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27 February 2015

Pretty Crazy Actually: Debunking the Latest MH370 Solution

So all week, people have been forwarding me Jeff Wise’s piece from New York Magazine in which he comes up with a “new” theory that explains everything about why we can’t find Malaysia Airlines flight 370.

How Crazy Am I to Think I Know Where MH370 Is? — NYMag

Obviously, I immediately read it with interest. Even excitement. As soon as I got to his theory, my mood changed to dismay.

The first section is about his own experience, so I’m happy to accept all that as truthful and based on his perception. I particularly liked the reference to Believers: people who had already chosen a single theory as true and wanted to convince the world. I had the same experience after I published The Mystery of Malaysia Airlines flight 370, where readers would mail me (or review me) complaining that the book was a waste of time because it didn’t deal properly with the only explanation that made sense. I didn’t mind if that was a theory I hadn’t covered, that’s fair enough. But in most cases, I had discussed the theory: the reader was just upset that I hadn’t proved it as true.

This is also an interesting section of Wise’s article because in it, he effectively establishes his credentials as understanding the various theories and ability to recognise a crackpot. This sets up legitimacy for the second half. He certainly had my sympathy by this time. It helped that I’d read his blog before and found him interesting and knowledgeable.

But once he started putting forward the pieces of his theory, it fell apart.

For a long time, I resisted even considering the possibility that someone might have tampered with the data. That would require an almost inconceivably sophisticated hijack operation, one so complicated and technically demanding that it would almost certainly need state-level backing. This was true conspiracy-theory material.

For the record, I agree with this. That’s not to say it is impossible, but there are easier ways to achieve the same results. Generally, the path of least resistance is the way to go. That doesn’t mean it didn’t happen and Wise says he found evidence, so lets run with it.

I realized that I already had a clue that hijackers had been in the E/E bay. Remember the satcom system disconnected and then rebooted three minutes after the plane left military radar behind.

Woah, no, wait! I don’t remember that at all. This refers to an earlier description in the text:

For about an hour after that, the plane was tracked on radar following a zigzag course and traveling fast. Then it disappeared from military radar. Three minutes later, the communications system logged back onto the satellite. This was a major revelation. It hadn’t stayed connected, as we’d always assumed. This event corresponded with the first satellite ping.

The first satellite ping is the only data we had once it disappeared from military radar. The communications system wasn’t logged onto the satellite before this and it didn’t log onto the satellite at that point. The system pinged the satellite and was refused [see comment below for more on this] because Malaysia airlines had not purchased the satellite service.

So Wise describes a three minute period between disappearing from military radar and the first ping to the satellite and suddenly this is rephrased as Remember the satcom system disconnected and then rebooted.

To be honest, it’s the phrasing that made me read more suspiciously. However it was just a sentence later when the whole theory derailed for me.

I spent a great deal of time trying to figure out how a person could physically turn the satcom off and on. The only way, apart from turning off half the entire electrical system, would be to go into the E/E bay and pull three particular circuit breakers. It is a maneuver that only a sophisticated operator would know how to execute, and the only reason I could think for wanting to do this was so that Inmarsat would find the records and misinterpret them. They turned on the satcom in order to provide a false trail of bread crumbs leading away from the plane’s true route.

Inmarsat had never released records like this before. No aircraft had ever been tracked like this before. The idea that it was even possible was a major revelation, even to Inmarsat. The data was never intended for tracking purposes.

MH370: Inmarsat details proposal for free flight-tracking – 5/12/2014 – Flight Global

“Now that we know we have these ‘pings’, why not make use of them?” says Inmarsat senior vice-president for external affairs Chris McLaughlin.

Wise seems to have forgotten this in his excitement. His inconceivably sophisticated hijack operation now is based on seeding false data in the form of pings on a satellite service that had not been paid for. What a crazy amount of effort this is on a hope and a prayer that someone would spot it, realise it was useful data and use it to lead the world in the wrong direction.

Once I threw out the troublesome BFO data, all the inexplicable coincidences and mismatched data went away. The answer became wonderfully simple. The plane must have gone north.

So if he throws away the data that no one expected us to have and accepts that the hijackers spoofed everything, then whatever theory he likes can be fit into the minimal information that remains. This is a mark of a Believer, without a doubt.

Using the BTO data set alone, I was able to chart the plane’s speed and general path, which happened to fall along national borders. Flying along borders, a military navigator told me, is a good way to avoid being spotted on radar.

Oh yes, definitely, borders are not at all important politically and most nations pay no attention to them whatsoever. Definitely not covered by military radar…no wait.

What military navigator would say such a thing? I mean, seriously, is this someone who disliked Wise? Of course borders are covered by radar; strategically this is a critical requirement of radar.

There aren’t a lot of places to land a plane as big as the 777, but, as luck would have it, I found one: a place just past the last handshake ring called Baikonur Cosmodrome.

If MH370 did land at Yubileyniy, it had 90 minutes to either hide or refuel and takeoff again before the sun rose. Hiding would be hard. This part of Kazakhstan is flat and treeless, and there are no large buildings nearby. The complex has been slowly crumbling for decades, with satellite images taken years apart showing little change, until, in October, 2013, a disused six-story building began to be dismantled. Next to it appeared a rectangle of bulldozed dirt with a trench at one end.

This implies it is some sort of abandoned airfield in the middle of nowhere. He then goes on to show satellite images that show a building being dismantled in October 2013 and a rectangle of bulldozed dirt. He drew in the silhouette of a 777 to show that it is the perfect size.

Perfect size if you don’t mind the wings touching the walls, I guess?

By March 2014, he says, the building was gone.

Construction experts told me these images most likely show site remediation: taking apart a building and burying the debris. Yet why, after decades, did the Russians suddenly need to clear this one lonely spot, in the heart of a frigid winter, finishing just before MH370 disappeared?

Let’s get this absolutely clear: Baikonur Cosmodrome is not abandoned. It is the largest operational space launch facility in the world. There are commercial, military and scientific missions launched from the site. It is the sole launch site for International Space Station missions. Inmarsat launched a spacecraft there just a few weeks ago.

Not a lonely spot. Full of scientists and foreigners and even Inmarsat employees. Are they all in on this?

To the best of my knowledge, this airstrip is the only one in the world built specifically for self-landing airplanes. The 777, which was developed in the ’90s, has the ability to autoland.

He’s talking about CATIII. This is a category of ILS equipment which allows for auto landing.

I’m not sure what he means by the only airstrip in the world built specifically for self-landing aircraft nor why that would make a difference. Either the airstrip supports CATIII or it doesn’t.

Most modern city airports support CATIII and thus allow for self-landing aircraft. Most modern aircraft have the ability to autoland. Baikonur is not special in this respect and the use of “only one in the world” is misleading.

The point of CATIII is to make it possible to land in visibility too poor for a visual landing. Normally, your commercial pilot, flying in bad weather, has to have the runway in sight at a predefined height or else he has to break off the approach. This is known as the decision height.

To autoland, the aircraft knows precisely the aircraft’s height above the ground and initiates the landing flare at the correct height for the model, usually about 15 metres (50 feet) above the ground. This means there is no decision height: the runway never has to be in sight.

From a hijacking perspective, this feature allows people who don’t have commercial-piloting experience to abscond with an airplane and get it safely on the ground, so long as they know what autopilot settings to input.

Well, yes, with a bit of luck and perfect conditions, this might work. The absconder would still need to reduce the speed as the flaps are are selected and manually activate reverse thrust, at least, but it would be easier to teach a person to autoland than to fly the Boeing 777.

I know I sound a bit grudging there. Quite honestly, by this point, it feels weird when Wise says something logical and factually correct.

Whether the plane went to Baikonur or elsewhere in Kazakhstan, my suspicion fell on Russia.

Again, the phrasing here is a logical fallacy: he’s put forward a failed case for Baikonar and then dismisses objections with the assumption that it has gone to Kazakhstan, which he has never shown based on the data he has chosen to accept as correct.

He defends his suspicion of the Russians with a headline that the Russians were responsible for the deteriorating situation in Ukraine. Then Wise points out that there were three suspects on board who match his profile: one Russian and two Ukrainians. He suspects all three of being special forces or covert operatives.

All were in their mid-40s, old enough to be experienced, young enough for vigorous action —about the same age as the military-intelligence officer who was running the show in eastern Ukraine.

Convinced yet? Me neither.

He hired Russian speakers to make phone calls to Odessa and Irkutsk to find out more about the men. Not surprisingly, their families weren’t interested in discussing his theory. Nevertheless, he says that the more he discovered, the more coherent the story seemed, as if the existence of 40-something “ethnically Russian” men somehow proved his point. His confidence is meant to lead the reader into nodding along knowingly even though he’s never actually justified his logic.

As if that all weren’t bad enough, he ends on a completely false note.

Last month, the Malaysian government declared that the aircraft is considered to have crashed and all those aboard are presumed dead. Malaysia’s transport minister told a local television station that a key factor in the decision was the fact that the search mission for the aircraft failed to achieve its objective.

Simply not true. The transport minister said no such thing and the declaration specifically says the opposite:

Read Full Statement in English

The underwater search is still ongoing at this time and the exercise is currently being performed by 4 vessels, namely the Go Phoenix, Fugro Discovery, Fugro Equator and Fugro Supporter. To date, the search has covered over 18,600 square kilometres (as of 28 Jan15).

The declaration defined the incident as an accident, which includes aircraft that have gone missing.

I’ll tell you a secret: I know what he misread. The declaration talks about the search and rescue mission in the past tense. That’s because there’s no one left to rescue. There are two points of detail to defend that the search and rescue is completed even though the search is still continuing, but I guess Wise never read that far.

He is clearly convinced that the search is over.

The search failed to deliver the airplane, but it has accomplished some other things: It occupied several thousand hours of worldwide airtime; it filled my wallet and then drained it; it torpedoed the idea that the application of rationality to plane disasters would inevitably yield ever-safer air travel. And it left behind a faint, lingering itch in the back of my mind, which I believe will quite likely never go away.

It’s a quick visit to the Australian Transport Safety Bureau to get the latest Operational Update. The search has not (yet) failed and, just last month, Search chief Martin Dolan spoke confidently about finding the wreckage.

I think Dolan be horrified to hear that his accomplishment was to have filled and drained Wise’s wallet. And honestly, the application of rationality has absolutely yielded ever-safer air travel. The effects to Wise’s mind I leave as an exercise for the reader.

I sure do understand his desire to sell his book. I want to sell mine, too. I have spent the last year discussing Malaysia Airlines flight 370 and wondering what happened to it, just like him. But coming up with hare-brained schemes and using persuasion tactics instead of facts, well, Wise is better than this.

If you are interested in thought experiments about what happened to Malaysia Airlines flight 370, then please consider my book, which takes the leading theories and considers their plausibility. I don’t have any simple answers but, quite frankly, neither does Wise, whatever he might claim.

[Edit: added reference to Bill's comment below to the main text]

20 February 2015

NTSB Open Docket of Bagram Cargo Crash Documents

The chilling video of a Boeing 747 crashing on take-off from Bagram Afghanistan meant that this tragic accident from April 2013 made headline news.

This is the dashcam video of the aircraft’s take off. Please note that it shows the actual impact and may be disturbing.

The Ministry of Transportation and Commercial Aviation in Afghanistan was joined by the American NTSB for the investigation.

The NTSB has now opened a docket on the crash, releasing factual information which forms the basis of the investigation. There is no analysis nor conclusion at this time; the final report has not yet been released. But the documents and photographs are enough to give us a heart-breaking picture of what happened that day.

The full set of files is available here: http://dms.ntsb.gov/pubdms/search/projList.cfm?ntsbnum=DCA13MA081

It’s hard not to draw conclusions from the information released so far. I’ve collected the key facts where they seem to help shed light on the cause.

The Boeing 747-400 registration N949CA was a converted cargo plane operated by National Airlines.

On the 29th of April in 2013, the cargo plane crashed shortly after take-off from Bagram Airfield in Afghanistan. All seven crew members onboard were killed and the aircraft was destroyed.

Bagram Airfield is the largest US Military base in Afghanistan. It is run by US Armed Forces but also occupied by the International Security Assistance Force (ISAF) and the Afghan Armed Forces.

The airfield was built in the 1950s and played a key role for the US during the Cold War and then in the Soviet war in Afghanistan. In 2007, Bagram Airfield was described as the size of a small town having over 40,000 inhabitants, with traffic jams, commercial shops and dual runway operations.

The original flight schedule was for the Boeing 747 to fly from Chateauroux, France to Camp Bastion, Afghanistan and then continue to the Dubai World Center at Al Aktoum, UAE airport. However, National Airlines couldn’t obtain clearance to overfly Pakistan for the flight departing Camp Bastion to Dubai. The dispatcher instead planned for the flight to fly to Bagram, refuel, and continue from there to Dubai.

The aircraft was held up en route to Camp Bastion as a result of indirect fire at the airport from the Taliban. The load manifest shows that the plane was loaded by National Air Cargo. National Airlines transported the cargo but National Air Cargo was responsible for the load planning, cargo/pallet build up and aircraft loading. The Boeing 747 was loaded with 94,119 kgs of cargo, including 5 Mine Resistant Ambush Protected (MRAP) armoured military vehicles on the main deck. National Air Cargo ground crew told the NTSB investigators that the Dubai offices conducted classes on how to palletize a Stryker, a military vehicle which weighed about 12-13 tons.

Of the five mine resistant armoured vehicles loaded onto the Boeing 747, two were MRAP all-terrain vehicles weighing about 12 tons each. The other three were MRAP Cougars weighing about 18 tons each.

It was the first time that National Airlines had transported the 18-ton military vehicles.

More importantly, it was the first time that National Air Cargo had ever attempted to load an 18-ton Cougar on a National Airlines B747-400.

The National Air Cargo Operations Specialist who was in charge of the pallet build-up for the accident flight load told NTSB Staff he did not have an SOP (standard operating procedure) for any particular load, there was no specific manual that they followed when building the pallets, and he did not know the load capacity of a pallet.

He further said that the only manual he had for reference in Camp Bastion was a dangerous goods manual. National Air Cargo staff did not have a copy of the National Airlines Cargo Operations Manual in Camp Bastion, and did not have a computer to view any manuals online.

There were seven crew. Two captains and two first officers, along with two mechanics and one loadmaster. The aircraft had a rest facility on board, allowing the 747 to be flown with a double crew. The accident Captain was highly experienced and described as “excellent” in his training transcripts and “having great CRM” by crew who had flown with him. The accident First Officer was new to the aircraft but was considered to have strong skills, both monitoring and flying, and was described as very well prepared for the change to the B747-400.

The loadmaster had worked for National Airlines for two and a half years and had been a ground handling supervisor/trainer before that.

Neither the accident Captain nor his First Officer had prior experience carrying mine resistant armoured vehicles. Neither did the loadmaster: he had never worked a National Airlines flight with an MRAP as part of the cargo load before, not even the 12 ton version. No special guidance, strapping diagrams or photos were provided to him.

The Chief Loadmaster was asked if there was a conscious decision by National Airlines to approve the loading of the 18-ton Cougars. He told the NTSB that it was up to National Air Cargo (the company who took the order) and that as the operator the flight, they stuck to “you call, we haul”.

The five heavy military vehicles were loaded onto the Boeing 747 and the flight crew continued on their journey to Bagram Airfield.

It’s early on in the Operation Chairman’s Factual Report that the focus turns to the broken strap that the flight crew found in the cargo bay after they landed at Bagram Airfield.

According to recorded data, at about 0957 while the airplane was still on the ramp in Bagram, the captain was made aware of a broken strap found by one of the other crewmembers, and the cockpit crew had a discussion about a possible shift of the cargo load during landing in Bagram. There was additional discussion on re-securing the load prior to departure.

Here’s the transcript of that conversation.

09:57:33 First Officer There’s your trouble Brad.
09:57:35 Captain What is it? What the [expletive] was that from?
09:57:39 First Officer One of those [expletive] straps is busted
09:57:42 Second Captain [unintelligible] tire
09:57:44 Captain No no, I know that… [unintelligible] No I know, but…
09:57:45 First Officer Give you one guess what was right there.
09:57:49 Captain What was right where?
09:57:49 First Officer Right here.
09:57:50 Captain A knot?
09:57:51 First Officer Uh huh.
09:57:52 Captain That was the one right at the door?
09:57:54 First Officer No… This was at… [unintelligible]
09:57:56 Captain So you (go on/goin) puttin more straps (on [expletive])?
09:57:59 First Officer (well) it just shifted (apparently/barely)
09:58:01 Second Captain There was a bunch of them first… That first (truck).
09:58:02 Captain Did it move? … [expletive] moved?
09:58:04 First Officer Yes. Just tightened up on the straps. The truck?
09:58:06 Second Captain [unintelligible] like… Tightened those straps up uh, quite a bit, on the first one
09:58:13 First Officer You know how that… Well you go look at the… Went and looked at them now… all the ones [unintelligble] they had a bunch like this, to keep them from moving backwards… a bunch like this [unintelligble][unintelligble]movin forward? All the one that were keepin em from movin backwards were all [expletive] loose.
09:58:28 Second Captain What the [expletive] do you think’s gonna happen when you [expletive] slam it on the runway and slam on the [expletive] brakes and don’t use reverse… [said in a joking manner]
09:58:35 Captain [sound of laughter]
09:58:36 First Officer There ain’t nothing you coulda done about that.
09:58:37 Second Captain [unintelligible]I’m putting it on the [expletive][expletive] board. I’m gettin off this plane, I’m scared. [said in a joking manner]
09:58:46 Captain Throw that out man, that’s evidence. [unintelligible] [The Loadmaster] don’t want that hangin around either.
09:58:50 Unknown No.
09:58:53 Captain I hope instead of [unintelligible] rather than just replacing that (strap) I hope he’s beefing the straps up more
09:58:59 Unknown Just on that one spot.
09:59:00 First Officer Yeah.
09:59:02 Unknown All the rest of them are fine.
09:59:06 First Officer He’s cinching them all down.
10:14:49 Notice [break in transcript]
10:14:57 Captain What’s up dude?
10:15:01 First Officer Did you throw that other strap away?
10:15:04 Captain What did you – Did you put a couple more on? How far did it move… a couple of inches?
10:15:13 Loadmaster Yeah they just moved a couple inches… cause you know, it’s nylon ya know, so.
10:15:20 First Officer (you throw some) numbers (in here)?
10:15:21 Captain That’s scare-… that’s [expletive] scary- without a lock (for those big heavy things/[unintelligible] anything). Man I don’t like that. I saw that, I was like [expletive], I never heard of such a thing.
10:15:30 Unknown [unintelligible] I’d be kinda interested ta… wish I could put a camera down there and watch it…
10:15:36 First Officer (You’d probably)[expletive] yourself.
10:15:37 Captain Right.
10:15:37 Unknown See what they do
10:15:39 Captain Those things are so [expletive] heavy you’d think though that they probably wouldn’t hardly move no matter what

Clearly, the Captain is not happy with the situation. Ultimately, it’s the Captain’s decision whether it is safe to fly or not, not the loadmaster’s. However, in order to declare cargo as unsafely loaded, the Captain has to have the training to make a qualified opinion.

A National Airlines B747-400 Check Airman stated that “the loadmasters have their job–there is very little interaction between pilots and loadmasters.” A B747-400 FO stated that pilots at National Airlines “relied on the loadmasters 100% to make sure the load was done and secured properly.”

A National Airlines B747-400 Check Airman told the NTSB that there were guidelines on how to strap down cargo in a document referred to as the “loading manual” but pilots were neither trained nor evaluated on that information.

There was nothing included in the National Airlines Flight Operations Training Manual that covered the review of a cargo load by the pilots.

In this company culture, the Captain could not feel supported in going against the loadmaster, even if he accepted that the final decision to fly or not fly rested with him. The Captain quite simply did not have the knowledge or expertise at his disposal to make that kind of decision.

The Captain was, as the National Airlines First Officer said to the NTSB, completely reliant on the loadmaster.

He decided to continue. In fact, it never seemed to have occurred to him that he could do anything else.

Here’s what the Captain would have said was a really [expletive] scary thing: loadmasters aren’t certified. There’s no agreed training, there are no currency checks, there’s nothing official.

There was no specific training for the Chief Loadmaster position.

The documents include an interview with Charles Dsouza, Base Support at Camp Bastion and one of the staff who helped with the palletizing and loading.

In the accident flight, he was pushing loads into the airplane. The load had 5 MRAPs, 3 Cougars and 2 smaller MRAPs. The Cougars were 18 tons, and this was the first time they had ever loaded something that large. They used PGF pallets, two together with a sheet of plywood between them. They tied the pallets together with straps, 3 long and wide ways. They were the same straps used on the tie down to the airplane.

He said the pallet could handle the weight of an 18 ton Cougar. He said there’s no written guidance on how to build a pallet. They just did it, not by manual, but by working as a team.

He never received training to build and load pallets. No one complained about his load. The load master checks his work, and Ralph was his supervisor who also checked his work. He said if there were any problems with the straps and chains, the load master would correct them, or Ralph would correct him.

The Chief Loadmaster told the NTSB that they’d never needed to replace any straps and there was no training to tell when a strap was no longer safe.

Although the FAA has no regulatory oversight over loadmasters, cargo loading on aircraft is within their jurisdiction. Cargo loading equipment and continuous analysis surveillance are considered “high criticality items” which means that these operations must be surveyed by the FAA every six months.

The Principal Maintenance Inspector from the FAA told investigators that he’d attempted to observe the loading process for National Airlines; however he’d only seen National Airline’s B747-400 loaded once, in 2012 when he went to Dubai for five days and they did a ramp inspection.

In Dubai for the one time he observed National Airlines, they loaded only general items and military items. He could not remember if the load was going into Afghanistan, and told NTSB Staff he was not allowed to go to Afghanistan because the State Department would not issue them visas to travel to Afghanistan, and they could only observe the aircraft in Dubai.

One FAA cabin safety inspector out of Minnesota was able to do an enroute cabin inspection, and he said he heard that “there was some fallout from it.”

When asked how he would survey an operation overseas like the National Airlines B747-400, he said that “you would just go to DXB [Dubai, UAE] and see what you see,” and the one time he went to Dubai, he observed the 757 when it arrived and left.

The Principal Maintenance Inspector said that he didn’t observe any of the pallet build ups since that was the Principal Operations Inspector’s responsibility. He said that he never had an opportunity to observe the straps.

The Principal Operations Inspector told the NTSB that he didn’t know that National Airlines was strapping the heavy vehicles to the seat tracks until after the accident, when he saw photographs of the strapping.

The FAA was not aware of any risk analysis done by National Airlines for the carriage of 18 ton military vehicles, and the FAA was not notified by National Airlines that they were carrying multiple MRAPs prior to the accident.

The FAA did not conduct a risk analysis when it was discovered that National Airlines was hauling heavy military vehicles like MRAPs because, according to the [Principal Operations Inspector], “the manual seemed sufficient,” and “if they were following their manual there should not be an issue.”

The FAA conducted a review of National Airlines manuals after the accident, specifically because it was unclear whether loadmasters were referring to Boeing or Telair when they discussed the guidance in the Cargo Operations manual. Turned out that National Airlines had combined the Boeing and Telair guidance into the manual to allow for “one stop shopping rather than having to reference separate manuals.”

A National Aviation Safety Inspection Program had just run an assessment of National Airlines at the time of the accident. The primary problem identified was that National Airlines were having problems training and hiring loadmasters.

The Director of Safety at National Airlines stated that no risk analysis was conducted for the carriage of heavy, centre-loaded floating palletised loads like the MRAPs. He said he wasn’t involved in the decision to begin carrying large, heavy military vehicles and the Safety Department was not asked to prove input.

In other words, no one actually took responsibility for making sure that the cargo transports were safe and the staff had no experience and little or no guidance.

“You call, we haul.”

The crew did not take on any additional cargo in Bagram, and only took on fuel for the flight to Dubai. The airplane refueled to 48,000 kilograms of fuel. A National Air Cargo ground crew met the airplane during refueling, and only spoke with the loadmaster at the entrance of the main deck door. The flight release for the Bagram to Dubai leg had been emailed to the captain while the airplane was in Camp Bastion, so there was no paperwork exchanged, and the ground crew did not enter the airplane or cockpit and only spoke with the loadmaster.

The aircraft taxied out normally for departure on runway 03 at Bagram. The take-off roll appeared normal and the aircraft rotated around the Charlie intersection of the runway.

Nine seconds later, the cockpit voice recorder stopped recording. Three seconds after that, the Flight Data Recorder stopped recording. The airborne aircraft pitched up until it appeared to stall, at which point it turned to the right and crashed into the ground just beyond the departure end of runway 03.

Twelve items were recovered from the runway following the accident in the vicinity of Taxiway C which was near the point of takeoff rotation. Eleven were identified as airplane structure and one was identified as being part of an MRAP.

The data and the physical evidence suggest that at least one 12-ton MRAP vehicle broke loose of its restraints and damaged the FDR and the CVR before breaking through the aft pressure bulkhead. That damaged hydraulic systems #1 and #2. The stabilizer jackscrew assembly was displaced and had scuff marks of paint on it, which possibly occurred on impact. However, if the paint was from the MRAP sliding into it and the stabilizer jackscrew was displaced during take-off, safe flight and landing were not longer possible.

That is just key information that I picked up out of the documents; there’s a lot more information in the docket. It seems to me that the investigators aren’t very far from a conclusion and it’s already pretty clear what some of the recommendations will be.

For me, the hardest part of this to read was the CVR transcript. The sound of the crew laughing and joking around is heartbreaking, knowing in an hour they would find themselves in an aircraft that could not be controlled. No report in the world can make that better.

06 February 2015

TransAsia Flight 235 Inexplicably with No Engines

TransAsia Airways Flight 235 was a scheduled Taiwanese domestic flight from Taipei Songhan Airport to the Kinmen Islands.

The aircraft, registration B-228516, was a twin-engine turboprop made for regional airliners, the ATR 72. It can seat up to 74 passengers and is operated by a two-pilot crew. B-22816 had two Pratt & Whitney Canada PW127M engines and was less than a year old. There were five crew and 53 passengers on board. The flight crew consisted of three extremely experienced pilots. The Captain (Pilot Flying) had 4,914 flight hours and the First Officer had 6,922 flight hours. A flight instructor who was in the jumpseat had over 16,000 flight hours.

The aircraft took off from Taipei and climbed through 1,000 feet. Two minutes after take-off, the flight crew declared an emergency.

Control Tower [inaudible] … wind 100 degrees, 9.9 knots. Clear to take off.
TransAsia GE235 Clear to take off, runway 10, TransAsia 235
TransAsia GE235 Mayday! Mayday! Engine flameout
Control tower TransAsia 235, please try again. Contact Taipei Approach on 119.7
Control tower TransAsia 235. Control tower. … TransAsia 235, Control tower.

Contact was lost at 10:53 GMT, just two minutes after departure.

Flight 235 passed over the Huangong Viaduct, where multiple cars with dashcams inadvertently recorded the disaster.

TransAsia Airways Flight 235 – Wikipedia

The aircraft, flying level, first cleared an apartment building. Then it rolled sharply, at nearly a 90-degree bank angle, left wing down. As the aircraft flew low over the elevated viaduct, its left wingtip struck the front of a taxi travelling west on the viaduct, and the outboard section of the wing was torn off when it struck the concrete guardrail at the edge of the viaduct. Two people in the taxi were injured.

The following shows the aircraft in its last moments before it crashed into the Keelung River and the wreckage after (caution, may be disturbing).

As of today (6 Feb 2015), 15 people have been rescued. 35 occupants of the aircraft were killed in the crash and eight are missing. Two were injured on the ground when the aircraft hit a taxi on the road but suffered only minor injuries.

The Taiwanese Aviation Council has released some preliminary data from their investigation, specifically the engine plots from the flight-data recorder. All times are given in GMT.

The blue dotted line is the right-hand engine, engine #2, which is the one that had the original fault. The green line is the left-hand engine, engine #1.

10:51:XX TransAsia Flight 235 received take-off clearance
10:52:33 TransAsia Flight 235 handed off to departure
10:52:38 The aircraft had been airborne for 37 seconds and was at 1,200 feet above mean sea level when a master warning showed that the right-hand engine (engine #2) had failed.
10:52:43 The left-hand engine (engine #1) was throttled back
10:53:06 The right-hand engine (engine #2) auto-feathered.

The director of the Aviation Safety Council said in a press event that there was no flame-out. The right-hand engine shifted into idle mode but the oil pressure never changed. It’s unclear what triggered this.

10:53:12 Stall warning activated
10:53:18 Stall warning ceased

According to the Aviation Herald, at 10:53:19 the crew discussed that engine #1 had already feathered, the fuel supply had already been cut to the engine and they decided to attempt a restart of engine #1. However, I’ve not seen a copy of the cockpit voice recorder data or a news report that it is released, so I’m not sure where this information has come from.

However, there’s no doubt that at this point, the left-hand engine, that is the working engine, was shut down manually. Now the aircraft has no power.

10:53:21 Stall warning activated
10:53:34 Mayday call while multiple attempts were made to restart the engine
10:54:34 A second master warning activated

Half a second later, all devices on the aircraft stopped recording.

The actions of the pilots don’t make sense. They clearly believed that an engine had flamed out but even taking this into account, there’s no reason to shut down the other one. The ATR 72 can fly on just one engine so losing the right-hand engine would not have necessarily been an issue.

Right now, it looks suspiciously like this tragedy could have been averted if the pilots had done nothing at all. But this is surprising considering how experienced all of the pilots were and I’m still hoping there will be some other explanation.

The Taiwanese Aviation Safety Council is leading the investigation, with the French BEA representing the country of manufacture and the Transportation Safety Board of Canada representing the country of engine manufacture. They expect to release a preliminary report in 30 days.

30 January 2015

Cirrus SR22 ditching into Pacific captured on video

The U.S. Coast Guard has released video footage of a Cirrus SR22 ditching into the Pacific on the 25th of Jan.

The SR22 was being flown by a commercial pilot on a repositioning flight from Tracy, California to Maui. It’s a long flight and well out of range for a normal Cirrus SR22.

The aircraft was fitted with ferry tanks – extra fuel tanks meant for large water crossings. The flight was uneventful for the first 14 hours or so… until the aircraft was about 900 miles from Hawaii, when pilot realised he was unable to transfer fuel from his aft auxiliary fuel tank. The fuel transfer system had malfunctioned: although the aircraft had plenty of fuel for the remainder of the flight, the pilot was unable to get it to the engine.

The pilot contacted the Hawaiian National Coast Guard and told them that he had only three hours of fuel remaining, not enough to make it to land.

He said he would ditch the aircraft around 320 miles north east of Maui by deploying the Cirrus Airframe Parachute System (CAPS).

The Coast Guard informed him of the cruise ship Veendam which was within his range and asked him to divert towards it. A Coast Guard HC-130 Hercules was deployed from Coast Guard Air Station Barbers Point on Oahu to assist and maintain communications. It must have been from there that the video footage was shot.

Once the pilot was near the cruise ship, around 250 miles northeast of Maui, he activated the CAPS and the parachute deployed.

The aircraft seemed to be almost floating as it descended until the impact with the water. If you watch the rocking of the aircraft as the pilot climbs out, you can see just how turbulent the sea was. At the time of the rescue, weather conditions were seas of nine to twelve feet and winds of 21-24 knots (40-45 kilometres or 25-28 miles per hour).

The aircraft sank very quickly after the pilot came free, possibly dragged under by the parachute.

The pilot inflated an emergency life raft and was rescued (“extracted”) about 30 minutes later by the crew of the cruise ship Veendam. He was unharmed.

There’s also a video taken within the cockpit at the same time. See the comments below for the link to the pilot’s video of the event taken on his mobile phone.

The NTSB reports that the investigation is in progress and the final report will be published on the NTSB website: WPR15LA089.

There is no intention to attempt to recover the aircraft. Poor plane…

16 January 2015

50/50 Blame for Pilot and Skydiver in Mid-Air Collision

The final report ERA14LA146 was released last month for the incredible collision between an aircraft and a parachutist with only minor injuries (and a totalled Cessna) as a result.

The accident happened at South Lakeland Airport in Florida on the 8th of March 2014. It was a clear day, blue skies and a light 3-5 knot wind. South Lakeland Airport is an uncontrolled grass strip at the edge of Lakeland’s Class D airspace.

The pilot was an 87-year-old WWII veteran who has been flying all his life. He was flying in the circuit and had done three touch-and-go landings on runway 32: touching down on the runway to immediately take off and go again. He was aware that skydiving operations were in progress.

While he was flying, another aircraft with a group of parachutists had departed South Lakeland Airport and climbed to jump altitude. The skydiver in question was the 4th skydiver to jump. He deployed his parachute and manoeuvred to be parallel to the runway. He was watching another skydiver at about the same altitude and then initiated a left-turn so that he would land into the wind. His approach path crossed the approach end of runway 32.

Meanwhile, the pilot called out that his next approach would be for a full-stop landing; he was finished practising for the day.

Robert Goyer of FLYING knows the airfield and wrote about it a few days after the accident.

Insight: Parachute-Cessna 170 Midair Collision | Flying Magazine

The airport is pretty small, and there’s a two-lane highway immediately to the east lined by power lines, which you can see in the photographs. There are tall trees at the departure end of the runway, but with more than 3,000 feet of available runway, the power lines are the greater hazard until after you’ve climbed out initially. On approach to Runway 32, there are high tension lines. It feels as though you’re descending into a funnel with only one place to go. On approach to Runway 32, where the Cessna was doing touch and goes, you can go missed in a emergency by executing a right turn over the airport grounds. Otherwise, once you’re as low as the Cessna was and already rotating for a touch and go, the options are even more limited.

What’s clear is that neither of them had seen the other and both were on their final approaches without any awareness of a conflict.

The Cessna 170 was on short final coming in to land as the skydiver glided across the runway. They were 75 feet above the ground when the pilot saw the skydiver.

“A parachutist dropped down in front of me and was going to land in the center of the approach end of the runway.”

Tim Telford was taking photographs of the skydiver as he was about to touch down and he couldn’t believe what he saw.

The pilot immediately climbed in a desperate attempt to avoid the man who had effectively dropped into his view. However, he wasn’t able to climb over the parachute and his right wing caught the parachute’s suspension lines.

The Cessna pitched up and then down. The skydiver was pulled up into the air like a marionette and then dropped to the ground as the nose of the plane sliced through the strings of his parachute. The aircraft crashed nose-first into the runway.

Unbelievably, both the pilot and the skydiver suffered only minor injuries. They were taken to hospital immediately but suffered only bruises, no broken bones.

The Cessna 170, on the other hand, was a write-off.

The NTSB report categorised the accident as a “collision with terrain/object (non-CFIT)” and “Uncontrolled descent” which I suppose is the closest they have for a mid-air collision of man and plane.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The failure of the pilot and the parachutist to see and avoid each other, which resulted in the airplane’s wing colliding with the parachute’s suspension lines.

The point is that both the pilot and the skydiver were responsibile to “see and avoid” the other traffic in the circuit. The fact that neither of them had a clue that the other one was there means that they were both at fault for the resulting collision.

I’m lucky enough to have never flown into an airfield at the same time as parachutists were dropping. I’ve been a passenger, though, and it’s a case of constant looking out and making sure that you know where the jumpers are and that there’s no chance of getting close to them.

Insight: Parachute-Cessna 170 Midair Collision | Flying Magazine

Even if the high wing of the 170 hadn’t blocked the vision of the pilot — and who looks for parachute traffic on rotation? — there was probably not enough time to get stopped without there being a collision. The pilot, likewise, was surely busy on the arrival over trees and power lines before setting up for the touch and go.

The parachutist likely had few options as well. New chutes are fairly maneuverable compared to old fashioned models, but there’s only so much a chutist could do under the circumstances, especially since he’d just cleared power lines behind him.

It does seem a bit unfair to the pilot, as the skydiver was out of his drop zone and should not have been landing on the active runway. I just think that on short final, you can’t really expect to see someone coming dropping down onto you from above. Your attention is ahead of you, gauging the touchdown point and ensuring that the runway is free of obstructions; I don’t think it would occur to me to be looking up!

The good news is that both pilot and skydiver were fine and said they planned to continue their hobbies despite the scare.

And Tim Telford got the photographs of his life!

02 January 2015

Five Aircraft That Did Not Crash In Thunderstorms

OK, that title is a bit misleading because there are thousands and thousands of aircraft that haven’t crashed in thunderstorms. Even counting only commercial airliners then, according to How many planes and passenger are there in the world? (Livecounter), there are 19,025 of them around the world right now. All of these have not crashed flying through a thunderstorm.

However, there’s a number of aircraft which have flown through thunderstorms and ended up in trouble. Some of them did crash. Others got away with a hard landing. What they have in common is that it wasn’t just the weather. The thunderstorm alone didn’t result in an immediate crash scenario.

Thunderstorms aren’t safe. Aircraft will make great detours in order to avoid flying through one. But in a commercial jet, flying through a thunderstorm doesn’t mean certain death or that the aircraft is going to fall to pieces. A pilot avoids flying through a thunderstorm for three reasons: it’s uncomfortable, it’s unpredictable and it’s a hostile environment for aviation. Aircraft in a thunderstorm are subjected to updrafts, downdrafts, icing, heavy precipitation and lightning, all of which have a level of risk associated with them.

The truth is, flying through a thunderstorm makes the aircraft a hell of a lot more vulnerable. When combined with general risks, such as aircraft structural integrity and human factors, the likelihood of an incident is increased.

Thunderstorm and icing shouldn’t have caused this aircraft to crash

We have to start with the obvious example: Air France flight 447. This has come up a lot when discussing AirAsia flight QZ8501 because there are some core similarities. Both aircraft were flying in thunderstorm conditions. Neither aircraft made a mayday call and in both instances the aircraft simply disappeared from radar. In the case of Air France flight 447, it took a week to find the initial wreckage in the South Atlantic ocean, quite a bit longer than the three days of searching for QZ8501. Finding the black box itself took almost two years but in the shallow waters of the Java Sea, it should be possible to locate the AirAsia black box very quickly: weeks, not years.

Air France flight 447 flew directly through a large system of thunderstorms and the pitot tubes became obstructed by ice crystals. The pitot tubes work as speed sensors and, without this data, the autopilot could not keep control of the aircraft. The aircraft was straight and level: if the flight crew had done nothing at all, the issue would have almost certainly resolved itself in a few minutes. But instead the Pilot Flying pulled the stick back, causing the aircraft to go into a climb and lose speed. The flight crew did not follow the correct procedure for loss of displayed airspeed information and appeared to be very confused by the situation. The confusion in the cockpit lasted until the aircraft crashed. In the most alarming human factors crash of the decade, the Pilot Flying effectively flew the Airbus A330 into the ocean.

Flying too high

Pulkovo Aviation Enterprise Flight 612 was a Tulopev 154 passenger airline which crashed north of Dontesk in 2006. The area was beset by heavy thunderstorms. The flight crew made a mayday call to report that they were experiencing severe turbulence as they approached the storm area. Two minutes later, the aircraft disappeared from radar. However, it was not the turbulence that brought the aircraft down. The flight crew initially tried to outclimb the thunderstorm, hoping to fly over the top, which may have been the same plan as the AirAsia flight had.

That day, it was an impossible task. The thunderstorm front was extremely high, with the clouds peaking out between 40,000 and 50,000 feet. Nevertheless, the flight crew climbed from their cruising altitude of 35,000 feet to their maximum altitude of 39,500 feet. Untrained in flying at high altitudes, they did not appear to have any idea of the risk

The maximum altitude of an aircraft is the highest altitude at which the aircraft can sustain level flight. As they flew through the thunderstorm, they were subjected to a severe updraft which lifted the aircraft to 42,000 feet in a matter of seconds. The angle of attacked increased and the airspeed dropped to zero. The air density was so low that the aircraft was no longer capable of flight. It fell into an unrecoverable spin. This flat spin is where a plane spins on its belly and gains no airspeed. Witnesses on the ground watched the aircraft spin into the ground at low speed but there was not a thing that the pilots could do.

In-flight break up near a storm

There was one incident in Florida where the wings broke off of a single engine aircraft flying in thunderstorm weather in Florida. The Pilatus PC-12 was flying at 26,000 feet when ATC cleared him to deviate right to avoid adverse weather ahead. As the pilot was turning to the right into cloud, the autopilot disengaged.

However, instead of taking control, the pilot ran through a test of the autopilot to see if it was working normally. Meanwhile, the aircraft continued in an uncontrolled turn. While he was testing, the aircraft dropped into a spin.

At 15,000 feet and travelling at about 338 knots, 175 knots above the maximum operating speed of the aircraft, the pilot appears to have finally realised that the aircraft, and not the autopilot, needed his full attention. He pulled back hard on the yoke, trying to yank the aircraft back up to straight and level. He effectively tore his wings off.

Struck by Lightning

In 2003 in Norway, a turboprop was struck by lightning. Generally speaking, lightning has no effect on modern aircraft, however in some instances the aircraft can lose functionality. In this instance, the flight crew were flying to Bodø in a Dornier 228 when they were confronted with a “wall of clouds”. The storm cells were reported as containing heavy precipitation and intense lightning activity.

Another aircraft reported a lightning strike as it was approaching Bodø airport. The Dornier 228 elected to approach from the opposite direction and communicated with Air Traffic Control about the weather and how to avoid the worst of the storms. The aircraft was at 6,000 feet when it entered heavy turbulence and the flight crew commented that the weather radar didn’t seem to be giving correct information. Thirty seconds later, a bolt of lightning hit the baggage door on the nose.

The crew were blinded for about half a minute. When they recovered, they discovered that their elevator, which controls pitch, wasn’t working correctly. By the time that the Captain took control, the aircraft speed had decayed to a stall. The aircraft stopped climbing at 7,800 feet. The flight crew used engine power to increase the airspeed and the aircraft continued its climb to 9,000 feet. The flight crew regained some control of the pitch using the elevator trim and were able to fly the aircraft to Bodø Airport, where they were given clearance to do whatever was needed to get the aircraft onto the ground. On the second attempt, they were able to get the turboprop onto the runway. They landed hard, snapping off the wheels, but there were no injuries.

The investigation found that there was considerable corrosion of the wires in the bonding and that some 30% of the wires may have been damaged previous to the lightning strike. As a result, the aircraft’s bondings couldn’t conduct the electric energy from the lightning and the transfer rod, which connected the elevator to the cockpit, was broken.

Into the Heart of the Storm

In 2002, an aircraft ditched into the river in Indonesia after flying through a severe thunderstorm. Garuda flight 421 was a Boeing 737 on a domestic flight when thunderstorms closed in, leaving the flight crew with nowhere to turn. They encountered severe turbulence and rain and hail clattered against the aircraft. The cockpit voice recording includes the sound of rain hitting the fuselage. The rain and hail is so torrential, it is almost impossible to hear the conversation in the cockpit. The recording was entered into the sound database of the UK Air Accidents Investigation Branch who found that the rain was the heaviest ever recorded on a cockpit recorder. Based on tests, investigators believe that the aircraft encountered hail/water content as high as 18 grams of hail per cubic metre of air. This is the equivalent of flying through 10,000 ice cubes per second.

The hail ingested by the engines was well above the certified levels. The engines both flamed out. The flight crew attempted to relight the engines but as they were still flying through the heavy precipitation, the first attempts didn’t work.

As if the situation wasn’t horrific enough, during the flight crew’s second attempt to relight the engine, the aircraft lost all power. The flight crew couldn’t know it at the time but investigators discovered that there was a fault in the newest cell of the battery: the level of electrolyte in that cells was much lower than the others. This denied the crew any chance of restarting the engines.

In a somewhat miraculous ending to a horrific situation, the captain managed to glide the Boeing 737 onto the Bengawan Solo River, where it came to a halt facing upstream with the nose up and pointing slightly to the right. There was only one fatality on impact, a cabin crew member. The rest of the crew and all of the passengers were rescued with only minor injuries by local villagers.


The point of this is not to strike fear into the hearts of nervous passengers but to try to explain how thunderstorms are dangerous and why pilots and air traffic control will work together to avoid them. Stormy weather rarely ends in disaster for commercial jets. In those instances where it is a contributing factor, we almost always see some other issue: bad training, human error or maintenance issues which are the actual cause of the crash.

So when you hear about thunderstorms ahead, don’t panic. Flying through a thunderstorm doesn’t make an aircraft spontaneously wreck like hitting an iceberg at sea.

19 December 2014

Near Miss with Drone at Heathrow

Last week, an Airprox Report was released regarding an incident in Heathrow airspace. An airprox is the term for a situation where the pilot or air traffic controllers believe that the distance between aircraft (taking into account relative positions and speed) are such that the safety of the aircraft involved may have been compromised.

FAQ Details | UK Airprox Board

If a pilot or controller is of the opinion that the distance between aircraft as well as their relative positions and speed was such that the safety of the aircraft involved was or may have been compromised then he or she may report an Airprox. In Airprox 016/2002 for example, the separation recorded on radar between the two aircraft was 400ft vertically and 3 miles horizontally: this is hardly a ‘near miss’ in the way people generally use these words. In the judgement of the air traffic controllers who reported the event it was an Airprox and was therefore fully investigated and assessed by the Airprox Board.

This particular airprox report is interesting because it involves a British Airways passenger plane and an a unmanned aircraft.

On the 22nd of July 2014, an Airbus 320 was on short final to land at Runway 09 Left at Heathrow. The weather was clear and the visibility was good. The pilot saw a small black object as the aircraft descended past 700 feet. He described it as a small radio-controlled helicopter and said that it passed about 20 feet over his left wing.

The model helicopter did not strike the aircraft and there was no further issue, however as the report notes, it was a serious distraction at a critical level of flight. The pilot reported it immediately to Heathrow Tower who warned inbound aircraft of the unidentified object but no further sightings were made.

At 700 feet, it seems likely that the “helicopter” was a multi-rotor aircraft using GPS, which can easily be bought in any enthusiast shop.

The Airprox Board worked with the local model-flying-club but were not able to identify the unmanned aircraft nor trace the operator.

AIRPROX REPORT No 2014117

The Board members were satisfied that the A320 crew had seen a model helicopter and were of the unanimous opinion that the operator of the model had chosen to fly it in an entirely inappropriate location. That the dangers associated with flying such a model in close proximity to a Commercial Air Transport aircraft in the final stages of landing were not self-evident was a cause for considerable concern.

A spokesman for the CAA told the BBC that the CAA had to depend on people using their common sense when they operated drones.

It seems odd to even have to point that out, but a similar event at Stockholm resulted in the operator of a drone blissfully unaware that he’d just shut down the airport.

That was just last week, when Stockholm-Bromma Airport had reports of a drone in the local area. The Swedish CAA closed the Bromma CTR for all traffic below 2000 feet which stopped all flights going into and out of the airport.

An hour later they found the man operating the drone. He was documenting the construction of a motorway and had no idea about airspace or that there were any restrictions on where he could fly his drone.

A powerful drone bought on the high street will weigh 7-10 kilograms; large enough to cause real danger to commercial aircraft. The U.S. Air Traffic Controllers Association (NATCA) has stated that reports of drones flying dangerously close to passenger aircraft is becoming a daily occurrence. The fact that they are flown at low altitudes mean that they are often interfering with aircraft on final approach, as in the Heathrow incident.

In the UK, an unmanned aircraft must remain within the line of sight of the person operating it and must not be flown within 150 metres (492 feet) of a congested area or large group of people. In the US, they may not be flown above 400 feet. Both countries have an exclusion zone around commercial airports where no unmanned aircraft can be flown without ATC permission.

Having seen the issue with lasers over the past few years, however, I suspect the issues with hobbyist drones at airports has only just begun.

12 December 2014

Plane vs Truck

This photograph is so remarkably perfectly timed, I thought it must be a still from an action movie or television series, done with special effects.

It turns out it’s absolutely a case of impeccable photography by Mr Robert W Madden, who was at the right place at the right time and managed to frame the shot perfectly.

It was taken in Guatemala in the aftermath of a magnitude 7.5 earthquake which struck Guatemala City on the 4th of February 1976.

Earthquake rocks Guatemala City — History.com This Day in History — 2/4/1976

It was 3:04 a.m. when the first large tremor, centered six miles under the Earth’s surface 120 miles northwest of Guatemala City, struck. The quake was the result of a clash between the Caribbean and North American plates on the Motagua Fault. In a matter of minutes, about one third of the city was destroyed. All over the city, sleeping residents were crushed and killed when their weak adobe homes collapsed on top of them.

Immediately, efforts began to rescue the thousands of people buried beneath the rubble. Many people could not be saved, as it was extremely difficult to get help to the city. The roads and bridges leading to Guatemala City had been extensively damaged. Thousands of those people lucky enough to be pulled out alive suffered broken backs and pelvises. It is estimated that more than 70,000 people suffered serious injuries. The U.S. Air Force assisted by airlifting food and medicine into the area. With all the available hospitals filled beyond capacity, the United States also set up a field hospital in Chimaltenango. The number of deceased overwhelmed the authorities, so communal grave sites had to be established. To make matters worse, strong aftershocks followed for an entire week, terrorizing the survivors, who were staying in improvised shelters.

Bob Madden worked for National Geographic magazine and was in Guatemala covering the rescue and recovery operations. He had apparently just disembarked from another aircraft and was standing on the highway near Sanarate.

The rescue plane was bringing food and medicine to the quake victims. It was trying to land on the highway when it got caught in strong crosswinds.

Amazingly, no one was seriously injured. The two men on the left of the photograph leapt from the pick-up truck just before the crash, adding an undeniable personal aspect to this unbelieveable photograph of the aircraft impacting the truck.

The spectacular photograph was featured in the June 1976 issue of National Geographic which was dedicated to the earthquake. This year Natijonal Geographic editors featured it as one of their 50 Greatest Pictures in a special in National Geographic magazine. It also won second prize in the “Spot News” category for 1976, which makes one wonder what the first prize photograph could possibly have shown.

Bob Madden has a great photography blog with tips and tricks as well as the opportunity to join him on a photo safari or photography workshop. In a post about patience, he has a published a number of his best photographs where he cites the amount of time it took him to get the photograph. Most of them are quite long: 15 days, five months, four hours. Underneath the photograph of the plane crash, however, it simply says Two seconds!.

It’s a brilliant example of how skill and instinct can make all the difference when you are in the right place at the right time.

I wasn’t able to find anything out about the plane or the pilot, although I did discover that you can buy a greeting card of the photograph. I have to admit, I’m not sure what the appropriate occasion might be.

28 November 2014

Overloaded, Overspeed and Out of Fuel

The situation started quietly: a Boeing 757 inbound to Newcastle International Airport (NCL) was asked to do a go around: break off the approach and try again.

The Thomas Cook aircraft was a Boeing 757-237 registration G-TCBC. There were seven crew on board and 235 passengers. The crew was scheduled for an early morning flight from Newcastle to the Canary Islands, landing at Fuerteventura and returning to Newcastle that afternoon. They could expect to be home for suppertime.

The Commander was 56 years old and held his ATPL with 13,374 flying hours (1,380 on type). He’d spent two and a half years flying the Boeing 757 before the incident. Prior to that, he’d flown Airbus aircraft for over thirteen years. He said he’d reached a stage where he felt comfortable with the B757. His First Officer had been rated on the Boeing 757 for over five years.

They reported for duty that morning at 0500 hours. The Captain said they were as well-rested as could be expected for that time of the morning. His mindset about his job was less than positive.

He sensed that the airline was in turmoil due to a major internal re-organisation programme. The direct effect for him was that he had been told that he would be one of several captains who would be demoted to first officer in March 2014 and that his salary would reduce significantly. He was unhappy about this impending change and the matter weighed heavily on his mind at work, despite his best efforts to ignore it.

The day’s flights were uneventful until they were on final approach to Newcastle. The Captain was the Pilot Flying. The runway was wet and the Automatic Terminal Information Service included a pilot report of windshear at 500 feet which had caused his aircraft to lose 15 knots of airspeed.

The Boeing 757 was set up with the landing gear down and flap 20, preparing to land with flap 25 as per Standard Operating Procedure. After a slightly late turn onto the intercept heading, the aircraft overshot the centreline in the process of capturing the localiser heading. Air Traffic Control noticed the overshoot and gave a new intercept heading.

The Captain thought there was a technical fault and commented on this to his First Officer repeatedly over the next few minutes. After the incident, no evidence of a system fault was found. The investigation found that the Captain believed that he’d experienced more technical problems than was usual for the past few months.

The flight crew had clear sight of the runway and the aircraft landing ahead of them. Everything seemed good.

Then the aircraft in front reported a possible birdstrike on the runway. Air Traffic Control immediately called the Thomas Cook Boeing 757 and instructed the flight crew to go around.

The Captain responded by saying “Go around” three times. He applied maximum thrust and disconnected the autothrottle.

The First Officer hadn’t expected a go around when everything looked fine and simply wasn’t sure what was happening. He heard the Captain’s repetition of the go around but it was not a standard call. The Captain’s call should have specified a flap setting, which would serve as the First Officer’s first instruction. He wasn’t quite sure what to do.

Air Traffic Control instructed the aircraft to climb straight ahead to 3,500 feet above mean sea level. The standard missed approach procedure, which both pilots would have reviewed before the flight, was to climb to 2,500 feet.

The controller probably meant to simplify the go-around procedure for the crew but this instruction came in as the crew were trying to initiate the change in plans and under a high work load. As a result, it was just another distraction.

The go around was badly handled. The Captain did not press the G/A (go-around) switch which would have helped configure the aircraft for him; specifically, it would have cleared the localiser and glideslope data until they set the aircraft up for the new approach. The Captain also did not disconnect the autopilot as a part of his initial response. So now, the autopilot was still trying to track the localiser and glidescope for a landing which they’d already missed.

Takeoff/Go-around switch – Wikipedia

The go around setting is used when an approach is taking place. If a pilot finds that they are unable to land, activating this switch (pushing thrust levers to TOGA detent) will increase the power to go-around thrust. Most importantly, the TO/GA switch modifies the autopilot mode, so it does not follow the ILS glideslope any more and it overrides any autothrottle mode which would keep the aircraft in landing configuration. On Airbus aircraft it does not disengage the autopilot, but causes it to stop following the ILS and perform Go Around maneuver automatically. In an emergency situation, using a TO/GA switch is often the quickest way of increasing thrust to abort a landing. On Airbus planes pushing throttles to TOGA detent does all regarding flight path and speed.

However, instead of using the TOGA switch, he disconnected the autothrottle and applied maximum thrust. At full power, the aircraft accelerated and continued to descend.

The speed was 187 knots and still increasing when the Captain said “go around” again and finally disconnecting the autopilot. An unexpected go around is always stressful and now he had to fly the aircraft manually and force himself to disregard the commands coming from the flight director, which was still set up for the approach. He did not tell the First Officer of the configuration changes and didn’t say anything as he disconnected the autopilot.

The First Officer didn’t check the panel so he didn’t realise that the aircraft had not been set up for the go around. Standard operating procedures had broken down and he became confused. His job, as pilot monitoring, was to watch for discrepancies, especially speed. He was aware that the go-around call was incomplete and that he hadn’t modified the flap settings but instead of querying the situation, he responded to the Air Traffic Control call, confirming that they would climb to 3,500 feet, and then he input the height on the mode control panel.

The First Officer was selecting the new altitude when the master warning alert sounded. He cancelled the master warning. He didn’t spot that the autothrottle had been switched off, although at this point he noticed that the Captain had disconnected the autopilot. The First Officer looked at the Captain to make sure everything was all right, surprised that he was flying the go around manually.

The aircraft reached the Flap 20 speed just after the autopilot was disengaged as the aircraft pitched up. Although the gear was retracted, the Flap 20 setting remained for a further 30 seconds.

The Commander called for Vref+80 climb thrust. Vref is the speed for the aircraft which is the safe manoeuvre speed with flaps up. In this instance, Vref was 125 knots so plus 80 means that the Captain wanted to go 205 knots.

But the First Officer became flustered when he couldn’t set the speed.

Because the commander called for a target speed of VREF+80 and climb thrust, the co-pilot tried to select the relevant speed on the MCP. However, he was unable to open the speed window to do so. He recalled that before the departure from NCL, an engineer had said the previous commander had mentioned having difficulty in viewing one of the digits in the speed window, so the co-pilot wondered if there was a technical malfunction. Meanwhile, although he was aware that the speed was increasing rapidly, he was trying to retract the flaps and failed to monitor the speed adequately.

Although he’d flown the Boeing 757 for over five years, he had very little experience performing a go around and couldn’t remember having practised much in the simulator training. Now he’d become overloaded. He had too many tasks at the same time; the human response to this is to limit the amount of processing and over-focus (or fixate) on a single task. He lost all overview of the situation and of his role as pilot monitoring.

The limit for safe manoeuvring of the aircraft with flaps set to 20 is 195 knots. The aircraft had exceeded this by 18 knots before the flaps began to retract. The aircraft speed remained above the flap limit speeds up until the point when the flaps were fully retracted. The aircraft reached 287 knots before the thrust levers were set back to idle position from the go around.

That’s what is known as overspeed: the airspeed has exceeded a safe limitation. In this case, the safe speed for the extended flaps was exceeded, which can cause damage to the flap system. In the case of a flap overspeed, a full inspection must be made of the flap system before the aircraft can fly again.

The Captain was doing his best to climb and maintain 3,500 foot above mean sea level flying by hand. He later described his First Officer as “stunned” and said that he was not offering the support that he could have.

The Captain asked for the autopilot to be engaged but that proved problematic as well. They didn’t speak, but the flight recorder shows that the autopilot was repeatedly engaged and disengaged over the course of the next few minutes. This may have the result of movements on the control or that the Captain was inadvertently disengaging it using the pitch trim before realising it had engaged.

Meanwhile, as the go-around switch had never been set, the Flight Director modes for localiser and glideslope were still set. The only other way to clear this would have been to turn the flight director off and on again. So even if the flight crew managed to engage the autopilot, it would still be trying to track the localiser and glideslope for the active runway, now behind them.

They were in a mess.

They were lucky that although the aircraft was flying well above the safe limits for the flaps, the flaps retracted normally. As they retracted past flight 1, the leading edge slats began retracting. However, due to the speed, the leading edge slats failed to fully retract. They stopped, partially extended. A caution message appeared on the Engine-Indicating and Crew-Alerting System (EICAS) but neither flight crew member acknowledged the caution.

It took six minutes for the First Officer to set up the speed window and autothrottle and the autopilot so that the autopilot could remain engaged.

Meanwhile air traffic control gave the flight crew vectors to lead the aircraft downwind under radar control for another approach to Newcastle. The workload was such that the aircraft was flying almost 500 feet below their cleared altitude (3,500 feet) and neither pilot noticed.

The First Officer suggested that they enter a holding pattern. The Captain decided not to and instead said they should extend the downwind leg. The First Officer informed Air Traffic Control that they had a slight technical problem.

The Captain asked how much fuel was remaining and the First Officer told them that they had 3,600 kg.

The First Officer was right to ask for a holding pattern: the flight crew were racing behind the plane and a holding pattern would give them the chance to find out what was going on. Although the Captain later stated that his First Officer seemed flustered and not giving full support, he turned down this opportunity to get caught up. By extending the downwind, the Captain made them do a whole new set of calculations. This solution did not relieve any of the pressure on the crew.

The First Officer spoke to Newcastle control on the radio as he started the Leading Edge Slat Disagree check list. He followed the first four steps correctly but at step five he made a mistake. The checklist said that the alternate flaps selector should be set to agree with the flap lever. He should have set the selector to UP as the flaps had been retracted. Instead, he set the alternate flaps selector to flap 1.

Eventually the automatics were successfully engaged but the slats remained partially extended due to an exceedence of the limiting speed by a significant margin. The co-pilot began the relevant Quick Reference Handbook checklist but he was frustrated by his poor performance prior to that. Interruption caused him to lose his place in the checklist and instead of starting again, in accordance with SOPs, he struggled to find where he had got to. The similarity in presentation of steps 2 and 4 made this quite difficult. Step 5 required the alternate flaps selector to be positioned to agree with the flap lever. The flap lever was in the up position but the co-pilot set the alternate flaps selector to flap 1, possibly as a result of his heightened anxiety.

In step six, the leading edge flaps were set to alternate. The First Officer did this, which meant that the leading edge flaps ran to the commanded flap 1 position.

This cleared the Leading Edge Slat Disagree message… but now the Trailing Edge Flap Disagree message lit up.

The First Officer hadn’t completed his checklist but the Captain saw the new caution and told the First Officer that he should change to the Trailing Edge Flap Disagree checklist.

Step seven, the next step of the checklist, would probably have made it clear to the First Officer where it had all gone wrong but he never got that far.

He started the Trailing Edge Flap Disagree checklist. This time he made it to step three before being interrupted by a radio call from Newcastle Tower. The extended downwind meant that the aircraft had now left controlled airspace.

It would have been nice if Air Traffic Control had notified them of this before they’d made it that far, giving the flight crew a choice to stay in controlled airspace to retain the best traffic separation service. As it was, they continued.

Standard operation would be that the Pilot Flying deals with the radio while the Pilot Monitoring goes through the checklists but neither flight crew ever seemed to consider the division of duties.

The First Officer acknowledged the ATC call and went back to his checklist. The Captain interrupted him again, asking for more flap. He was increasingly convinced that they had a flap fault and wanted to confirm the problem. “Let’s go for flap 5,” he told the First Officer.

The First Officer stopped the checklist and tried to move the flaps with the flap lever. He was clearly disorientated as he selected both the flap lever and the alternate flaps selector to the flap 5 position. Nothing happened.

The Captain did not notice that the First Officer had mishandled the flaps but he did notice that the flaps were not moving. This was the confirmation he was waiting for: they had a flap fault and would have to do a flapless landing.

The First Officer never completed the checklist. Had he ever completed steps four and five, the flaps would have been controlled and referenced to the alternate flaps selector: that is, he would have been led to diagnose the actual fault which he had caused.

No other flap/slat issues were recorded for the remainder of the flight and the landing was made using flap 30. Other than the conditions associated with excessive speed and partial slat extension, the flap and slat parameters reacted as expected for the given crew selections.

The Captain needed to decide what to do.

He explained later that he had a landing distance of 1,600 metres in his head for a flapless landing, and that the week before, he’d seen an aircraft landing at Newcastle with flap 20 and it had appeared to use much more than this. He knew that the Newcastle runway didn’t have a stopway for overruns. He didn’t like the idea of a flapless landing on that runway, which was wet and had reported windshear earlier.

The flight’s alternative airfield was Edinburgh but he knew the runway there was not much longer than Newcastle’s.

“That’s all the flap we have got,” said the Captain. “We need a longer runway, don’t we.”

The First Officer knew where the closest longer runway was. “Yeah, we need Manchester, don’t we?”

It seemed obvious to both of them: so obvious that neither checked the Calculation of Operational Landing Distance which would have told them that the runway at Newcastle was plenty long enough for a flapless landing. There was no discussion of the decision, let alone a review.

They needed 2,000 kg of fuel to fly to Manchester, which meant using the final reserve fuel. The Captain decided that they must divert immediately.

The First Officer agreed and informed Newcastle that they could not get the flaps down and that they were diverting to Manchester.

Fuel Emergency (EU-OPS 1.375 b)

The Commander shall declare an emergency when the calculated usable fuel on landing, at the nearest adequate aerodrome where a safe landing can be performed, is less than final reserve fuel.

The Captain had never dealt with a low fuel situation but he told investigators that he knew that he needed to make a MAYDAY call as soon as he was aware that they would need to use final reserve fuel. He could not explain why he did not do so.

Thomas Cook, the operator of the flight, did an internal investigation to try to understand how the situation has deteriorated from a simple go around at Newcastle. They came to the conclusion that the pilots felt more in control of the situation once they had made a decision, so although they knew it meant landing with less fuel than normal, they accepted this as a necessary part of the solution.

Meanwhile, Air Traffic Control instructed the flight to turn onto heading 230º and climb to FL100 and asked what cruising altitude they would like. The flight crew decided it was better to stop the climb at 10,000 feet. The First Officer selected Flap Up without going back to his unfinished checklist. He forgot about the alternate flap selector which he’d set to flap 5, so the flaps remained partially extended. Neither pilot ever thought to check the pressure settings.

They proceeded with the flight.

The forward fuel pump low pressure light illuminated on the fuel panel. The First Officer commented on this but no action was taken. Meanwhile, the Captain called in the cabin manager for a briefing on the flaps situation and to explain that they were diverting to Manchester.

Air Traffic Control cleared the flight direct to Pole Hill VOR.

The flight crew levelled off at what they thought was FL100, 10,000 feet above sea level. However, they hadn’t changed the pressure settings and so the pressure was still set up for Newcastle. When the aircraft levelled off, it was 420 feet above the cleared level.

Now the First Officer found that he could not program the new route into Route 1 in the flight management computer. The Captain used raw data to navigate towards the Pole Hill reporting point.

The commander used the heading select to navigate by hand towards the Pole Hill reporting point. Clearly frustrated with all the technical difficulties they were experiencing, he decided that they needed to declare a MAYDAY.

They should have done this as soon as they knew that the aircraft was going to land with less than final reserve; that is, when they diverted for Manchester.

The First Officer told Air Traffic Control but didn’t use the standard phrasing. Instead, he almost conversationally added “and we want to declare a mayday” at the end of a call.

The controller acknowledged this with “Roger” and then followed up. “Have you got any more details for the paramedic?” He had clearly presumed that there was a passenger issue on board as he had no information to lead him to believe that the flight was in difficulties.

The First Officer explained that they didn’t need a paramedic but that they would be making a flapless landing at Manchester. He did not mention the fuel situation. His attention was split between the flight management computer and the radio calls. As a result, his performance was extremely poor.

He had lost confidence in his own ability and he had probably reached an over-aroused mental state, where his capacity to think straight had started to deteriorate. Like the commander, he was now experiencing a low fuel scenario for the first time. At this point it is likely they were both task-saturated. This helps explain why the After Take-Off Checks were missed.

It’s likely that he couldn’t program the new waypoint in the flight management computer because he hadn’t activated Route 1. In any event, he eventually decided to enter the data into Route 2 which was then activated. The flight crew were finally receiving navigational assistance from the flight management computer for the first time since the initial go around.

That’s when the LOW FUEL caution light and the fuel configuration light turned on. The First Officer then told Air Traffic Control that they were requesting a priority landing due to a low fuel warning. Newcastle Air Traffic Control said they would pass the message on and asked if an emergency was being declared.

The First Officer confirmed this and he was asked to squawk 7700, which is the code for a general emergency. This means that for every controller in the area who could see the flight on secondary radar, it was clear that the flight crew had declared MAYDAY.

At no point did the crew discuss the fuel situation. They didn’t appear to take into account the extra miles they were covering in their approach from east of Newcastle, nor the fact that they would use more fuel because of the non-standard flap configuration for the cruise. They’d decided to stay at 10,000 feet but their predicted fuel burn was based on cruising at 17,000 feet.

The First Officer tried again with the flaps and this time after various selections, he found that the flaps appeared to be working normally. He’d managed to turn off the alternate flap lever, which cleared the disagree indications. He retracted the flaps to conserve fuel and concluded that the flaps were finally back under normal control (although they had been all along).

The Quick Reference Handbook specifically warns against troubleshooting by deviating from non-normal procedures prior to the completion of appropriate checklists. The crew ignored this and made random flap selections without referencing either checklist.

They managed to regain normal control of the flaps, but if they’d followed the Quick Reference Handbook in the first place, they wouldn’t have even had to consider a flapless landing, let alone a diversion.

At any event, their flaps were now clearly working as expected. They’d had a low fuel indication for fifteen minutes and the Captain knew that Newcastle was still the nearest airport. He didn’t revisit the plan but continued to Manchester. He later told investigators that they’d already made the decision to divert and besides, he didn’t think the First Officer would consider a return to Newcastle.

…the commander felt there was little time available to conduct a joint review of the situation but that he did mentally review things himself. He also remarked that the situation had felt unreal and that it seemed to get out of control very easily. He recalled that on a couple of occasions he had tried to offer the co-pilot some reassurance.

The First Officer changed frequencies to Scottish Control and identified the aircraft. He did not mention the MAYDAY. There was no response, but neither of the flight crew seemed to notice. They had now realised that they’d never done the After Take-Off Checks after the Go Around at Newcastle and went through the checks, including resetting the pressure and descending to FL100.

After a further discussion about the flaps, the crew agreed that they should be able to land normally with Flap 30 but they would slow up early just in case.

They were unsure whether there’d been a flap overspeed or not and were perplexed as to why the automatic systems had not worked as expected.

Scottish Control did not realise the aircraft was on frequency until six minutes later, when the First Officer called again to request direct routing to Manchester.

The flight was given clearance for a direct 10-nautical-mile final into Runway 23R at Manchester. The Captain commented that they needed to do something about the fuel, over fifteen minutes after the low fuel caution for the right tank. This was the first reference in the cockpit to a fuel imbalance.

The First Officer didn’t respond, as at that moment Air Traffic Control gave them the weather at Manchester airport followed by the descent clearance.

After the call, the Captain asked for the fuel to be balanced. Investigators believe there was an imbalance of close to 800 kg by this time. The First Officer opened the fuel crossfeed and turned off the right fuel pumps without referring to the Low Fuel checklist. Neither seemed concerned about their fuel consumption.

It seems that as the flight crew had already accepted that they were landing in a low fuel situation, the warnings were treated as expected consequences of the solution. But if at least they’d referred to the Fuel Configuration checklist at that point, as per standard operating procedure, it would have referred the crew to the Low Fuel checklist and they might have paid more attention to the fuel levels in the right tank.

The aircraft started its descent. Ten nautical miles from touchdown, the fuel crossfeed was closed and the fuel pumps turned back on.

Following the Low Fuel checklist would have meant that the crossfeed was left open with all pumps on until landing. Instead, the crossfeed was only open for eleven minutes. As the thrust was at minimum for most of those eleven minutes, there was not enough time to balance the tank levels.

By this time, the Captain had realised that their fuel levels were critical. “We’re committed to land now, we have to land,” he said, and then later, “We don’t want to go around. We can’t.”

The First Officer acknowledged the situation. Normally, the crew would have discussed the Flight Crew Training Manual notes regarding an approach and landing with a low fuel warning. At the very least, they should have discussed the possibility of a further go around, rather than just dismissing the possibility.

Manchester Air Traffic Control should have been told that their fuel situation was critical. Nothing was said after the initial request for direct routing due to low fuel.

From the Thomas Cook internal investigation into the situation:

An important point here is that both crew felt so much better about the situation after the decision was made, it made them reluctant to question it further (if unconsciously). The choice to go to Manchester ‘felt’ very good and this affect probably duped the crew into a false sense that the choice was better than it was in reality, and stopped them reviewing or scrutinising it.

It is probable that the criticality of the fuel situation was never properly realised for a number of reasons; partly due to being consumed with a reflection on earlier mistakes, partly due to a reticence to discuss further problems during the flight (and therefore a tacit reassurance from each other), and partly due to unfamiliarity around diverting and what to expect. However the main reason is probably that the crew viewed the fuel state as being planned as part of the decision to divert…….Because below-minimum fuel was part of that ‘very good’ decision, and the fuel state progressed ‘as planned’ in line with that ‘very good’ decision, the actual criticality of the fuel situation did not make the impact upon the crew that it might have done. This even applied to the EICAS message and failure to run the low fuel QRH.

There’s a happy ending to this one. At 16:49, the aircraft landed safely on flap 30 and taxied to the stand.

There were only 200 kilograms of fuel in the right tank. With the crossfeed valves closed, the right engine was dangerously close to flaming out and certainly would have if they’d been asked to go around.

The day was over for the flight crew. The Captain made a note in the technical log that they were unable to select a speed in the speed window after the go around. He also noted that the LE Slat Asymmetry and Flaps Disagree warnings had been displayed. He did not isolate the cockpit voice recorder or preserve the flight data recorder data although he later stated that he was aware that it was a serious incident. He didn’t debrief the First Officer or review the situation with the crew before dispersing. He didn’t fill in his report immediately as he was in the habit of leaving them for a couple of days. He did attempt to contact the Duty Flight Operations Manager but failed.

On the way home, he realised that he hadn’t told the engineers about the possibility of a flap overspeed event. He phoned in and it was added to the technical log.

The engineers analysed the flight data and discovered that the flap 1 speed limit had been exceeded by 46 knots. Thomas Cook started an internal investigation as the details began to come clear. The day after that, they reported the flight to the AAIB who began their own investigation immediately.

The internal investigation included the following report from the Captain:

He remembered that he called “go around”, but did not state “flaps 20” and that he advanced the thrust levers. He knew that he needed to do something with his thumb, but instead of pressing the Go Around switch, he said he must have disconnected the autothrottle.

The AAIB computed the minimum landing distance for the 757 as 1,455 metres for a flapless landing. If you add a safety margin of 15% in case of technical emergency, that’s a total landing distance required of 1,685 metres. Newcastle’s runway is 2,125 metres.

What should have been a straight-forward go around at Newcastle Airport went very wrong as a dozen small issues cascaded into an avalanche. The niggling feeling that he needed to do something with his thumb led him to disconnect the autothrottle rather than hit the Go Around switch, meaning that he had to advance the thrust levers manually. Because the G/A switch wasn’t selected, the autopilot had to be disconnected in order for the aircraft to climb. And so it went on: a simple mistake in the correct sequence of pressing buttons came damn close to risking fuel exhaustion in the right engine.

Thomas Cook have adjusted their training for go arounds to include the advice that the flight crew need to take their time and discuss their intended actions, and if necessary to re-engage the autopilot first. Obviously it needed to be said.

This incident is especially interesting because unlike many recent go-around incidents, this was not a case of the pilots being unable to hand-fly the plane. On the contrary, the Captain was clearly able to go around and return into the circuit under manual control, despite the Flight Director working against him. He then continued to hand-fly and navigate the Boeing 757 to the first waypoint en route to Manchester. In this case, the combined lack of knowledge of the flight crew regarding the automatic systems in the aircraft and an inexplicable lack of adherence to checklists caused them to get into such a muddle that they became totally unable to fly the plane safely.


For more like this, pick up the first book in my series, Why Planes Crash. Why Planes Crash: Casenotes 2001 covers eleven incidents and accidents in detail from all over the world in 2001.

21 November 2014

The Story of Diamond Jack Palmer and the Pelikaan

The story of Diamond Jack Palmer is a typically Australian story of a beach comber whose luck was in when he found diamonds worth a few million on the beach but couldn’t quite keep up with his luck.

It’s also a fascinating aviation story.

It starts with the Koninklijke Nederlandsch-Indische Luchtvaart Maatschappij airline and their Dutch Dakota DC-3 registration PK-AFV, known as Pelikaan.

KNILM logofrom the personal collection of Jorge González

KNILM (the Royal Dutch Indies Airways) was founded in 1928 and headquartered in Amsterdam. They initially offered services from Batavia (now Jakarta) to Bandung and Semarang. The airline rapidly expanded and, in 1930, they offered their first international flight connecting to Singapore. In 1938 they started operations in Sydney, Australia.

When the Japanese invaded the Dutch East Indies (now Indonesia), the airline evacuated all the aircraft it could to Australia.

Ivan Vasilyevich Smirnov was a Russian WWI flying ace who returned to military flying as a captain in the army aviation corps in Indonesia after the attack at Pearl Harbor. He was asked to evacuate the Pelikaan with two crew and nine passengers fleeing Java. They left just in time: the Japanese took the Bandung area three days later.

In the early hours of the morning, shortly before take-off, the Bandung airport manager handed Captain Smirnov a cigar-box shaped packaged wrapped in brown paper. Smirnov was told to hand the package to a representative of the Commonwealth Bank once he reached Australia.

The package contained diamonds which were later said to be valued somewhere between 3 million and 10 million pounds sterling in today’s money (4 million to 17 million US dollars). Ivan Smirnov claimed that he was did not know what was in the package. He and his fleeing passengers departed Bandung normally.

As the aircraft skirted the Kimberley coast of Western Australia, about 80 kilometres from its destination, Smirnov saw smoke over the town of Broome, which was under attack by nine Japanese Zeros. Japanese fighter ace Lt Zenjiro Miyano spotted the Dakota and led three Zeros to attack.

Mitsubishi A6M3 Zero (Commemorative Air Force / American Airpower Heritage Flying Museum)

The Zeros attacked the defenseless Dakota, firing at its port side. The port engine caught fire. Smirnov was badly wounded but managed to put the aircraft into a deep spiral dive.

His only option was to crash land on the beach. The right tyre exploded forcing the aircraft to veer to the right and into the water, which extinguished the fire in the port engine. The Dakota sank into the sand and swung into the surf which was at high tide.

The Zeros dived to strafe the Dakota again and they scrambled out of the plane to find protection on the beach. Four passengers were killed by the Zeros. Smirnov was badly wounded and sent one of the uninjured passengers to the aircraft to recover the cargo. The passenger picked up the post, the log book and the brown paper wrapped package but then he was hit by a wave and dropped the goods. He recovered the log book and the post but could not find the package.

The following day, while the survivors were waiting for a rescue party, a Japanese Kawanishi H6K dropped four bombs but did not cause any further damage.

Five days later, the survivors were rescued. The representative from the Commonwealth Bank came specifically for the package and Captain Smirnov had to tell him it was lost. The story of the diamonds spread like wildfire, although Smirnov said he never knew what was in the package, only that it was valuable.

It didn’t take long for local man Jack Palmer head to the wreckage to salvage what he could. He and “two Aborigines” collected what they could find. Apparently, he found the cigar box and tipped the largest diamonds into “aluminum cups” which he hid and wrapped the rest in a rag. He showed them to Frank Robinson and James Mulgrue, who were waiting nearby on a motorboat. He’s said to have told them, “Take a handful for each of yourself and don’t tell anyone.”

Investigating party standing in front of crashed Netherlands East Indies KLM Dakota DC-3 passenger transport PK-AFV ‘Pelikaan’ at Carnot Bay, Lieutenant Laurie O’Neil (second from left), ‘Diamond’ Jack Palmer (third from left) and Warrant Officer Gus Clinch (fourth from left), Western Australia, March 1942

What’s definitely known is that the three of them were at the aircraft wreck and that afterwards, Palmer was seen around town spending money and bragging that he no longer had to work, only to sit and smoke cigars. He later handed over two salt-cellars of diamonds to the authorities.

From the Advocate, an Australian newspaper, in a short piece published 4th May 1942:

BROOME, Sunday.-The discovery by a beach comber of £300,000 worth of diamonds on a remote north-western beach has been revealed.
Addressed to the Commonwealth Bank, the diamonds were handed in a parcel to Captain Smernof, Dutch pilot of one of the last planes to leave Java after its capture by the Japanese.

The plane was shot down by Japanese raiders returning from their first raid on Broome early in March, and crashed into four feet of water in Carnot Bay, 60 miles north of Broome. Of the complement of 12, four died of injuries and were buried in the sand hills near the lonely beach. The others were discovered by natives and rescued, but when a search of the plane was made the diamonds could not be found. Later officials made another search, but without success, and the Dutch authorities then despatched a special officer to investigate.

Two days later, Jack Palmer, middle-aged and ill clad, arrived on his way to enlist. He said he had given up his occupation of beach comber, and had abandoned his lugger. Then, producing a pair of large salt and pepper shakers, he poured out on an official’s desk a glittering stream of diamonds. He had found them in a sodden parcel partly embedded in tidal mud near the beach of Carnot Bay. The diamonds are now safe in the Perth Commonwealth Bank.

Palmer was immediately taken into custody for interrogation. He claimed that was all he had and that the package had broken apart with most of the diamonds falling into the sea.

More diamonds showed up in the area, presumably stashed or spent by Palmer, but the total amount recovered was just over 10% of the original shipment.

“Diamond Jack Palmer” and the two men who met him on the motorboat were tried for the theft of the diamonds in 1943. The two accomplices were acquitted as it was determined that no theft had been committed by them. Palmer had handed over two salt-cellars of diamonds to the authorities and although the majority of the diamonds were still missing, the investigation was unable to prove that he had stolen the rest.

The remains of the Dakota remained on the beach until 1970, when the stripped fuselage was broken up by dynamite. The leading edge of one of the wings is apparently all that remains now.

In an interesting addendum, in 1989 a veteran named Norman Keys wrote about his recollections of the crash near Broome.

About the Broome 1942 exhibition

Excerpt from a letter written by Norman Keys dated 29 September 1989. Australian War Memorial PR90/030

After a few days on the beach when the woman and her child and some of the crew were buried, one of the survivors when searching for water was found by one of the local natives who took the rest of the survivors to a dutch [sic] mission station about fifty miles from the beach the plane had landed on. The message got through to Broome 300 miles south and that’s where I entered the story with a trip in a utility to pick them up.

When I arrived at the Beagle Bay Mission the four survivors were in a pretty bad way and the Captain Smirnoff appeared to me to be delirious and kept repeating that he had to get back to the aircraft to pick up the diamonds. For a brief period we considered going back to the aircraft with some native guides but it was decided that we had to get the survivors to hospital in Broome as soon as possible and so began the worst 300 miles trip of my life with my passengers cursing every bump. I never really believed the existence of the diamonds until some time later it was reported in the paper that a beachcomber had come across the plane and found some diamonds and was handing them out to the natives as favours and later in Broome was freely displaying them. It turned out that there was a fortune in Dutch diamonds being evacuated from Java to the bank in Melbourne. There were court cases following the discovery of the diamonds but the bulk of the shipment has never been discovered and the belief is that they are still buried somewhere in N.W. Australia.

The interesting thing is that this is the first reference that Captain Smirnov may have known about his cargo of diamonds. After the crash, he had consistently stated that he never knew what was in the package, only that he needed to deliver it. Based on Norman Keys’ account, he may have known exactly what he was carrying but unable to do anything about it.

The remaining diamonds were never recovered.