I found this on a webpage called Funny air traffic controllers quotes and amusing aviation conversations and I just had to share. The story was submitted by an Air Traffic Controller named Jim.

In 1978 I was a trainee Air Traffic Controller under supervision at Collage Station Texas, Easterwood Tower. This is a true story of a radio discussion one afternoon:

Unknown Aircraft: “Hello…?”

Easterwood Tower (me): “Please say again.”

Unknown Aircraft: “What?”

Easterwood Tower: “Who is this?”

Unknown Aircraft: “This is Joe”

Easterwood Tower: “This is Easterwood Tower, where are you?”

Unknown Aircraft: “I’m in the plane!”

(I looked down the flight line, checking if someone was sitting in a parked plane playing with the radio. I didn’t see anything, and the senior controller was becoming more interested in my handling of the situation.)

Easterwood Tower: “Joe, where is the pilot?”

Unknown Aircraft: “He got out when the engine quit..”

(I could only imagine a bizarre scenario in which the pilot had jumped from the plane.)

Easterwood Tower: “Joe, what does your airspeed indicator read?”

Unknown Aircraft: (Long pause) “Zero?”

(So the plane was now in a stall, I thought.)

Easterwood Tower: “Joe, whatever you have in front of you – a stick or a steering wheel – push it forward – you need to get airspeed over your wings!”

Unknown Aircraft: “Are you sure?”

Easterwood Tower: “Yes Joe you need to push it forward… (pause)… What does your airspeed indicator read now?”

Unknown Aircraft: “It’s still zero.”

(I thought, oh my god, Joe’s plane was in a falling leaf spin. I couldn’t help him. Joe was going to die. I did not know what to do. I looked to the senior controller. He said, “Ask him where his plane is.”)

Easterwood Tower: “Joe, where is your plane?”

Unknown Aircraft: “We are parked down at the end of the runway, the pilot got out when the engine quit and walked back to the hanger..”

Easterwood Tower: “Joe, get off the radio.”

John Smith regularly took flying holidays with his family. His youngest daughter, Jacqueline, followed in his footsteps, getting her PPL once she turned 18. The father and daughter were in a syndicate of five people who owned a Piper Cherokee Arrow (PA-28R-201T) and the logs show that they took the plane most Easter weekends, booking it weeks in advance.

In 2007, they spent Easter weekend in Oban, flying every day along with wife and mother Angela in the back seat. A member of staff at Oban remembered them and posted to an online forum: “I spoke to the family shortly before they departed for home, and they came across as very nice people who were enjoying their flying in this part of the world.” But when it came time to return home, the weather was bad. They decided to depart Oban despite the clouds. The next morning, the wreckage was discovered in a farmer’s field in the west Highlands, just nine nautical miles from Oban Airport.

John Smith gained his UK PPL in March 1980 which was valid for life. He had 324 hours experience. His medical certificate expired on November 2006 and he had not submitted the annual exercise ECG required as a result of his heart condition. However, there is no evidence that he had any medical issues during the flight.

Jacqueline Smith’s was one of the first of the new-style JAR PPLs which only have a five year validity. In 2005, the CAA did not send any notifications that a renewal was required and numerous pilots were later found to be flying on expired licences. Jacqueline Smith did renew her Single Engine Piston (Land) rating and may well have overlooked the fact that her licence had expired.

Friday, 6 April 2007

The flight departs Andrewsfield Airfield in Essex with three on board. Father and daughter regularly flew together, with John Smith in the left seat and Jacqueline Smith in the right seat, regardless of who was the pilot in command. As such, it’s not possible to tell who flew the aircraft that day. Jacqueline Smith’s logbook shows that John Smith had flown the seven previous flight hours as commander and in the accident report, John Smith is referred to as the “commander” for simplicity’s sake. As he had more experience and was the one discussing the flight with airfield staff, it seems likely that he was, in fact, the pilot in command.

13:44 The family flight arrives at Blackpool Airport to refuel. John Smith is seemingly unaware that Blackpool required prior permission for all incoming flights. This was a temporary condition due to deal with heavy traffic over the bank holiday weekend so the Smiths would not have known this simply by looking at the plates. It’s not an uncommon mistake.

14:51 They departed Blackpool, arriving at Oban at 16:30. Oban Airport at the time required prior permission as standard and the Smiths were required to give at least three hours notice. John Smith expressed surprise when the Air/Ground Operator raised the matter with him after their landing.

The family toured around the local area every day in the aircraft. On Sunday the 8th, after returning from their flight, they refuelled to full ready for their flight home the following day. They went to a local hotel for dinner and drinks and arrived at the airfield the following morning.

Monday 9 April 2007

10:00 The family arrives at Oban airfield and loads the aircraft with their luggage. They report to the office and pick up the weather reports and forecasts.

The aftercast shows that between 10:00 and 12:00 hours, the cloud base was low with rain and drizzle around the mountains. Visibility at Oban varied between 4,000 metres and 10km and hill fog would have been extensive, with visibility less than 200 metres. Cloud was scattered or broken with a base varying from 400 feet to 1,500 feet and a top of 2,000 feet. But further broken or overcast clouds were above that laying starting at 2,000 to 3,000 feet with a top varying from 5,000 to 7,000 feet and further broken layers of cloud above that.

Later, a number of pilots around Scotland said that they had cancelled their flights on Monday owing to the rain and cloud. The Professional Pilots Rumour Network includes posts from pilots in the area in the days following the accident.

Light aircraft down near Oban – PPRuNe Forums:

“I know the area around Oban well and that afternoon I wouldn’t have been tempted to get airborne.”

“Ben Vorlich and the like were shrouded in mist, and the winds were very strong – you could certainly believe the weather guesser’s prediction of 28 knot+ gusts. I’ve never flown into Oban before (just overflys from my plank days), so all that, plus the surrounding terrain, was a big factor in my decision to go have lunch elsewhere and leave that for another day.”

However, John Smith hopes that he can get his family home. He comments that the weather is clearer in England and mentions as a part of conversation that he is not instrument rated. He decides that they will go up to have a look at the weather but, if it isn’t suitable, they will return to the airfield. The Air/Ground operator tells him that they won’t be charged for an additional landing if they have to come back. The family board the aircraft and do an engine check before heading for the runway.

10:35 The aircraft departs west and at approximately 1,000 feet above mean sea level it disappears into the cloud.

John Smith transmits that they are at 1,500 feet amsl and changing to the en-route frequency.

Oban Air/Ground give them the frequency for the appropriate Scottish ATC station and warns them that they’re unlikely to receive a reply until they are further south.

John Smith acknowledges this without reading back the frequency.

10:42 The aircraft is high enough to appear on radar tracking at Tiree in a climbing left-hand turn passing through 3,300 ft. It then does a complete circle to approximately 5,800 feet over the Isle of Kerrera, 8 nautical miles south-west of Oban. The aircraft turns were becoming tighter and its altitude seems to vary between 5,600 and 5,900 feet. The flight then appears to “wander” in a roughly south-easterly track.

From the Air Accident Investigation Branch official report Piper PA-28R-201T Turbo Cherokee Arrow III, G-JMTT:

The weather at takeoff and the forecast for the first part of the flight over south-western Scotland was not suitable for the intended Visual Flight Rules (VFR) flight. It is possible that the aircraft climbed in a hole in the cloud over the Isle of Kerrera. Once the aircraft had climbed to height the pilots would not have been able to keep in sight of the surface, as the privileges of their licences required them to do.

Neither pilot was trained in instrument flying other than the basic familiarisation training as a part of their initial training, which is meant to allow a pilot who accidentally flies into instrument conditions enough information to be able to fly back out. It is unlikely that either of the Smiths was experienced enough to maintain control of the aircraft in cloud.

10:48 The aircraft altitude reduces to approximately 5,300 feet and about thirty seconds later, the aircraft enters a left turn. During this turn, Tiree radar records that the altitude drops to 4,700 feet and then to 3,700 feet in under 16 seconds.

Lowther loses secondary radar tracking for 23 seconds. There’s no mechanical reason for this and it is likely that there was no line of sight between the radar and the aircraft transponder, which is consistent with the aircraft in a severe nose-down attitude.

In summary, the radar data shows the aircraft climbing to, and holding, a relatively stable cruise altitude but with no set direction. Turns were initiated, culminating in a relatively tight turn associated with a large descent rate and unusual aircraft attitudes. Electrical power was available at least until nearly the end of the last recorded turn, well after the tight descending turn was initiated. Given the location of the end of the radar track relative to the accident site location and disparity between the direction of the last recorded track and the estimated impact direction at the accident site, the aircraft carried out at least one further half turn between loss of the radar track and impact. It is also possible that it carried out further complete turns or other manoeuvres below radar coverage. The time between the loss of radar track information and impact is not known.

11:55 Oban’s Air/Ground Operator phones Scottish ATC to enquire whether G-JMTT has made contact with them. It has not.

There is no reason to file a flight plan for this flight, thus the Air/Ground Operator cannot know the route they are taking back to Andrewsfield. He thought they maybe planning to stop at Blackpool to refuel again, but the Smith’s have not contacted Blackpool for prior permission, which they were made aware was required on Friday’s flight. If ATC had been formally notified of the flight, overdue action would have been initiated within an hour of G-JMTT’s non-arrival. In practice, it would not have made a difference.

Tuesday 10 April 2007

One of the other pilots of the plane becomes concerned as he is unable to contact John Smith by phone. He contacts Oban and confirms that the flight departed the day before. He contacts John Smith’s office, who tell him that John Smith was expected in for 10am meeting but he has not arrived. He then contacts Andrewsfield who state that they have not heard from G-JMTT. He phones Distress and Diversion to inform them that G-JMTT is overdue. A full overdue action is instigated at 14:08.

13:40 Angus McFadyen, a farmer near Loch Scammadale, is out with his son, checking the sheep in the hills above Bragleenmore Farm. They discover the wreckage on a hillside at 963 feet above sea level and contact the Strathclyde police to report the crash.

Both wings were sheared off but McFadyen later tells the BBC that he recognised the fuselage as being from a plane. He finds the engine and the remnants of the cockpit 32 metres (104 feet) away.

The impact crater and other features are consistent with a high-speed nose-down impact at a speed of between 140 and 200 knots.

14:50 Distress and Diversion are contacted regarding the wreckage. The search is called off and the accident investigation begins.

So What Happened?

Post-mortems were carried out on all the occupants of the aircraft. All three died on impact. There were no obvious signs of disease and all the occupants tested negative for drugs. Although it is possible that a medical situation incapacitated one or both of the pilots in the flight, there was no evidence that this was the case.

However, both John and Jacquelyn Smith tested positive for alcohol. John’s result was the equivalent of a blood alcohol concentration of 99mg/100ml and Jacquelyn’s was 48mg/100ml. Angela Smith, in the backseat, tested negative, making it unlikely that the alcohol detected could have been produced post-mortem.

It is an offence to perform an aviation function where the proportion of alcohol in your blood is over 20mg/100ml. As a comparison, the legal limit for driving in the UK is 80mg/100ml. John Smith was legally too drunk to drive and yet appears to have been in command of the aircraft. Jacquelyn Smith had a lower result but still was not legal to fly.

Based on the weather reports, the flight took place in cloud (Instrument Meteorological Conditions or IMC), which meant that the pilots were unable to determine the attitude of the aircraft visually by looking at the horizon. They had to rely on instruments as they were not in sight of the ground.

The flight instruments in the plane consisted of electric Horizontal Situation Indicators and Turn Coordinators and a vacuum-driven Attitude Indicator (Artificial Horizon).

The vacuum pressure was supplied by a vacuum pump with no back-up. On the right side of the instrument panel was a gauge to show the level of suction and on the left side of the instrument panel was a warning light which illuminates if the suction drops too low.

The Century III autopilot on the plane relied on the vacuum-driven Attitude Indicator as its attitude reference source. The pressure from the altimeter is used to command the autopilot to maintain the set altitude. The autopilot is reliant on the pitch information as given by the Attitude Indicator, which is also the primary instrument for safe flight in IMC. Without the Attitude Indicator, the autopilot would not function correctly and would not be able to hold a heading or an attitude.

The GPS unit was damaged in the crash and so it is not possible to determine the aircraft’s last recorded position nor see what communication and navigation frequencies were set.

The flight was tracked externally by two radar installations. The radar tracking is not completely accurate and in fact, the tracks from Lowther don’t quite coincide with the tracks from Tiree. However, there’s certainly enough data to understand the “motion trends” and get a general feel for what the aircraft was doing.

The plane appears to have been “under reasonably precise control” until the final tight turn when the aircraft starts to descend rapidly. Lowther then loses secondary radar, indicative of the aircraft being in an unusual attitude. From the data, it appears that the Smiths had lost control of the aircraft and were plummeting nose first towards the ground.

The vacuum pump was severely damaged, the rotor and vane assembly had shattered. However, close examination showed rub marks on the fracture faces … which meant that that the engine-driven end of the pump must have still been rotating after the coupling fractured. That meant the engine was still running.

That means that the fracture must have occurred before the aircraft crashed into the ground.

The vacuum pump was eleven years old and had done approximately 994 hours. The pump manufacturer had sent out a Service Letter which limited its use to 6 years and 500 hours but the aircraft owners were not aware of this. The service manual was unclear and it could be understood that the pump needed to be replaced at the 1,000 hour inspection.

The vacuum pump had only one function on this aircraft: to supply vacuum pressure to operate the Attitude Indicator.

If there was no vacuum pressure, the gyro rotor within the Attitude Indicator would slow down and then start to topple. This takes quite some time and minutes could pass before the gyro was moving slow enough to become unbalanced.

The Attitude Indicator will give false information based on the movement of the gyro: it can’t tell the difference between the plane movements and the gyro toppling. If the autopilot were engaged, it would follow the false indications of pitching and rolling shown by the Attitude Indicator.

If the plane has lost vacuum pressure, the Attitude Indicator will not show it. The suction gauge should show a zero reading and the vacuum pressure failure light should illuminate.

As a result of the impact damage, it was impossible to determine whether the light was illuminated before the plane crashed. Nor is it possible to determine whether the autopilot was engaged at the time of the crash. But the faulty readings of the Attitude Indicator could confuse a pilot as easily as they do the autopilot. Flying in cloud, a pilot relies on the Attitude Indicator because his own responses cannot be trusted.

With the absence of outside visual references, physical sensations can produce compelling perceptions of the aircraft’s attitude and manoeuvres that differ markedly from those indicated by the flight instruments and spatial disorientation can occur. This tends to be more likely when recent and/or total instrument flying experience is low and in a high stress situation, or with alcohol in the pilot’s blood.

The flying conditions through cloud would have been stressful. Neither pilot had been trained in instrument flying. Both pilots had blood alcohol levels over the legal limit. Score three out of three for spatial disorientation.

Flying through clouds, the pilot would have suffered from “the leans”. A major breakthrough in aviation safety in the early 20th century was understanding this phenomenon and teaching pilots to use instruments for visual input, rather than trusting the false sensation of leaning. Instrument training teaches a pilot to use all the instruments in order to get a clear understanding of the aircraft’s attitude, including what to do under circumstances like this where a primary instrument has failed.

Without visual input, a pilot can inadvertently put the aircraft into a turn in order to try to straighten out a non-existent turn. This inadvertent turn then develops into a spiral dive and the plane accelerates nose-first into the ground, just as the radar tracking shows.

Although the Air Accidents Investigation Branch did not have records of accidents caused by vacuum system failures, their US counterpart, the National Transport Safety Board, had 62 accidents/incidents over the past twenty years which cited the vacuum system as one of the factors. Of those incidents, 40 were fatal. Reports showed that in many, the pilot was aware of the loss of vacuum pressure before losing control in IMC conditions – that is to say, flying through cloud.

It’s still possible that something else happened, that the pilot was incapacitated in such a way that did not leave medical evidence … and it is impossible to prove without a doubt that the vacuum pump failed completely; however the final spiral dive combined with high airspeed are standard symptoms of spatial disorientation and there is clear evidence that the pump must have broken before the impact.

The Air Accidents Investigation Branch concluded that the failed vacuum pump was the only failure discovered in the wreckage that could have caused the resulting loss of control of the aircraft. It is unclear when the vacuum pump failed but they estimate that the resulting erroneous readings probably started just before the aircraft entered the final left turn, approximately 24 seconds before the radar track was lost.

Conclusion

The aircraft crashed after control was lost while in IMC. The characteristics of the final flight path, particularly the high airspeed, the rapid descent and the rate of turn, were consistent with the effects of spatial disorientation. The pilots were not IMC or Instrument Rated, and alcohol was present in both pilots. It is likely that the accident resulted from loss of control as a result of the pilots following unreliable indications from the AI, whilst in IMC. The AAIB has made four Safety Recommendations relating to the maintenance of vacuum pumps.

The pilots were not IMC or Instrument rated. Had they been flying under VFR conditions, in sight of the surface, they would probably have been able to maintain control of the aircraft.

Four recommendations were made, focused on the correct maintenance of vacuum pumps. As for VFR pilots who fly in bad weather because they just really want to get home, well, there’s not much that the AAIB can recommend other than Don’t!

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On the 28th of July in 1945 a B25 crashed into the Empire State Building. The photographs look like something out of an old King Kong movie, with flames licking up the building. But the fire was extinguished within 40 minutes, still the only fire at such a height that was ever successfully controlled.

And if that hasn’t already got you wanting more, the accident also resulted in 19-year-old Betty Lou Oliver taking the Guinness World record for the longest survived elevator fall recorded.

So what happened?

Lieutenant Colonel William Franklin Smith Jr was the pilot of the B25 bomber.

750thSquad

Col Smith was with the original complement of officers as a 1st Lieutenant when the unit was formed and a Lt Col at the end of the war. He had a jaunty and devil-may-care attitude and was very popular with the men who flew with him. He witnessed all 236 missions of the 457th but fate caught up with him in 1945 after returning from England. He and several others were flying a B-25 bomber from Boston to his new assignment in the midwest.

The plane, a North American B-25 Mitchell medium bomber, was called the “Old John Feather Merchant”.

Lt. Colonel Smith was flying from Boston to Newark airport where he would pick up his superior officers. He travelled through steadily increasing fog and requested a weather report at 25 miles east of his destination. ATC at New York Municipal Airport (now La Guardia) reported that the ceiling was “near zero” and visibility forward limited to three miles.

The B-25 that Crashed Into the Empire State Building • Damn Interesting

Municipal tower reported extremely poor visibility over New York, and urged him to land, but Lt. Colonel Smith requested and received clearance from the military to continue his flight. “From where I’m sitting,” the tower operator warned, “I can’t see the top of the Empire State Building.” Despite the advice from the Municipal tower, Smith plunged into the soupy fog with his two crewmen, bound for Manhattan.

The Empire State Building, built in 1930, is 1,453 feet to the tip of the broadcast tower. It was built to take the impact of a 10-ton aircraft.

Gloria Pall was 18 and worked at the Empire State Building on the 56th floor, having been turned down by the Catholic War Relief Services group on the 79th floor because she was Jewish.

Eyewitnesses reported seeing the bomber overhead at about 500 feet and said that it just missed the Rockefeller center. The plane then climbed away back into the fog.

Historical Perspective: Plane hits Empire State Building

No one knows for sure, but investigators believe that Col. Smith looked down through a break in the cloud cover and saw a curved river and thought it to be the East River, when in fact it was the Hudson. Seeing this curve it is believed that he then descended for his approach at Newark airport. It is believed that the planes speed at this time was 225 mph.

Lt Colonel Smith appears to have seen the building at the last moment: the gear was moving up and the nose was pitched up but he was already too close to the building to evade it. The bomber crashed into the building at the 78th and 79th floor. The building was rocked by the impact which was heard for miles. A fire burst out immediately.

Gloria Pall was working that Saturday but she didn’t mind because the weather wasn’t good enough to go to the beach anyway. She remembers being disappointed that the “pea-soup fog” blocked her view when there was a loud explosion that threw her against the room.

The day a B-25 Bomber crashed into the Empire State Building

“It’s the German Buzz Bomb!” yelled Sarah, who was usually calm. “They tricked us. They didn’t really surrender!”

Another lady screamed that it was Martians. “We’re being invaded,” she yelled. “I just know it. We’re not getting out of here alive!”

Joan’s boss, Hazel, a short, rotund sweet-faced redhead, was calmly sitting in front of her Danish pastry and coffee. She was still on her break and had just returned from the first floor coffee shop.

The aircraft with a 67-foot wingspan created an 18 x 20 foot hole. The fuel tank exploded. Lt Colonel Smith and three others onboard died on impact and eleven office workers died immediately by the flying metal or in the fire.

Historical Perspective: Plane hits Empire State Building

The 102-foot building was rocked by the impact. Many people who were in the street at the time saw flames shooting from the point of impact, which was at the 913-foot level. The impact was heard as far as two miles away. Flames and dense smoke obscured the top of the structure. Later on a wing was found on Madison Avenue, one block away.

Nearby buildings were damaged by fragments of the impact and one of the planes engines was found on the South side of the building in the top of a twelve story building. The engine had flown over thirty-third St. and had crashed through a skylight in a penthouse. The engine started a $78,000.00 fire in the studio of sculptor Henry Hering.

Here’s a news reel from the time:

The plane crashed into the north side of the building. One wing was found on Madison Avenue. One of the engines was found on the south side of the building.The other engine fell down an elevator shaft and damaged the cables, including cutting the safety cables, as it fell.

Therese Fortier Willig was on the 79th floor, working for the Catholic Relief Services.
The Day A Bomber Hit The Empire State Building : NPR

“In the other side of the office, all I could see was flames,” Willig said. “Mr. Fountain was walking through the office when the plane hit the building and he was on fire — I mean, his clothes were on fire, his head was on fire. Six of us managed to get into this one office that seemed to be untouched by the fire and close the door before it engulfed us. There was no doubt that the other people must have been killed.”

Betty Lou Oliver, a 19-year-old elevator operator, was on the 80th floor. She was badly burned in the initial fire. Rescue workers placed her into the elevator to send her down an ambulance waiting at the bottom, with no idea that the cables had been damaged. There was a sound like a gunshot when the final cables snapped.

Our Local Correspondents: Up and Then Down : The New Yorker

By the time the car crashed into the buffer in the pit (a hydraulic truncheon designed to be a cushion of last resort), a thousand feet of cable had piled up beneath it, serving as a kind of spring. A pillow of air pressure, as the speeding car compressed the air in the shaft, may have helped ease the impact as well. Still, the landing was not soft. The car’s walls buckled, and steel debris tore up through the floor. It was the woman’s good fortune to be cowering in a corner when the car hit. She was severely injured but alive.

This remains the longest fall survived in an elevator according to the Guinness Book of World Records.

Gloria Pall and her friend Joan escaped the building using the stairwell, which had two long flights of steps between landing. One hundred and twelve flights later, they reached the ground floor and dashed out of the building.

The day a B-25 Bomber crashed into the Empire State Building

As Joan and I went over to look at the engine on 33rd Street, Mayor Fiorello LaGuardia came over to us to ask how we were, and congratulated us on our survival. As we turned to go, my boss pushed his way through the crowd and approached me.

“You ought to come in next Saturday because you didn’t even work two hours today,” he said, oblivious to my disheveled appearance, and the fact that I had my arm in a sling and traces of debris still on my clothes and face.

“What a grump,” I thought, “With all these people applauding us, he’s punishing me for surviving! How insensitive!” Joan and I turned, climbed over the rope that partitioned off the building, and limped our way down the street to the BMT subway so we could get back to Brooklyn.

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I’ve been reading an old accident investigation report from the National Transportation Safety Committee in Indonesia. You may recall the frightening photographs that hit the press in March 2007, when this Boeing 737 overran the runway at Yogyakarta and was destroyed from the impact and resulting fire. One flight attendant and twenty passengers were killed and twelve others were seriously injured.

The accident investigation report reference KNKT/07.06/07.02.35 is available online at the NTSC site as a PDF: Final Report.

Here’s my summary and analysis of the key information including excerpts from the Aircraft Accident Investigation Report by the NTSC. All images are from the report unless otherwise noted, in which case they link to the original source.

All times are given in UTC. Local time for Yogyakarta, Indonesia is UTC+7 hours.

On 7 March 2007, a Boeing Company 737-497 aircraft, registered PK-GZC, was being operated by Garuda Indonesia on an instrument flight rules (IFR), scheduled passenger service, as flight number GA200 from Soekarno-Hatta Airport, Jakarta to Adi Sucipto Airport, Yogyakarta. There were two pilots, five flight attendants, and 133 passengers on board.

ATC referred to the flight as “Indonesia 200″.

Here’s the timeline of the events:

21:30 Pilot in Command (PIC) and co-pilot commence duty at Jakarta.

Both pilots had over a day of rest time before the flight. There’s no evidence that either was unfit for duty.

The PIC had logged 13,421 hours flight time with 3,703 as pilot in command on type. He completed Controlled Flight into Terrain and Approach-and-Landing Reduction training recurrency just over a year before the accident.

The copilot had logged 1,528 hours of which 1,353 were on type.

Both crew members had attended an introductory seminar for the Enhanced Ground Proximity Warning System in 2005.

However, the accident report notes that there is no evidence that either pilot had been checked or received Boeing 373 similator training for appropriate vital actions and responses for alerts as warnings, such as TOO LOW TERRAIN and WHOOP, WHOOP, PULL UP. Note that the correct response to such a warning is to take control of the aircraft and aggressively apply maximum thrust, get the wings level and pitch up to 20 degrees. This will be important later.

23:17 Indonesia 200 departs Jakarta.

PIC was the pilot flying with the copilot offering monitoring and support. The initial flight was uneventful.

Up to the time of the top of descent briefing, the oral communication between the PIC and the copilot, air traffic control approach and tower controllers, and the company radio, were in normal tones and in an orderly manner. Subsequently, during the approach below 10,000 feet and prior to reaching 4,000 feet, the PIC was singing and there was some minor non-essential conversation, which was not in accordance with the Garuda Basic Operations Manual policy for a sterile cockpit below 10,000 feet.

23:43 PIC begins the crew briefing. The briefing is interrupted by Yogya Approach with clearance. After the radio call, the PIC continued with the crew briefing for an ILS approach.

23:54:10 Pressure altitude 6,560 feet, airspeed 269 knots
Yogya Approach asks the crew to confirm that they are visual.
The copilot responds with ‘affirm’.

At no time did the copilot inform ATC that they were flying the 09 ILS approach.

The Approach Controller cleared Indonesia 200 “for visual approach runway zero nine, proceed to long final, report runway in sight.”

The copilot read back the clearance and asked if they were cleared to descend to circuit altitude.

23:54:33 Pressure altitude 5,792 feet, airspeed 279 knots
The Approach controller clears Indonesia 200 to descend to 2,500 feet.

During this descent the PIC commented “Oops, strong wind”, showing a lack of observation of the strong wind they’d encountered during the flight. The wind at this stage had decreased from previous levels as they descended.

Eleven seconds after expressing concern about the wind, the PIC said ‘Target enam koma enam ILS, kagak dapat dong’ (the target is 6 point 6 ILS, we will not reach it). The PIC then attempted to trade off excess airspeed and lose height, but only succeeded in flying a flight path that was erratic in pitch, causing the airspeed and altitude to vary considerably. The PIC flew an unstabilized approach.

23:55:19 Pressure altitude 4,384 feet, airspeed 293 knots
The aircraft at this stage is at 3,419 feet above aerodrome elevation and flying much too fast.

The Garuda Aircraft Operation’s Manual specifies a maximum control speed in the terminal area below 10,000 feet as 250 knots. A speed over 250 knots requires air traffic control approval.

The airspeed increased from 288 knots to 293 knots then reduced to 243 knots.

Effectively, the PIC went into a steep descent to trade height for speed at a point in the approach when he should be losing height and speed. He lost 2,912 feet with his erratic flight path.

23:55:33 Aircraft is 10 miles out. Initial fix in the approach chart is 2,500. Aircraft was 1,427 feet above this and travelling at 283 knots.

The company Operations Manual required the aircraft to be configured for the landing, with the landing gear extended, flaps 15, and the airspeed 150 knots, when approaching the final approach point (FAP), one dot up on the glideslope instrument. When GA200 passed the FAP, the speed was 254 knots (groundspeed 286 knots), and it was in the clean configuration, meaning that the landing gear and flaps were not extended.

This is twenty seconds after he’d stated that they won’t reach the target.

23:56:35 Pressure altitude 3,456 feet, airspeed 239.5 knots
Wing flaps 1 degree position set.
Yogyakarta Tower: Surface wind calm, continue approach runway 09 report final

Runway 09 has a landing distance of 2,200 metres.

23:56:46 Pressure altitude 3,296 feet, speed 231 knots
PIC: gear down

They are now 2,596 feet above aerodrome elevation.

The gears are extended. The plane continues to descend. It is too high and too fast.

23:56:49 PIC: oh there is something not right

Between 23:56:49 and 23:57:20 the aircraft was in an unstabilized approach condition with the speed varying between 229 and 244 knots, pitch varying between 3.5 degrees up and 3.8 degrees down, and the rate of descent reached 3,520 feet per minute at 23:57:20.

[...]

The PIC said ‘The target is 6.6 ILS, we will not reach it’. The PIC flew an unstabilized approach. He also realized the abnormal situation when he commented ‘Wah, nggak beres nih!’ (‘Oh, there is something not right’). So, the PIC’s intention to continue to land the aircraft, from an excessively high and fast approach, was a sign that his attention was channelized during a stressful time.

23:57:13 PIC: check speed, flaps fifteen

23:57:15 Ground Proximity Warning System: SINK RATE SINK RATE
The terrain closure rate is 3,461 feet per minute. The aircraft is 1,369 feet above the runway.

23:57:17 Copilot: flaps five

The PIC requested fifteen as well as a speed check. The copilot did not offer a speed check nor did he make any attempt to explain why he intended to set the flaps to five instead of fifteen.

The reason was clear. The recorded airspeed of the aircraft at that point was was 238 knots. The maximum indicated airspeed for extension of flaps to the 15 position is 205 knots. So why didn’t he say so?

At interview the copilot stated that he did not extend the flaps to 15 degrees as instructed by the PIC, because the airspeed exceeded the maximum operating speed for flaps 15.

The PIC stated that he was unaware of the actual airspeed, and expected that the copilot would inform him of any speed concerns.

Quite right! On the other hand, he’s already ignored the Ground Proximity Warning System and he did not react to any of the other statements by the co-pilot, so it may not have made a difference. Still, there’s a critical failure here in terms of monitoring and support.

23:57:19 Tower Controller: Indonesia 200, wind calm, check gear down and lock clear to land runway 09
Ground Proximity Warning System: TOO LOW TERRAIN TOO LOW TERRAIN

23:57:23 The copilot selects wing flaps to the five degree position.
PIC: Clear to land Indonesia 200

Remember that as far as the tower controller is aware, they are doing a visual approach.

23:57:29 PIC: Check speed, flaps fifteen
PIC: Flaps fifteen
PIC: Flap fifteen
PIC: Check speed, flap fifteen

Their speed was around 252 knots at the first of these four times the PIC requested flaps fifteen. Maximum flaps operating speed for Flaps 5 is 250 knots. Flaps 15 maximum is 205 knots.

During this time, and until 1 second before the GPWS sounded ‘ten’, meaning 10 feet above the runway, the GPWS warning continued to sound loudly.

At interview, the PIC stated that he continued to call for flap fifteen because he was committed to land from the approach, and was aware that he would not be able to use flaps 40 as planned. He knew the risks, but believed that he could safely land using flaps 15, even with the higher airspeed required for a flap 15 approach.

23:57:34 Flaps reach the five degrees position
The aircraft is 569 feet above the runway. Airspeed is 254 knots, rate of descent is 1,600 feet per minute.

Garuda Indonesia Operations Manual states that any approach that becomes unstabilised below 500 feet above the aerodrome in VMC requires an immediate go around. The aircraft had never achieved a stabilised approach.

23:57:37 PIC: flight attendant, landing position

This was seventeen seconds before touchdown. The flight attendants should have been given enough time to sit and fasten their seat belts and “sit quietly for one minute to recall the emergency memory items.”

23:57:41 Ground Proximity Warning System: WHOOP, WHOOP, PULL UP

You’ll remember the correct response to this warning is to aggressively apply maximum thrust. That is, go around.

23:57:43 Copilot: Wah Captain, go around Captain

The aircraft is 217 feet above the runway. I don’t know about you but I was shouting “Go around!” at my screen long before this point.

23:57:45 Ground Proximity Warning System: WHOOP, WHOOP, PULL UP

There’s no justifiable reason not to go around at this point. This is pretty much the definition of an unstabilised approach. Almost every factor is wrong.

The copilot should have taken control and initiated a go around as the PIC hadn’t.

The PIC response to the situation is telling.

23:57:47 PIC: Landing checklist completed, right?

The PIC does not appear to have registered the warnings nor the copilot’s call to go around at all. The accident report describes his actions as fixated.

He intended to land the aircraft, so that the other tasks and warnings (GPWS ‘PULL UP’ and calls from the copilot) were either not heard or were disregarded. His attention was channelized and focused on landing the aircraft from the approach.

That is to say, his every priority was the landing and he simply disregarded all information that was not directly relevant to landing the plane. He never considered aborting the landing, so information relevant to not landing the plane was disregarded.

The copilot made no attempt to take control of the aircraft from the PIC.

Seven seconds before touchdown, the rate of descent was 1,400 feet per minute and decreasing. The aircraft crossed the runway 09 threshold at 89 feet above the ground (704 feet pressure altitude), at an airspeed of 234 knots (groundspeed of 236 knots).

The aircraft is travelling 98 knots too fast as it crosses the threshold.

The aircraft levelled off about ten feet above the runway for 4 seconds before touching down with a groundspeed of 235 knots.

The touchdown should have occurred around 300 metres from the landing threshold. The touchdown zone ends at 620 metres.

23:57:54 The aircraft touches down for the first time, 860 metres from the threshold, airspeed 221 knots.

The landing speed for 40 degrees flap is 134 knots. The maximum tyre speed is 195 knots groundspeed.

The plane’s touchdown speed was 221 knots. It landed 240 metres past the touchdown zone.

23:57:54 Copilot: go around

The aircraft bounces. Twice.

At the third (final) touchdown, the nose landing gear touches down heavily before the main landing gear.

The g force at the third (final) touchdown was about 2.9 g, and the aircraft’s pitch angle was about -1 degree (nose down), which caused the nose landing gear to touchdown heavily before the main landing gear. The left nose wheel tire failed due to high rotational forces applied during the initial landing roll. The subsequent bending load on the left nose wheel axle was above the material’s ultimate strength and caused the left axle to fail. Metal from the failed left nose wheel slashed the right nose wheel tire, causing deep cuts to the tire’s crown. The outer hub of the right nose wheel separated, leaving pieces on the runway. The inboard hub of the right nose wheel remained attached to the right axle and was scoring the runway during the high speed landing roll.

I have to give the PIC credit, that’s perfectly lined up on the centre-line, even after two bounces!

23:58:10 The aircraft overran the departure end of runway 09 at Yogyakarta Airport.

The Runway End Safety Area (RESA) is a paved area of 60 metres long. There is an additional 98 metres of grass thereafter which is not defined as part of the RESA. The ICAO standard requires a distance of at least 90 metres and recommends a RESA of 240 metres or more for a Category 3 airport such as Yogyakarta.

The PIC reported that as the aircraft was about to leave the runway, he shut down both engines. The aircraft crossed a road, and impacted an embankment before stopping in a rice paddy field 252 meters from the threshold of runway 27 (departure end of runway 09).

The fire fighting personnel noted the fast and high approach of the aircraft and the burst wheel on the runway. They mobilised two fire fighting vehicles to the perimeter fence immediately. But they couldn’t get past the embankment that the aircraft had barrelled through.

The fire fighters were unable to reach the wreckage due to the embankment and remained in position about 130 metres from the centre of the crash site. They sprayed the foam fire suppressant from the embankment but it was too far for the spray gun to reach. They attempted to deploy the flexible hose but it was punctured by vehicles driving over it and on the airport fencing. As a result of the lack of pressure, they were not able to cover the whole surface of the wreckage.

The fire was uncontrolled and consumed the aircraft.

The Airport Emergency Plan (AEP) required, the chief of fire fighting AP1 to lead the fire fighting operation, but at the time of the accident he was not able to lead the operation, due to too many people trying to act as leader and giving commands to fire fighting personnel. About 45 minutes after the accident, two city fire fighting vehicles arrived and were ordered by an un-qualified person to start hosing the fire. However, the city vehicles did not have foam; only water.

02:10 The fire is finally extinguished. The rescue operation continues.

Human factors are always an issue in any emergency situation and must be taken into account. But this Garuda Indonesia accident was so beset by problems, it is off the charts.

The co-pilot appears to have completely failed to offer basic monitoring and support to the pilot. He did not appear to notice the wind, he did not warn the PIC of excessive speed, he chose not to fulfil the PIC’s instructions but did not tell the PIC, and he did not respond at all to the repeated requests for a speed check. Once it was clear that the PIC planned to continue the landing from an unstabilised approach, he should have taken control of the aircraft and gone around.

The chaos of the rescue operations encompasses a further few pages of the report, which I have not covered in detail here. It took over two hours to extinguish the fire and although the report is not clear on the effects of this, it does say that this delay “may have significantly reduced survivability”.

But all of this pales into insignificance in the face of the pilot who continued the approach and landing despite all evidence available to him that this was an unsafe landing.

Garuda Indonesia’s policy is very clear: in case of an unstabilised approach, go around. Let’s see how many of the elements of a stabilised approach were in place?

Garuda Stabilised Approach Procedure
Recommended Elements of a Stabilized Approach
All approaches should be stabilized by 1000 feet HAA in instrument meteorological condition (IMC) and by 500 feet HAA in visual meteorological conditions (VMC). An approach is considered stabilized when all of the following criteria are met:

• the aircraft is on the correct flight path.
• only small changes in heading/pitch are required to maintain the correct flight path.
• the aircraft speed is not more than VREF +20 knots indicated airspeed and not less than VREF.
• the aircraft is in the correct landing configuration.
• sink rate is no greater than 1,000 fpm; if an approach require a sink rate greater than 1,000 fpm, a special briefing should be conducted.
• power setting is appropriate for the aircraft configuration.
• all briefing and checklist have been conducted.

These conditions should be maintained throughout the rest of the approach
for it to be considered a stabilized approach. If the above criteria cannot be
established and maintained at and below 500 HAA, initiate a go-around.

The PIC did not reduce the aircraft’s speed to the target airspeed of 141 knots for the approach. The actual speed was 245 knots. The aircraft was not in the landing configuration, and the actual sink rate of 3,520 fpm exceeded the Operations Manual requirement of not greater than 1,000 fpm. The landing checklist was not completed.

In fact, I’d say that out of the seven criteria, the approach might have fulfilled one: I presume the power setting was appropriate.

As the aircraft crosses the runway threshold it should be:

• Stabilized on target airspeed to within +10 knots until arresting the rate of flare.
• On a stabilized flight path using normal maneuvering.
• Positioned to make a normal landing in the touchdown zone (i.e., first 3,000 feet or first third of the runway, whichever is the less).

Initiate a go-around if the above criteria cannot be maintained.

Not any of these were in place.

The investigators asked the PIC what happened.

During interview he said to investigator that ‘his goal was to reach the runway and to avoid severe damage’. He ‘heard, but did not listen to the other voice (GPWS), and flaps 15 and speed 205 was enough to land’. The PIC experienced a heightened sense of urgency, and was motivated to escape from what he perceived to be a looming catastrophe, being too high to reach the runway (09 threshold). He fixated on an escape route, ‘which seem most obvious’, aiming to get the aircraft on the ground by making a steep descent. His decision was flawed, and in choosing the landing option rather than the go around, fixated on a dangerous option.

The NTSC Aircraft Accident Investigation Report concludes with the following primary causes:

1. Flight crew communication and coordination was less than effective after the aircraft passed 2,336 feet on descent after flap 1 was selected. Therefore the safety of the flight was compromized.
2. The PIC flew the aircraft at an excessively high airspeed and steep descent during the approach. The crew did not abort the approach when stabilized approach criteria were not met.
3. The pilot in command did not act on the 15 GPWS alerts and warnings, and the two calls from the copilot to go around.
4. The copilot did not follow company instructions and take control of the aircraft from the pilot in command when he saw that the pilot in command repeatedly ignored warnings to go around.
5. Garuda did not provide simulator training for its Boeing 737 flight crews covering vital actions and required responses to GPWS and EGPWS alerts and warnings such as ‘TOO LOW TERRAIN’ and ‘WHOOP, WHOOP PULL UP’.

For full details, read the final report from the NTSC.

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If you found this post interesting you might enjoy the following:

• Tipsy Nipper Crash Video
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• Human Factors: Crossair Flight 850
• Biggin Hill Accident Report
• Alaska Airlines Flight 1866
• Unfit to Fly
• How to Drown a Jet

A few years back I wrote about this Tipsy Nipper going into a flat spin. I didn’t realise it at the time but a few months after my post, the pilot posted his video of the spin to YouTube with commentary. You have to watch this!

The spin was supposed to be a normal erect spin to the right, but for various unintentional reasons the spin went flat, up until that point I had never flat spun an aircraft. I eventualy mananged to get the aircraft into a normal erect spin from which I was able to recover. This aircraft is not fitted with an electric starter motor, so I was unable to restart the engine.

During the “flare” to land the main undercarriage caught the top wires of a barbed wire fence that was invisible to me.

After coming to rest inverted I waited 20mins for the rescue services to come and right the aircraft so I was able to exit via the outward opening canopy.

The aircraft rotated 26 times total, I was extremely disorientated after the recovery to straight and level flight, and was unable to read the instruments.

From the video I estimate I recovered at about 700ft from an entry altitude of 3500ft. If you listen carefully you will hear me say:”I think this is it”. At that stage I did not think I would be able to recover. However I continued to try various control inputs based on the aircraft attitude and rotational rate, which eventually effected a recovery.

My thanks go to the emergency services that found me and allowed my escape.

Here’s my original post from the time:

Fear of Landing » Tipsy Nipper feeling Dippy

Ever wondered what you’d do if you entered an unintentional spin? What about a flat spin, where the plane is horizontal and spinning like a top, all the while falling out of the sky.

Last autumn, there was a post to the Tipsy Nipper Owner’s Group Forum with this photograph and the following comment.

Whilst walking in the RSPB nature reserve in Tollesbury Essex I came across this Nipper after it had crash landed on Monday evening.

They were in the process of removing it on Tuesday morning when I went past, the pilot had a lucky escape as it had flipped over in the marsh, the pilot had to be freed by emergency crews.

The plane was immediately recognised as belonging to Neil Spooner but local news confirmed that he was unharmed. He posted on the message board within the week to let the members know what had happened:

A rather disturbing occurance, normal spin entry and the spin went flat. Having never done any flat spin training was rather at a loss as to what to do to recover (normal spin recovery techniques don’t work in a flat spin). However, a quick review of spin aerodynamics on the way down gave me a few ideas, one of which obviously worked. The engine stopped during the spin (22 rotations) which meant an outfield landing in a rather inhospitable area. The main wheels caught the two top wires of a barbed wire fence in the flare which both decelerated the aircraft and flipped it on its back. I spent 20mins waiting for the emergency services to turn up (pretty good I think) The police air support heli’ landed close by and 2 crew lifted the tail so I could open the canopy and step out. Absolutely no injuries except my pride.

Twenty-two rotations! No, he wasn’t counting, he had a webcam and laptop connected so that he could analyse his aerobatics later. You can read the full accident report as a PDF on the Air Accidents Investigation Branch website.

If you found this post interesting you might enjoy the following:

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I wasn’t sure what I was going to write about today and then I saw this unbelievable video posted on Golf Hotel Whiskey entitled Amazing video of how NOT to land a Cessna Citation 2. Although the incident was over five years ago, I’d never seen it before.

The Citation, OY-JET, was coming into Atlantic City, New Jersey. He had the airport diagram attached to his control column which read “Arpt CLOSED to jet traffic”. The pilot flew a low pass over runway 29 and then climbed out to the right. He then came in to land on runway 11.

Somewhat telling is the commentary from the person who started filming: “We’ve got a nutball trying to land.” Even he didn’t expect to see the landing go so completely wrong, though. And then at the half-way mark of the video, just when I thought it was all over, things suddenly get exciting again. Take a look:

The pilot stated that he “lost the brakes”; however there as no fault found with the brake system nor the emergency brake system. However, examination of the runway shows that the treadmarks start about two-thirds down the runway.

OY-JET appears to have touched down about 800-1,000 feet beyond the approach end of runway 11. The video shows us the windsock with a tailwind which as been estimated at 10-15 knots. Runway 11 is a 2,948 foot asphalt runway.

NTSB Factual Report NYC05LA085

According to the Cessna 525A Landing Distance Chart, an airplane with a landing weight of 11,400 pounds required 3,000 feet of landing distance, in a no wind situation. With a 10 knot tailwind, the airplane required 3,570 feet of landing distance.

So if he’d landed on the numbers, he still would have not have been able to land safely. Touching down a third of the way down, he had no chance at all.

The same pilot has been in the news once before, as a result of this photograph taken into the cockpit of a Cessna 550 Citation II at Copenhagen five years previous. Maybe he’d planned to go skinny-dipping?

The NTSB have published Probable Cause on their website.

The pilot’s improper decision to plan a flight to a runway of insufficient length, his improper in-flight decision to land on that inadequate runway with a tailwind, and his failure to obtain the proper touchdown point.

Other than that, though, it was a lovely landing.

The owner of the aircraft appears to have one heck of a sense of humour. They’ve replaced the ruined aircraft with a Cessna 680:

Photos: Cessna 680 Citation Sovereign Aircraft Pictures | Airliners.net

The new registration? OY-WET

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If you found this post interesting you might enjoy the following:

• Tipsy Nipper Crash Video
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• A Close Encounter with an Emu
• Cross Country Solo

The 398th was a B-17 bomb group in the 8th Air Force 1st Air Division during World War II. The US Eighth Air Force was the largest of the Army Air Forces, engaged in heavy bombing of enemy targets in France, Belgium, the Netherlands and Germany. The Boeing B-17 Flying Fortress was a four-engine heavy bomber aircraft which was heavily used in the strategic bombing campaigns of World War II.

Boeing B-17 Flying Fortress – Wikipedia, the free encyclopedia

From its pre-war inception, the USAAC (later USAAF) touted the aircraft as a strategic weapon; it was a potent, high-flying, long-range bomber that was able to defend itself, and to return home despite extensive battle damage. It quickly took on mythic proportions, and widely circulated stories and photos of B-17s surviving battle damage increased its iconic status.

The 398th were stationed in Nuthampstead, England during the final year of the conflict where they ran 195 combat missions. Thanks to the hard work of the 398th Bomb Group Memorial Association, the locations, combat diaries, log books and missions are all documented on the web. They have also collected priceless memories from “friends of the 398th” – both Brits who remember the 398th while stationed in England and other squadrons who flew with them.

You could spend all day on this website and never get bored. It’s an amazing collection.

I received permission from the association to share one story with you and it was difficult to decide. You know me, though, I’m a sucker for a happy ending. And this happy ending against unbelievable odds has to be read:

It Was A Fortress Coming Home by Allen Ostrom tells the story of the B-17 Flying Fortress on the 15th of October 1944. 90-year-old Allen Ostrom is the military historian for the 389th Bomb Group. The story starts on the ground:

“They’re 20 minutes early. Can’t be the 398th.”

They could hear it before they could see it! Something was coming home. But what?

All eyes turned toward the northeast, aligning with the main runway, each ground guy and stood-down airman straining to make out this “wail of a Banshee,” as one called it.

Not like a single B-17 with its characteristic deep roar of the engines blended with four thrashing propellers. This was a howl! Like a powerful wind blowing into a huge whistle.

Then it came into view. It WAS a B-17!

The B-17 Flying Fortress took a direct hit over Cologne, Germany. The crew had just dropped their bombs and were turning away when a flak burst took out the nose of the aircraft.

The togglier was killed instantly. Here’s a front view of the Flying Fortress that day:

The full size view and more photographs of the damage are on http://www.398th.org/.

Lt. deLancey described the scene from the cockpit:

“Part of the nose peeled back and obstructed my vision and that of my co-pilot, 1st Lt. Phillip H. Stahlman of Shippenville, Pennsylvania. What little there was left in front of me looked like a scrap heap. The wind was rushing through. Our feet were exposed to the open air at nearly 30,000 feet above the ground. The temperature was unbearable.”

They had no oxygen, no maps, no radio and and practically no instruments. They descended and turned back towards allied territory.

By this time they were down to 2,000 feet.

“We finally agreed that we were over Belgium and were flying in a southwesterly direction,” said the pilot.

“About this time a pair of P-51’s showed up and flew a loose formation on us across Belgium. I often wondered what they thought as they looked at the mess up front.”

Amazingly, the American crew made their way over France and found England where the skill of the flight crew came into its own:

“Once over England, LeDoux soon picked up landmarks and gave me course corrections taking us directly to Nuthampstead. It was just a great bit of navigation. Ray just stood there on the flight deck and gave us the headings from memory.”

They weren’t safe on the ground yet, though, and Allen Ostrom’s account had me at the edge of my seat until the very end:

Nearing the field, Stahlman let the landing gear down. That was an assurance. But a check of the hydraulic pump sent another spray of oil to the cockpit floor. Probably no brakes!

Nevertheless, a flare from Ruckel’s pistol had to announce the “ready or not” landing. No “downwind leg” and “final approach” this time. Straight in!

“The landing was strictly by guess and feel,” said DeLancey. “Without instruments, I suspect I came in a little hot. Also, I had to lean to the left to see straight ahead.

1st Lieutenant Lawrence deLancey was awarded a Silver Start for bringing a plane home that, by all rights, had no business flying. The navigator, 2nd Lt Raymond J. LeDoux, received the Distinguished Flying Cross.

Read the whole account at It Was A Fortress Coming Home.

I recommend also taking a look at the 398th Veterans’ WWII Personal Histories and read, well, everything. And you can also watch the 398th Timeless Voices Interviews and see and hear the men tell their stories first hand in an amazing collection of oral history. This is an outstanding selection of real stories from real people, with hidden gems such as Nunzio Addabbo, 398th Navigator explaining how he paid for his flying lessons at 17 by picking blueberries and James (Dean) Hill, 398th Pilot remembering flying the bomber: seeing the flak coming up and knowing you had to fly through it.

The 398th Bomb Group Memorial Association have created a truly wonderful website to share their stories and memories with a wider audience. The next time you see Kipling’s words “Lest we forget” on Remembrance / Memorial / Anzac Day, take a moment to savour treasures such as this one.

On the 1st of April this year, Southwest Airlines flight 812 departed from Phoenix for Sacramento. There were five crew and 118 passengers on board.

At 34,000 feet, climbing through to FL360, there was a loud sharp noise. The cabin experienced rapid decompression and the oxygen masks deployed.

Shawna Malvini Redden, a passenger on the flight, blogged about the experience:

The Blue Muse: Southwest Flight 812: I prefer my plane without a sunroof, thanks

An explosion. A loud rush of air. A nosedive toward the ground. An oxygen mask? I had not anticipated a change in cabin pressure.

With hypoxic fingers, I fumble the mask. With chagrin, I realize it really does not inflate.

To my right, a mother shrieks in hysteria, her panic rising above the din. Ahead, a young man with curly brown hair and an easy smile walks about, helping to affix oxygen masks. Behind me, a woman’s tears stream down her face as the shock sets in.

I realize I have my seat mate’s hand in a death grip.

This is Southwest Flight 812.

The pilot immediately began a descent. The Federal Aviation Commission released the audio recordings this week which you can hear on the FAA site or read online: PDF Transcripts of Southwest Flight 812, April 1, 2011.

Here’s the initial discussion, with added punctuation and the times given as local time. R6 and D31 are controllers covering specific sectors in the Los Angeles Air Route Traffic Control Center.

15:55:57	Southwest Airlines 812	Southwest eight twelve. Thirty two climbin to flight level three six zero.
15:56:00	R60	Southwest eight twelve LA center roger.
15:57:47	Southwest Airlines 812	Center (unintelligible) eight twelve
15:57:51	R60	Southwest uh I’m sorry who was that
15:57:55	Southwest Airlines 812	…twelve
15:57:56	R60	I missed that last call. Who was that?
15:57:57	Southwest Airlines 812	…twelve
15:58:00	R60	Southwest eight twelve uh was that you?
15:58:02	Southwest Airlines 812	Yes sir (unintelligible) declaring an emergency descent declaring an emergency we lost the cabin.
15:58:08	R60	Yeah Southwest eight twelve I’m sorry, I could not understand that. Please say again.
15:58:12	Southwest Airlines 812	Requesting an emergency descent. We’ve lost the cabin. We’re starting down.
15:58:15	R60	Southwest eight twelve descend and maintain flight level two four zero.
15:58:20	Southwest Airlines 812	Two four zero Southwest eight twelve.
15:58:24	R60	What altitude do you need?
15:58:26	Southwest Airlines 812	(unintelligible) We need uh ten thousand.
15:58:29	R60	Understood.
15:58:33	D31	Sector ten and thirty one.
15:58:35	R60	Yeah this is Sector uh sixty. Southwest eight twelve is a emergency decompression descent he’d like ten thousand feet. Can you approve that?
15:58:43	D31	Uh…
15:58:45	R60	He’s doin’ it anyway.
15:58:47	D31	Yes. Yes, approved.
15:58:48	R60	He’s descending to ten thousand (unintelligible) I’ll be flashing him to you.
15:58:52	Unknown	You done good.

The flight was approved for a direct return to Phoenix but then they realised that Yuma International Airport, a “shared use” military and commercial airport, was closer. The flight landed at Yuma at 16:32 local time. A flight attendent and one passenger received minor injuries as a result of the incident; both were treated at the airport.

The aircraft had a large tear in the fuselage. The NTSB reported that it was a 5-foot by 1-foot (152cm by 30cm) hole in the crown area on the left side, aft of the over-wing exit.

NTSB Continues Investigation of Southwest Airlines Flight 812

The 59-inch longitudinal fracture occurred in the aluminum fuselage skin along the lap joint at stringer-4 left (S-4L) between body station (BS) 666 and BS 725. At S-4L, the crown skin overlaps the lower skin forming a lap joint. The two skins are connected at the lap joint by three rows of rivets (referred to as lower, middle, and upper row of rivets.) The fracture was through the lower skin and connected 58 consecutive rivet holes in the lower row of lap joint rivets. The exterior surface of the skin in the area of S-4L is painted blue. Evidence of blue paint was also found inside the joint between the upper and lower skin and on several areas of the skin fracture surface.

Southwest grounded 80 aircraft as a result of this incident, all Boeing 737-300s which had not already had the skin on their fuselage replaced. Boeing announced a Service Bulletin instructing operators to inspect the aircraft. This was followed by the FAA issuing an Emergency Airworthiness Directive on the subject.

NTSB Continues Investigation of Southwest Airlines Flight 812

The Federal Aviation Administration issued Emergency Airworthiness Directive AD 2011-08-51 on April 5 mandating the inspections in the Boeing Service Bulletin. To date, the NTSB has been informed that 136 airplanes have been inspected worldwide in accordance with the Service Bulletin and Airworthiness Directive including all U.S. registered airplanes covered by the Directive. As stated in a previous release, four of these airplanes were found to have crack indications at a single rivet and one airplane was found to have crack indications at two rivets. These airplanes had accumulated between 40,000 and 45,000 total cycles. The lap joints from these areas of the subject airplanes have been removed and will be fully documented as part of the NTSB investigation.

The investigation continues but it did make me happy to hear the utter competence with which the flight crew and ATC dealt with the emergency. Hurray for happy endings!

A RusAir passenger jet, a Tupolev 134, crashed in northern Russia on Monday the 21st of June, killing 47. The five remaining survivors, including one crew member, are still being treated in hospital.

The flight was en route from Domodedovo airport in Moscow to the city of Petrozavodsk. The Federal Aviation Regulator stated that the approach was conducted in darkness and poor weather, with a cloud base of 170m and visibility of 2,100 metres.

The aircraft’s approach was too low. It clipped a tree and severed the power line to the airport, causing the runway lights to go off for ten seconds. An air traffic controller on site stated that the airport visibility was at minimum and that the crew should not have continued their descent. He said that he ordered the crew to abort when the runway lights went off but it was too late.

The Deputy Prime Minister, Sergei Ivanov, claimed that the crew had failed to see the runway and instead were attempting to land on the road.

The captain had logged 8,500 hours including 3,100 hours on the Tu-134, while the co-pilot had 813 hours on type from a total of 2,580 hours.

Moscow-based Interstate Aviation Committee (MAK) is investigating the incident. The preliminary findings have not found any technical faults with the Tupolev and have attributed the disaster to pilot error.

Experts transcribe air-ground conversations in Petrozavodsk plane crash | Russia | RIA Novosti

The experts have ruled out technical failure as the possible cause of Tu-134 crash. In both reports on the circumstances of the crash, MAK said the engines of the Tu-134 passenger jet were operating normally, as were all radar, electronic, lighting and other systems at the airport where the Tu-134 airliner crashed.

Pilot error has been identified as the most likely cause of the tragedy.

The only surviving crew member, Yulia Skvortsova, confirmed that it was not a planned emergency landing. She stated that the co-pilot was at the controls at the time of the landing and believes that the aircraft did not go around because the co-pilot wanted to save fuel.

Tu-134 crash survivor reveals horror flight’s details — RT

Skvortsova is still being treated at a Moscow hospital, but had been released from the intensive therapy unit on Monday. She believes that the ill-fated aircraft did not make a second landing approach, despite the bad weather, because the second pilot wanted to save fuel. Small airlines like the one which operated the crashed plane often fine pilots for overspending.

Ukranews.com reported that the aircraft did not have enough fuel for a second approach although this has not been confirmed by MAK.

The Russian president, Dmitry Medvedev, has insisted that the remaining Tupolev 134 airliners must be withdrawn from service. In addition, the air transport safety chief has reaffirmed that any commercial airliners that do not have collision-avoidance technology installed by next year will be grounded.

This video from Reuters shows amateur video footage directly after the accident:

The Bureau d’Enquêtes et d’Analyses today released an Update on Investigation regarding flight Air France 447. AF 447 was an Airbus A330-203 on a scheduled flight from Rio de Janeiro Galeão to Paris Charles de Gaulle on the 1st of June 2009. Contact with the flight was lost in the early hours of the morning. A week later, a few pieces of the aircraft were found.

The crash made international headlines because the aircraft appeared to simply disappear: there was no mayday call nor radar information and initial attempts to find the crash site and wreckage has failed.

Last month, an expedition ship, the Alucia, discovered the wreckage at the bottom of the South Atlantic Ocean and was able to recover the black boxes. This Update on Investigation is a result of the data recovered. It is not a final report.

The BEA have released an English translation of the document which I am using for this post. However, it includes a foreword to state that the original text in French should be considered the work of reference.

You can read the full document online: Update on Investigation in PDF format. The French original is also available: accident survenu a l’Airbus A330-203. The report is also available in German and Portuguese translations.

I’ve written this to help people keep to the facts in mind when reading news coverage, which traditionally gets somewhat confused and over-excited when reporting on this incident.

Here are the highlights of the document, hopefully in an easy-to-follow format.

The report confirms that there were no initial issues with the crew nor the weight and balance of the flight.

22:29 The flight took off.

Initially, the Captain was Pilot Not Flying and one of the co-pilots was Pilot Flying which was in accordance with standard procedure. During the flight, the Captain took a rest break and the other co-pilot took his place as Pilot Not Flying.

This is important to understand as I’ve already seen media headlines screaming that the Captain was not in the cockpit when the problems began. This is a non-issue. There were three flight-crew members on board, all fully trained, in order to ensure that the pilots can have rest breaks.

SKYbrary – Pilot Flying and Pilot Not Flying

When two pilots fly a fixed-wing aeroplane which requires a two-person flight crew, the aircraft commander, who must be appropriately qualified and hold the rank of Captain, occupies the left hand seat and the First Officer or Co-Pilot occupies the right hand seat.

Before the commencement of each flight sector, the aircraft commander decides which pilot will take direct responsibility for flying the aircraft for the complete flight or for particular parts of it such as the Descent/Approach and Landing and they become ‘Pilot Flying’ (PF) for that sector or the specified part of it. The other pilot is then designated for that sector or relevant parts of it as ‘Pilot Monitoring’ (PM) or alternatively as ‘Pilot Not Flying’ (PNF) and in that role must monitor the flight management and aircraft control actions of the PF and carry out support duties such as communications and check-list reading. The Operations Manual will specify fully the roles for the PF and PM/PNF, but one of the most important aspects of the duties of any PM/PNF is the cross-check of the actions of PF. Indeed, this part of the role represents one of the most important single reasons why a two-pilot flight crew is specified.

01:35 The crew were in contact with air traffic control. Everything seemed normal.

01:55 The Captain woke the second co-pilot to take his place as Pilot Not Flying.

Between 1 h 59 min 32 and 2 h 01 min 46, the Captain attended the briefing between the two co-pilots, during which the PF said, in particular “the little bit of turbulence that you just saw […] we should find the same ahead […] we’re in the cloud layer unfortunately we can’t climb much for the moment because the temperature is falling more slowly than forecast” and that “the logon with Dakar failed”. The Captain left the cockpit.

At this stage, everything was normal. Ten minutes later, the incident begins.

02:06 The Pilot Flying warns the cabin crew about upcoming turbulence.

02:08 The crew make a slight turn to the left. The turbulence increased and they reduce the speed to about Mach 0.8.

At this point, it’s worth watching the timeline including the seconds.

02:10:16 The autopilot and then the auto-thrust disengages. The Pilot Flying says, “I have the controls.” The plane begins to roll to the right. The Pilot Flying rolls left and raises the nose. The stall warning sounds. The plane appears slows right down.

The recorded parameters show a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS).

The autopilot and auto-thrust remained disengaged for the rest of the flight.

Now in my opinion, the notes in the Update on Investigation are very interesting:

Note 1: The angle of attack is the angle between the airflow and longitudinal axis of the airplane. This information is not presented to pilots.

Note 2 : In alternate or direct law, the angle-of-attack protections are no longer available but a stall warning is triggered when the greatest of the valid angle-of-attack values exceeds a certain threshold.

Alternate Law means that there is a disruption to the aircraft flight control system(s). As the data input could not be trusted (the speed displays in this case), some of the monitoring protective functions of the control system are not available.

It’s interesting that this is pointed out: the angle-of-attack was critical to the incident and that the Airbus A330 does not display this information as flight information for the flight crew.

At any rate, the angle of attack increased and the plane began to climb.

The recordings show that the Pilot Flying made nose down control inputs. The Pilot Not Flying attempts to call the Captain back to the cockpit.

The vertical speed, which had reached 7,000 ft/min, dropped to 700 ft/min and the roll varied between 12 degrees right and 10 degrees left. The speed displayed on the left side increased sharply to 215 kt (Mach 0.68). The airplane was then at an altitude of about 37,500 ft and the recorded angle of attack was around 4 degrees.

If I understand this correctly, the speed displayed on the left side increased but the integrated standby instrument system had not updated yet, so would have shown 60 knots. I’m not quite clear on this though.

02:10:51 The stall warner triggers again.

The thrust levers are moved to the Take Off/Go Around position. The Pilot Flying maintains nose-up inputs on the controls. The recorded angle of attack continues to increase.

Around fifteen seconds later, the speed displayed on the ISIS increased sharply towards 185 kt; it was then consistent with the other recorded speed. The PF continued to make nose-up inputs. The airplane’s altitude reached its maximum of about 38,000 ft, its pitch attitude and angle of attack being 16 degrees.

Note: The inconsistency between the speeds displayed on the left side and on the ISIS lasted a little less than one minute.

02:11:40 The Captain re-enters the cockpit. The report says that the recorded speeds “became invalid” which means that the measured speeds were shown as below 30 knots. The stall warning stopped.

The altitude was then about 35,000 ft, the angle of attack exceeded 40 degrees and the vertical speed was about -10,000 ft/min.

This means the plane was falling out of the sky. The Pilot Flying holds the sidestick to full left and nose-up position for around 30 seconds.

There is a lot of speculation that this is what caused the crash. Based on the information given here, it would seem that the plane was in a stall and the nose needed to come down. Pitching the nose-up to the full extent would be a bad response in a stall situation.

However this is a preliminary report and no such conclusion is drawn in the report. It is not stated in the report that the crash was caused by this action, simply that the action occurred.

02:12:02 The Pilot Flying says, “I don’t have any more indications” and the Pilot Not Flying responds with, “we have no valid indications”.

By now, the thrust levers are in the idle position and the engine power is at 55%.

The Pilot Flying pitches the nose down, decreases the angle of attack and the speeds become valid again. The stall warning sounds again.

02:13:32 The pilot says “we’re going to arrive at level one hundred”. Fifteen seconds later, both pilots manipulate the sidesticks and the Pilot Flying passes control to the Pilot Not Flying.

02:14:28 The recordings stop.

The document includes a list of new findings. The penultimate point is chilling:

After the autopilot disengagement:

• the airplane climbed to 38,000 ft,
• the stall warning was triggered and the airplane stalled,
• the inputs made by the PF were mainly nose-up,
• the descent lasted 3 min 30, during which the airplane remained stalled. The angle of attack increased and remained above 35 degrees,
• the engines were operating and always responded to crew commands.

The information in this report would seem to imply that the pilot became overwhelmed and incorrectly interpreted the situation. I recommend reading the full Update on Investigation. The initial problem remains the pitot and the bad speed data. The pilot was handed control of a plane (when the autopilot and auto-thrust failed) that was incorrectly configured. There are many aspects to any incident and AF 447 is no exception. It is possible that the BEA will conclude that pilot error was a primary cause but, as yet, we do not have a full report.

So remember: be wary of news reports that state any cause as fact until the BEA release their conclusions!