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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.

12 November 2014

Crash on Go-Around: Russian Video

This video is harrowing to watch but it’s the most classic example of a stall in the circuit I think I’ve ever seen. The dash cam on this microlight is recording a go-around and crash at a small airfield near Moscow. It was featured in Life News at which point the video began to go viral. The original article is here: Авиакатастрофа под Владимиром попала на запись видеорегистратора – Первый по срочным новостям.

The aircraft was an Evektor Harmony, a light sports aircraft which weighs just 311 kilos empty (686 pounds). The aircraft’s stall speed at VS1 is 45 knots and at VS0 with full flaps it is 40 knots. It’s unclear in the video what the configuration of the aircraft is.

In the left seat is a student pilot and in the right seat is his instructor, who died in the crash. The Life News article refers to the instructor as the pilot but I suspect this is based on being in charge rather than a reference to who was Pilot Flying. It certainly does not look like there was ever a clear decision as to who was in control of the aircraft. There is no official information on the accident yet.

The video begins with what looks like a standard touch and go with some crosswind. The student pilot on the left has the stick, the instructor has the power. It seems to me like the student is looking at the instructor for reassurance and the instructor pulls back on the power, possibly because he couldn’t see how close to the trees they were? The student pulls back instinctively, pulling them right into a stall. Then there’s that awful slip to the left and its all over.

If you were shouting RIGHT RUDDER at the screen while watching this video, you are not alone, as you can see from the commentary on /r/flying on Reddit:

Apparently, photographs from the wreckage show that the flaps were down which might explain why they were climbing away so slowly.

It’s hard to understand what exactly happened or how they managed to do so much wrong on what should have been a simple missed approach.

An investigation is in progress.

07 November 2014

Captain Fired After Nose-Wheel Landing

The Captain of a Boeing 737-700 landed hard at LaGuardia Airport, collapsing the nose gear. But it’s actually what happened leading up to the hard landing that makes this particular case interesting. The final report has not been released; however various public documents, including the Chariman’s factual reports, are now available on the NTSB site:

Accident ID DCA13FA131 Mode Aviation occurred on July 22, 2013 in Flushing, NY United States Last Modified on October 28, 2014 09:10 Public Released on October 28, 2014 08:10 Total 30 document items

Southwest Airlines flight 345 on 22 July 2013 was a scheduled passenger service from Nashville International Airport in Tennessee to LaGuardia Airport in New York carrying 145 passengers and 5 crew. The Captain started her sequence of trips on the 21st of July and the First Officer began his on the 19th. They met up on the morning of the 22nd at Los Angeles International. They had not previously flown together. They flew into Nashville International Airport, arriving at noon, and changed aircraft to the Boeing 737-700. The Captain invited the First Officer to do the next leg as the Pilot Flying and the Captain would take the role of Pilot Monitoring. An American Airlines pilot was in the jumpseat of the cockpit for the trip to New York.

The American Airlines pilot in the jump seat described it as a normal flight.

Once the flight was airborne, both accident crewmembers were very personable. They talked shop and he did not see any issues personality-wise. The captain occasionally gave the accident F/O guidance and he would say ok. The jumpseat occupant did not see any issues in that regard. He thought the accident F/O might be new, based on how the captain was guiding him. The accident F/O made small procedural errors like one time forgetting to push the LNAV right away. During the descent, the captain was giving the accident F/O small instruction tips.

The initial flight was uneventful until they drew close to LaGuardia Airport. There was significant weather in the area and some thunderstorm activity. While they were holding because of the weather, the First Officer briefed a visual approach to Runway 4 backed up with the ILS to Runway 4. They computed the landing distances for the wet runway and the Onboard Performance Computer bracketed out Autobrakes 2, which means that the 2 setting for autobrakes would be not enough for the circumstances. They chose setting 3 for the Autobrakes. During the briefing, the Captain asked if the First Officer wanted Flaps 40. The First Officer agreed, “Yeah, since it’s wet and stuff. Yup.”

The Captain also mentioned that tailwinds on arrival were reaching as high as 30 knots. It’s clear at this point that she was concerned about their landing distance at LaGuardia.

The first officer said that about 98% of the time, he had landed with a 30º flap setting, but he estimated that he had landed with 40º flaps about 30-50 times during the previous year-and-a-half. He stated that a pilot had to be “on his game” with a 40º flap landing, since the airplane had more drag, it required a higher power setting, and a pilot needed to keep a better check of airspeed, because it was quick to decrease. He characterized a 40º flap landing as a power on landing without the pilot reducing power until the airplane was established in the flare with the main gear about 3-4 feet above the runway.

Of note is his description of a 40º flap landing as a power on landing: that is, one flies the aircraft to the ground as opposed to gliding it. The power is only reduced at the very last moment.

The American Airlines pilot in the jump seat barely recalled the conversation.

He remembered a discussion earlier in the flight between the crewmembers that the captain had only been to LGA once before and the F/O had been there a few times. There was a little discussion about going into LGA, but he did not recall much. He thought there was a concern about the length of the runway and the water. He did not remember a discussion about not being fast or high on the approach. He was not paying that close attention.

They were still almost an hour away from landing. There were thunderstorms and clouds between them at the airport; however LaGuardia airport itself appeared to be clear and the aircraft landing before them reported no turbulence on approach.

They broke out of the cloud at about 2,000 feet as they were passed to Tower. The flight crew completed the before landing checklist. The Tower Controller at LaGuardia cleared the aircraft to land.

Up until then, both crew members characterised their cockpit interactions and CRM as good. But as they descended towards the airport, it started to break down.

Interviews with SWA management and training personnel, indicate that the correct protocol would be that when the autopilot was engaged, the PF would be responsible for manipulating the FMC or commanding the PM to do so. The PF would also command a flap setting, which the PM would accomplish. It would not be normal procedure for the PM to manipulate the FMC, flaps, or gear without being asked or commanded.

The First Officer’s recollection was that during the original briefing, the Captain made the decision to use Flaps 40 as she was concerned about the landing distance with the runway being wet. He agreed.

He described her as wanting to be in control. On the approach, he noticed that as he was slowing from 250 knots to approach speed, she started spinning the Mode Control Panel dials without him asking her to set his speeds. As he was about to call for a speed, he found she was ahead of him and already dialling it in.

Under normal circumstances, the Pilot Flying would either set the speeds himself or request that the Pilot Monitoring did it. The First Officer said that it happened that a Captain would say “Hey, I’m going to do this for you” and he would say OK. However, he did not recall the Captain asking or saying anything until after she’d made the changes.

The Captain remembers looking out the window and thinking that the pitch angle did not look good. She realised that they did not have flaps 40 set as per the briefing, which means their performance calculations were wrong. The First Officer, as Pilot Flying, had forgotten and only called for the flaps to be taken as far as 30º.

As Pilot Monitoring, it is her responsibility to notify the pilot flying of anything she notices. However, she should not make changes to the configuration of the aircraft: it is the Pilot Flying’s job to request or make changes.

When they hit the final approach fix, the aircraft was configured for landing with the gear down, flaps 30 and speed brakes armed. The next important phase of the approach was the aircraft reaching 1,000 feet above ground level. The aircraft was on autopilot with the First Officer keeping his hands lightly on the controls ready to take over.

The 1,000 foot call-out is important because the aircraft must be fully configured for landing at this point. If the aircraft is not yet completely configured, the correct response is to break off the approach and go around.

In her interview, the Captain said that she informed the First Officer that the flaps were set to 30 and she was going to set them to 40 and that the First Officer confirmed this. The First Officer’s recollection was that she simply changed the setting and told him afterwards. He was not sure if this happened before or after the 1,000 foot call out although he did know that no further configuration changes should happen after that time.

The cockpit voice recorder has the exchange.

17:43:03 First Officer A thousand feet. Thirty six and sinking six hundred.
17:43:06 Captain Thousand feet.
17:43:11 Cockpit Area Microphone [sound similar to trim]
17:43:30 Captain Oh, we’re forty
17:43:31 First Officer Oh there you go
17:43:32 Cockpit Area Microphone [sound similar to flap handle movement]
17:43:34 Captain That was like an hour and a half ago that we briefed that. I’m sorry
17:43:36 First Officer [sounds of laughter]
17:43:37 Captain All the sudden I started looking at that runway going ‘something’s wrong.’
17:43:39 First Officer Okay.
17:43:40 Captain Okay flaps are at forty.
17:43:41 First Officer Forty, we got it. Green light.
17:43:42 Captain Green light.

The captain said that when she realized that the flaps were not set to 40º, she was pretty certain that they were on the glideslope. She did not recall at what altitude the flaps were set to 40º but it was a “good time” prior to the 500 foot call out. She said she did not remember if they were below 1,000 feet when the flaps were set to 40º, but the flaps should have been down by then. Later in the interview, she stated that “the call for flaps 40 was made with plenty of time before the 500 foot callout. By the book, it would have been a go around.”

The Captain watched the landing through the HUD, which means she was watching the aircraft on the glideslope of the ILS. The Pilot Flying was flying a visual approach and his reference for this was the PAPI.

The Precision Approach Path Indicator (PAPI) is a visual display which provides vertical guidance for the approach path. In a normal approach, the PAPI would show two whites and two reds. More whites means that the angle of the approach is too high. More reds than white means that the angle of the approach is too low.

At around 500 feet, the First Officer disconnected the autopilot and autothrottles. The PAPI indicated two whites and two reds and he was satisfied with his airspeed and crosswind corrections. As far as he was concerned, everything was fine.

The Captain was watching through the Heads Up Display which gave her additional information, including wind.

The first officer said that out of the corner of his eye he noticed that the captain appeared to be somewhat uncomfortable with the approach. As they crossed over the runway overrun, he noticed that the PAPI indicated 3 white lights and one red, which meant that they were a little high on the glidepath. He knew that he would need to make a slight correction to land in the touchdown zone. He said that he then felt the captain’s handon top of his on the throttles, and she pulled his hand and the throttles back retarding the throttles to what felt like the idle position.

He said that he did not recall her making any comments, before, or during her retarding the throttles. The first officer said that he had never had a captain put his/her hand over his on the throttles during an approach, although some captains would guard the throttles by placing their hand below his behind the throttle levers. He said he never had a captain pull the throttles back on him while he was flying an approach.

As the First Officer continued his final approach, the PAPI shifted from two reds and two whites to three whites and a red, thus signalling that the aircraft was slightly high. The Captain, watching from the Heads Up Display, said that she believed that the aircraft was going too fast and that the pitch was too low.

She said it felt as though they were being pushed over the ground. She said that over the threshold, she verbalized that they had to get the airplane down, and she put her hand over the first officer’s hand on the throttle, but was not touching his hand. She said there was no standard procedure for that, but was certain that it was explained as a technique. She said she had verbalized that they had to get the airplane down on the ground, but she did not get the reaction she needed from the first officer, and did not believe she had time to try to articulate it again. She said she believed that if she did not act, the airplane would have continued to float past the touchdown zone.

Another relevant point is that the Captain had been watching the approach on the Heads Up Display. The Jeppesen approach plate (11-1) for ILS Runway 4, states that the VGSI [PAPI] and ILS glidepath are not coincident. This means that even coming down perfectly on the PAPI, the aircraft could show as high on the ILS glideslope. The NTSB have so far makes no comment as to whether this may have led the Captain to overreact as the approach appeared higher than it was.

Regardless, it is quite clear from the data that at the runway threshold, both the glideslope deviation and the PAPI visual guidance indicated that the aircraft was high.

From the transcript of the Cockpit Voice Recorder

17:44:00 Captain Clear to land.
17:44:07 Captain Correcting nicely. Don’t get too much on the speed.
17:44:12 Captain Ooh.
17:44:12 First Officer Come on.
17:44:14 Captain One hundred. Gotta get [unintelligible]
17:44:17 Captain Get down. Get down. Get down. Get down.
17:44:23 Captain I got it.
17:44:23 First Officer Okay you got it.
17:44:26 Captain [sound similar to inhalation]
17:44:26 Captain [expletive]
17:44:26 Cockpit Area Microphone [sound of impact]

The two things that jump out at me here are that her phrasing is not clear and non-standard (most significantly, “I got it” rather than “I have control” when she is taking control of the aircraft. The second is that if the approach was not stabilised: she should have called for the first officer to go around, rather than try to correct the issue and take control at low level.

The American Airlines pilot in the jump seat was unable to say much about the final moments.

The airplane was low; he was thinking they were low and the nose still looked low. He was not
familiar with the airplane and was seated in the jumpseat, but it did not look right. He thought the altitude was in the 150-200 foot range. There was a 2-4 second delay after the throttles went to idle and then the captain said my aircraft and the accident F/O lifted his hands up in the air. He did not notice what the F/O did when the captain pulled the throttles to idle.

The jumpseat occupant was concerned about the pitch being low so he was looking outside the airplane. After the transfer of control, he seemed to recall a pitch down at that point. The airplane pitched over further down. He became tunnel visioned on the cement and he did not look back inside. The ground was coming up quicker than he thought it should have.

The First Officer said that he acknowledged and released control of the aircraft and then scanned the altimeter and airspeed. He looked out at the rapidly approaching runway and said that all he could think to do was brace for impact. There was no time to say anything.

The Captain may have let the nose wheel drop drying to catch the ILS glideslope and by the time she realised, it was too late for a correction.

The captain said that she saw the nose hit the runway, and felt the impact of the nose hitting, but did not feel the nose wheel hit, and had no recollection of which gear hit first. She said it was a hard impact, and the airplane started sliding. She said she tried to control the airplane with rudder and brakes. The airplane veered slightly to the right before stopping on the runway.

Asked his impression of what section of the airplane touched down first, [the American Airlines pilot in the jumpseat] said the nose wheel first. He did not remember how far down the runway they touched down. He did not recall any markings on the runway before they touched down. He was looking “at concrete” but he was looked at the centerline. When they did the pitch over when the nose hit, it felt like “one big jarring moment” and then the nose was on the ground. He did not feel an arresting sensation like the nose wheel touched first and then collapsed. The nose was on the ground and they were sliding and he thought a panel or 2 became dislodged in the cockpit. After a few seconds, smoke entered the cockpit from underneath the floor boards and around the pedestal.

Boeing have submitted their report based on the Flight Data Recorder:

The FDR data show the airplane configured for a flaps 40 approach with the autopilot and autothrottle engaged, and on glideslope and localizer at 500 feet Radio Altitude (RA). The autopilot and autothrottle were disengaged at approximately 410 feet RA. As the approach continued, the airplane began deviating above the glide path due to increased thrust and a slight increase in pitch attitude while maintaining the selected speed of VREF40+6. At the runway threshold, the airplane was at 60 feet RA and on a 2.1-degree glide path. The throttles were reduced to forward idle at 46 feet RA, and at 32 feet RA the cockpit voice recorder indicated that a transfer of control was made from the First Officer to the Captain. After the transfer, but prior to touchdown, the control column relaxed to neutral deflection, the throttles were advanced.

Due to the early reduction in thrust to forward idle, the absence of control column input prior to touchdown, and the nose-down pitch tendency in ground effects, the airplane pitch attitude decreased to a nose-down attitude of -3.1 degrees and touched down on the nose gear prior to the main gear touching down.

In other words, the Captain pulled the power back because she believed that they were too high. The nose pitched down and as the aircraft touched down on the runway, it landed nose-gear first.

The investigation is still in progress; however the Captain has been already terminated by the airline.

10 October 2014

Bit of a Fender Bender at Dublin Airport

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

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

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

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

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

The Evening Standard followed suit:

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

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

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

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

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

The notice has since been deleted from the site.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

26 September 2014

Hypoxia on Kalitta 66

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

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

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

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

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

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

This transcript is from the National Air Traffic Controllers Association.

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

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

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

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

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

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

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

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

Great Lakes Region Award Winner

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

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

19 September 2014

Pilot Suicides: Fact vs Fiction

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

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

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

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

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

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

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

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

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

1982: Japan Airlines Flight 350

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

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

The flight proceeded normally from there until the final approach.

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

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

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

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

Passengers reported that the aircraft nose dropped suddenly.

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

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

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

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

Troubled Pilot – TIME

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

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

1994: Royal Air Maroc Flight 630

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

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

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

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

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

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

1997 SilkAir Flight 185

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

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

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

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

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

09:05:15 The cockpit voice recorder stopped recording

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

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

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

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

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

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

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

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

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

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

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

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

1999: EgyptAir Flight 990

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

2013: Mozambique Airlines Flight 470

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

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

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

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

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

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

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

From the preliminary report:

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

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

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


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

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

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

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

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

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

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

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

12 September 2014

UPS 1354 and the unforgiving nature of flight

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The symptoms of fatigue include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

15 August 2014

The Runaway Runway Van

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The van continued.

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

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

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

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

Air Canada flight 1126 landed without incident.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

From the incident report:

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

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

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

01 August 2014

Congo Crocodile Plane Crash

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

Let’s start by looking at the crash.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Essentially, it fell out of the sky.”

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

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

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