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24 January 2014

Suicide by Plane

It was a quiet Saturday in Tampa on the 5th of January in 2002. A 15-year-old high-school student arrived at the St. Petersburg-Clearwater International (KPIE). He started learning to fly May the previous year and had been taking lessons at the airport once or twice a month. He had a flying lesson scheduled for 17:00.

In the US, a student may not fly solo until their 16th birthday but training flights, where the instructor is the pilot-in-command, are possible. What better way to celebrate your 16th birthday with your first solo flight!

The student pilot checked in at the school. He’d done 19 hours in the aircraft already and that day, he was planning to work on traffic patterns. His flight instructor was just finishing up a previous lesson. He told the student to go ahead and do the pre-flight checks on the training aircraft and handed him the keys. The plane was a two-year-old Cessna 172R, a four-seater single engine aircraft commonly used for flight instruction.

This attracted some attention after the event, but it is absolutely standard. I remember that as a student pilot I was amazed and awed that I was given the full responsibility of verifying that the aircraft was airworthy. I was just a student, surely someone should be checking my work? But no, it is important that pilots understand from an early time that this responsibility belongs to the pilot and no one else. After a few weeks, it became common-place.

Also, the student was trusted by the flying school. The FAA said that he often helped out by washing and fuelling aircraft as needed. Denying him access to the aircraft would not have made sense, especially as once he was 16, he would be expected to fly it on his own as a part of progressing his licence.

A lineman fuelling another aircraft saw the student walk to the Cessna with what he believes was the books for the aircraft. He recognised him as one of the students. He finished fuelling the aircraft and as he drove to his parking position, he saw the student remove the tie-downs, so presumed that the student must have previously completed his pre-flight checks. He parked the fuel truck about 50 feet from the Cessna.

As he got out of the fuel truck, he heard the engine turn over unsuccessfully. He walked towards the Cessna and was near the wing-tip when the engine started and running. The student applied power and started rolling forwards, most certainly not standard procedure. The aircraft turned left towards Taxiway A without making a call to Ground Control. It did not stop at the hold short line but entered runway 35R without permission and took off immediately.

The departure time was noted as 16:51.

The tower controllers were alarmed and immediately called out to the student pilot on frequency and also on the emergency frequency 121.5MHz. They received no response. The Cessna climbed out and turned right towards the southeast. They notified Tampa approach and McDill Airforce Base.

16:52:40 Saint Petersburg Tower: I don’t know if you can see him, a mile to our southeast is primary target, southeast bound. Do you show that on your radar, a primary target to our southeast?

16:52:48 Tampa West Satellite: I see, ah, I see something down there.

16:52:40 Saint Petersburg Tower: Okay, that’s a Cessna departed here unauthorized. We don’t know what he’s doing, he just took off.

A local Coast Guard helicopter had just taken off when they heard that a Cessna had departed the airfield and was travelling towards the Airforce Base.

The student had not spoken to anyone. The helicopter offered to help and were asked to try to verify the Cessna’s intentions. The Cessna continued southeast and climbed to 3,700 feet as the helicopter set off in pursuit.

The Cessna entered McDill Air Force Base’s restricted airspace and descended towards the tower. It flew past in front and below of the tower windows and then pulled up again. He then overflew two KC-135 tankers, passing less than a hundred feet over them. Northeast of the airforce base, he turned crosswind as if attempting to return. The Coast Guard Helicopter caught up to him.

They were now 14 miles from St. Petersburg-Clearwater International and the Cessna was heading northeast, towards downtown Tampa. The Coast Guard Helicopter flew alongside the Cessna at about 400-500 feet away. As they were only five miles from Peter O. Knight Airport, the crew gestured through the open side door that he should route there and land the aircraft.

The student pilot made eye contact and gestured back but the the crew had no idea what the gesture meant, if anything. The Cessna did not deviate from its course. There wasn’t much else they could do.

They called Tampa.

17:02:46 Coast Guard helicopter: Yes sir, we’re currently in the vicinity of Tampa General (unintelligible) chase to a single Cessna [callsign] November Two Three Seven One November. Been advised he took off from Saint Pete. It’s a fifteen year old student, took off with unauthorised clearance. We’re trying to give him hand signals to maybe get him to land at at Peter O Knight, however he doesn’t seem to be responding and, uh, we’re just, we may impede on your airspace here, sir.

Two F-15 combat jets were scrambled from Miami to intercept the aircraft but they arrived too late.

The Cessna continued northeast, now only 300 feet above downtown Tampa. At 17:03, it flew directly into the 28th floor of the 42-story Bank of America building.

The wings sheared off as the aircraft collided into the building. A woman was working on the floor where the plane struck. “Suddenly you’re looking out into the open air, the blue sky, 28 floors up.”

Air traffic control worked together to stop departures in the area, an attempt to clear the skies as much as possible while they worked out what was going on.

The student was dead on impact. Although the plane leaked fuel, there was no fire. No one else was hurt. When they opened the cockpit, they found a 2-page scrawled suicide note on his person.

I have prepared this statement in regards to the acts I am about to commit. First of all, Osama bin Laden is absolutely justified in the terror he has caused on 9-11. He has brought a mighty nation to its knees! God blesses him and the others who helped make September 11th happen. The U.S. will have to face the consequences for its horrific actions against the Palestinian people and Iraqis by its allegiance with the monstrous Israelis–who want nothing short of world domination! You will pay–God help you–and I will make you pay! There will be more coming! Al Qaeda and other organizations have met with me several times to discuss the option of me joining. I didn’t. This is an operation done by me only. I had no other help, although, I am acting on their behalf.

Investigators found no evidence that he was connected to any terrorist groups at all.

I don’t know why this is the bit that made me wince but when I read the analysis of the wreckage I realised: the boy had his seatbelt on.

The postmortem confirmed that the pilot was not under the influence of alcohol or drugs. The cause of death was listed as “Lacerations of brain fractures of skull due to blunt impact to head.” The manner of death was listed as Suicide.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

  • The pilot’s unauthorized use of an aircraft for the purpose of committing suicide.

In the 20 years previous to this accident, 140 aircraft were stolen and then crashed. Of those, two others were determined to be suicides. A further 18 suicides took place in non-stolen aircraft: that is, the pilots either used their own aircraft or rented an aircraft. 2002 seems marked by these violent death-by-aircraft incidents but the question of what, if anything, can be done to save these pilots and their aircraft remains unanswered. It is certainly clear that airport security is not the critical factor.

17 January 2014

Last Words Air France 447

Today, I have a chilling ATC transcript for you from Plane Crash Info.com. Plane Crash Info, run by Richard Kebabjian, is an excellent database of aviation incidents, including photographs, statistics and articles on unusual accidents. Last words is a heart-breaking series of cockpit voice recordings and transcripts from fatal crashes, forcing us to remember that plane crashes aren’t just sensationalist headlines but real people in real emergencies.

Mr Kebabjian kindly gave me permission to reprint his annotated transcript from 2009 when Air France 447 disappeared over the Atlantic.


June 1, 2009
Atlantic Ocean, 570 miles northeast of Natal, Brazil
Air France 447
Airbus A-330-203
F-GZCP

The Airbus went missing over the Atlantic Ocean on a flight from Rio de Janeiro, Brazil to Paris, France.

The last radio contact with the flight was at 01:33 UTC. The aircraft left CINDACTA III radar coverage at 01:48 UTC, flying normally at FL350. The aircraft reportedly went through a thunderstorm with strong turbulence at 02:00 UTC. At 02:14 UTC an automated message was received indicating a failure of the electrical system. The plane carried 12 crew members and 216 passengers. The wreckage was finally discovered on April 3, 2011 using unmanned submarines. Flight447 passed into clouds associated with a large system of thunderstorms, its speed sensors became iced over, and the autopilot disengaged. In the ensuing confusion, the pilots lost control of the airplane because they reacted incorrectly to the loss of instrumentation and then seemed unable to comprehend the nature of the problems they had caused.

Marc Dubois – Captain
Pierre-Cédric Bonin – Copilot
David Robert – Copilot
FA – Flight Attendant

Translated from French

02:03:44 (Bonin) The inter-tropical convergence… look, we’re in it, between ‘Salpu’ and ‘Tasil.’ And then, look, we’re right in it…
02:05:55 (Robert) Yes, let’s call them in the back, to let them know…
02:05:59 (FA) Yes? Marilyn.
02:06:04 (Bonin) Yes, Marilyn, it’s Pierre up front… Listen, in 2 minutes, we’re going to be getting into an area where things are going to be moving around a little bit more than now. You’ll want to take care.
02:06:13 (FA) OK, we should sit down then?
02:06:15 (Bonin) Well, I think that’s not a bad idea. Give your friends a heads-up.
02:06:18 (FA) Yeah, OK, I’ll tell the others in the back. Thanks a lot.
02:06:19 (Bonin) I’ll call you back as soon as we’re out of it.
02:06:20 (FA) OK.
02:06:50 (Bonin) Let’s go for the anti-icing system. It’s better than nothing.
Because they are flying through clouds, the pilots turn on the anti-icing system to try to keep ice off the flight surfaces; ice reduces the plane’s aerodynamic efficiency, weighs it down, and in extreme cases, can cause it to crash.
02:07:00 (Bonin) We seem to be at the end of the cloud layer, it might be OK.
02:08:03 (Robert) You can possibly pull it a little to the left.
02:08:05 (Bonin) You can possibly pull it a little to the left. We’re agreed that we’re in manual, yeah?
An alarm sounds for 2.2 seconds, indicating that the autopilot is disconnecting. The cause is the fact that the plane’s pitot tubes, externally mounted sensors that determine air speed, have iced over, so the human pilots will now have to fly the plane by hand. Aside from the loss of airspeed indication, everything is working fine. Neither Bonin nor Roberts has ever received training in how to deal with an unreliable airspeed indicator at cruise altitude, or in flying the airplane by hand under such conditions.
02:10:06 (Bonin) I have the controls.
02:10:07 (Robert) OK.
Perhaps spooked by everything that has unfolded over the past few minutes—the turbulence, the strange electrical phenomena, his colleague’s failure to route around the potentially dangerous storm—Bonin reacts irrationally. He pulls back on the side stick to put the airplane into a steep climb. Almost as soon as Bonin pulls up into a climb, the plane’s computer reacts. A warning chime alerts the cockpit to the fact that they are leaving their programmed altitude. Then the stall warning sounds. This is a synthesized human voice that repeatedly calls out, "Stall!" in English, followed by a loud and intentionally annoying sound called a "cricket."
02:10:07 (Robert) What’s this?
02:10:15 (Bonin) There’s no good… there’s no good speed indication.
02:10:16 (Robert) We’ve lost the, the, the speeds, then?
The plane is soon climbing at a blistering rate of 7000 feet per minute. While it is gaining altitude, it is losing speed, until it is crawling along at only 93 knots, a speed more typical of a small Cessna than an airliner. Robert notices Bonin’s error and tries to correct him.
02:10:27 (Robert) Pay attention to your speed. Pay attention to your speed.
02:10:28 (Bonin) OK, OK, I’m descending.
02:10:30 (Robert Stabilize.
02:10:31 (Bonin) Yeah.
02:10:31 (Robert) Descend… It says we’re going up… It says we’re going up, so descend.
02:10:36 (Robert) Descend!
02:10:37 (Bonin) Here we go, we’re descending.
02:10:38 (Robert) Gently!
Bonin eases the back pressure on the stick, and the plane gains speed as its climb becomes more shallow. It accelerates to 223 knots. The stall warning falls silent. For a moment, the co-pilots are in control of the airplane.
02:10:41(Bonin) We’re… yeah, we’re in a climb.
02:10:49 (Robert) Damn it, where is he?
02:10:55 (Robert) Damn it!
Another of the pitot tubes begins to function once more. The cockpit’s avionics are now all functioning normally. The flight crew has all the information that they need to fly safely, and all the systems are fully functional. The problems that occur from this point forward are entirely due to human error.
02:11:03 (Bonin) I’m in TOGA, huh?
Bonin’s statement here offers a crucial window onto his reasoning. TOGA is an acronym for Take Off, Go Around. When a plane is taking off or aborting a landing—"going around"—it must gain both speed and altitude as efficiently as possible. At this critical phase of flight, pilots are trained to increase engine speed to the TOGA level and raise the nose to a certain pitch angle.  Clearly, here Bonin is trying to achieve the same effect: He wants to increase speed and to climb away from danger. But he is not at sea level; he is in the far thinner air of 37,500 feet. The engines generate less thrust here, and the wings generate less lift. Raising the nose to a certain angle of pitch does not result in the same angle of climb, but far less. Indeed, it can—and will—result in a descent.
02:11:06 (Robert) Damn it, is he coming or not?
The plane now reaches its maximum altitude. With engines at full power, the nose pitched upward at an angle of 18 degrees, it moves horizontally for an instant and then begins to sink back toward the ocean.
02:11:21 (Robert)
We still have the engines! What the hell is happening? I don’t understand what’s happening. 
Robert has no idea that, despite their conversation about descending, Bonin has continued to pull back on the side stick. The men are utterly failing to engage in an important process known as crew resource management, or CRM. They are failing, essentially, to cooperate. It is not clear to either one of them who is responsible for what, and who is doing what. This is a natural result of having two co-pilots flying the plane. "When you have a captain and a first officer in the cockpit, it’s clear who’s in charge. The vertical speed toward the ocean accelerates. If Bonin were to let go of the controls, the nose would fall and the plane would regain forward speed. But because he is holding the stick all the way back, the nose remains high and the plane has barely enough forward speed for the controls to be effective. As turbulence continues to buffet the plane, it is nearly impossible to keep the wings level. 
02:11:32 (Bonin)
Damn it, I don’t have control of the plane, I don’t have control of the plane at all! 
02:11:37 (Robert) Left seat taking control! 
At last, the more senior of the pilots (and the one who seems to have a somewhat better grasp of the situation) now takes control of the airplane. Unfortunately, he, too, seems unaware of the fact that the plane is now stalled, and pulls back on the stick as well. Although the plane’s nose is pitched up, it is descending at a 40-degree angle. The stall warning continues to sound. At any rate, Bonin soon after takes back the controls.

A minute and a half after the crisis began, the captain returns to the cockpit. The stall warning continues to blare.
02:11:43 (Captain)
What the hell are you doing? 
02:11:45 (Bonin) We’ve lost control of the plane! 
02:11:47 (Robert) We’ve totally lost control of the plane. We don’t understand at all… We’ve tried everything.
By now the plane has returned to its initial altitude but is falling fast. With its nose pitched 15 degrees up, and a forward speed of 100 knots, it is descending at a rate of 10,000 feet per minute, at an angle of 41.5 degrees. It will maintain this attitude with little variation all the way to the sea. Though the pitot tubes are now fully functional, the forward airspeed is so low—below 60 knots—that the angle-of-attack inputs are no longer accepted as valid, and the stall-warning horn temporarily stops. This may give the pilots the impression that their situation is improving, when in fact it signals just the reverse.

The captain of the flight makes no attempt to physically take control of the airplane. Had Dubois done so, he almost certainly would have understood, as a pilot with many hours flying light airplanes, the insanity of pulling back on the controls while stalled. But instead, he takes a seat behind the other two pilots.

02:12:14 (Robert) What do you think? What do you think? What should we do?
As the stall warning continues to blare, the three pilots discuss the situation with no hint of understanding the nature of their problem. No one mentions the word "stall." As the plane is buffeted by turbulence, the captain urges Bonin to level the wings—advice that does nothing to address their main problem. The men briefly discuss, incredibly, whether they are in fact climbing or descending, before agreeing that they are indeed descending. As the plane approaches 10,000 feet, Robert tries to take back the controls, and pushes forward on the stick, but the plane is in "dual input" mode, and so the system averages his inputs with those of Bonin, who continues to pull back. The nose remains high.
02:13:40 (Robert) Climb… climb… climb… climb…
02:13:40 (Bonin)
But I’ve had the stick back the whole time!
At last, Bonin tells the others the crucial fact whose import he has so grievously failed to understand himself.
02:13:42 (Captain) No, no, no… Don’t climb… no, no.
02:13:43 (Robert) Descend, then… Give me the controls… Give me the controls!
Bonin yields the controls, and Robert finally puts the nose down. The plane begins to regain speed. But it is still descending at a precipitous angle. As they near 2000 feet, the aircraft’s sensors detect the fast-approaching surface and trigger a new alarm. There is no time left to build up speed by pushing the plane’s nose forward into a dive. At any rate, without warning his colleagues, Bonin once again takes back the controls and pulls his side stick all the way back
02:14:23 (Robert) Damn it, we’re going to crash… This can’t be happening!
02:14:25 (Bonin) But what’s happening?
02:14:27 (Captain) Ten degrees of pitch…
Exactly 1.4 seconds later, the cockpit voice recorder stops.

Reprinted with permission from Plane Crash Info.com.

10 January 2014

Memorial in the middle of the Desert: UTA Flight 772

There’s this viral set of photographs going around of the UTA Flight memorial. It’s a fascinating story and I think it is the most amazing modern memorial.

It was originally featured in Google Sightseeing in 2009.

Even by Saharan standards, the Ténéré region of northern Niger is pretty desolate: a vast sea of sand, broken only by the occasional rocky outcrop, where barely an inch of rain falls each year. So it’s something of a surprise to see a huge picture of a DC-10 among the dunes.

Here is an embedded map showing the memorial in satellite.


View Larger Map

If you zoom out, you can see just how isolated the memorial is.

UTA Flight 772 was a scheduled flight from N’Djamena International Airport in Chad to Paris Charles de Gaulle in France. The flight originated in Brazzaville, the People’s Republic of Congo, and landed in N’Djamena with no issues. It departed N’Djamena at 13:13.

46 minutes into the flight, cruising at 35,100 feet, the aircraft broke up over the Sahara desert. All 155 passengers and 15 crew members were lost.

The accident investigation determined that the cause of the break-up was an explosion. Traces of the explosive PETN (penthrite) were found in the forward cargo hold. Pieces of a dark grey Samsonite suitcase were covered in a layer of PETN. The report concluded that the bomb had been checked in with luggage at Brazzaville airport.

Six Libyans were tried and convicted in absentia at the Paris Assize Court.

An association was formed to represent the victims families, Les Familles de l’Attentat du DC10 d’UTA. In 2007, this association used compensation funds paid by the Libyan government to construct a memorial to the 170 victims who died on UTA Flight 772.

I lost my father in this plane bombing, I became later on the leader of the families group and negotiated with Libya… but the task I am the more proud of is this Memorial in the middle of the desert.

Guillaume de Saint Marc

The wreckage was half-buried in the sand at the remote desert location. They drove with trucks and camped out on site in order to build the memorial.


Le mémorial du Ténéré (film documentaire) by Familles_du_DC10_UTA

The memorial shows a life-size silhouette of the DC-10 inside a compass – a circle of dark stones with arrows pointing North, South, East and West. 170 broken mirrors, one for each victim of the bombing, were placed around the edge.

The rocks come from the mountains you see at the West of the site [driving across] 70 km of sand.

Difficult to transport, even with the trucks we had. And very difficult work for the person in charge of collecting the stones in a very hot spot, with no shade.

Guillaume de Saint Marc

The project took two months in total with a hundred people working to hand-place the rocks and mirrors. They dug out the starboard wing from the sand and integrated it into the design.

A commemoration plaque listing all of the victims’ names was attached to the wing which was placed at the north point of the compass.

I wanted this Memorial to be visible from planes or satellite, the result is far over our expectations! It’s very emotional for me and the other families.

Guillaume de Saint Marc

But the winds of the desert are unforgiving, and like the wreck of the DC-10, the memorial is slowly disappearing under the sand.

This photo was posted to Panoramio in 2008, just one year later, and you can see that the rocks are almost covered.

If you want to see more photographs or find out more about the memorial (in French), visit Les Familles de l’Attentat du DC10 d’UTA. They have amazing slide shows of the photographs available online as well as a 52 minute documentary for sale about the building of the memorial.

The stones and mirrors are probably not visible anymore and I dread the day when Google update their satellite images. And yet, something about the transience of the site makes it even more poignant to me. Well done to Guillaume de Saint Marc and the families of the victims for making such a beautiful memorial.

03 January 2014

Live Footage of Accident from 1910

I’m travelling so just a quicky today. This silent film, 1910 Aeroplane Flight and Wreck shows M. Cody piloting an aeroplane that almost certainly shouldn’t be able to fly. It was filmed on 23 June of 1910, although it’s not known who by. The clip is particularly interesting because the camera follows the plane, which was not common at the time. The short documentary was produced by the Biograph Company. This makes M. Cody one of the first stunt pilots to appear on film.

A review from IMDb:

It’s really hard to rate many of the early films, as they were mostly very short films featuring practically no story. By 1910, when this film was made, this had changed a bit–though the bulk of films still were only a few minutes long. Sure, there were some exceptions such as Georges Méliès’ feature-length “Voyage dans le Lune” (1902) which was 14 minutes long and “The Great Train Robbery” (1903) which was 12 minutes long. But the bulk of the films people went to see were a lot like the 4 minute long “Aeroplane Flight and Wreck”. Essentially, most films still hadn’t changed that much since the early Lumière Brothers films other than they’d gotten a bit longer (from 90 seconds to 240 seconds) and the camera was no longer stationary during the entire film.

Here in this film, something occurs that the Lumières could not have done–the camera follows (as best it can) a plane taking off and soon crashing. Audiences of the day must have been astounded to watch an early airplane (apparently a Curtis biplane) spectacularly crash–especially because in 1910 few people had still actually seen an airplane. By today’s standards, the crash is a major anti-climax, as the plane is only going perhaps 20 miles and hour when it thuds unexpectedly to the earth from a height of perhaps 10 or 20 feet! I would assume the crash was not planned and just occurred by chance. Considering the pilot looked okay afterwords, it seems this was actually a very good thing— giving the audiences a thrill.

While most modern audiences probably won’t be particularly amazed by the film, it is great for film buffs and people who would like to see perhaps the earliest footage of a plane in flight (the 1903 Wright Brothers flight was only captures by a camera–not a moving picture camera and very few additional flights actually occurred between 1903 and 1910).

I’ll tell you straight, just looking at the work needed to get it into the air makes me glad I live in a world with modern aviation.

Wishing all the best for all of us in 2014!

13 December 2013

Sequence of Events in the Cockpit on Asiana Flight 214

Last week, the NTSB held the Asiana Flight 214 Investigative Hearing.

On the 6th of July 2013, Asiana Flight 214, a scheduled passenger flight from Incheon, South Korea to San Francisco, CA, crashed on final approach after striking the seawall a few hundred feet short of the runway.

The investigation is continuing but a key aspect of the hearing is the sequence of events, as presented by Bill English of the NTSB. His presentation is available on video and I have summarised it below. This explanation of the sequence of events in the cockpit makes it clear how the aircraft ended up much too low and too slow on final approach to San Francisco Airport.

A key issue I’d like to highlight is that the Captain was transitioning from a highly automated Airbus to a Boeing which allows for much more manual control by the pilot. This goes some way to explaining his confusion but does not in any way excuse why no one was watching the airspeed and why the instructor did not take control and initiate a go around much earlier.

Here’s the excerpt from the hearing as broadcast by Bloomberg TV:

The following is not a transcript but my summary of the presentation by Mr English with some clarification of acronyms and technical terms.

The departure from Incheon and the ten-hour flight were routine. The Boeing 777 reached San Francisco area with clear weather and light winds.

The flight crew were vectored for a visual approach to runway 28L as the glideslope portion of the Instrument Landing System was out of service. This had been announced by an FAA Notice to Airman covering the period of the 1st June through 22nd August.

The Pilot Flying was in the left seat. He was a captain transitioning from the Airbus 320 to the Boeing 777. He had 9,700 hours flight time with less than 45 hours in the Boeing 777.

The Pilot Monitoring was in the right seat. He was a newly certified instructor pilot with 12,000 flight hours and 3,200 hours on the Boeing 777.

There were two relief pilots on the flight. One of them was in the cockpit, sitting in the jumpseat.

After reporting the airport in sight, the flight was cleared for a visual approach for a 14-mile straight in final.

Air Traffic Control instructed the crew to maintain 180 knots until five miles out. There was no altitude restriction.

The aircraft passed over the Dumbarton Bridge, descending through 4,800 feet on the extended centre-line of the runway. Indicated airspeed was about 210 knots, decent rate was 1,300 feet per minute. The autopilot was engaged and set to flight level change mode descending to a selected altitude of 1,800 feet. This was the normal Final Approach Fix (FAF) altitude. The autothrottle was engaged in hold mode with the thrust levers at idle.

All of this is an expected configuration for this descent to the Final Approach Fix at five miles out.

Shortly after passing the bridge, the flight crew switched the autopilot to vertical speed mode, with a commanded descent rate of 1,000 feet per minute and the autothrottle was switched to speed mode, with a selected airspeed of 172 knots.

That rate of descent was not fast enough to remain on the normal glidepath. The airplane was now above the normal angle of descent.

The landing gear was extended and the descent rate was briefly selected to 1,500 feet per minute and then back to 1,000 feet per minute.

At this point, the aircraft was about six miles from the runway, flying at about 175 knots, descending through 2,400 feet, well above the glidepath.

The airplane approached the San Mateo Bridge, which is at about the Final Approach Fix point, five miles out. This means that at this point, the aircraft should have been at about 1,800 feet.

The Mode Control Panel (MCP) select altitude was changed to 3,000 feet to prepare for a possible go around, which is a normal action for an approach. This means that if you have to do a go around, the auto-pilot will automatically climb out to 3,000 feet.

Shortly afterwards, the airspeed select was set to 152 knots. The aircraft was still high, well above the desired glidepath.

At an altitude of about 1,600 feet, at about 3.5 miles from the runway, recorded data from the cockpit indicates that the flight level change switch on the Mode Control Panel was activated.

This changes the autopilot and autothrottle operating mode. Flight level change is a autopilot mode normally used for altitude changes during the climbout, cruise and initial descent, but not as a part of the final approach. According to the Boeing Flightcrew Training Manual, it is not recommended for use past the Final Approach Fix.

As a result of this change, the autopilot (AFDS) began to command a pitch up and power increase as it attempted to climb the aircraft to 3,000 feet at 152 knots. That is, the aircraft is at travelling at low speed and now trying to climb to the altitude which had been previously selected on the Mode Control Panel in case of a go-around.

The pilot flying responded by disconnecting the autopilot and manually retarding the throttles to idle. In this configuration, the autopilot was not commanding the airplane, although the system made inputs to the flight directors because it was still in flight level change mode. The flight director computes and displays the proper pitch and bank angles required for the aircraft to follow the glideslope.

As a part of this configuration change, the autothrottle transitioned to hold mode with the thrust levels in the idle position due to the manual override. These modes were sounded on the Flight Mode Annunciator, which is meant to keep the crew informed about the system status.

The autopilot was no longer flying the plane. The throttles were set to idle. The autothrottles were no longer controlling airspeed. Despite this, the airspeed select was changed to 137 knots. This would have had no effect.

About five seconds later, the flight recorder data shows that the left side flight director was switched off, but the right side remained on.

About 1.4 miles from from the runway and at about 500 feet altitude, the Boeing 777 descended through the normal glideslope. It passed through the desired speed of 137 knots and was now rapidly decelerating.

The Precision Approach Path Indicator (PAPI) is a visual display next to the runway 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. The PAPI shifted to three reds and one white and then to four reds.

The pitch attitude steadily increased as the pilot pulled back on the column, trying to maintain the correct glidepath as per the PAPI indicators. But with no power, it did nothing but slow the plane down even further.

There was no mention of the decaying speed on the cockpit voice recorder.

The thrust levers remained at idle. The aircraft continued to lose airspeed and sink below the glidepath.

24 seconds from impact, the airplane was .9 miles from the runway and at 300 feet altitude. It continued to descend well below the PAPI glidepath, decelerating through 120 knots and at a pitch attitude of about 7 degrees nose up.

At about 11 seconds before the impact, an audible alert consistent with low airspeed caution sounded through the cockpit.

Three seconds later, with the aircraft just below 100 feet above the water, the throttle levels were (finally) moved forward to full power to initiate a go-around. This was followed four to five seconds later by stick-shaker activation and a verbal call to go-around.

The action was too late and the main gear and underside of the aft fuselage struck the seawall.

The lowest recorded airspeed was recorded at 103 knots which was about 34 knots below the desired airspeed.

Here’s the newly released video of the aircraft at the time of impact:

The tail of the aircraft broke off at the aft pressure bulkhead.

The aircraft slid along the runway before the fuselage lifted into an approximate 30 degree nose-down angle and pivoted 330 degrees, before coming to rest off the left side of the runway.

The NTSB has not identified any anomalies with the aircraft prior to impact. The investigation continues.

22 November 2013

Giant 4241 Heavy, Confirm You Know Which Airport You Are At

Last week, international news headlines were filled with the headlines of a Boeing 747 that landed at the wrong airport. Meanwhile, pilots all over the world cringed at the thought of making that kind of mistake and ending up in the media spotlight. But of course the question on most people’s lips has been, how could someone accidentally land at the wrong airport?

It’s not that uncommon. I wrote about another incident just last year at Oops, Wrong Airport. But what makes this one special is the transcript after they landed.

Let’s get to the details. The aircraft was a Boeing 747 Dreamlifter, a specially modified jet specifically designed to haul large cargo.

Boeing: Boeing 747 Dreamlifter Fact Sheet

The Boeing Dreamlifter is a modified 747-400 passenger airplane that can haul more cargo by volume than any airplane in the world. It is the primary means of transporting major assemblies of the Boeing 787 Dreamliner from suppliers around the world to the 787 final assembly site in Everett, Wash. This reduces delivery times to as little as one day from as many as 30 days today.
Range: Dependent on payload but comparable to other members of the 747 family of aircraft.
Wing Span: 211.5 feet (64.44 meters)
Length: 235 feet, 2 inches (71.68 meters)
Height (fin tip): 70 feet, 8 inches (21.54 meters)

N780BA, operated by Atlas Air, was meant to be picking up B-787 fuselage parts in Wichita, Kansas that evening, for delivery to Boeing in Seattle, Washington.

It departed New York’s John F. Kennedy International Airport without incident at 19:26 local time, bound for McConnell Air Force Base.

However, despite what appeared at first to be a normal approach and landing, the flight crew actually landed at a much smaller general aviation airport: Col. James Jabara Airport.

Boeing Dreamlifter takes flight in NE Wichita | Local News – Home

A Dreamlifter is supposed to need a runway 9,199 feet long to take off at maximum takeoff weight, and 7,000 feet to land at maximum landing weight. The runway length at Jabara is 6,101 feet.

Colonel James Jabara Airport handles general aviation and air taxi traffic. It has a single concrete runway 18/36, which is 6,101 feet (1,860 meters) long. It’s named after James Jabara, an American pilot who served in World War II and the Korean War and was officially the first American flying ace: a military aviator credited with shooting down several enemy aircraft during aerial combat.

The aircraft, callsign Giant 4241 Heavy, was talking to McConnell Air Force Base tower frequency and reported they were inbound for the RNAV (GPS) approach on runway 19L.

You can listen to the transcript of the relevant calls as an MP3 on Kansas.com. It starts out as a normal GPS approach on runway 19L.

Giant 4241 heavy: Good evening, McConnell Tower. Giant 4241 heavy is on the …er, GPS, RNAV GPS approach 19 left.
McConnell Tower: Giant 4241 heavy, McConnell Tower. Check wheels down. Runway 19 left, wind 140 at 4, cleared to land.
Giant 4241 heavy: Clear to land, runway 19 left, wheels down. Giant 4241 heavy.
McConnell Tower: Giant 4241 heavy, check wheels down.
Giant 4241 heavy: Giant 4241, go ahead.
McConnell Tower: Giant 4241 heavy, check wheels down and expect a mid-field turnoff at Delta.

But somehow it swiftly goes wrong.

Giant 4241 heavy: Giant 1440…4241. We might…We’ll get back to here momentarily, we’re not on your approach.
McConnell Tower: Giant 4241 heavy, McConnell is 9 miles south of you.
Giant 4241 heavy: Uh, yes sir. We just landed at the other airport.

So, well, oops? There’s not a lot you can say to that, really.

Giant 4241 heavy: Uh, apparently we’ve landed at B E C
McConnell Tower: Giant 4241 heavy, verify you’re on the ground at Beech Airport?
Giant 4241 heavy: We think so.

I shouldn’t laugh. I know I shouldn’t laugh. But oh, his voice. You can hear that he’s dying inside.

So, BEC is Beechcraft Factory Airport, which lies between Jabara and McConnell. They aren’t at Beech Airport at all, but they don’t know that yet.

Here’s the lay of the land from SkyVector.

SkyVector: Flight Planning / Aeronautical Charts

McConnell Tower: Giant 4241 heavy, McConnell Supervisor. Verify you are full stopped and landed. Stopped at BEC airport?
Giant 4241 heavy: Affirmative
McConnell Tower: Giant 4241 heavy, McConnell Tower. Are you able to make an approach, uh, a departure off that airport and back in the air to McConnell?
Giant 4241 heavy: Tower, we’re working on those details now sir.
McConnell Tower: Roger.

It’s about four minutes later when they speak up again.

Giant 4241 heavy: And McConnell Tower, Giant 4241.
McConnell Tower: Giant 4241 heavy, McConnell Tower.
Giant 4241 heavy: Yes sir, do you have a quick, is there a tower frequency here? For Beech?
McConnell Tower: Giant 4241 heavy, Beech Tower is actually closed at this time.
Giant 4241 heavy: Okay. Is there a Unicom frequency?

Unicom frequencies are used at airfields where there’s no active control tower. They may be staffed by ground personnel who can offer advice. Local aircraft can also use the frequency to announce what they are doing, effectively keeping in contact with all other aircraft traffic in the local area. As the 747 is blocking the runway, it’s important that they have contact with other incoming aircraft.

McConnell Tower: Giant 4241 heavy, stand by.
Giant 4241 heavy: And one more thing, do you have the coordinates for the airport?
McConnell Tower: Giant 4241 heavy, stand by on that.

The coordinates they are requesting are the longitude and latitude of Beech Airport.

The flightcrew of Giant 4241 is definitely flustered now, struggling to note the coordinates which are clearly not what they were expecting.

McConnell Tower: Giant 4241 heavy, I have the coordinates when ready to copy.
Giant 4241 heavy: Tower ready, go ahead
McConnell Tower: Beech is Kilo Bravo Echo Charlie, North 37 degrees 41 point 64, West 97 degrees 12 point 90.
Giant 4241 heavy: OK, let me read those back. North 374164?
McConnell Tower: Affirmative.
Giant 4241 heavy: OK, and then East 92129…uh, zero?
McConnell Tower: West 97 degrees 12 point 90
Giant 4241 heavy: Sorry about that, can’t read my own handwriting, West 9212 decimal 90
McConnell Tower: West 9712 decimal 90
Giant 4241 heavy: OK, 9712 decimal uh decimal 90
Giant 4241 heavy: Alright, here’s the coordinates we’re showing currently for us: North 3744 decimal 4, West 09713 decimal 3
McConnell Tower: Giant 4241 heavy, roger, stand by.

So, definitely not at Beech Airport.

McConnell Tower: Giant 4241 heavy… Did you do a circle around the airport and then land, or did you make it straight in?

I don’t think he really needs the answer to that question.

Giant 4241 heavy: Straight in, sir.
McConnell Tower: Giant 4241 heavy, roger.
McConnell Tower: Giant 4241 heavy, can you say your coordinates again?
Giant 4241 heavy: Alright, currently we are showing North 3744 decimal 4, West 09713 decimal 3. We’ve got a gentleman here, outside the aircraft now.

I like how he keeps saying “currently,” like his coordinates might inexplicably change at any moment.

McConnell Tower: Giant 4241 heavy, roger.
Giant 4241 heavy: And sir, do you have a frequency by chance?

Because we really would like to be talking to someone at this mystery airfield where we appear to have landed…

McConnell Tower: Giant 4241 heavy, from the target we saw on the radar scope, we have you overtop, the target was overtop of Jabara airport, which is approximately 8 miles north of McConnell airport. Unicom frequency is 1 2 3 point 7, say again 1 2 3 point 7
Giant 4241 heavy: Alright, this gentleman is giving us a frequency, we’re going to try it out, 1 2 3 point 7 as well.

What a nice gentleman and a nice positive identification that they really are at Jabara.

Giant 4241 heavy: McConnell Tower, Giant 4241.
McConnell Tower: Giant 4241 heavy, in contact
Giant 4241 heavy: Yes sir, we are in contact with the company right now, we’ll analyze for performance status.
McConnell Tower: Giant 4241 heavy, roger.

The controller doesn’t sound confident that the flight crew know what they are doing… and who can blame him? They have not yet acknowledged that they are at Jabara.

McConnell Tower: Giant 4241 heavy, and confirm you know which airport you’re at.

Giant 4241 heavy: Well, we think we have a pretty good pulse. Uh, how many… let me ask you this, how many airports directly to the south of 19, uh, of your 19, are there?

This was maybe not the best way to inspire confidence.

McConnell Tower: Giant 4241 heavy, uh you’re currently north of McConnell. And there’s three along the approach.

Giant 4241 heavy: Sorry, I meant north. I’m sorry, I’m looking at something else. We are showing about six miles north of you.
McConnell Tower: Copy, six miles north.

I love how the controller sounds like he just can’t quite believe what’s happening.

McConnell Tower: And 4241 heavy, affirmative. Right now we …are still trying to figure it out.
Giant 4241 heavy: OK, thanks.
Giant 4241 heavy: Tower, we just had a twin engine aircraft, a turboprop aircraft go over the top of us.
McConnell Tower: Giant 4241 heavy, roger. It appears you are at Jabara.
Giant 4241 heavy: Uh, say again?

I know, I shouldn’t laugh. But honestly! It’s hard to resist wondering why one of the flight crew didn’t simply get an iPhone out and check Google maps….

McConnell Tower: Giant 4241 heavy, we saw the plane on the radar and it appears you are at Jabara airport.
Giant 4241 heavy: Say the name of it again?
McConnell Tower: Jabara
Giant 4241 heavy: Jabaro?
McConnell Tower: Giant 4241 heavy, that’s J A B A R A
Giant 4241 heavy: OK. Alright. Uh, copy that.

Flight crew is still not 100% convinced though.

Giant 4241 heavy: OK, we also show we are just short of, about a mile short of WARUN* now.
McConnell Tower: Giant 4241 heavy, roger. Yes. That’s Jabara.
Giant 4241 heavy: McConnell Tower, Giant 4241
McConnell Tower: Giant 4241 heavy.
Giant 4241 heavy: Yes sir, it looks like we do confirm that it is Jabara.
McConnell Tower: Giant 4241 heavy, roger.

*Thanks to the Redditor who corrected my transcript to WARUN, the final approach fix for the RNAV GPS approach on 19L.

So now they know where they are. But acceptance is only half the battle.

McConnell Tower: Giant 4241, say intentions?
Giant 4241 heavy: Uh, we’re talking to the company now, we’re trying to assess our performance situation as far as being able to leave this airport and come to you.
McConnell Tower: Giant 4241 heavy, roger. Just keep us advised.
Giant 4241 heavy: OK, yeah. We will not take off without clearing it through you as well.
McConnell Tower: Giant 4241 heavy, roger.

It’s important to remember that the runway they are on is only 6,100 feet and that aircraft can’t reverse.

McConnell Tower: Giant 4241 heavy, McConnell Tower. Can you confirm, are you on the runway?
Giant 4241 heavy: Affirmative. I am on their Unicom frequency as well, talking to local traffic. We’re trying to, uh, we’re trying to assess our situation as far as clearing the runway is concerned.
McConnell Tower: Giant 4241 heavy, roger.

In the end, Boeing delivered an aircraft tug from McConnell to Jabara to turn the 747 around. The tug drove down the local highway at 13 mph with a police escort.

Boeing’s Massive Dreamlifter Lands at the Wrong Airport, Gets Stuck (Updated) | Autopia | Wired.com

For any pilot who has needed some navigation help from ATC (or has simply been corrected by ATC), the audio is familiar cringeworthy listening. The upside is that these pilots have set the bar rather high for future embarrassing communications with a controller.

To the great relief of everyone involved, the aircraft was not heavily loaded and not carrying much fuel. It would be able to take off from the short runway. The departure the following day went seamlessly. It should be noted that a different flight crew was given the job of delivering the aircraft to McConnell.

According to FlightAware.com, the aircraft departed Jabara at 13:16, arriving safely at McConnell Air Force Base 19 minutes later. You can see how they flew almost a full circle to reposition the aircraft at McConnell. Apparently the 747 only used about 4,500 feet of the 6,100 foot runaway to take off.

Needless to say, the NTSB is investigating.

25 October 2013

Near Miss over Scotland

UK news headlines have highlighted a near miss over Scotland in June this year, when two Boeing 747s lost separation. In the UK, an aviation near miss is known as an airprox and the UK Airprox Board has just released a compendium of the airprox incidents assessed at their September 2013 meeting. I was immediately intrigued as this type of near miss between commercial aircraft isn’t something I would expect to see in 2013 (since Ueberlingen, really).

There were two commercial aircraft heading out to sea for a long crossing. Both were Boeing 747′s, still one of the fastest heavy jets in commercial use.

12:50:40 Aircraft 2 requested a climb from FL320 to FL340. The traffic controller co-ordinated the climb with the next sector and the pilot was cleared for FL340. At the time, the aircraft was 20.1 nautical miles from the Montrose sector.

12:52:00 Aircraft 1 contacted the Montrose sector maintaining FL340.

The two aircraft were 24.3 nautical miles apart and on converging tracks.

The air traffic controller said usually, he would put the electronic strips of conflicting traffic together and suitably highlighted. On this occasion, he hadn’t done this.

12:55:22 A Short-Term Conflict Alert was triggered. The two aircraft were 9.8 nautical miles apart.

In class C airspace, the minimum separation for the two aircraft at the same altitude was 5 nautical miles horizontally.

The Air Traffic Controller was not immediately able to transmit as another aircraft was transmitted on the frequency. As soon as it was free, he transmitted to Aircraft 1. Note that the correct call signs were used at all times and the two call signs were not in any way similar to each other.

ATCO to Aircraft 1 Avoiding action, turn left immediately heading two seven zero degrees, traffic on your right one o’clock.

Aircraft 1: Two seven zero.

ATCO to Aircraft 2: Avoiding action turn right immediately heading zero five zero degress traffic in your left eleven o’clock.

Aircraft 2 acknowledged the call with his call sign.

Here’s the diagram from the report. You can see that the two aircraft are converging, but if Aircraft 1 turns left and Aircraft 2 turns right,
it will be resolved.

These instructions should have separated the aircraft easily.

12:56:00 The two aircraft were 6.6 nautical miles apart and were still on converging headings.

The air traffic controller said he was aware that neither aircraft had given a full readback repeating the instructions but he was concerned that the crew’s workload was high and he didn’t want to distract them further.

He specifically avoided giving them an instruction to climb or descend as he would risk giving instruction that conflicted with the on-board Traffic Collision Awareness System (TCAS), which only gives vertical instructions.

And here’s where it went wrong:

Somehow, the captain of Aircraft 1 believed he had been given an instruction for an immediate right turn. It was clear that this was to keep separation from another aircraft and the captain believed that this other aircraft had been told to turn left to heading 270. As Aircraft 1 turned right, the crew saw Aircraft 2 at the same level, flying straight towards them.

Meanwhile, the captain of Aircraft 2 had understood an immediate left turn for heading 270. He was under the impression that Aircraft 1 was turning right with a heading of 050. He started the turn and then checked with the controller.

Aircraft 2: And just to confirm, did you give us a heading?

ATCO to Aircraft 2: Affirm. Avoiding action turn right immediately heading zero five zero degrees.

Aircraft 2: Zero five zero right turn.

ATCO to Aircraft 1: Avoiding action turn left immediately heading two six zero degrees traffic in your right one o’clock.

Aircraft 1: Two six zero with traffic in sight.

12:56:17 Separation was lost, triggering a high-level Short-Term Conflict Alert. The distance between the aircraft was 4.9 nautical miles with both at FL340.

A second controller came to provide assistance and recommended that the aircraft be given vertical instructions.

ATCO to Aircraft 1: Descend now immediately.

A Traffic Collision Avoidance System (TCAS) is installed into all modern commercial transport aircraft . It interrogates the transponders of all nearby aircraft, receiving their altitude and distance. The TCAS offers traffic advisories to alert the flight crew of nearby aircraft. When the flight crew receives a traffic advisory (TA), they are not expected to perform avoidance manoeuvres, simply to be aware that there is the possibility of a conflict, in which case the TCAS will offer a resolution advisory (RA). It gives the flight crew a chance to locate the other aircraft visually and prepare for the next instruction.

TCAS predictions are based on the assumption that aircraft are flying straight.

As Aircraft 2 turned (correctly) to the right, his TCAS alerted him of the conflict with an instruction to climb to avoid the other aircraft. He reported this to the controller.

Aircraft 2: Resolution advisory in the climb.

The TCAS in Aircraft 1 gave the pilot an instruction to descend. It wasn’t reported but the flight crew followed it.

Although the controller was right to be nervous, his instruction and the TCAS advisory were in synch.

The two aircraft were now 3.5 nautical miles apart with a vertical separation of 300 feet.

12:56:37 Aircraft 1 was at FL332 as Aircraft 2 was climbing through FL344, so vertical separation was regained with the horizontal distance now 2.8 nautical miles.

The potential conflict officially becomes a near miss.

So, the first issue is that both aircraft were placed on the same level when they were less than 25 nautical miles from each other. However, it’s not unusual and within the report, it’s not cited as a cause, simply a contributing factor. The next instruction by the controller was more than sufficient to keep the required 5 nautical miles required separation.

The cause, then, is that both crews somehow misunderstood the controller and followed the instructions that were given to the other aircraft.

It was apparent that both crews had taken each others’ instructions, and the Board found it hard to determine why this had occurred; unfortunately no Human Factor report was available from either crew. The Board was surprised that all four pilots had misheard or misinterpreted the avoiding action instructions despite at least one of the crews reading them back correctly. One airline pilot Member wondered if there could have been callsign confusion; this was discounted because they were not similar, nor could they have been confused with heading information – ATSI confirmed that the transmissions were clear on the RT recording.

Having discounted this, the Board considered other potential causes of confusion. It was possible that the crews may have been distracted because this would have been about the time that they would have been receiving their Oceanic clearances on data-link. Another possibility mooted by an airline-pilot Member was that, having settled into their trans-Atlantic routine, it was unusual for pilots to be issued with avoiding action instructions at that altitude and location. Expecting only routine information to be transmitted at that time, they may have been perplexed by the avoiding action information and instinctively responded without properly assimilating it.

The best explanation given was that flight crew practice avoiding action in conjunction with TCAS alerts (which are always climb or descend) rather than ATC instructions. So it was not a type of instruction that they expected or were familiar with.

PART C: ASSESSMENT OF CAUSE AND RISK

Cause: The pilots of ac on converging tracks flew into conflict because, although they acknowledged timely avoiding action, they did not follow it.
Contributory Factor(s): The Montrose T & P climbed the ac to the same level.

Degree of risk: C.

ERC Score: 102.

I’ve written about the Toyko near miss in Why Planes Crash: 2001 and the Ueberlingen collision is covered in the upcoming 2002 book. So it is a relief to see TCAS doing its job in this case and ensuring that the aircraft did not come any closer. TCAS should only offer a further level of protection but in this case, it did the job.

I’m not sure this incident deserves the press it has been receiving but for considering airprox situations and how to avoid them escalating, it’s sure to continue to gain attention.

You can read the full report here, which covers fourteen reported events. This incident is filed as 2013054, which starts on page 61.

11 October 2013

Cessna Missing Barrington Tops and the 2013 Search

Special thanks to Mark Nolan who filled me in on this and made scans of the original investigation available to me so that I could use primary sources for this post.


On the 9th of August in 1981, a Cessna 210 registration VH-MDX was on a booked flight from Prosperpine to Bankstown, with a refueling stop in Coolangatta.

John Challinor owned the company to which the Cessna 210 was registered. He also owned a motor yacht which sailed from Sydney on the 31st of July. Noel Wildash and Ken Price were two of the crew members. They picked up Challinor, Rhett Bosler and Phillip Pembroke on the Sunday night and headed for Prosperpine.

Challinor had arranged for pilot Michael Hutchins to fly VH-MDX from Sydney to Prosperpine on Saturday the 8th of August to fly everyone back to Sydney.

Saturday night, Hutchins arrived and spent the night on the boat. The next morning he refueled and shortly after 10am he departed Prosperpine for Coolangatta with four passengers on board: Wildash, Price, Bosler and Pembroke.

The aircraft had been serviced from new and had just completed a 100 hourly inspection. It was approved for IFR operations but not for flight into known or forecast icing conditions, as it was not equipped with suitable de-icing equipment.

At Coolangatta, Mr Gordon Grieg, an experienced pilot, was manning the refuelling pumps when VH-MDX taxied in. From the investigation notes:

He said he was surprised at the amount of power used – about 1500 rpm. When the five occupants left the aircraft, he found he knew one of them, Ken Price – well. They looked a bit scared. The pilot looked pale and a little tired. They all went to the Clubhouse and chatted for a while. The pilot seemed impatient to get away again.

Mr Greig said that the wind was making the flight bumpy and unpleasant. The pilot remarked that there was some problem with the gyros or electrics and it was suggested by Mr Greig that they remain overnight at Coolangatta but this was not acceptable to the pilot. They boarded the aircraft, Ken Price taking the right front seat, two medium weight passengers in the centre seats and the largest – a man with a black beard, the left rear seat. The pilot had trouble with the engine start, cranking and cranking, and eventually it fired. The aircraft then taxied and departed. Mr Greig estimated the weight of the men as – Pilot 11 1/2 stone, Ken price 16 1/2 stone, the two centre seat passengers 11-12 stone and the rear seat passenger (he had a black beard) 16 stone.

VH-MDX picked up weather forecasts while they were there.

Weather forecasts indicated a strong west-southwesterly airflow over northern New South Wales, with considerable cumulus or cumulus up to 6000 feet to the east and over the coast. The freezing level was expected to be between 4000 and 7000 feet above mean sea level, and moderate icing was forecast in cloud above that level. A SIGMET (forecast of significant weather which may affect aircraft safety) was current, indicating occasional severe turbulence existed below 12,000 feet to the east of the mountains.

The flight was planned Night VMC (remaining in visual conditions).

They departed Coolangatta and proceeded “without recorded incident” to Taree. Their flight plan had them track along the coast to Taree, then inland via Singleton and Mt. McQuoid in order to avoid the controlled airspace and military restricted areas surrounding Williamtown.

Note: All times are in GMT: add ten hours for Australian EST. I have added punctuation and dropped some of the standard callsign references from the official transcript for clarity.

08:50:31 VH-MDX contact Sydney Flight Information Service 5 on 121.6 to report that they are cruising at 8,000 feet and estimate overhead Singleton at 19:30 EST.

MDX: Ah, Mike Delta Xray was at Taree at five zero eight thousand estimating Singleton at time three zero.

FIS 5: Mike Delta Xray would you prefer a clearance via overhead Willie if it’s available?

MDX: Mike Delta Xray would prefer Williamtown.

08:53:00 Sydney FIS 5 contact Williamtown Tower and then speak to Sector One for clearance.

FIS 5: There’s an aircraft following, a Mike Delta Xray night VMC 210. He was at Taree at five zero…

Sector One: Before you go on, we’re not night VMC so clearance would not be available in controlled area.

FIS 5: It won’t?

Sector One: It won’t be available in my airspace, anyway.

The airspace in Sector One did not have the weather conditions to allow for the night visual flight. However, they agree to check with Williamtown Approach to see if it’s possible for MDX to fly low level along the coast.

FIS 5: Approach, you have Mike Delta Xray, a Cessna 210. He’s overhead Taree at this stage. Sector One advises his airspace is nonVMC. Would there be a clearance available for that aircraft coastal?

Williamtown Approach: I’ll check on the weather and let you know.

FIS 5: OK then and if you could advise the highest level that he could expect.

08:54:30 Sydney FIS 5 call MDX back to let them know the options.

FIS 5: I have checked you with Sydney Control and they advise their airspace high level is non-VMC. A clearance coastal at a lower level may be available, I will advise. So would you prefer to take that or track now via Craven, Singleton?

VH-MDX: I prefer to go coastal.

08:56:00 However, a few minutes later, MDX calls back.

VH-MDX: Rather than wait for the clearance, we’ll track via Craven, thank you.

09:01:13The controllers continue to discuss the weather conditions and the possibility for clearance on behalf of MDX.

FIS 5: OK, he couldn’t wait, he ended up virtually on the boundary so he took off back to Craven.

Williamtown Approach: Was it that critical, was it?

FIS 5: It was that close, yes.

Williamtown Approach: He was running out of gas or something, was he?

FIS 5: No, he just didn’t want to hang around. He was virtually on controlled airspace and he didn’t want to hold in the area, so he’s tracking down to Craven.

Williamtown Approach: Which way is he going? Craven-Singleton or something?

FIS 5: Yes, he was going to go Craven-Singleton.

09:19:19 MDX confirm to Sydney FIS 5 that they are overhead Craven.

VH-MDX: Sydney, Mike Delta Xray at Craven at one eight, 8000, Singleton 36 and we’re experiencing considerable turbulence now and quite a lot of down draught.

FIS 5: Mike Delta Xray, roger. Standby.

09:23:25 FIS 5 is dealing with other flights in the area and discussing the turbulence and clouds at different levels when MDX call back.

VH-MDX: Sydney, Mike Delta Xray is in the clag, in turbulence and would request a clearance to ah 10,000 from 8000.

FIS 5: Echo Sierra Victor, Sydney. Understand the winds at 9000 are westerlies about 70 knots. Are there any clouds in that area?

ESV: Ah negative, there’s no cloud at all above 8000 feet.

FIS 5: Mike Delta Xray, Sydney. Echo Sierra Victor advises no cloud about 8000 feet; however the westerly winds are about 76 knots.

VH-MDX: Just to compound a little problem, I lost my AH and DI and if I could get 10, I’d appreciate it and also a radar steer to Bankstown.

FIS 5: No traffic at one zero thousand. Report cruising one zero thousand. Can you maintain a rate of climb without your artificial horizon?

VH-MDX: Yes, affirmative, I’ll go to ten thousand…

09:25:41 He’s lost his artificial horizon (AH) and his directional indicator (DI). Sydney FIS 5 contact him to make sure his other instruments are working and that he has visual contact with the ground, which means he could work around the failure.

FIS 5: Just to confirm your ADF and VOR on board the aircraft are operating normally.

VH-MDX: My ADF is going all over the place.

FIS 5:Roger. Just confirm in VMC at this time.

VH-MDX: Negative.

(It doesn’t matter how often I read that exchange, I feel sick every time.)

09:26:51 Sydney FIS 5 don’t bother to respond to that call; they go straight for radar identification.

FIS 5: Uncertainty phase declared Mike Delta Xray 0926 in IMC VFR

FIS 5: We’ve got an aircraft who’s in IMC on climb to one zero thousand, without an artificial horizon on track Craven Singleton with a wonky ADF. I’ll see if he’s got a transponder, or which he has, if I can get him to squawk, what code for you, for us, thanks, if we can identify him.

09:28:28 MDX is radar identified thirty-six miles north of Singleton on the Mt Sandon-Singleton track.

But the pilot has a new problem: the aircraft isn’t climbing.

VH-MDX: I’m struggling to get to 85.

FIS 5: Mike Delta Xray Roger

VH-MDX: Ah Sydney, Mike Delta Xray. Can you give me a vector to West Maitland please?

09:31:08 Sydney FIS 5 relay the request to Sector One, who confirm that the aircraft has turned southbound and ask FIS 5 to get his current heading.

FIS 5: Mike Delta Xray, present heading?

VH-MDX: Mike Delta Xray is averaging somewhere around 220.

Sector One: 220, tell him I don’t know what it’s like for cloud. He’s in cloud at the moment, is he?

FIS 5: Yes, mate.

Sector One: And he’s lost his artificial horizon.

FIS 5: And his ADF by the sound of things.

Sector One: And his ADF.

FIS 5: Yes, he’s got problems, this boy.

09:34:15 Sydney FIS give MDX a track for West Maitland and is trying to find out what the cloud cover is like over Williamtown when MDX call back.

VH-MDX: We’ve picked up a fair amount of ice and I can just make out a few towns on the coast. I’d appreciate it .. Oh hell, we just got in a down draught and we’re down at about a thousand a minute.

FIS 5: MDX, roger. Is the aircraft equipped with pitot heating?

VH-MDX: It’s a single (engined) and we’ll try to continue our flight plan.

FIS 5: Roger. The lights are on at Maitland, the lights are on at Maitland.

VH-MDX: Say again Maitland?

FIS 5: The lights are on at Maitland, if you wish to divert and make a landing at Maitland.

VH-MDX: No, we thought we had a … just to compound things, we thought we had a cockpit fire but we seemed to resolve that little problem. West Maitland but would appreciate it if you could leave the lights on for a while.

FIS 5: Mike Delta Xray Wilco.

09:35:43 The only copy of the audio transcript that I could find was very hard to understand. But by now, you can hear the stress in the voices.

FIS 5: Mike Delta Xray, Sydney. If possible could you squawk code now 3000 with ident?

VH-MDX: We’re squawking 300 ident and we’re up and down like a yo-yo.

FIS 5: Roger, we’re looking for you.

VH-MDX: Sydney, MDX. We’re having a little bit of a problem in that our standby compass is swinging like blazes.

FIS 5: Roger, are you able to maintain a gyro heading?

VH-MDX: Negative, we’ve lost the AH and DI, the vacuum pump’s gone.

FIS 5: MDX Roger Sydney.

VH-MDX: And we’re picking up ice

FIS 5: And your present altitude?

VH-MDX: Seven and a half.

FIS 5: Roger and if possible, could you give us some idea of your present endurance when available?

09:37:54 MDX is no longer in a position to answer questions.

VH-MDX: We’re having strife up here, we’re…

VH-MDX: We’re losing a hell of a lot of…

VH-MDX: We’re down to six and a half

FIS 5: Mike Delta Xray, roger, Sydney. Your lowest safe in that area is six thousand, at this time if you continue towards the coast, towards Williamstown, Sir.

09:39:23 The last transmission from MDX is received.

FIS 5: Mike Delta Xray.

FIS 5: Mike Delta Xray, Sydney.

VH-MDX: Five thousand!

FIS 5: Mike Delta Xray, Sydney.

FIS 5: Mike Delta Xray, Sydney.

FIS 5: Mike Delta Xray. Mike Delta Xray, Sydney.

A NASA instructor was conducting a Night/VMC dual training flight in the local area. He diverted to Singleton due to “a wall of cloud” lying on a line to Nelson Bay and heard the exchange between final exchanges between Sydney and MDX.

This is from the investigation notes:

He remembered thinking that the pilot’s voice was very casual when commenting that his aircraft was going up and down like something or other and detailing other problems he was having.

The voice became more panicky, however, and on the last call – which was short and said only “Sydney – 5000” or something like that, it was nearly screaming.

He heard no calls from the aircraft after that.

The last known radar position of the aircraft was recorded as over Barrington Tops at 09:36 GMT.

Sydney Air Search and Rescue immediately diverted a number of commercial flights into the area to carry out a visual search. The aircraft were in the vicinity within ten minutes of the last transmission. A full-scale search was in place by the next morning, despite gale-force winds and temperatures at or below freezing. The search area was centred aroudn the Barrington Tops, described in the search report as “the most heavily forested, rugged, inaccessible part of New South Wales”. If the fuel did not ignite, there would be no visible scar, making it difficult to locate the crash site.

The search continued for nine days.

From the search report:

During the period of the search fixed wing aircraft flew 80 sorties totalling 191 search hours and holicopters flew 109 sorties, totally 175 search hours.

In addition, large ground search parties comprising Police, Forestry, Water Board, Bushwalkers, State Emergency Services personnel supported by 4WD vehicles and trail bikes searched a large part of the most probable area.

The extreme cold at the higher parts of the Barrington Tops and the strong westerly winds made the search dangerous both on the ground and in the air.

Assistance of the RAAF was made available to photograph the complete search area, subsequent analysis failed to reveal any significant information. Action to utilise Satelite information from “Landsat” and the U.S.A.F. also resulted in nil information.

Ground search by Police and volunteers also failed to provide any information as to the whereabouts of the missing aircraft.

Search terminated Tuesday 18th August 1981 following a total of 412.75 hours of unsuccessful air search.

The Air Traffic Controller on duty at Sydney that night posted about it on a blog dedicated to collecting information about the crash: Missing Plane Over Barrington Tops.

I was the ATS officer on the Sydney Sector (FIS 5) who had the misfortune to be on duty when these events occurred. It was one of the worst nights of my life.
[…]
You may like to know that I was also rostered on the same sector the next day when the search got underway in full with daylight, from memory I think there were 22 aircraft including helicopters involved, I remember afterwards being kept so busy as it stopped one thinking about the events of the night before. They (the search aircraft) found a few older wrecks but never MDX or any indication of the crash site.
[…]
There had been numerous accidents where pilots had inadvertently overstressed the aeroplane and pulled the wings off, so it may well be that the wings are in one place or several places and the fuselage body in another and it would be badly compacted either way, so really anybody looking for the aircraft would probably only see perhaps a wing tip or wing and a bit of tail.

The Bushwalkers Wilderness Rescue Squad were involved in the original search and they have never given up. Over the past thirty years, they have been searching through sectors on foot and collating information about the possible crash site.

One of the amazing things about this blog is the friends that I’ve made since I started it. One of those friends is Mark Nolan.

Mark Nolan is a corporal in the Australian Army. He’s also a bushwalker and a pilot. He’s been obsessed with the mystery for years, driven, as he puts it, by wanting to know the end of the story. This year, he found newly released documents in the national archives with new information. Using modern technology, it’s possible that Mark and the Bushwalkers have managed to limit the area where VH-MDX is likely to have crashed. He’s convinced they have a better than average chance of finding it this time, especially because the New South Wales Police Rescue Squad are hosting a full scale search with them:

They will be searching next week, from the 17th to the 21st of October.

Mark, stay safe. We’ll be waiting for you to to tell us every last detail about the search upon your return.

We’re all hoping you’ve cracked it!

04 October 2013

We’ve Lost the Cabin: Update on Southwest Flight 812

Last week, the National Transportation Safety Board released an accident brief about the emergency descent of Southwest Airlines flight 812 to Yuma, Arizona on the 1st of April, 2011.

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

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 Federal Aviation Commission released the audio recordings after the event 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 attendant and one passenger received minor injuries as a result of the incident; both were treated at the airport.

A section of the fuselage skin about 5-foot by 1-foot (152cm by 30cm) had fractured and flapped open hole in the crown area on the left side, aft of the over-wing exit.

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 which led to 136 aircraft worldwide being inspected for fatigue cracking.

Now, we finally have a report on the investigation which clarifies a few of the issues.

One aspect of the incident which was surprising is that both of the people injured were airline staff and neither had their oxygen masks on.

Here’s a pop quiz!

When the aircraft loses pressurisation, what is your number one priority?

  1. Getting your oxygen mask on
  2. Helping other people get their oxygen masks on first because real men don’t need oxygen
  3. Get your oxygen mask on
  4. Making an announcement about putting oxygen masks on
  5. Get your bloody oxygen mask on!

If your answer has an even number, please get out of my aircraft.

Seriously, the flight attendant lost consciousness because he didn’t put his oxygen mask on. The passenger, an off duty airline employee stood to help him and as a result also lost consciousness and fell, cutting his face, in a misguided attempt to help the cabin crew member. They both regained consciousness as the aircraft descended.

After the decompression, flight attendant A stated that there were two “high priority” tasks: ensuring that the passengers put on their oxygen masks and establishing communication with the flight crew. He recalled that he went to the forward galley and was about to either call the captain on the interphone or make a P/A announcement to the passengers when he lost consciousness, fell, and struck his nose on the forward partition. Although Southwest Airlines training materials indicated that the first action a flight attendant should take after a decompression was to take oxygen from the nearest mask immediately, he stated that he thought he “could get a lot more done” before getting his oxygen mask on.

Get your oxygen mask on. Now, let’s not speak of this again.

The aircraft was manufactured on May 22nd in 1996 by the Boeing Company at its facility in Wichita, Kansas. The fuselage sections were shipped by rail to the final assembly facility in Renton, Washington.

The Wichita facility was divested in 2005; it’s now known as Spirit Aerosystems. The Boeing policy at the time was to keep documentation for current year plus six years, so the fuselage section build paperwork for the aircraft is no longer available. What’s clear, however, is that work on the fuselage was a “split installation” with the work partially performed at Wichita and finished off at Renton.

The skin panel is a flat piece of aluminium with a doubler bonded to it. The stringers, frames and other internal structures are installed, creating the built-up panel assembly.

Typically a skin panel should have two manufacture markings: one for the skin panel and one for the built-up panel assembly. The built up panel assembly should also have a marking to show that it was approved by the Quality Assurance process.

The three-panel crown assembly from S-10L and S-10R that included the fracture had QA stamps dated February 16, 1996, with the exception of the crown skin panel above the fractured skin panel. The panel assemblies aft of the accident crown panel had QA stamps dated February 27, 1996. One of the three panel assemblies forward of the accident crown panel had a QA stamp dated February 23, 1996, while the other two markings were obstructed. The accident crown skin panel above the fracture and coincident with the lap joint where the fracture occurred only had a stamp for the skin panel manufacture and was dated March 5, 1996.

Emphasis mine.

In tests, they found that the crack growth rate would hit the full length in 38,261 cycles. The aircraft had 39,786 cycles at the time of the accident. So it’s crystal clear: the aircraft had the fault from the start.

Now, I never did metalworking in school but this doesn’t sound good:

Examination of the rivets in the fracture area revealed that 10 of the 58 lower-row rivets were oversized, while the upper-row rivets were standard sized. Numerous bucked tails on the lower-row rivets exhibited a finish that was different than rivets elsewhere on the panel, ranging anywhere from exposed bare aluminum to partially covered with primer to fully covered with primer coating. Additionally, many rivets in the lap joint were under driven, and areas around the driven heads exhibited curled metal consistent with metal burrs. Microscopic examination of the disassembled rivets revealed the diameter of the shank portion in the area adjacent to the bucked tail portion for a majority of the rivets was larger (expanded) compared to the diameter of the shank.

All of the skin panels around were clearly marked and had an inspection stamp from Boeing Wichita and were dated between 18 Jan and 27 Feb 1996. Only this crown skin panel was dated later (5 Mar) and was missing the inspection stamp. Thus, it seems that the crown skin panel must have been replaced during manufacture.

Translation: shoddy repair job at the last minute. The NTSB refer to this as a “lack of attention to detail and extremely poor manufacturing technique”.

We’ll never know why the crown skin panel was replaced or how the Quality Assurance process failed to spot the shoddy repair. It’s not even possible to determine whether it happened at Boeing Wichita or Boeing Renton.

Evidence indicates that during drilling of the S-4L lap joint, the crown skin panel and the upper left fuselage panel were misaligned, so most of the lower rivet row holes were misdrilled. Many of the installed rivets did not completely fill the holes in the lower skin panel, which significantly reduced the fatigue life of the panel. The pressurization loads on the fuselage skin initiated fatigue cracking at rivet hole 85 almost immediately after manufacture. Fatigue cracking subsequently initiated in adjacent rivets along the skin panel and grew over time with each application of pressurization loads. The NTSB concludes that on the accident flight, the cumulative amount of fatigue cracking reached a critical length, and the panel’s residual strength was not sufficient to carry the loads, which resulted in the hole flapping open and rapid depressurization of the airplane.

The Emergency Airworthiness Directive required all Boeing 737 classic aircraft from line numbers 2553 to 332 to have their lap joints inspected for similar multiple site damage from cracking. There were no similar findings on any other aircraft. This appears to be a one-off Quality Assurance error which slipped through the net.

PROBABLE CAUSE
The National Transportation Safety Board determines that the probable cause of this accident was the improper installation of the fuselage crown skin panel at the S-4L lap joint during the manufacturing process, which resulted in multiple site damage fatigue cracking and eventual failure of the lower skin panel. Contributing to the injuries was flight attendant A’s incorrect assessment of his time of useful consciousness, which led to his failure to follow procedures requiring immediate donning of an oxygen mask when cabin pressure is lost.

I know sometimes it is frightening to think about all that can go wrong in a modern aircraft. This site is a top hit for people who have searched on fear of flying and I wince a little each time when I think about what they arrive here to find.

A single panel slipped through the net; no other aircraft manufactured at the same time suffered from the issue. Systemic issues of shoddy workmanship affecting entire batches of aircraft have become a thing of the past.

Every crew member (OK, except one) and even the passengers knew exactly what to do.

The Captain responded immediately with an emergency descent and a plan of action. The professionalism in the flight crew interactions with Air Traffic Control are shining examples of aviation when it works. And thus, what would have been a fatal accident just a few decades ago became an incident – frightening for everyone on the aircraft, to be sure! But in the end, it’s an amazing story that the passengers will repeat at family gatherings for decades, rather than a tragedy. And that’s a triumph of modern aviation.

27 September 2013

The Incredible Story of David Riggs

It made international news: David Riggs’ body was discovered on Friday by a search and rescue team diving a lake in northeastern China after a Lancair 320, carrying the pilot and his translator, struck the surface and crashed. David Riggs, notorious stunt pilot who lost his pilot’s license twice, had been in the news – and on this blog – over the past few years for his escapades.

He’s been in the news before, of course. I first noticed the name in 2008 when he buzzed the Santa Monica pier in a Czechoslovakian L-39.


Two high-performance military jets departed Van Nuys airport in California as a formation flight to gather footage for a film in production called Kerosene Cowboys. The plan was for the jets to do four passes off of the coast of the Santa Monica pier, west of a banner tow aircraft towing a banner for the film. The first passes went as planned and then David Riggs broke away and flew low over the beach area for multiple passes in excess of 250 knots (two of the passes were below 500 feet) and then pulled into a steep climb just before the pier.

He explained that he did the fly-by’s to promote his new movie; there was a meeting including “film market buyers and producers” at the Loew’s Beach Hotel overlooking the pier. Dave Riggs was the CEO of Afterburner Films, Inc.

He had his private pilot certificate revoked but a few months after the sentence, he obtained a Canadian pilot’s license.

Here is a photograph of the L-39, a high-performance jet trainer aircraft, (taken by Chris Kennedy and featured on Airport-Data.com):

248717

If you think it looks vaguely familiar, that might be because you’ve seen the viral YouTube video about a frightening Close Call with Terrain:

Is it the same plane in the video?


Rigg’s revocation turned into a suspension and his US private pilot’s license was restored after 210 days.

He became involved with a business called Mach One Aviation and Incredible Adventures which offered 45 minutes filmed flights in old military training jets with his business partner, Doug Gillis.

On the 18th of May, a group of eight people arrived at Boulder City, Nevada. They’d paid for a 45-minute filmed “adventure flight”. Two L-39s (one of which was Riggs’ plane, although it’s not clear to me whether Riggs was flying it) were taking the passengers out one at a time. They had just departed for the third tour of the day, when Gillis’ L-39 failed for unknown reasons. The L-39 crashed just after take-off from Boulder City Airport, killing Gillis, who was the pilot, and the paying passenger in the rear seat. The final report has not yet been released but the FAA stated unequivocably that at the time of the crash, the company was illegally selling rides in the L-39. Riggs’ pilot license was revoked again as a result of this.

Gillis, Riggs’ partner and the pilot of the doomed L-39, had already had his ATPC revoked three years previous for signing a fraudulent Flight Review Endorsement to a pilot involved in a fatal L-29 crash in 2009.

Shortly after the Boulder crash, Riggs returned to Canada to try to get a commercial license. In 2013, he de-registered his yellow Lancair 360, N360DR, in the US and registered it in Canada.

Kristy Graham, the author of Aviation Criminal | The True Story, contacted Transport Canada in September 2013 and confirmed that Riggs application for a commercial license was not granted as his FAA certificate had been suspended.

Nevertheless, he took his aircraft to China to fly in the Shenyang Airshow.

While there, he took off “in rainy conditions” from Shenyang Faku General Aviation Base. He was apparently practising making his Lancair graze the surface to produce a skiing effect. Around 1pm local time, some part of the aircraft caught the water and it crashed into Caihu Lake.

Local pilot reported missing after his plane crashes in China – latimes.com

David G. Riggs was reportedly flying a Lancair 320, a high-performance single-engine aircraft made from a kit, when he struck the surface of a lake outside Shenyang, where he was planning to perform in an airshow. Aboard was an 18-year-old woman serving as his translator, who was killed, according to the Xinhua News Agency.

Witnesses said Riggs was practising a stunt in the rain that required him to gently touch the wheels on the water to produce a skiing effect. Apparently, the landing gear or another part of the plane caught the water.

His passenger, a 19-year-old translator, was pulled from the water but died later that day.

Tributes paid to ‘beautiful’ Queen’s College student killed in China plane crash (This is The West Country)

Talented musician Justina Zhang, 19, was working as a Chinese translator for Hollywood stunt pilot David Riggs when their aircraft crashed into Caihu Lake in north-east China during a trial flight at around 1pm on Tuesday last week.

His body was recovered three days later and cremated over the weekend.

I watch air shows with glee but a stunt pilot, more than any other pilot, has to be able to do a risk-vs-reward assessment and ensure that he is keeping himself and others safe. Taking a passenger on a trial flight for an air show routine seems in itself a dreadfully poor decision. But looking at his history, it really does feel like it was only a matter of time before he crashed an aircraft and it was probably inevitable that he would take someone with him.