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20 February 2015

NTSB Open Docket of Bagram Cargo Crash Documents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Here’s the transcript of that conversation.

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

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

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

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

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

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

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

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

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

There was no specific training for the Chief Loadmaster position.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“You call, we haul.”

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

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

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

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

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

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

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

06 February 2015

TransAsia Flight 235 Inexplicably with No Engines

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

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

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

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

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

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

TransAsia Airways Flight 235 – Wikipedia

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

30 January 2015

Cirrus SR22 ditching into Pacific captured on video

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

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

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

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

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

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

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

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

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

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

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

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

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

16 January 2015

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

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

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

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

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

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

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

Insight: Parachute-Cessna 170 Midair Collision | Flying Magazine

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

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

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

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

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

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

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

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

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

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

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

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

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

Insight: Parachute-Cessna 170 Midair Collision | Flying Magazine

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

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

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

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

And Tim Telford got the photographs of his life!

02 January 2015

Five Aircraft That Did Not Crash In Thunderstorms

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

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

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

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

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

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

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

Flying too high

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

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

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

In-flight break up near a storm

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

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

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

Struck by Lightning

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

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

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

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

Into the Heart of the Storm

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

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

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

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


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

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

19 December 2014

Near Miss with Drone at Heathrow

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

FAQ Details | UK Airprox Board

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

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

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

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

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

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

AIRPROX REPORT No 2014117

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

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

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

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

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

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

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

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