variable ceiling. The cloud base at their location at that time was about 350 feet.

At 1,000 feet above sea level, about 250 feet above ground level, the Enhanced Ground Proximity Warning System (EGPWS) sink rate caution alert sounded through the cockpit. The captain reduced the vertical speed to about 1,000 feet per minute and called out runway in sight. The first officer confirmed she also had the runway in sight.

The Captain reduced the speed further but the aircraft was still descending rapidly and aiming for a point one mile short of the runway. The First Officer made no further altitude call outs after the initial 1,000 foot and neither crew member seemed to be aware at how low they were.

The next sound on the cockpit voice recorder is the sound of rustling with the volume increasing for about 5.4 seconds as they hit the trees.

The Captain and First Officer had just enough time to realise what was happening before the aircraft impacted the ground and caught fire. They were killed in the impact.

The NTSB found that there were many steps that could have reduced the risk factor of this flight: the First Officer could have reported herself as fatigued. The dispatcher should have given the flight crew better information about their flight. The Captain could have gone around as soon as the planned “profile approach” did not start as expected.

However, in the end, the death of the flight crew was caused by continuing an unstabilised approach long after it was clear that things were not as they should be.

The acting Chairman of the NTSB closed the hearing with this statement:

Air transportation is as safe as it is today largely because rigorous aviation safety practices have been developed out of respect for the inherently unforgiving nature of flight.

In the end, that lack of respect caused this accident and their deaths. Maybe someone else will learn from their mistakes.

More details can be found on the NTSB site on their page detailing the Board Meeting: UPS Flight 1354.

15 August 2014

The Runaway Runway Van

I often talk about how an accident is caused by many small things that have gone wrong as opposed to one big mistake. This incident which was reported by the Transportation Safety Board of Canada last month is a perfect example of this.

The 11th of March in 2013 was a rainy night at Toronto International Airport in Ontario. Sunwing Airlines, a Canadian aviation company based in Etobicoke, offer scheduled and chartered airline services out of Toronto and routinely do their maintenance and grooming during the evenings, while the aircraft are parked at gates at the east side of Terminal One.

That evening, an engineer and a technician went to fix C-FTLK, a Boeing 737-800. The technician drove them there in a Sunwing maintenance van: a 2007 Chevrolet Express Cargo 2500 with a 4.8 L engine and a 4-speed automatic transmission.

The van was painted white with a large Sunwing logo on both sides. On the roof was a large aluminum platform with a ladder running down the left side. On the front left corner of the platform as an orange beacon light.

The engineer completed his work at 23:00. The groomers were still onboard cleaning up the cabin and flight deck.

The technician drove the engineer back to the company facility and then returned to the 737 to finish off. He parked the van left of the nose of the aircraft waited for the groomers to finish.

It was about half an hour later when the groomers finished and exited the aircraft using the left-hand main door.

The last of the groomers tried to close the aircraft door behind him but struggled with the weight of the door in the rain. The technician pulled forward and got out of the van, signalling to the groomer to leave the door, that he would take care of it. The groomers left.

The technician checked the ground power unit on the right side of the aircraft before boarding the Boeing 737 through the left-hand main door and checking the the cockpit.

When he came out, he realised that his van was gone.

Up in the airport control tower, it was a quiet night. Night operations are not very busy at Toronto International and multiple ATC roles during the day are regularly combined at night.

That night, there were three air traffic controllers. One was working as the tower controller, one was working combined north and south ground and the third was there for post-handover monitoring.

Meanwhile, the little-van-that-could made its break for freedom. The technician had left it idling and in drive. Once he disappeared into the cockpit of the aircraft, the van began to move.

It rolled forward, grazing the outer cowling of the Boeing 737′s left engine. Undeterred, it rolled under the wing and continued forward, heading straight for runway 24R, the active runway.

The van’s speed varied between one and five miles per hour as it drove across the apron and into the manoeuvering area.

Ground controllers at Toronto watch the traffic from the window and have a radar display for the Airport Surface Detection Equipment (ASDE). The surface detection equipment is a safety system which monitors the manoeuvering area of the airport in order to help controllers detect potential runway conflicts. It provides detailed coverage of movement on runways and taxiways.

However, it doesn’t cover the aprons or the gate area, in order to reduce the clutter on the display. The first seven hundred feet of the little van’s epic journey were not monitored by the surface detection equipment. It reached intersection DV.

The ground controller saw the movement on his display, a slow-moving target just past the gate area. He thought it might be a false target. He spent two minutes on other duties before checking his display again.

The van continued.

The tower controller was standing and moving around as he kept watched over both the departure and arrival runways.

The ground controller looked back at the display and saw that his slow-moving target was now coming up to the threshold of Runway 24R. He showed the tower controller the blip on the display. Neither could think what the display might mean as they scanned their electronic flight progress strips and looked outside. They had no idea what the blip might be.

The third controller scanned the area with binoculars but the van was over a mile from the tower and in shadows near the brightly lit Terminal 1. The controller never saw the van; there seemed to be nothing there.

Air Canada flight 178 was an Embraer EMB190 registration C-FLWH. It was inbound to Toronto from Edmonton International with five crew and sixty-seven passengers on board. They’d been cleared for an instrument approach to Runway 24R. It was a quiet night and Air Canada 178 was number two, after Air Canada flight 1126 which was seven nautical miles ahead of them.

Air Canada flight 1126 landed without incident.

The crew could see the airfield clearly and saw the preceding aircraft vacate the runway from five nautical miles out. The approach was stable and the crew continued.

The tower controller had an unknown something entering the active runway and Air Canada flight 178 on late finals. He still didn’t know what it was out there but he urgently needed to abort the incoming landing. Because he was asking an aircraft less than 4,000 feet from the runway threshold to pull up and go around, the controller spoke quickly and as a result, his words were elided. “Air Canada” became “ercana” in his rush. In addition, the aircraft’s Extended Ground Proximity Warning System sounded at the exact same moment.

Time (UTC) Source of message Cockpit audio Meaning Aircraft position
03:39:04 EGPWS–automated “Minimums” Descent below the decision height 250 feet radar altitude (796 feet asl), 4,500 feet from the threshold
03:39:07 Pilot monitoring “Runway in sight” The runway is in sight visually approx. 230 feet radar altitude
03:39:08 Pilot flying “Landing” Continuing the landing approx. 220 feet radar altitude
03:39:12 EGPWS–automated “Two hundred” Radio altimeter callout for descent below 200 feet 200 feet radar altitude, 2,550 feet from the threshold
03:39:12 ATC “ɛrkænə 178, pull up and go around, sir” Instruction to Air Canada 178 to go-around 200 feet radar altitude, 2,550 feet from the threshold

The controller waited a few seconds and when he didn’t get a response, he called again.

Time (UTC) Source of message Cockpit audio Meaning Aircraft position
03:39:19 ATC “178, pull up and go around” Second instruction to Air Canada 178 to go around 125 feet radar altitude, 1,100 feet from the threshold
03:39:23 EGPWS–automated “Fifty” Radio altimeter callout for descent below 50 feet 50 feet radar altitude, approximately overhead the displaced threshold

The controller did not get any response to his calls. He could clearly see the radar blip blocking the runway and the Air Canada flight heading right for it.

During a normal approach, such as the one flown by Air Canada 178, the EGPWS makes several standard automated aural call outs, which are broadcast simultaneously over the cockpit speakers and the pilots’ headsets. During post-incident simulation, it was noted by TSB investigators that the callouts were significantly louder than the radio or intercom audio, which is delivered solely to the pilots’ headsets. The volume of the intercom and radio is adjustable by the flight crew, whereas the EGPWS audio is not.

The flight crew had clear sight of the runway and were seconds away from landing. That, combined with the dodgy acoustics, led them to believe that although they clearly heard the words “go around”, the instruction must be meant for another aircraft. They continued.

The controllers stared at the runway. They must have been holding their breath.

Air Canada flight 178 cruised directly over the top of the van and touched down. The separation between the van and the aircraft was less than thirty-five feet.

As Air Canada 178 cruised down the runway, the tower controller called them a third time and asked if they’d seen anything on the runway. This time the crew responded. They hadn’t seen a thing.

The van trundled across the runway and continued straight across taxiway D7.

The controllers reported the incident and the airport authority sent staff out to search the area.

The van drove into the grass. It got stuck when it struck a taxiway reflector sign and stopped, once again out of sight of the radar display, where it waited patiently for someone to rescue it.

Fourteen minutes later, airport staff discovered the missing white van. The engine was running and the headlights, taillights and beacon were all on. The automatic transmission was set to drive.

The Air Canada flight continued on to Ottawa. Air Canada Operations, by now aware of the near-miss, instructed the crew to disconnect the power to the digital voice-data recorders upon their arrival. These DVDRs record two hours of the conversation in the cockpit (as opposed to on the radio) and then over-write the data.

At Ottawa, the flight crew was met by company maintenance staff who said that they would disconnect the DVDRs. However, they didn’t get around to doing so until an hour later, and the cockpit voice data from the landing at Toronto was overwritten.

The investigators discovered that the beacon on top of the van, which was designed to use a 37.5 watt bulb, actually only had a 7 watt bulb installed.

Although visibility was good, a seven watt bulb was not enough to draw attention to the vehicle. The flight crew expected an uneventful landing and could not see any obstacles on the runway. Although the cockpit voice data was lost, the crew stated that they discussed the transmission to go around and agreed that it couldn’t be meant for them. As the report put it, the communication was insufficient to challenge the flight crew’s mental model of the situation.

From the incident report:

Following the occurrence, the Greater Toronto Airports Authority (GTAA) issued directives to the Toronto Pearson aviation community reiterating the prohibition against leaving vehicles idling and unsecured on the airside. The GTAA also published and disseminated information on the luminosity requirements for vehicle roof beacons and did spot checks to inspect beacons and require inoperative or inadequate beacons to be repaired or replaced. Sunwing Airlines reported to Transport Canada that it has inspected all of its airside vehicles and ensured that their roof beacons meet specified luminosity standards.

The van was returned to service with a new beacon bulb installed.

So, another happy ending… but more by luck than good management on this occasion!

01 August 2014

Congo Crocodile Plane Crash

The incredible story of the crocodile that crashed a plane is quickly becoming a piece of aviation folklore. The details have been published in mainstream newspapers all over the world and is now listed under incredible accidents on otherwise respectable aviation websites. There’s only one problem: there’s no official reason to believe it ever happened.

Let’s start by looking at the crash.

On August 25th in 2010, a Filair flight flying from Kinshasa Ndolo crashed into a house while attempting to land at Bandundu. The aircraft, a Let L-410, is a Czech turboprop which is a popular small passenger aircraft. The Captain was Danny Philemotte, the Belgian owner of the airline. The First Officer was British pilot Chris Wilson.

That day there were three crew members and sixteen passengers on the flight. They were flying into Bandundu but the aircraft executed a go-around – that is, they circled around to attempt the landing again.

On the second attempt, something went terribly wrong. Apparently after the aircraft went around, it turned and then crashed. A witness on the ground reported that it “fell out of the sky like a leaf” while in its final descent. The aircraft crashed into an empty mud-and-brick house about 2 kilometres (1¼ miles) from the airport. No one on the ground was hurt. The crew and fourteen passengers were dead on impact. Two passengers survived the initial crash but one died soon afterwards in hospital.

Initially, Radio Okapi reported that the turboprop ran out of fuel as a result of breaking off the first approach. However, 150 litres of “kerosene” were recovered from the wreckage, so although a fuel malfunction is possible, the aircraft had more than enough fuel to continue the flight.

Two days later, the surviving passenger gave an unclear statement about the moments leading up to the crash. She was still in critical condition but made a statement, in which she said that the passengers panicked and stampeded the cockpit because the aircraft was landing at a reserve strip instead of runway 11/29.

There’s no evidence of a reserve strip at that airfield that I can find, although it is poorly documented. More importantly, how would the passengers know?

This is the only official statement collected from the surviving passenger.

Normally there would be a full scale investigation into the crash but unfortunately, this doesn’t appear to have been the case. Part of this is the region: Filair and all airlines based in the Democratic Republic of the Congo are banned from flying in the European Union specifically because the DRC aviation authority does not maintain the regulatory oversight standards required by the European Union. It’s not particularly surprising that the investigation itself has not proceeded as one might hope.

This mean that there’s not a lot of information about the crash and no real hope of ever getting more. The black boxes were recovered from the aircraft but no further information has been forthcoming. The British AAIB has asked for access to them but after four years, there seems little hope that the recordings or transcripts of their contents will ever be released. As a result, there’s a lot of speculation as to why a functional aircraft with 150 litres of fuel and competent pilots could just fall out of the sky.

There is no further official information or investigation results regarding this crash.

However, two months after the event, a Congolese tabloid ran with an astounding story: the plane crashed because there was a crocodile on board which panicked the passengers. The surviving passenger told Jeune Afrique how the crocodile had escaped from someone’s bag and caused the passengers to run for the cockpit. There was no clear explanation as to why the passengers might all decide on that course of action.

She had never mentioned a crocodile in her initial statement, only the reserve strip. There were no other reports of a crocodile at the scene of the crash. The article had a noticeable lack of detail and verifiable information in the article and no follow-up with the passenger or the aviation authority was ever done. On the Aviation Safety Network, one commenter summed it up quite bluntly:

[I] believe the newspaper who broke that story paid a lot of money for that story (and got what they wanted).

The crocodile tale got picked up by various other tabloids with ever more witty headlines. The story was embellished with unverifiable details which were never part of the initial reports nor in the first article: the crocodile was illegal, hidden in a hold-all by a passenger hoping to smuggle it out for sale. The crocodile escaped from the crash unharmed but one of the rescuers killed it with a machete. There was a video of the crocodile on YouTube (which has never been found). The crocodile scared the cabin crew member and it was she who ran to the cockpit in fear.

No one in the aviation industry was able to find any means of verifying this tale and the Aviation Safety Network went so far as to ban any comments claiming the crocodile was the cause of the crash. The bizarre explanation was on the road to being forgotten.

However, four years later, at the UK inquest of the British First Officer, the crocodile crash theory came into the public eye again.

As a part of the inquest, the Assistant Coroner read out an email which was written by the First Officer’s father to the Congolese officials. In this email, the First Officer’s father said that there was this story he’d been told, that it was a crocodile who caused a panic and that the resulting weight shift may have caused the plane to go into a nose dive.

That was enough for the mainstream press to run with the story. Again, there was no official statement, no follow-up to the initial article with any verifiable facts, nothing but a single tabloid piece claiming to have inside information from the only surviving passenger, with no reason given as to why she wouldn’t go to the police. And the scenario as explained at the inquest was not the result of any investigation, as implied by some media, but a single statement made by the grieving father about a story that he had been told.

The inquest also heard that the aircraft might have been sabotaged by a rival company competing for business: an accusation which was equally lacking in any verifiable details.

An air accident investigator at the inquest stated that he believed the aircraft stalled. This is one of the most common causes of a crash on approach, especially on a turn. However, it’s impossible to tell without more details of the accident.

Panic over escaped crocodile could have crashed plane, inquest hears – Telegraph

Timothy Atkinson, an air accident investigator, said he had reviewed the evidence given to him by Congolese authorities but was unable to draw any definitive conclusions because they were not handed over the black box.

He said: “To date we have no information from the black box reader, it has been almost four years since the accident.

“The aircraft struck a mud and brick building with a straw roof, and it came to a rest against another one on the ground.

“The most likely explanation I can find is that the aircraft stalled and, or was in a spin prior to impact.

“There is no evidence suggesting an engine failure, or a nose dive, although I cannot be sure without looking at the plane.

“It would reinforce the idea that the accident appears to have the hallmarks of a stall and spin, which may have been from a variety of causes.

“Essentially, it fell out of the sky.”

The Assistant Coroner recorded an open conclusion, stating that there were only vague guesses as to what happened with this crash.

Is it possible that the passengers stampeded the cockpit? It is, but I can find no other record of a plane crash caused by the passengers rushing to the front (or any other direction).

If that is what happened, it’s technically possible that a crocodile was in the aircraft and caused the stampede. But realistically, I think this version of events are more to do with an irresistible headline than truth.

25 July 2014

Aviation Disasters in 2014: Is It Safe to Fly?

This week, another two fatal aviation accidents made international news. TransAsia Airways flight 222 crashed in heavy rain while attempting an emergency landing at Magong, Penghu Island, Taiwan. Air Algérie flight AH-5017 crashed near Mali after twice changing course in an attempt to avoid thunderstorms covering the region.

Both of these accidents appear to have been the result of aircraft unable to cope with the serious bad weather in which they found themselves. It is too early to know what decisions might have been made in order to avoid the fatal weather conditions.

This news is especially disturbing after last week’s loss of Malaysia Airlines flight 17 which was shot down by a missile. “It’s a bad week for those frightened of flying,” said one media outlet.

It’s true, the past seven days have seen a shocking loss of life owing to fatal aircraft disasters. The front pages of newspapers around the world are covered with the aftermath of these tragic flights: MH17 Ukraine Crisis! Mali Air Crash! Taiwan Crash Details! Each one another death toll. But why now? Why are all these planes crashing around us?

Here’s the thing: The pace of the crashes right now is shocking. But looking at 2014 as a whole, the numbers aren’t extreme. It will be some time before we can sensibly think about long-term trends or whether 2014 itself was a bad year.

I’m reading (and writing) about crashes all the time. Terrible crashes, pointless crashes, crashes where everyone on board died. The difference is not that flying is a lot more dangerous than we thought it was. The difference is Malaysia Airlines flight 370.

The disappearance of Malaysia Airlines flight 370 gripped the world, and rightly so. It’s been over four months and we still have no answers. We simply have no idea what happened that day. CNN covered the search and investigation 24×7 in the weeks following the investigation and I still regularly get asked as to my opinion on the crash as a conversation starter when I mention that I write about aviation. It’s a high-profile, horrendous case and worse, completely unsolved.

In May, coverage tailed off a little bit but every scrap of news still made the front page. In June, details of the Australian search parties were the only news that offered any insight into this unbelievable mystery. It seems incredible that an aircraft could just disappear like that. It is incredible and I find it hard to accept that we might never know what happened.

Last week, the first thing I heard about MH17 was that Malaysia Airlines had “lost contact with another plane”. I’ll tell the truth: my stomach lurched. My thoughts were barely coherent: my god, it really is a plot, there’s someone stealing planes, who would do this, how are they doing this, what the hell is happening?. However, it almost immediately became clear that the aircraft was not “lost” in the sense of an aircraft flying without radar contact and other communications. As the horrifying truth came out, it also became obvious that the fact that it was Malaysia Airlines was a horrific coincidence: it could have been any one of a number of different airliners in the area at that time.

The silence from TransAsia Airways flight 222, a domestic flight, was immediately identifiable as a crash however, news reports refer to the control tower losing contact with the aircraft. And then yesterday, I was inundated with reports of an aircraft that was lost: disappeared off radar, no communications. Of course, Air Algérie flight 501was lost, as it had possibly broken up in the air and certainly crashed with no survivors. But I was struck in both instances by the media focus on the loss of contact, almost as if the aircraft were possibly still out there and flying. And I was intrigued by the press coverage: quite frankly a lot more than I would expect for foreign aircraft disasters.

I put together some figures to try to get a handle on whether the number of accidents this year (as opposed to this week) was typical or if we are seeing a spike in air crash disasters.

I started by going through the Aviation Safety Network’s database and analysed through the occurrences per year, that is, including all aviation accidents and incidents that were reported. There have been a total of 85 occurrences so far in 2014 so I looked at the previous four years to see if this was unexpectedly high. I also checked the information for 1994 just for a quick comparison: over the same time period, there were 115 occurrences in 1994, by far the most per year. 1984, in comparison, dropped to 90 – still more than 2014 for the same time period but well within recent averages.

The result shows that 2014 is not (yet) a particularly bad year for aviation issues. But the numbers above include all kinds of incidents, whereas what we’ve been seeing this year are fatal air craft disasters. So I decided to focus on fatalities. Aviation Safety Network have a list of the worst 100 accidents which they have ranked based on the number of fatalities. Of the fatal accidents in 2014, only two made the list: the loss of MH17 over Ukraine with 298 fatalities and Malaysia Airlines flight 370 with 239 fatalities.

I half-expected to see that the worst crashes were recent as aviation becomes more of a mass transit option: we’re squeezing in more passengers per square metre than ever before and planes are getting bigger. But actually, the worst accidents broken down by year is trending downwards (see the dotted line).

Finally, I looked at the Aviation Safety Network fatality rates. Here’s where we can see a worrying trend. In 2014 so far, there have been twelve accidents with a total of 761 fatalities. Over a ten-year period, Aviation Safety Network reports an average 17 accidents with 376 fatalities between January and July. The average for the full twelve months over the last ten years is 676 fatalities, so we can see that we’ve already bypassed the annual average for fatalities… and 2014 still has another five months to go. Based on these figures, fewer planes are crashing but there are more fatalities. That’s not hard to analyse. This is a direct result of the two Malaysia Airlines disasters both of which individually count among the 100 highest fatalities ever. Those two flights account for 537 fatalities between them, just over 70% of the 761 fatalities for the year. The two most recent crashes this week would not have caused a blip on these stats.

That’s not to say that the past seven days haven’t been an extremely bad week for aviation, nor to imply that some crashes and loss of life are more serious than others. But the big reason that I think flying suddenly seems so dangerous is that the recent two crashes were reported as international news and in other years, they wouldn’t have been.

I would expect to talk about these crashes at an airfield or on an aviation forum. I would certainly read up on them myself and consider whether to analyse them for the Why Planes Crash series. There are hundreds of aviation accidents every year that I don’t write about, which was part of the point of Why Planes Crash. It gives me the opportunity to cover interesting aviation accidents which didn’t involve a large number of fatalities and/or happened in foreign countries and/or didn’t have someone famous on board. These accidents are under-represented on the aircraft disaster television shows and even on Wikipedia, with the result that most people have never even heard of them.

In the West, we tend to talk about 9/11 as the tragic accident that changed aviation security forever. However, in China, the date that connects to aviation history happened half a year later on the 7th of May 2002. The events of that day, now simply referred to as 5.7, changed airport security for ever. And yet, outside of aviation communities, that flight number and date are rarely recognised as important.

The point is that I wouldn’t expect to see these week’s crashes, as tragic as they may be, on the front page of newspapers around the world.

Now, obviously I’m heavily in favour of aviation being covered in the mainstream news. And the media supply the news that people are interested in; I’m certainly not trying to imply some kind of media conspiracy. But what scares me is the comments: aviation is getting more dangerous, so many planes have crashed this year, I’m never flying again, something is going horrifyingly wrong.

And I think it comes down to this: this year, the most unbelievable aviation disaster happened: we lost a commercial aircraft, a Boeing 777 with 239 souls on board, and we don’t know what happened to it nor where it went. The idea of losing contact with an aircraft has become an emotional trigger and so now these crashes — devastating to the survivors of those poor souls but not usually at the centre of attention — attract our immediate attention.

The phrase “contact was lost” has become an emotional trigger. The crashes this week are front page news because the entire idea that we could lose an airliner is in our conciousness and on our minds. These sad crashes are isolated events in the aviation community. They all have different causes. They are tragic, of course they are, but they aren’t a sign of the apocalypse.

If I could talk to everyone reading these articles and feeling full of fear, I would take their hands and say just this: Flying isn’t more dangerous this year than it was last year. You’re just paying more attention.

18 July 2014

The Information So Far: Malaysia Airlines flight 17

Malaysia Airlines flight 17 was a passenger jet en route from Amsterdam to Kuala Lumpur. The aircraft was a B777-200ER, registration 9M-MRD, manufactured in July 1997 and with a total of 75,322 hours. In a sad coincidence, the first flight of the aircraft was 17 July 1997.

There were 283 passengers (including three infants) and fifteen Malaysian crew members.

MH17 departed normally from Amsterdam at 10:14 UTC (just past noon local time) and was due to arrive at Kuala Lumpur International Airport at 22:00 UTC. The expected flight time was 11 hours 45 minutes.

The planned route for the flight took the aircraft directly over the Ukraine and Russia. The flight plan requested a cruising altitude of 35,000 feet but when MH17 entered Ukrainian airspace, they were given an altitude of 33,000 feet.

At 14:15 UTC, four hours into the flight, Ukrainian Air Traffic Control lost contact with the flight. At the moment of lost contact, the Boeing 777 was 30 km (20 miles) from the TAMAK waypoint, which is about 50 km (30 miles) from the Russian-Ukraine border. There was no distress call.

The aircraft wreckage was scattered over a two kilometre area at the village of Hrabove near the Russian border. The state of the wreckage made it clear that it had broken up before impact with the ground. The news was quickly released: the commercial aircraft full of civilians had been shot down.

Two key questions arose very quickly: Why was an aircraft flying over a war zone and who shot it down?

The conflict between Russia and Ukraine has become focused on the question of the Ukraine entering trade agreements with the EU rather than maintaining closer ties with Russia. In November 2013 the then-president of the Ukraine rejected a much anticipated EU economic proposal which was criticised as setting up Ukraine for long-term economic disaster by taking away the Russian export market whilst tying it to markets from which it can only import. Instead, the then-president accepted a new deal from Russia offering $15 billion in aid and other economic benefits. The conflict reached a crisis point in February when Ukraine ousted their pro-Russian president and the new government refocused on a closer relationship with the European Union. Russia argued that a relatively small group of anti-Russian extremists in Ukraine had staged the coup and that they were a threat to the Russian-speaking people who live in Eastern Ukraine and Crimea.

In March, the Russians took control of Crimea. However, Ukrainian government continues to claim Crimea as a part of Ukraine. As a result, airline operators and aircraft were recommended to avoid the area over Crimea, the Black Sea and the Sea of Asov. This was, however, not because of fears that civilian aircraft would be shot down but because there were two different services (Russian and Ukrainian) both managing the airspace at the same time.

Europe safety agency urges airlines to avoid Crimean airspace | Reuters

“It is unsafe if more than one Air Traffic Service provider is in charge of one single Flight Information Region (FIR); no compromise can be made with the safety of the flying passengers,” Patrick Ky, executive director at EASA, said.

Eurocontrol, the European air traffic management agency, said it strongly advised carriers against flying through the region, known as Simferopol FIR, and published a map of alternative routes.

The US and the UK both released a Notice To AirMen (NOTAM) advising that this area be avoided, but the area specified was south of the crash site.

In the aftermath, many airlines announced that they had previously taken the decision to reroute to avoid flying over the conflict zone. FlightRadar24, however, have pointed out that their logs show that some of these airlines were in fact still routing over Ukraine in the days previous. Many airlines certainly continued to route over the 32,000 foot no-fly zone. The most frequent flyers over Donetsk last week were Aeroflot (86 flights), Singapore Airlines (75), Ukraine International Airlines (62), Lufthansa (56) and Malaysia Airlines (48).

On the 14th of July, a new NOTAM was issued which covered the Dnipropetrovsk region. This NOTAM did include the airspace over Eastern Ukraine but only up to FL320, that is to say, the airspace up to a flight level of 32,000 feet. This was apparently in response to a Ukrainian cargo plane which was shot down at 21,000 feet.

The airspace over 33,000 feet was not controlled and was not closed. Malaysia Airlines have come under fire for routing over a war zone but have countered that the flight plan was approved by Eurcontrol, who are responsible for determining civil aircraft flight paths over European airspace.

In April, the International Civil Aviation Organization identified an area over the Crimean peninsula as risky. At no point did MH17 fly into, or request to fly into, this area. At all times, MH17 was in airspace approved by the ICAO.

Eurocontrol’s response is quite clear:

According to our information, the aircraft was flying at Flight Level 330 (approximately 10,000 metres/33,000 feet) when it disappeared from the radar. This route had been closed by the Ukrainian authorities from ground to flight level 320 but was open at the level at which the aircraft was flying.
Since the crash, the Ukrainian authorities have informed EUROCONTROL of the closure of routes from the ground to unlimited in Eastern Ukraine (Dnipropetrovsk Flight Information Region). All flight plans that are filed using these routes are now being rejected by EUROCONTROL. The routes will remain closed until further notice.

On that day, a number of commercial aircraft flew over the area, including Aeroflot, Air India, Lufthansa, Singapore Airlines and Virgin Atlantic and of course, Malaysian Airlines MH17.
The New York Times reported that the missile was detected by military satellite.

Jetliner Explodes Over Ukraine; Struck by Missile, Officials Say – NYTimes.com

GRABOVO, Ukraine — A Malaysia Airlines Boeing 777 with 298 people aboard exploded, crashed and burned on a flowered wheat field Thursday in a part of eastern Ukraine controlled by pro-Russia separatists, blown out of the sky at 33,000 feet by what Ukrainian and American officials described as a Russian-made antiaircraft missile.

Ukraine accused the separatists of carrying out what it called a terrorist attack. American intelligence and military officials said the plane had been destroyed by a Russian SA-series missile, based on surveillance satellite data that showed the final trajectory and impact of the missile but not its point of origin.

The Ukraine’s Interior Ministry specifically stated that MH17 was hit by a Surface-to-Air Missile (SAM), specifically the SA-11 Buk missile system. The Soviet-designed Buk missile launcher has a maximum range of 13 nautical miles and can fire up to a ceiling of 39,400 feet, so the Malaysian Boeing 777 was easily in range of it — and still would have been if they’d been given their requested altitude of 35,000 feet. It has a radar guidance system and a 70 kilogram warhead. Both Russian and Ukrainian forces have these high-end missile systems.

At this stage, it seems very likely that the aircraft was shot down by a power SAM but no one has taken responsibility for the shot. Ukrainian President Petro Poroshenko claim that the separatists carried out the attack with Russian support. Russian President Vladimir Putin did not make any statement on who shot the missile, focusing instead on the political aspect. “The state over whose territory this occurred bears responsibility for this awful tragedy.”

Up until now, the pro-Russia separatists in the Ukraine were known to have portable surface-to-air missiles but there was not any hard information that they had access to high-end missile systems with that high of a range. However, on Twitter there was apparently a photograph posted by separatists, now deleted, showed a photograph of a Buk missile system. In addition, Associated Press journalists stated that they saw what looked like a Buk missile launcher in Snizhne, an eastern town which is held by the separatists. It is possible that they captured a Ukrainian Buk missile launcher or that they were supplied the technology by the Russians along with the training of how to use it.

There was also the question of a post on a social networking service by a military commander of the rebels, in which he ported that the rebels had shot down an aircraft at approximately the same time as MH17 disappeared, in the same area. The post was deleted shortly after the news of the MH17 crash was released, however it is still visible on the Wayback Machine (an Internet archive) and can be translated using online services such as Google Translate: Wall | VK. The poster appears to have believed that the aircraft was a Ukrainian military cargo plane and stated, “We did warn you – do not fly in our sky.”

Meanwhile, the Ukrainian authorities released recordings of phone conversations which they claim are between the separatists and Russian military officedrs. The BBC has published the recordings of the three phone calls with translations.

BBC News – MH17 crash: Ukraine releases alleged intercepts

Malaysia Airlines appear to have learned a lot about crisis management this year and have released information as information has become confirmed but without the missteps seen after the loss of Malaysia Airlines flight 370.

As of this posting, the US has stated that the SAM missile was fired from an area controlled by the Russian-separatists in eastern Ukraine. The US and UK aviation authorities are deploying teams to Ukraine to assist in the investigation. I’m sure more news will be released over the next few days.

The tragic human loss can get side-lined in such a crash, especially with the political issues and the question of blame. I am heartsick but glad to see that the BBC has made an effort to tell the stories of some of those who were lost on the flight.

BBC News – MH17 crash: Passengers on Malaysia Airlines plane in Ukraine

Cor Pan joked on Facebook about his plane disappearing shortly before it took off…

Yuli Hastini and John Paulisen and their two young children were on their way to pay their respects at Yuli’s mother’s grave…

Australian teacher Francesca Davison and her husband Liam were returning home from a holiday in Europe…

Glenn Thomas, a former journalist and WHO media relations coordinator, was travelling to the Aids conference…

Flight Attendant Nur Shazana Mohd Salleh was a happy person who had a feeling this month was special…

This, and the photographs of the luggage and personal items strewn on the fields, are heartbreaking. This is not just about politics and warfare, it’s about people.

11 July 2014

Near Miss at Barcelona

Last week, a plane spotter named Miguel Angel was filming flights coming into Barcelona airport when he captured this video:

Five days later, that video has had over 20 million views.

The aircraft on the taxi-way is Aerolíneas Argentinas flight AR-1163, an Airbus A340 which was departing Barcelona for a flight to Buenos Aires, Argentina.

Coming into land was UTair flight UT5187, a Boeing 767-300 inbound to Barcelona from Moscow.

It is hard to see from the video just how close the two aircraft were to each other but it is clear that the Aerolíneas Argentinas flight is entering the active runway much too late for a safe crossing. The UTair was on short final and descended through to about 200 feet above ground level when the flight crew initiated a go-around.

The distance from the runway threshold (where the UTair Boeing would have touched down) and the taxiway Mike intersection (where the Argentinas Airbus was crossing) was 1,166 meters (3,826 feet).

Initial reports said that the Argentinas flight had been told to hold at the active runway and then crossed anyway. In fact, the UTair flight crew specifically said that they heard air traffic control instruct the Argentinas Airbus to wait for the UTair aircraft to land before crossing the order. Siberian Times quoted First Officer Kirill Kuzmin:

‘Before getting close to the runway we heard the air traffic controller’s command allowing Argentinians to cross the runway after we had landed.

‘The Argentinians repeated the comment which meant that they heard and accepted it.

‘But then suddenly – and without a clear reason – the Argentinians got onto the runway just as our altitude was going below 100 metres.’

AENA (Aeropuertos Españoles y Navegación Aérea) who operate the airport and the air traffic control at Barcelona, initially stated that there was sufficient separation and that UTair could have continued the landing without issue.

However at less than 20 seconds from touchdown and apparently about 40 seconds laterally from the Argentinas Airbus, it seems pretty obvious that aborting the landing was the only sane decision.

AENA stated that no safety report was filed and that both aircraft were where they should have been. A go-around doesn’t necessarily rate a safety report. At London Heathrow in 2010, there were 551 go-arounds, 0.24% of the total arrivals, often because the previously landing aircraft has not vacated the runway in the expected time.

The following day, CIAIAC (Comisión de Investigación de Accidentes e Incidentes de Aviación Civil), Spain’s aviation authority, announced that an investigation into the occurrence had been opened. The provisional information is on their website.

AENA’s statement that both aircraft were where they should be implies that UTair was cleared for landing and Argentinas were cleared to cross the active runway. A look at the Barcelona chart shows that the route that the Argentinas Airbus was taking would lead it to cross Runway 02 three times in order to get to Runway 25R.

An unverified account of the sequence of events has been posted to aviation forums and is supposedly an explanation as given by a Barcelona air traffic controller.

Airport was about to change from night configuration to day configuration. At night, runway 02 is used for landing and 07R for take-off, while during the day 25L becomes the take-off runway and 25R is used for landing (unless winds favor runways 07L/R).

Two of the three ground Air Traffic Controllers work in a smaller Tower located near the main Terminal (frequencies 121.65 and 122.225) while the other ground frequency (121.7), delivery and the two tower frequencies (118.1 and 119.1) are located in the main Tower. 121.65 (122.225 not used at night) cleared the Aerolineas Argentinas A340 to cross runway 02, which he thought was not active as he expected the airport to be in day configuration. Meanwhile, the UT Air Boeing 767 was cleared to land on the same runway by Tower (118.1).

Crossing the active runway usually requires some coordination between the two towers but this is not necessary in night configuration.

That is, this poster believes that the air traffic controller who cleared the Argentinas Airbus thought that Runway 02 was already inactive and thus didn’t need Tower clearance to cross. It’s certainly the case that Runway 02 is generally inactive during the day and thus can be crossed by the various taxi-ways without aircraft needing to hold. At night, specifically from 23:00 to 07:00 local time, Barcelona prefers to use Runway 02 for noise abatement reasons. The UTair flight landed 15 minutes after the go-around, at 07:06 local time.

Under normal circumstances, an aircraft would always speak to the tower before crossing an active runway, as Tower is responsible for coordinating the landing and departing traffic. Having listened to the Tower frequency at LiveATC, UTAir flight 5187 is clearly on the channel (and told clear to land) but Argentinas flight 1163 is not.

So the anonymous posting sounds feasible, although we will need to wait for a final report from the Spanish aviation authority to find out exactly what happened.

04 July 2014

Reconsidering the Cause of TWA Flight 800

TWA flight 800, a Boeing 747 that exploded shortly after take-off, was one of the most expensive investigations ever.

On the 17th of July in 1996, TWA flight 800 had just departed New York for a scheduled passenger flight to Paris when tragedy struck.

The moments before the crash were recovered from the cockpit voice recorder. The air traffic controller asked the pilots to maintain FL130 (13,000 feet). The Captain said, “Look at that crazy fuel flow indicator there on number four … see that?” The air traffic controller then cleared the flight to climb to and maintain FL150 (15,000 feet). A crew member selected climb thrust and a loud sound was recorded before the CVR stopped.

Forty seconds later, the captain of a Boeing 737 reported that he had just seen an explosion up ahead.

The aircraft had disintegrated fourteen minutes into the flight at 13,800 feet. The wreckage crashed into the sea off the coast of Long Island.

Initially, it was believed that the aircraft was the target of a terrorist attack which meant that there was both an FBI investigation and an NTSB investigation. There were 19 teams in the NTSB investigation, making it the largest air-crash investigation in U.S. history.

The debris was scattered across 150 square miles of ocean. US Navy salvage divers retrieved hundreds of thousands of aircraft fragments and the wreckage recovery alone took nine months. Despite the difficulties, 95% of the aircraft and its contents were salvaged from the ocean, including pieces as small as a coin. Investigators were now faced with a the incredible task of assembling these fragments into the original fuselage, a monumentally difficult but critically important jigsaw puzzle.

It was this reconstruction and the detailed analysis that led to the eventual investigation conclusion, as it showed that investigators needed to focus on the centre of the aircraft, especially the centre fuel tank. This small section of the aircraft had broken into 700 pieces and these fragments, as well as the locations where they been found, pointed towards an explosion inside the tank. The locations where the pieces of the aircraft had been found bore out this conclusion: the centre section was found closest to the flight path as the fuel tank and the area around it disintegrated. The nose then fell into the ocean while the rear half of the aircraft with the wings continued forward with the momentum of the flight.

The key question then was how it happened, as fuel-tanks don’t normally explode. The NTSB asked for help from Caltech’s explosion-dynamics lab to investigate this.

Now, in order to have a flame, you’ve got to have three things. One, you need fuel—in this case, the little bit of aviation-grade kerosene, called Jet A, that was left over when the flight arrived at JFK from Athens. The 747 is a marvelous airplane that can fly all the way from New York to Paris, with just the fuel in its wings. Airliners don’t like to carry around extra fuel, which is weight that could be used for more passengers, so they didn’t refill the center tank when they refueled at JFK. Two, you’ve got to have air. Well, the tank was full of air, except for about 50 gallons of kerosene lying on the floor of this 13,000 gallon tank—a layer maybe three-sixteenths of an inch deep. And three, you need some source of ignition.

But to get an explosion, you need fuel vapor. If you set liquid fuel on fire, you’ll just get a puddle of burning fuel. This is not something you want in an aircraft, but it’s not going to cause an explosion. So how do we get vaporized fuel? Well, July 17 was a hot day, and there’s a set of air-conditioning units that sit underneath the tank. As the air conditioners run, the heat from the machinery could have seeped upward and heated the fuel, causing some of it to evaporate. So now we have fuel vapor and air, and if we have ignition, we can possibly have an explosion.

Learning from a Tragedy: Explosions and Flight 800—Engineering & Science no. 2 1998

Caltech did research tests that showed that at 13,800 feet, with the dropping air pressure increasing the amount of vapour in the tank, the amount of energy needed to ignite the Jet A fuel was much less and that the temperature itself would rise more quickly in an almost empty tank. This meant that a very small spark would be enough to ignite the fuel tank. The next mystery was what had caused the spark. The cockpit voice recorder showed two “dropouts of background power harmonics” in the second before the recording ended, which were consistent with an arc on cockpit wiring. This, in combination with the Captain’s comment on the “crazy readings”, mean that a short circuit from damaged wiring was extremely likely. The Fuel Quantity Indication System is in the tank and although the voltages and currents used by the system are kept very low, the wiring is located within the centre tank.

Four years after the accident, the most extensive NTSB investigation ever held in the US was concluded with a final report in August, 2000. The report stated that the most likely cause of the explosion was a short circuit involving the Fuel Quantity Indication System which allowed a very small electrical spark to ignite the fuel in the centre tank. The low amount of fuel in the tank and the low air pressure affected the vapour-to-air ratio in the tank and the temperature of the tank was provably higher than expected as a result of the air conditioning and again the lack of fuel in the tank to soak up the heat. After years of costly investigation, they concluded that the flammable fuel vapours ignited and exploded, taking TWA flight 800 with it.

But the documentary group TWA 800 Project think that they are wrong.

In 2013, TWA 800 Project launched a website and documentary to argue that that the official investigation had been handled incorrectly seventeen years before.

According to the website, an investigator on the case was extremely unhappy with the investigation. He attempted to report this to his superiors, but was threatened with being kicked off the investigation and worse. The website says that the whistleblowers from the NTSB, TWA and the Air Line Pilots Association who submitted evidence for the documentary could not come forward until they had retired and were able to avoid retaliation.

In “TWA Flight 800” whistleblower and senior aviation accident investigator at the time Hank Hughes talks about bringing serious problems with the investigation to the attention of then-Investigator in Charge, Mr. Al Dickinson of the NTSB, with no results. Finally, on May 10, 1999 Hank Hughes, under whistleblower protection, appeared before a senate judiciary committee to detail a long list of serious problems with the TWA Flight 800 investigation, including informing the committee that “chemical swabbing wasn’t done on an ongoing basis,…ERT [Evidence Recovery Team (FBI)] qualification in basic forensics [was] very limited.” Hughes also informed the Senate of an incident where he caught an FBI agent hammering on a piece of wreckage in an attempt to flatten it.

The petition was submitted amidst the publicity of the documentary and alleges that TWA Flight 800 was shot down by a proximity fused missile, a possibility they claim was not considered by the NTSB in their investigation.

Where an accident warrants an investigation and report, the NTSB is mandated to offer detailed narrative accident report, which includes the facts, conditions and circumstances of the accident as well as probable cause and appropriate recommendations.

A petition for reconsideration or modification of the NTSB’s findings, especially when it comes to the probable cause, can be filed by a party to the investigation or a person with a direct interest. The petition must be based on new evidence or be able to show that the Board’s findings were not correct.

The petition claims that new analyses and evidence demonstrate that a detonation or high-velocity explosion caused the crash.

The new evidence put forward included:

  • Two new analyses of FAA radar data
  • Twenty FBI eyewitness interview summaries apparently not previously available
  • Analysis of “spike-tooth” fractures found in multiple locations
  • Evidence of explosive residue

The petitioners claim that the radar evidence shows that there was a powerful and sideways projected explosion which occurred simultaneously with the loss of electrical power, which is not accounted for in the NTSB analysis. The petitioners also claim that the witness statements describe a firework or streak of light which they believe is more consistent with a high-velocity explosion, rather than the low-velocity fuel-air explosion that the NTSB determined.

The primary interest here is of course that a senior investigator on the case is a part of the petition to re-open the investigation. Hank Hughes was assigned as the Survival Factors Specialist on the NTSB’s Go-Team responding to the crash.

He claims that the investigation was “egregiously conducted” because of the FBI involvement. The FBI took control of the investigation at the start because based on eyewitness accounts, they believed that the aircraft may have been shot down by a missile strike: intriguingly exactly what the petition is trying to prove.

The NTSB allowed the FBI to virtually commandeer the NTSB’s investigation, permitting the FBI to determine who would and who would not have access to the evidence. As a result, from the beginning of the wreckage/evidence recovery effort, the FBI, an agency with virtually no aviation accident investigation expertise, with an Evidence Recovery Team so inexperienced that I was asked to give them a crash course on the subject several weeks into the investigation, had virtually complete control of the critical initial evidence handling phase, even to the point of refusing NTSB investigators access to key wreckage and other hard evidence. The FBI, critically, also refused to allow NTSB investigators to interview eyewitnesses for months after the crash. FBI interviews and recording methods were, per the NTSB’s standards, neither thorough nor reliable.

The cost to the investigation in terms of preserving evidence and getting thorough eyewitness accounts was incalculable. From the beginning to the end of the FBI’s participation in the Flight 800 investigation, the NTSB consistently violated previously mentioned regulations pertaining to continuing its own investigation according to normal NTSB procedures and working with the FBI to ensure that “evidence of the criminal act” was properly preserved.

It’s difficult to understand how the FBI’s interference in trying to prove a criminal act directly led to the investigation concluding — according to Hank Hughes, wrongly — that no criminal act occurred.

The NTSB assembled a team of investigators not previously associated with the original investigation to consider the petition. This week, the NTSB put forward an official response as a result of this investigation.

They determined that the petition advanced two claims which the NTSB could consider under to reopen the case. One was the radar evidence, which the NTSB says included no new data but simply a different analysis focused on the petitioners’ alternative explanation of the crash.

The petitioners apply various calculations to primary radar returns recorded by one facility after the time of the explosion. However, they overestimated the accuracy with which the radar could determine the position of the airborne object.

As a result, they tried to make calculations of speed and distance that were not meaningful, and the conclusions they drew were unsupported.

In addition, the NTSB notes that no radar data from any site showed an object, such as a missile, traveling toward or intercepting the airplane’s track.

The second was the twenty witness summaries obtained from the FBI, which the NTSB treated as new evidence. Project TWA 800 claimed that the summaries did not match the conclusions drawn by the NTSB in their final report and that the NTSB must revise finding 8 in the report which stated that the streaks of light which witnesses reported seeing were not related to a missile. The NTSB considered the witness summaries but stated that they contained no new unique vantage points nor information.

Of the 20 summaries, 8 include mention of a light ascending in the sky, and 3 of those 8 indicated that the light came from the ground, horizon, or ocean (5 of the 8 did not provide a point of origin). The NTSB’s final report discusses statements from 736 witnesses, 258 of whom saw a streak of light. Of those 258 witnesses, 25 indicated that the streak of light originated from the surface or the horizon. When the 20 new summaries (8 of which described a streak of light ascending, 3 of those 8 described a surface or horizon point of origin) are considered as new, unique witnesses, the percentage of witnesses who saw a streak becomes 35.2 percent (originally 35 percent) and the percentage who saw the streak originate at the surface or horizon becomes 10.5 percent (originally 9.7 percent).

As a result of their investigation, yesterday the NTSB officially denied the petition for reconsideration in its entirety.

The original investigation looked for evidence of fragments from a missile warhead and found none. Further, the damage patterns within the airplane were consistent with a center wing tank explosion. Lastly, the distribution of debris was also consistent with an in-flight breakup started by a fuel-air explosion within the center wing tank.

Ultimately, the petitioners did not show that the NTSB’s conclusion or determination of probable cause were wrong.

You can read the entire response from the NTSB here: Response to Petition for Reconsideration.

It’s difficult for me to understand why the FBI and the NTSB would enter a conspiracy to cover up the very theory that the FBI set out to prove from the onset. Having read through the Project TWA 800 website as well as the NTSB TWA 800 website, I’m inclined to believe that the most expensive investigation of its time was focused on determining the truth, although some (most?) of them believed from the start that it was a criminal act. After four years, the investigation discovered the truth, which was more convoluted and complicated than the simplistic terrorist theory. It’s hardly surprising that some of those involved with the investigation at the time are still disappointed that they were wrong.