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26 July 2013

UPS Flight 6 Uncontained Cargo Fire

A few days ago, the General Civil Aviation Authority of the United Arab Emirates has released its final report on the Boeing 747 which crashed on the 3rd of September in 2010 after an uncontained cargo fire.

Uncontained Cargo Fire Leading to Loss of Control Inflight and Uncontrolled Descent Into Terrain

The 326-page accident report is excellently written and deals with all the issues involved with this tragic flight and an analysis of the situation. Truth be told, it’s hard to think of a more hopeless situation that a modern pilot could find herself in. Here’s a summary of the main points.

11:35 UPS Airlines Boeing 747-400AF, a two-crew four-engine wide-body aircraft, arrives from Hong Kong on a scheduled cargo service.

The Flight Crew reported a failure with the PACK 1 air conditioner during the flight. The ground engineer could not replicate the fault.

The PACKs provide preconditioned air to the pressurised fuselage. The Boeing 747 has three PACKs.

14:51 The Boeing 747 departs as UPS Airlines Flight 6 as a scheduled cargo flight to Cologne Bonn Airport. The First Officer is the Pilot Flying and the Captain is the Pilot Not Flying. They depart on Runway 30R and fly north west over the southern Arabian Gulf.

The First Officer flew the aircraft manually to an altitude of 11,300 feet and then engaged the autopilot after receiving another PACK 1 fault. The flight crew reset PACK 1 which cleared the fault.

The aircraft continued to climb. Shortly before they reached their cruising altitude of 32,000 feet, a fire warning bell sounded and the master warning light illuminated. They had a fire on the forward main deck.

The Captain took control of the aircraft.

15:12:57 CAPT in cockpit: Fire, main deck forward. Alright, I’ll fly the aircraft
15:13:07 CAPT in cockpit: I got the radio, go ahead and run [the checklist]

15:13:14 CAPT to ATC: Just got a fire indication on the main deck I need to land ASAP
15:13:19 BAE-C: Doha at your ten o’clock and one hundred miles is that close enough?
15:13:23 CAPT: how about we turn around and go back to Dubai, I’d like to declare an emergency
15:13:27 BAE-C: UPS six make a right turn heading zero nine zero descend to flight level two eight zero.

Doha was closer, they were about 180 miles from Dubai. However, it is unlikely that the crew understood the extent of the fire.

The crew put on oxygen masks and worked their way through the Fire/Smoke/Fumes checklist.

The fire suppression system automatically shut down PACK 2 and 3. The flight crew manually turned the switches to OFF, in accordance with their check list. In fire suppression mode, PACK 1 should have continued to supply preconditioned air to the upper deck. This provides positive air pressure to the cockpit to prevent smoke and fumes from entering the cockpit area. However, at 15:15:21, PACK 1 stopped operating. This meant that no packs were operating and there was no ventilation to the upper deck and flight deck.

Smoke began to enter the cockpit.

15:15:23 CAPT to ATC: I need a descent down to ten thousand right away sir.

It’s unclear why the Captain requested the descent, although it seems to me he was probably reacting to the smoke and concerned about available oxygen. However, this was not on his checklist, which stated he should fly at 25,000 feet, the optimum altitude to prevent combustion.

His action did not support the fire suppression system which was based on depressurisation and oxygen deprivation.

The uncontained cargo fire severely damaged the control cables, the truss frame supporting the cables and the cable tension.

15:15:37 CAPT: alright. I’ve barely got control
15:15:38 F.O: I can’t hear you
15:15:41 CAPT: Alright
15:15:47 F.O: alright… find out what the hell’s goin on, I’ve barely got control of the aircraft.
15:16:41 CAPT: I have no control of the aircraft.
15:15:43 F.O: okay… what?
15:16:47 CAPT: I have no pitch control of the aircraft
15:15:53 F.O: you don’t have control at all?
15:16:42 CAPT: I have no control of the aircraft.
15:16:47 CAPT: I have no pitch control of the aircraft.

They regained control of the elevator control system through the autopilot. Meanwhile, the cockpit was filling with smoke. Within two minutes, neither crew member could see the control panels or look out of the cockpit.

15:16:57 CAPT: Pull the smoke handle.

Pulling the smoke handle might have caused a pressure differential, drawing more smoke into the cockpit. The Captain contacted ATC to report the situation and then spoke to the First Officer.

15:17:39 CAPT: Can you see anything?
15:17:40 F.O: No, I can’t see anything.

The flight crew attempted to input the Dubai Runway 12 left data into the flight management computer, so that they could configure the aircraft for an auto-flight/auto-land approach, but they couldn’t see the FMC display for all the smoke.

At that point, the Captain’s oxygen supply failed.

15:19:56 CAPT: I’ve got no oxygen.
15:19:58 F.O: Okay
15:20:00 F.O: Keep working at it, you got it.
15:20:02 CAPT: I got no oxygen I can’t breathe.
15:20:04 F.O: okay okay.
15:20:06 F.O: what do you want me to get you?
15:20:08 CAPT: Oxygen.
15:20:11 F.O: Okay
15:20:12 CAPT: Get me oxygen.
15:20:12 F.O: hold on okay.
15:20:16 F.O: Are you okay?
15:20:17 CAPT: (I’m out of) oxygen.
15:20:19 F.O: I don’t know where to get it.
15:20:20 CAPT:(I’m out of) oxygen.
15:20:21 F.O: Okay
15:20:21 CAPT:You fly (the aircraft)

A portable oxygen bottle was behind the Captain’s seat, next to the left-hand observer’s seat, but neither crew member retrieved the bottle. The Captain moved aft of the cockpit area, presumably to try to find the supplementary oxygen. He removed his oxygen mask and smoke goggles and said, “I cannot see.” That was the last recording which included the Captain; he died as a result of carbon monoxide inhalation.

Seven minutes had elapsed since the fire alarm had first sounded. The First Officer was now Pilot Flying, with no support nor monitoring. A nearby aircraft contacted him to relay information to Bahrain. The First Officer established communication and attempted to cope with a swiftly escalating task load, which left him no time to enquire after the Captain.

15:25:42 PF: I would like immediate vectors to the nearest airport I’m gonna need radar guidance I cannot see.

Based on his comments, the investigators believe that the pilot was able to see heading, speed and altitude select windows. He could not see the primary flight displays. He could not read the navigation display. Thus he could set up flight configurations but he couldn’t see the response. He also made numerous comments about not being able to see outside and that the heat was increasing and his oxygen was getting low.

He couldn’t see the radio either, so he couldn’t change frequency although he was now out of range of the controller at BAE-C. The controller asked aircraft to relay information to and from the Boeing. Dubai ATC also transmitted several advisory messages to the flight on local frequencies in hopes of getting a message to the Boeing, including “any runway is available.” They turned on the lights for Runway 30L.

A relay aircraft contacted the Pilot Flying and attempted to pass his information on to Bahrain. The relay aircraft (identified as 751) struggled to relay the information and get answers from Bahrain. The relay system was of little use to the Pilot Flying who didn’t know his own altitude or speed and needed immediate data.

15:29:59 PF: Okay Bahrain give me what is my current airspeed?
15:30:07 PF: Current airspeed immediately immediately.
15:30:14 PF: What is my distance from Dubai International UPS er six what is my distance we are on fire it is getting very hot and we cannot see.
15:30:22 RELAY AIRCRAFT: Okay I ask Bahrain understood and UPS six request the distance from Dubai from now?
15:30:28 PF: Sir I need to speak directly to you I cannot be passed along I need to speak directly to you I am flying blind.
15:30:36 RELAY AIRCRAFT: Understood UPS six we are just changes to another aircraft to be with Dubai to relay with you I ask again to Bahrain Bahrain distance UPS six to Dubai?

The workload of the Pilot Flying was immense. He was communicating through aircraft relays while he controlled the flight and attempted to navigate to Dubai International, with no access to navigation equipment and no possibility of looking out the window. He repeatedly asked the relays for information on height, speed and direction in order to plan his blind flight. There was no opportunity to finish the checklist nor check on the Captain.

The options available to the pilot were limited. The aircraft was seriously compromised but without primary instruments, so the First Officer couldn’t see what was and wasn’t working. He couldn’t even ditch the aircraft in the Arabian Gulf as he didn’t know his own altitude and couldn’t see out the window.

The Boeing 747 approached Dubai travelling 350 knots at an altitude of 9,000 feet and descending.

The computed airspeed was 350 knots, at an altitude of 9,000 feet and descending on a heading of 105° which was an interception heading for the ILS at RWY12L. The FMC was tuned for RWY12L, the PF selected the ‘Approach’ push button on the Mode Control Panel [MCP] the aircraft captures the Glide Slope (G/S). The AP did not transition into the Localizer Mode while the Localizer was armed.

ATC at Dubai asked a relay aircraft to advise the Pilot Flying, “You’re too fast and too high. Can you make a 360? Perform a 360 if able.”

The First Officer responded simply with, “Negative, negative, negative.”

The Pilot Flying set the landing gear lever to down. This caused an aural warning alarm: Landing Gear Disagree Caution.

15:38:20 PF: “I have no gear.”

The aircraft passed north of the aerodrome on a heading of 89° at a speed of 320 knots, altitude 4200 feet and descending.

He had no landing gear. He was fast and high. The fire was still burning and the cockpit was thick with smoke. He couldn’t see a thing. And now he’d overflown the airport.

There was another airfield, Sharjah Airport, which was 10 nautical miles to the left of the aircraft. The relay pilot asked if the Pilot Flying could turn left onto a 10 mile final approach for Sharjah’s runway 30.

19:38:37 PF: Sir, where are we? Where are we located?
19:38:39 RELAY AIRCRAFT: Are you able to do a left turn now, to Sharjah? It’s ten miles away.
19:38:43 PF: Gimme a left turn, what heading?

The relay aircraft advised that SHJ was at 095° from the current position at 10nm. The PF acknowledged the heading change to 095° for SHJ.

However, the Pilot Flying selected 195°. The aircraft banked to the right as the Flight Management Computer captured the heading change. The aircraft entered a descending right-hand turn at an altitude of 4,000 feet. Then there were a number of pitch oscillations commanded by the Pilot Flying as the elevator effectiveness decreased.

The aircraft was heading straight for Dubai Silicone Oasis, a large urban community. I suppose the one good thing in this fiasco is that it never made it that far.

15:40:15 RELAY AIRCRAFT: Okay Dubai field is three o’clock it’s at your three o’clock and five miles
15:40:20 PF: What is my altitude, and my heading?
15:40:25 PF: My airspeed?

The pitch control was ineffective. The control column was fully aft but there was no corresponding elevator movement.

The aircraft was out of control.

15:41:33 The Ground Proximity Warning System sounds an alert: PULL UP

15:41:35 [data ends]

The Boeing crashed into a service road in the Nad Al Sheba military base nine miles south of Dubai.

So what caused the fire to go so quickly out of control?

The cargo loaded in Hong Kong included a large amount of lithium batteries distributed throughout the cargo decks. However, packing slips and package details, showing that the cargo contained lithium batteries and electronic devices packed with lithium batteries, were not inspected until after the accident. At least three of the shipments contained lithium ion batteries which are specified as a hazard class 9 and should have been declared as hazardous cargo.

Lithium batteries have a history of thermal runaway and fire, are unstable when damaged and can short circuit if exposed to overcharging, the application of reverse polarity or exposure to high temperature are all potential failure scenarios which can lead to thermal runaway. Once a battery is in thermal runaway, it cannot be extinguished with the types of extinguishing agent used on board aircraft and the potential for auto ignition of adjacent combustible material exists.

The investigators believe that a lithium battery or batteries went into an “energetic failure characterised by thermal runaway” – in other words a battery auto-ignited. This started a chain reaction, igniting all the combustible material on the deck. The resulting fast-burning blaze then ignited the adjacent cargo, which also included lithium batteries. The remaining cargo then ignited and continued in a sustained state of combustion, that is, the conflagration continued burning until the crash.

The single point of failure in this accident was the inability of the cargo compartment liner to prevent the fire and smoke penetration of the area above pallet locations in main deck fire zone 3.

This resulted in severe damage to the aircraft control and crew survivability systems, resulting in numerous cascading failures.

As the cargo compartment liner failed, the thermal energy available was immediately affecting the systems above the fire location: this included the control assembly trusses, the oxygen system, the ECS ducting and the habitable area above the fire in the supernumerary compartment and in the cockpit.

The probable causes start with the fire developing in the palletized cargo, which escalated rapidly into a catastrophic uncontained fire. The cargo compartment liners failed. The heat from the fire caused the malfunctions in the truss assemblies and control cables, disabling the cable tension and elevator function. The heat also affected the supplementary oxygen system, cutting off the Captain’s oxygen supply. The rate and volume of toxic smoke obscured the view of the primary flight displays and the view outside the cockpit, exacerbated by the shutdown of PACK 1. And finally, the fire detection itself did not give enough time for the flight crew or the smoke suppression systems to react before the fire was a conflagration.

A key consideration that the investigation puts forward is the useful response time in the case of an onboard fire.

A study conducted by the Transportation Safety Board of Canada, in which 15 in-flight fires between 1967 and 1998 were investigated, revealed that the average elapsed time between the discovery of an in-flight fire and the aircraft ditched, conducted a forced landing, or crashed ranged between 5 and 35 minutes, average landing of the aircraft is 17 minutes.

Two other B747 Freighter accidents caused by main deck cargo fires have similar time of detection to time of loss of the aircraft time frames, South African Airways Flight 295 was 19 minutes before loss of contact and Asiana Airlines Flight 991 was eight minutes. Both aircraft had cargo that ignited in the aft of the main deck cargo compartment.

The accident aircraft in this case, was 28 minutes from the time of detection until loss of control in flight. The cargo that ignited was in the forward section of the main deck cargo compartment. The average time is seventeen minutes. This should be factored into the fire checklist that an immediate landing should be announced, planned, organised and executed without delay.

These findings indicate that crews may have a limited time to complete various checklist actions before an emergency landing needs to be completed and the checklist guidance to initiate such a diversion should be provided and should appear early in a checklist sequence.

The English language accident report is very long; it is a very thorough investigation and well worth a read to understand the full context of the flight.

All I can hope is that something good comes out of such a detailed analysis in order to stop such a tragic crash from happening again.


If you found this interesting, you’ll probably enjoy my e-book, Why Planes Crash.

28 June 2013

Engine Failure on Airbus A330 leads to High Speed Rejected Take Off

This video of a Rejected Take Off (RTO) by Simon Lowe is making the rounds. It shows an Airbus A330 at Manchester Airport aborting take-off at high speed directly after a bang as the right engine fails. The Thomas Cook flight was en route to the Dominican Republic.

It is a lovely textbook case of a good reactions in the cockpit:

The aircraft was an Airbus A330-200. The Thomas Cook flight was departing Manchester Airport for the Dominican Republic. The A330 was travelling at around 110 knots when the right-hand engine, a Rolls Royce Trent 772, fails with a bang.

The Pilot Flying sure was on the ball with this one. There’s no time to assess the problem or think about options. Having decided not to continue the take-off and deal with the problem in the air, the Pilot Flying has only seconds to safely stop the aircraft on the tarmac.

The thrust reversers are activated immediately but just for a few seconds and if you watch the tyres you can see the smoke from the wheel braking. There’s a slight deviation from the centreline as the engine goes and immediate rudder deflection to straighten the aircraft. The Emergency Response vehicles are on their way immediately upon hearing the sound, they are already there by the time the Pilot Not Flying has reported the problem.

Simply amazing.

A quick search on AV-Herald shows that this is not the first instance of engine trouble in that aircraft:

The Aviation Herald Search results for “G-OMYT”

Simon Lowe was at Manchester Airport that day to film a large cargo plane, almost certainly the visiting Antonov An-225 Mriya . He told the BBC that it was just luck that he caught the footage, but his YouTube channel is full of great aviation videos. He’s probably best known for this detailed video of a birdstrike, also taken at Manchester:

Meanwhile, there’s a second video of the A330 showing the incident from the side. Eddie Leathwood is a young plane spotter who was sad that he was going to miss the visiting Antonov 225 because he was at school. His uncle went to the airport to film the Antonov for Eddie and so he was on site with the camera out when the A330 was taking off.

It was filmed from the Aviation Spotters area, with the kind of helpful commentary you only find in the North of England:

PS: Simon Lowe also got his cargo plane footage. Wow, the Antonov really is huge, isn’t it!

21 June 2013

The Siren Call of Aerobatics: Cirrus SR22 Crash

It was the 13th of November, 2011. Two pilots were flying a rented Cirrus SR22, on their way home from the Stuart Air Show at Witham Field in Martin County, Florida. The pilot in the left seat was a 23 year-old private pilot. In the right seat, was a 34-year old commercial pilot whose family says had over 6,000 hours experience. The pilots were cousins and best friends.

About 10 miles south of Witham Field, they saw a Sukhoi SU-29 and an Extra-300 flying in formation, piloted by friends. The Cirrus SR22 joined the formation and the planes proceeded southwest.

ERA12FA068: Sunday, November 13, 2011 in Boynton Beach, FL

Shortly after the flight crossed the northern border of the Loxahatchee National Wildlife Refuge, the pilot of the Su-29 observed the accident airplane’s pitch smoothly increase upward to an angle of about 30 degrees. The airplane then began a roll to the left, and pitched nose-down as it rolled to an inverted attitude. As the airplane descended, it began to roll right, before it impacted the marsh below in an approximate 80-degree nose-down pitch attitude.

The pilot of the Su-29 contacted air traffic control as he orbited around the wreck. It was already clear that neither pilot could have survived.

A man walking his dog saw the three aircraft which flew overhead at a low altitude, less than 1,000 feet above the ground. The FAA confirmed this with radar data, the SR22 was flying at a recorded pressure altitude of 521 feet.

Local news coverage the day of the crash:

It was not immediately clear who was flying the plane. The safety restraints had to be cut from the left-seat pilot but it appeared that the right-seat pilot was not wearing his shoulder harness. However, the right-seat pilot was much more experienced, a commercial pilot with over 6,000 hours of flying experience, including helicopters, corporate jets and single and twin engine aircraft.

He was described as “a really good stick” and an “adrenaline junkie” and was clearly well-liked within the group.

He’d obtained his private pilot certificate in 1996 and then gave it up in 2006, when he submitted a “letter of surrender” to the FAA, abandoning his commercial pilot certificate. The reason for his surrender was “in anticipation of FAA certification action” but the FAA file contained no further details or even any reference to incidents that might have led the pilot to expect action.

In 2008, he obtained a student pilot certificate and over the next two years, he obtained his commercial pilot certificate with ratings for single and multi-engine aircraft, rotercraft helicopters, instrument airplane and helicopter.

The SR22 was rented in his name from 11-13 November for personal use. As a part of the rental agreement, the right-seat pilot agreed that the aircraft would not be used or operated by any other person. This, combined with the pilot’s experience and statements by witnesses, has led the NTSB to state that it was “most likely” that the right-seat pilot was in control of the aircraft.

The Cirrus SR22 is a single-engine four-seater and is currently the world’s best-selling single-engine aircraft. The SR22 is best known for the Cirrus Aircraft Parachute System (CAPS) which lowers the aeroplane slowly to the ground in the event of loss of control or other in-flight emergencies. The accident aircraft, registration N661FT, was operated by Air Orlando Flight School as a rental aircraft.

A Blackberry mobile device found in the wreckage had photographs taken that day. The final four photographs were taken from the aircraft directly before the crash.

Two of the photos depicted two other airplanes flying in a trailing formation off of the accident airplane’s right wing, while one of the later photos shows one airplane in a trailing formation off of the accident airplane’s left wing. The airplanes immediately off of the accident airplane’s left and right wings in the two photos appeared to be the same, though the registration number was not visible in either photo. One of the photos also showed that the left seat pilot was wearing a black t-shirt and that both shoulder restraints were on, while another photo showed that the right seat pilot was wearing a gray t-shirt. Only the right shoulder of the right seat occupant was visible, and the occupant did not appear to be wearing that shoulder restraint.

A witness on the ground saw the aircraft shortly before the crash. He was standing with an acquaintance when they heard several loud and low airplanes.

He remarked to his acquaintance about how close each of the airplanes was flying to the others as they flew from the northeast to the southwest. The airplane that was trailing in the formation began to lag behind when the witness looked away. Just then, the acquaintance remarked, “Whoa, that guy snapped a roll!,” referring to the lagging airplane in the formation.

Another witness said that he’d observed two or three low wing aircraft flying southwest in close formation. He said one of the airplanes did a barrel roll before he lost sight of the formation behind trees.

A barrel roll. In a Cirrus SR22. Let’s just make sure this is clear: the Cirrus SR22 is not an aeroplane meant for loop-de-loops. It is neither certified nor designed for aerobatic operations, nor even for turns where the angle of bank exceeds 60°. For an aileron roll, you pull the aircraft into a 90° bank. I mean, you don’t. I don’t. We wouldn’t do this in a plane which isn’t made for it. But it seemed the pilot of the SR22 that day did.

The investigation confirmed the aerobatic maneuvers when they reviewed the data from the flight recorder. And when they reviewed the flight earlier that day. And when they reviewed the flight from the day before…

On November 11, 2011, two days prior to the accident flight, the airplane departed BCT at 1654 and climbed to an altitude of about 2,000 feet, before beginning a shallow descent to 1,800 feet. At 1658, the airplane began to pitch up and roll to the left, reaching about 30 degrees of nose-up pitch and completing 360 degrees of roll. The airplane then continued to FA44, and landed at 1701.

On the morning of the accident flight, the airplane departed from BCT at 1030 and climbed to an altitude of 1,500 feet. At 1037, the airplane began descending and leveled off at an altitude of about 600 feet at 1048. At 1057, the airplane began pitching nose-up and rolling to the left, reaching 32 degrees of nose-up pitch and completing 360 degrees of roll. The airplane completed a low pass down runway 12 at SUA at a GPS altitude of less than 75 feet and an indicated airspeed of 142 knots before it climbed to about 500 feet, circled the airport, and landed at 1105.

After they departed SUA, they climbed to 1,000 feet but the flight recorder showed that at 17:34, the flight descended, with a GPS altitude of 161 feet and the measured pressure altitude was 0 feet. Over the next few minutes, the GPS altitude varied from a high of 195 feet to a low of 38 feet.

Beginning at 1736:18, while flying at a GPS altitude of 61 feet, the airplane began a roll to the left that reached a maximum bank angle of 66 degrees about 4 seconds later. The airplane then began rolling back to the right, and at 1736:19 reached a maximum right bank angle of 70 degrees, after climbing to a GPS altitude of 308 feet. At that time, the recorded pressure altitude was 109 feet. The airplane returned to a relatively level roll attitude about 4 seconds later.

Then the aircraft descended again, reaching a low GPS altitude of 145 feet (the pressure altitude was an invalid negative number).

The pitch angle then began to increase, reaching a maximum of 27 degrees nose-up at 1736:36, at a GPS altitude of 129 feet, and a pressure altitude of 29 feet. Within 2 seconds, a left roll began that continued past 90 degrees, and as the roll increased, the pitch angle also began to rapidly decrease. As the airplane reached 178 degrees of left roll, the pitch had decreased to 30 degrees nose-down, at a maximum pressure altitude of 353 feet. The airplane then began to descend, and the pitch continued to decrease to 67 degrees nose-down one second later, as the roll transitioned past inverted to 138 degrees of right roll. The final recorded data point, one second later, showed the airplane in a 68 degree nose-down pitch attitude and a 42-degree right roll, at a pressure altitude of 205 feet and an airspeed of 156 knots.

That can be hard to visualise but COPA safety have done an excellent video based on the data. The following shows the aerobatics performed in the SR-22 over the course of these two flights and the accident flight:

One of the pilots of the aircraft said that he’d heard that the right-seat pilot had “rolled the Cirrus” in the past but had never seen him do it. But he’d never logged aerobatic flight hours and was not known to have aerobatic experience. Maybe if he had, he’d have better understood the stresses he was putting the aircraft under.

It’s possible that the lack of a harness was the final straw which caused the right-seat pilot to lose control of the aircraft. At that height, in that aircraft, he had no chance of recovery.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The right seat pilot’s decision to attempt a low-altitude aerobatic maneuver in a non-aerobatic airplane.

The parachute was found in a bag near the wreckage. The ballistic recovery parachute system activated on impact. However, even if one of the pilots pulled the handle to activate the parachute, it wouldn’t have made any difference, not at that height.

You can read the full report here: ERA12FA068: Sunday, November 13, 2011 in Boynton Beach, FL


If you are interested in air crash investigations, you’ll probably enjoy my e-book, Why Planes Crash.

PS: If you don’t have an e-book reader and would prefer the book in PDF format, just email me at sylvia@fearoflanding.com and we’ll work something out.

17 May 2013

Taking Control at 150 Feet

The Indonesian National Transportation Safety Committee have released a preliminary report regarding the PT Lion Mentari Airlines accident at Ngurah Rai International Airport on Bali on the 13th of April this year.

Here’s a summary what we know so far. All timestamps are in UTC: Java’s timezone is UTC+7 and Bali’s timezone is UTC+8.

05:45 Lion Air flight LNI 904 departs Husein Sastranegara International Airport, a scheduled passenger service from Bandung on Java to Bali.

On board the Boeing 737-800 were two flight crew, five flight attendants, ninety-five adult passengers, five children and an infant.

The Pilot in Command, the Captain, had 15,000 hours flying experience with 7,000 on type. His second-in-command had 1,200 hours, 923 on type.

The second-in-command was Pilot Flying and the Captain was Pilot Monitoring.

This was their last flight of the day: the final leg of a schedule that had them flying Palu-Balikpapan-Banjarmasin-Bandung-Bali. The flight was uneventful until the approach into Bali.

06:48 The flight crew contact Bali Approach and begin their descent.

06:59 The aircraft is vectored for a VOR/DME approach to runway 09 and cleared to continue the descent.

For a VOR/DME approach, you follow a specific route and descend based on your distance from the runway until you reach the minimum descent altitude (MDA) for that approach. As you approach the airfield, you should have the runway (and surrounding terrain) in sight.

Once you reach the minimum descent altitude, you must stop your descent unless you have the runway in sight and can continue the landing visually.

For a straight-in approach on Runway 09 at Ngurah Rai International, the minimum descent altitude is 470 feet.

If you do not have the runway in sight at the minimum descent altitude, you must stop your descent. You can continue your approach at that altitude until the missed approach point (MAP) which is a specific distance by DME from the runway. If you reach the missed approach point and still can’t see the runway, you must break off the approach and climb away.

07:04 The flight crew contact Ngurah Tower (Bali Control Tower).

It was raining and visibility was bad.

07:08 The aircraft is 1,600 feet above ground level. The controller at Ngurah Tower sees the aircraft on final approach and tells them they are clear to land.

07:08:56 At 900 feet above ground level, the Pilot Flying states that he does not have the runway in sight.

07:09:33 The Enhanced Ground Proximity Warning System sounds an alert: MINIMUM, MINIMUM. The Boeing is now about 550 feet above ground level.

The Pilot Flying disengaged the autopilot and the auto throttle and continued his descent. They continued to their minimum descent altitude of 470 feet.

The pilot of an aircraft five nautical miles behind the Lion Air flight stated later that the crew could not see the runway at the minimum descent altitude and decided to go around. On their second approach, they made a safe landing.

07:09:53 The Boeing is approximately 150 feet above the ground. The Captain takes control of the aircraft as the Pilot Flying says again that he can’t see the runway.

07:10:01 The EGPWS sounds “TWENTY”. The Captain commands a go-around – that is, to break off the approach.

He took the right decision but he made it much too late. He should have stopped the descent at the minimum descent altitude of 470 feet. He should have commanded a go-around when his first officer stated he still couldn’t see the runway. He should have done something before the situation became critical.

One second later, it was all over.

07:10:02 The aircraft impacts the water.

The Boeing 737-800 came to a stop 20 metres from the shore, approximately 300 metres southwest of the runway threshold.

The pilot of an aircraft holding short on runway 09 contacted Ngurah Tower to say the Lion Air flight had crashed into the sea. The Tower Controller looked over and saw the Boeing tail section through the airport fence.

07:11 The Tower controller presses the crash bell and contacts the Airport Rescue and Fire Fighting team.

07:15 The Rescue team arrives on the scene

The Boeing 737-800 was submerged in 2-5 metres of shallow water with all the doors open. The right engine and the main landing gear were ripped off.

07:55 All occupants are evacuated from the submerged Boeing 737-800. Four passengers suffered serious injury and were taken to hospital.

All of the observed damage was consistent with post-accident contact with the sea floor, coral reef and sea wall.

Now an interesting point here is that when the investigators examined the wreckage, they found the flap handle in the flaps 15 position. The approach configuration was flap 40 and the flaps appeared to still be in the flap 40 position. This means that twenty feet above the ground, the Captain called for a go-around and one of them raised the flaps. I can’t help thinking that such a manoeuvre would cause twenty feet of sink right there, although I guess they impacted before the flaps actually moved. To be fair, at 20 feet at flaps 40, getting back up into the air was always going to be a challenge.

This is only a preliminary report but immediate safety recommendations have been made.

You won’t be surprised to hear that they are all focused on the training, policy and procedures for pilots at Lion Air.

4 SAFETY RECOMMENDATIONS

As a result of the factual information and initial findings, the National Transportation
Safety Committee issued immediate safety recommendations to address safety issues
identified in this report.

4.1 PT. Lion Mentari Airlines

  • To emphasise to pilots the importance of complying with the descent minima of the published instrument approach procedure when the visual reference cannot be obtained at the minimum altitude.
  • To review the policy and procedures regarding the risk associated with
    changeover of control at critical altitudes or critical time.
  • To ensure the pilots are properly trained during the initial and recurrent training program with regard to changeover of control at critical altitudes and or critical time.

You can read the original report as a PDF document here: http://www.dephub.go.id/knkt/ntsc_aviation/baru/pre/Preliminary_Report_PK-LKS_Lion_Air.pdf

10 May 2013

Six Exclamations You Never Want to Hear in the Cockpit

6. We’ve lost the cabin!

Southwest Flight 812 was climbing through 34,000 feet when there was the sound of an explosion and the oxygen masks dropped. The pilots, recognising a rapid decompression, immediately began a descent. A 5-foot by 1-foot (152cm by 30cm) tear in the fuselage skin opened the aircraft right up and the flight crew had no idea what was happening in the back. As they descended, they declared an emergency with the chilling words, “We’ve lost the cabin.”

The flight crew informed ATC that they were descending to ten thousand feet immediately and the controller correctly contacted the next sector on their behalf to pass on the situation.

5:58:35 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.

I should bloody well hope so.

The final report has yet to be released but you can read my post written at the time here: We’ve Lost the Cabin: Southwest Flight 812. The preliminary report is here: Accident Investigations – NTSB – Rapid Decompression Due to Fuselage Rupture

5. Where’s that guy going?

To be fair, Dublin is a pretty confusing airport and it isn’t hard to get lost. The Monarch Airbus was running late and took a wrong turn. It might have been forgiven, if the flight crew hadn’t become completely disoriented and managed to blunder into the active runway. A Ryanair 737 had just commenced its take-off run when the Monarch flight began to cross on the far end.

EI-DYH

The recording on the Ryanair CVR is of everyone talking at once:

Captain/First Officer: Where’s that Monarch/Where’s that guy going
First Officer: He’s taxiing out in front of us
Captain/First Officer: Stop/Abandon!

The Ryanair Captain initiated a high speed rejected take-off at 124 knots. By the time the Air Traffic Controller realised what was happening and shouted at the Ryanair to stop, the First Officer responded, we’re stopped.

The Ryanair flight returned to the stand to have its brakes inspected. Meanwhile, the Monarch flight continued on its way, taking off three minutes later. That’s probably the first time ever I’ve felt sorry for a Ryanair flight for being late.

You can read the full analysis of the incident here: Runway Incursion at Dublin

4. Remember that crazy guy…?

The Gulfstream III was cleared for a visual approach into Aspen but it was getting late and the weather wasn’t all it could be. The Captain said they’d try one approach and if they didn’t nail it, they would divert. But the aircraft was a private hire and the client was not impressed that they might not make the destination. Under pressure, the Captain and First Officer said they’d do their best, even while they watched the aircraft in front call missed approaches because they couldn’t see the runway.

“Remember that crazy guy,” says the First Officer, “in that Lear[jet] when we were … on the ground in Aspen last time and he [stated that he could] see the airport but he couldn’t see it?”

We’ll never know if the Captain remembered that crazy guy or not but the Captain proceeded to do exactly the same thing, heading away from the airport, which he thought was on his right. 12 minutes later, less than 500 feet over the ground, the aircraft did a sudden steep left turn, the first sign that he’d actually seen the runway. It was too late. The aircraft hit the ground at a 40° bank and the engines on full power and crushed up like an accordion.

This accident is covered in detail in my book, Why Planes Crash: 2001.

3. We’re still at 2,000 feet, right?

In 1972, Eastern Air Lines Flight 401 crashed into the Florida Everglades on approach to Miami. When they lowered the landing gear, the indicator didn’t come on for the nose wheel. The flight crew investigated the problem as the jet circled west over the Everglades at 2,000 feet. The Captain, First Officer, and Second Officer all focused on the problem, and a maintenance engineer on the flight joined them – and not a single one was watching the flight instruments. The Captain accidentally leaned against the yoke and the aircraft entered a slow descent.

There was nothing wrong with the nose gear. A $12 lightbulb in the control panel had burnt out. The First Officer’s final words were, “We’re still at 2,000 feet, right?” as the left wing hit the ground.

You can read the details of the accident here: Eastern Air Lines Flight 401

2. [*sound of laughing*] This is &$%!ing great!

A ferry flight and the crew were bored. So for a laugh, the pilots decided to find out how high the CRJ-200 could go.

They had to force it to keep climbing and pulled back hard at full power, stressing the engines. The aircraft slowly lumbered up into the thin air to FL410 (41,000 feet).

After the pilots overrode the anti-stall devices for the fourth time to keep the aircraft up there, both engines flamed out and the aircraft stalled. They tried to jumpstart the engines as they called ATC, declaring initially a single engine failure. Eventually they realised they weren’t going to get the engines running and admitted both engines were out. The crew tried to glide it into Jefferson City airport but the CRJ-200, at that moment with the aerodynamics of a brick, crashed 2 1/2 miles short of the runway.

The full report is here: Accident Investigations – NTSB – Crash of Pinnacle Airlines Flight 3701 and I’ll be covering this incident in the fourth book of the Why Planes Crash series.

1. Have You Ever Done a Barrel Roll in the Dark?

The ferry pilots of a Cessna Citation private jet were also probably just bored. It was a routine ferry flight from the Czech Republic to Sweden. Eleven minutes into the night flight, the aircraft disappeared from radar. It was a mystery — until the investigators listened to the Cockpit Voice Recorder. The two pilots started talking about barrel rolls – turning the plane into a horizontal corkscrew – and discussed whether either had ever tried one at night. The last clear decision was to try it and see. What’s the worst that could happen? They lost control and the aircraft plunged 20,000 feet into the forest before either of them had the chance to say “That was a really stupid idea.”

There’s a full blog post about the accident and German preliminary report here: Can a Citation Do Belly Rolls in the Dark?

Top tip for pilots: When you are having a laugh in the cockpit, think about how it is going to sound in the accident report.


If you found this post interesting, you’ll probably like Why Planes Crash, available now for just $3.99

If you don’t have an e-book reader and would prefer the book in PDF format, just email me at sylvia@fearoflanding.com and we’ll work something out.

03 May 2013

Bagram Crash

This week the chilling dashcam video of a Boeing 747 crashing at Bagram airfield has spread across the Internet. I’m not sure there’s much to say about it at this stage but I can’t get it out of my head.

Here’s the details as I understand them.

Crash: National Air Cargo B744 at Bagram on Apr 29th 2013, lost height shortly after takeoff

A National Air Cargo Boeing 747-400 freighter on behalf of US Mobility Command, registration N949CA performing cargo flight N8-102 from Bagram (Afghanistan) to Dubai Al Maktoum (United Arab Emirates) with 7 crew and cargo consisting of 5 military vehicles, has crashed shortly after takeoff from Bagram Air Base’s runway 03 at 15:30L (11:00Z) and erupted into flames near the end of the runway within the perimeter of the Air Base. All 7 crew are reported perished in the crash.

National Air Cargo confirmed their aircraft N949CA with 7 crew, 4 pilots, 2 mechanics and a load master – initial information had been 8 crew -crashed at Bagram. The airline later added, that the aircraft had been loaded with all cargo in Camp Bastion (Afghanistan, about 300nm southwest of Bagram), the cargo had been inspected at Camp Bastion, the aircraft subsequently positioned to Bagram for a refuelling stop with no difficulty, no cargo was added or removed, however, the cargo was again inspected before the aircraft departed for the leg to Dubai Al Maktoum.

The NTSB reported the Boeing 747-400 was operated by National Air Cargo and destined for Dubai Al Maktoum when it crashed just after takeoff from Bagram and came to rest within the boundaries of the Air Base. All 7 occupants, all American citizens, were killed.


It’s been said that the aircraft was carrying four or five MRAPs (an armoured fighting vehicle) and that one of the flight crew reported “load shift” on the radio directly before the crash, but I’ve not been able to verify either of these statements.

The aircraft was a Boeing 747 registration N949CA. Here’s a video of it landing at Amsterdam from earlier in the year:

National Airlines Cargo Boeing 747-400F [N949CA] *SMOOTH* landing @ Amsterdam Airport Schiphol – YouTube


Afghanistan 747 crash additional angles (original footage + CGI) – YouTube

Two reconstructed angles of the National Air Cargo 747 that crashed in Afghanistan on April 29, 2013. Created by object-tracking the original footage to create a flightpath (Audio simulated).


Statement from National Air Cargo

National Air Cargo will not speculate as to the cause of the accident involving National Flight NCR102. With our full cooperation, an investigation by appropriate authorities is under way, and we encourage everyone to join us in respecting that process and allowing it to take its appropriate course.

Here are some facts regarding the aircraft and its movements prior to the accident:

  • National Flight NCR102 was en route to Dubai from Camp Bastian and had stopped to refuel at Bagram Air Base.
  • The cargo contained within the aircraft was properly loaded and secured, and had passed all necessary inspections prior to departing Camp Bastian.
  • The aircraft landed safely and uneventfully in Bagram.
  • No additional cargo or personnel was added during the stop in Bagram, and the aircraft’s cargo was again inspected prior to departure.

Please visit www.nationalaircargo.com for updates regarding this tragic accident. Media inquiries can be directed to publicrelations@nationalairlines.aero.

About National Airlines:
National Airlines is a wholly owned subsidiary of National Air Cargo Holdings. National Airlines, based in Orlando, FL operates scheduled and on-demand cargo service globally and charter passenger service in the Middle East.


It’s not quite clear to me why an aircraft travelling from Camp Bastion to Dubai would go to Bagram for refueling:


National Air Flight 102: A Preliminary Report from NYC Aviation

The fact that the gear was down indicates that the crew was experiencing problems immediately after takeoff that focused their attention elsewhere. From the video, you can see the aircraft’s speed was deteriorating. There is a transient smoke stream from the engines just before the stall, which is an indication of an acceleration of the engine core’s RPM – the crew were likely firewalling the throttles. There was a light dip of the left wing at the beginning of the stall. The pilot likely countered with right rudder, a correct but excessive input that caused the aircraft to enter a spin to the right. At this point, airspeed appears to be nearly undetectable but probably around 100 knots.

Swept wing aircraft, especially ones with high angles of sweep like the 747, pitch up at the last moment of a stall before the nose drops and airspeed is recovered. In the video, the nose does not drop until the aircraft is on its side and rapidly losing altitude. Once the aircraft is on a knife-edge, the airflow will cause the vertical stabilizer to weather vane. This brings the nose down. During this time, the right rotation also stops. If there had been an engine failure, the rotation would have continued in the direction of the failed engine. As the wings are brought level, the nose down attitude remains stable through impact. At this point, there are vapor trails from the horizontal stabilizers and wing. This indicates a high pressure differential which is clearly from the high angles of attack on the surfaces.

The crew had a controllability problem that was present from rotation. Pilot training and instinct is to lower the nose if the aircraft is pitching up. This wasn’t possible. To put this aircraft in the position it was would have required excessive nose up elevator or excessive rear Center of Gravity (CG). Since this was a routine flight and the aircraft had not likely had major maintenance causing a critical failure of the flight controls, a rear CG is the likely problem.

This is also indicated on the final moments prior to impact. Had the CG been in the proper location, the nose down pitch would have continued as the CG forward of the wing’s lift would have accelerated towards the earth from gravity while the wing resisted this acceleration due to airflow (drag) on the wing, even with a major failure of the trim or elevator. Just prior to impact, the pitch remains mostly stable, indicating the CG was between the wing and tail, and the weight on each was proportional to the lift being generated. The proportion of the surface area of the wing to tail surface would be equal and inversely proportion of the CG between them. IE: if the surface area was 70% wing and 30% tail, the CG would be 30% back from the wing, or 70% forward of the tail.

There are many other possibilities, example pilot error. Though this is unlikely, these must be considered until conclusively found otherwise.


The Ministry of Transportation and Commercial Aviation in Afghanistan is investigating, joined by the American NTSB.

A devastating accident and heartbreaking video. I wish there were some result that could make it less tragic.

26 April 2013

£3,400 fine for airspace infringement

This week, a 25-year old pilot was fined £3,400 for airspace infringement. The case was somewhat dramatically reported on in the Herts and Essex observer: Pilot fined after causing havoc over Stansted airport | Uttlesford village headlines

The Court Reporter has written up the case, including the claim that, “At one point, Marriott’s poorly-equipped Piper Super Cub was said to have been just 1,215 feet from a Ryanair Boeing 737.” I would have thought that if there was a real risk of collision, the pilot would have been charged with a lot more than “entering controlled airspace”. But the infringement did manage to cause a bit of havoc, to be sure.

On the 30th of September, the pilot flew the Piper Super Cub to the adorably named Cuckoo Tye Farm in Suffolk to visit a friend.

He said that he was returning to Tisted using the same route but the wind was strong and, although he was a confident navigator, he became lost.

The aircraft did not have GPS nor a mode-C transponder. He entered Stansted controlled airspace at 13:20.

You are required to have a transponder if you are flying in controlled airspace but, to be fair, he didn’t intend to fly into controlled airspace, he just got lost. He told the court that he recognised Stansted but misjudged the distance. He stated that he deliberately flew low level so that he would remain below commercial traffic.

However, that wasn’t very reassuring for the Air Traffic Controllers. They could see an unknown aircraft in their area but had no idea what height it was at – information which would have been passed on by the transponder. All departing flights were suspended while the Piper Super Cub “drifted” through Stansted and Luton airspace.

Infringements into control zones aren’t uncommon, especially in the southeast of England, where airspace is tight. I had an autopilot failure flying over White Waltham and I deviated slightly east while I tried to work out the problem – putting me just inside of Heathrow’s control zone. The friendly controller from Farnham, who was watching me on his radar, contacted me to ask if everything was OK (yes, sort of) before informing me what I’d done (Oh no!) and kindly offering me a heading to get the hell out before I caused chaos (Thank you, kind soul, whoever you are).

The key point though, is that the pilot needs to be talking to someone. I was lucky that the controller I was in contact with took the lead before I’d even realised I had gone astray. If he hadn’t, then the moment that I realised, it would have been my responsibility to tell someone.

I don’t have to know where I am to do this. A pan pan call can be used to declare any urgent problem. A pan pan call follows the same format as a Mayday call but tells the controller immediately that you are not in distress: that is there is no immediate danger to people or the aircraft. So a pilot would use a pan pan call for a fuel shortage, a navigational system failure or simply to let someone know as soon as possible that he is lost. In my case, I was already speaking to a controller who could see me on radar. Otherwise, I would have contacted the UK Distress and Diversion cell (D&D) on 121.5 (Civil Emergencies frequency).

A Piper Super Cub (not the aircraft involved in the incident) photographed by Geoff Collins and displayed under Creative Commons

So, the problem with this infringement into Stansted airspace is not that the pilot got lost. It’s that the pilot did not contact anyone in order to tell them that 1) he was lost, 2) he was flying at low level and 3) he would be happy with help to get back on track. The Magistrates chairman made this clear:

“You knew the airspace in this part of England is very congested and therefore the burden’s on you to be spot-on in your navigation.” He added that Marriott had recognised he was lost but repeatedly failed to contact air traffic control.

“While you knew what altitude you were at no-one else did, or what your intentions were. You felt safe but that’s not the point.”

The pilot, who pleaded guilty, argued that he was concentrating on his flying and navigation as per the golden rule of aviation: Aviate first, navigate second and communicate third. Clearly, his priority has to be to fly the plane: it would be ludicrous to try to speak to someone if the aircraft is not under control. But, by his own account, he was flying straight and level and at low altitude to avoid possible commercial traffic, so he was fine. Having screwed up on navigation, he needs to communicate that failure, rather than continue to bumble through, hoping that he will get it sorted.

After yesterday’s hearing, [the pilot] said he still had his licence and had not flown since although the ordeal had not put him off. “It was a frightening experience,” he said. “That’s why I deliberately didn’t contact anyone. I was still trying to work out where I was and where I was going.”

For eleven minutes, he caused a serious disruption across two major international airports who had no means of speaking to him. It was his job to communicate to someone what was happening, even if that is the uncomfortable admission that he had screwed up. He appears not to have grasped that although he felt safe, no one else knew that he was under the commercial traffic and out of the way.

He said he thought the CAA decision to prosecute was “incredibly harsh” over something he described as “one navigation error”.

Except that the problem was, it wasn’t just a navigation error. It was a continuing, eleven minute long, navigation error in which he entered Stansted and Luton’s airspace and did not contact anyone at that time to help them work around his error. In the end, he was fined £3,400 but kept his licence. To be honest, I think he was lucky that it wasn’t the other way around.

12 April 2013

Texting and Flying with no Fuel

The National Transportation Safety Board (NTSB) has announced that a pilot sending and receiving text messages was a self-induced distraction and considered a contributing factor in the crash.

From the accident report:

On August 26, 2011, at 1841 central daylight time (all times cdt), a Eurocopter AS-350-B2 helicopter, N352LN, sustained substantial damage when it impacted terrain during an autorotation following a loss of power near the Midwest National Air Center (KGPH), Mosby, Missouri. The pilot, flight nurse, flight paramedic, and patient received fatal injuries.

This was a Helicopter Emergency Medical Services (HEMS) flight in Missouri to transport the patient from Harrison County Community Hospital to Liberty Hospital.

The NTSB gave a presentation about the investigation at their Board meeting last Tuesday. You can read the remarks and see the slides here: Board Meeting: Aviation Accident Investigation. My breakdown of the events is based on these presentations and the abstract. The final report has not yet been released.

Chairman Deborah A.P. Hersman – Opening Remarks

HEMS is a specialized segment of aviation with one goal: saving lives. The flights are not scheduled. Nor are they routine. By definition, these flights involve emergencies and urgency – transporting individuals who are in critical condition or delivering donor organs. There is always pressure to accomplish the mission.

But, in other respects, as we’ll hear this morning, it was a classic aviation accident. That is because this fatal crash involved perhaps the most crucial and time-honored aspect of safe flight: aeronautical decision making.

Here’s what happened:

17:19 LifeNet receives the request for transport
17:20 The pilot is notified and makes immediate preparations to leave

The pilot slept 5 hours or less the previous night. He chose not to stay at the sleeping quarters at the pilot’s base (which were apparently comfortable and quiet) and said that he slept badly and felt tired. His cumulative duty time was over 12 hours.

As a part of his pre-flight checks, the pilot should have noticed the low fuel in the helicopter. The daily flight log wasn’t signed. The “Conform Your Aircraft” entries were not signed. No fuel samples were taken. And most importantly, there was only one hour of fuel on board.

There was not enough fuel for his planned routing.

17:30 The pilot reports that he has departed from the helicopter’s base at Rosecrans Memorial Airport with two hours of fuel and 3 persons on board.

His before-takeoff confirmation checklist was the second opportunity for the pilot to recognise the fuel situation. He didn’t appear to notice the issue.

Records show that the pilot was sending and receiving personal text messages during this first flight.

17:58 The helicopter lands at the helipad at Harrison County Community Hospital to pick up the patient.

18:00 Pilot contacts his HEMS communication center. He explains that he doesn’t have enough fuel to fly to Liberty Hospital and asks for help locating a nearby fuel option.

He never said how much fuel he had left. The communication specialist did not ask. Neither did the communication specialist contact the Operational Control Center (OCC) regarding the situation. The OOC is available 24 hours a day and staffed by a qualified pilot. It wasn’t a requirement to contact the OCC; however if they had, the OCC would have queried the situation more extensively and and almost certainly recommended aborting the mission.

Neither the pilot nor the communication specialist considered the possibility that they could cancel the flight and have fuel brought to the helicopter.

This self-induced pressure is common to all EMS pilots. Even though the pilot was isolated from the patient’s condition, he must know that an EMS helicopter isn’t requested unless the medical situation is urgent and that delays can be fatal.

The following is from a NASA publication in 1993 investigating the problem. The bolding is mine.
Emergency 911: EMS Helicopter Operations / Lifeguard & Priority Handling

During the years 1978-1986, this increased use of helicopters for emergency medical and air ambulance services came at a high price. In a study of 59 EMS accidents during this period, the NTSB found that the accident rates for EMS helicopter operations were approximately 3.5 times higher than for other non-scheduled Part 135 Air Taxi helicopter operations. Human error, directly or indirectly, was attributed as the cause of the majority of these accidents. To the credit of the EMS industry, these accident rates decreased significantly following the NTSB report and recommendations.

Time pressure was cited as an frequent contributor to incidents–the patient’s critical condition led to a sense of urgency about the flight, which often resulted in inadequate pre-flight planning. Reporters cited such oversights as not stopping for refueling; failure to obtain or review correct charts; overflying scheduled aircraft maintenance; inadequate or less-than-thorough weather briefings; and inadequate evaluation of weather briefings preceding the go/no-go decision. Patient criticality was reported as a major contributor to time pressure in 44 percent of the reports. Time pressure associated with the patient’s condition seemed to be present regardless of whether the patient was already on-board the aircraft or the pilot was enroute for patient pick-up.

There were no opportunities for refuelling close by. The pilot and the communication specialist discovered that the Midwest National Air Center (GPH) was the only airport with Jet-A fuel on the planned route.

The destination hospital was 62 nautical miles away. Midwest National Air Center was 58 nautical miles.

They agreed that the flight should proceed to Midwest National Air Center.

The pilot was sending and receiving text messages during the phone call.

18:11 The helicopter departs Harrison County Community Hospital.

The pilot reported 45 minutes of fuel and 4 persons on board. At that time, he actually had about 30 minutes of fuel on board.

Midwest National Air Center was 32 minutes away.

In order to continue the flight legally, he required at least 32 minutes plus 20 minutes reserve. This was his third chance to deal with the fuel situation.

In addition, the flight time to Midwest National Air Center was just two minutes shorter than the planned flight to Liberty Hospital. If the pilot did not have enough fuel to make it to the hospital, he wasn’t going to make it to Midwest National Air Center. If the operations personnel had been contacted, they would almost certainly asked for details regarding the fuel situation while he was still on the ground. With only 30 minutes fuel and no reserve, he should have aborted the mission and waited for fuel to be delivered.

He’d been up 13 hours after a bad night’s sleep. Fatigue increases attentional lapses and reaction time. Fatigued pilots persevere with ineffective solutions. He had the choice of cancelling the mission or attempting to refuel 32 minutes away with 30 minutes of fuel on board. Maybe he thought he’d get there on the fumes.

He chose to continue.

18:22 Pilot sends his last text.

There’s no evidence that he was distracted by texting at the time of the accident.

18:41 The helicopter runs out of fuel and the engine loses power. The pilot does not respond effectively to execute an autorotation and the helicopter crashes into the ground at a 40° nose-down attitude at a high rate of descent.

All four occupants of the helicopter were killed in the impact.

The NTSB identified four safety issues:

  • Distraction due to non-operational use of personal electronic devices during flight and ground operations.
  • They argue that the texting was a self-induced distraction and contributed to the bad decision making.

  • Lack of Air Methods Operational Control Center (OCC) involvement in decision-making.
  • There was no policy for the OCC to be notified of the situation. The NTSB believe that operationally qualified personnel would “likely have recognized the pilot’s decision to continue the mission as inappropriate.”

  • Inadequate guidance on autorotation entry procedures
  • The pilot should have simultaneously applied “aft cyclic and down collective in order to maintain rotor rpm and execute a successful autorotation”. However, the investigation discovered that the pilot’s autorotation training was done at lower airspeeds, where less aft cyclic is needed. The lack of training may have contributed to the pilot’s failure to react appropriately.

  • Lack of a flight recorder.
  • The helicopter did not have a flight recorder nor was it required to have one. However, if a flight recorder had been installed, we would know more about what happened after engine power was lost.

NATIONAL TRANSPORTATION SAFETY BOARD Public Meeting of April 9, 2013 (Information subject to editing)
Medical Helicopter Operated by LifeNet Crash near Midwest National Airport Mosby, Missouri

Probable Cause
The National Transportation Safety Board determines that the probable causes of this accident were the pilot’s failure to confirm that the helicopter had adequate fuel onboard to complete the mission before making the first departure, his improper decision to continue the mission and make a second departure after he became aware of a critically low fuel level, and his failure to successfully enter an autorotation when the engine lost power due to fuel exhaustion. Contributing to the accident were (1) the pilot’s distracted attention due to personal texting during safety – critical ground and flight operations, (2) his degraded performance due to fatigue, (3) the operator’s lack of a policy requiring that an operational control center specialist be notified of abnormal fuel situations, and (4) the lack of practice representative of an actual engine failure at cruise airspeed in the pilot’s autorotation training in the accident make and model helicopter.

We’ll never know what he was thinking but it’s not hard to imagine a scenario. Tired and distracted, he missed the fuel situation during his pre-flight checks. At the hospital he was aware of his error but there was no easy fix. Everyone was relying on him to transport a patient, probably critical, to the next hospital just 35 minutes away. Aborting the mission at that stage would have been difficult to bear. So I imagine he continued, hoping the fuel gauges weren’t all that exact, hoping that he could make it to the Midwest National Air Center on fumes.

05 April 2013

Severe Icing in Mountainous Terrain

This ATC recording with an MU-2 in severe icing is not new but it is new to me and it is incredible. I was on the edge of my seat.

The MU-2 is made by Mitsubishi. It is a Japanese high-wing, twin-engine turboprop. In the US they were assembled and sold by Mooney but they fell out of production in the mid-1980s.

The captain of the plane, Moray Isaac, posted details about the incident in the YouTube comments:

I was the Captain of that flight and would like to add some facts and clear up some misconceptions posted by some. Firstly, I am an ATR rated commercial pilot with 13000 PIC hours in turboprop, turbojet and turbofan aircraft not an owner/operator and had extensive training in the operation of the MU2.

The flight route had reported cloud tops at FL190 and we were cruising at FL230 that night, the aircraft did not have weather radar and we entered cloud, heavy ice and executed a 180 within two minutes of encountering. The anti-ice systems were on and operable according to cockpit indications. We had a tailwind of 70 plus kts and once the turn was initiated the A/C could not maintain altitude with full power, torque and temp limiters off.

We descended into the cloud layer we had been above which further exacerbated the icing problem. The critical problems occurred as the engines failed due to ice ingestion from the prop hubs as we descended into warmer air. The starboard engine failed and was feathered as per emergency checklist… while descending at 4000 feet per minute the port engine failed after and a restart was attempted, but unsuccessful due too severe first stage impeller damage from ice ingestion.

The starboard engine was them unfeathered and restarted, then I attempted a second time to restart the port engine, which was successful. Interestingly, post incident inspection showed cracked bleed lines running to the engine inlets, all cockpit indications showed green, valves open but bleed air was getting dumped overboard which resulted in ice build up on the engine inlets and reduced air intake performance.

Also and most importantly, this A/C did not have the optional pilot selectable ignition modification. It was the only A/C I have flown, and authorized by the MOT and the FAA at the time, to operate in icing conditions without it, if I had that option, the engines could have relit and the emergency would not have become so dire. The company retrofitted the A/C shortly after.

On another note, we descended to 3500 above SL, about 5 to 15 seconds from ground/lake impact and if not for the heroics of two IFR terminal controllers that night, Jim and his brother, who came over from a different sector and helped by transposing the radar image onto a topographical map and directing us over a valley, we would not be here, forever indebted, thanks guys. Also thanks to whoever posted this transcript, and all the encouraging posts from my fellow aviators.

Moray Isaac

My favourite moment is when the controller says they’re clear of terrain at 7 (thousand feet) and then just says “Wow.” He clearly can’t believe it.

Maybe I’m blind, but I can’t find any reference to the incident in the list of Transportation Safety Board of Canada – Aviation reports, despite the fact that it is a declared emergency. It would have been nice to see the details.

I tend to agree with the pilot, though, I think they might have had angels on board.

29 March 2013

Pilot Prosecution in New Zealand

I only just became aware of this court case which ended last week. Pacific Blue were a regional airline based in New Zealand. The airline is now Virgin Australia Airlines (NZ). The flight in question was departing from Queenstown, New Zealand for Sydney, Australia.

The incident happened on the 22nd of June in 2010.

Pacific Blue admits takeoff after deadline – National News | TVNZ

Pacific Blue admits one of its flights out of Queenstown took off four minutes after the shut-off point for departures in the evening.

The Civil Aviation Authority (CAA) is investigating the incident in which flight DJ 89 from Queenstown to Sydney on Tuesday, June 22, departed Queenstown Airport in darkness, potentially endangering the 140 passengers and crew aboard.

Pacific Blue said its internal procedure states aircraft at Queenstown should take off no later than 30 minutes before evening twilight.

It said on this occasion the plane took off about 26 minutes before twilight.

We have real video footage from the flight. The passengers on the plane included competitors and flight crew from The Amazing Race, a television reality show. The flight was filmed as a part of episode 7 and you can see them on the aircraft at around the 02:20 mark and the film shows some views at take-off between 02:52 and 03:12.

As far as I understand it, the curfew is in place to allow for a visual return to the airfield in case of an engine failure on take-off. The other issue is whether the pilot disregarded his airline’s 16-knot crosswind limit. The pilot stated that he disagreed with the control tower readings at the time and stated that the crosswind was well under 16 knots based on the windsock.

The pilot was charged in April 2011:

Pilot charged after ‘unsafe’ takeoff – travel | Stuff.co.nz

The Civil Aviation Authority has charged the pilot of a Pacific Blue passenger jet for allegedly compromising safety by taking off from Queenstown Airport last year after the deadline for departures.

It was reported at the time Flight DJ89 departed Queenstown for Sydney on June 22 in darkness, potentially endangering the 140 passengers and crew aboard.

CAA said today that two charges had been laid under the Civil Aviation Act following an extensive investigation into the departure of the B737-800 aircraft from Queenstown, in conditions of poor light and visibility.

“The investigation concluded that the airline’s procedures and operating conditions were breached in this take off…and that safety was compromised as a result.”

Director of Civil Aviation Steve Douglas said that the airline had not been charged.

The media frenzy was immediate. A Pilots Professional Rumour Network located in New Zealand posted to the message board to clarify key details:

Some Facts

Pacific Blue has a company requirement to depart Queenstown 30 prior to ECT. It is not an aerodrome requirement. Business jets and local operators often operate until ECT.

The aircraft was airborne at approximately 0525z. 20min before ECT. The pilot was actually ready for departure earlier but waited for a lull in the wind.

Previously a significant front of weather had passed through the field. This was the reason the flight was delayed. By the time of the departure there was only light rain. As is very common at Queenstown a low band of cloud had built up around the Frankton Arm/Township area, around 1000ft agl.

The controllers reported that this layer was more extensive, however the tower’s view of the departure area is obscured by Deer Park. The pilot stated that cloud in the area had dissipated and was suitable for departure. He was only now concerned with the crosswind. The pilot’s assessment of the cloud proved more accurate.

When the aircraft departed it levelled out under the layer of cloud in the Frankton Arm. (It did not descend as reported). Reaching Kelvin Heights golf course the aircraft resumed climbing and followed the published visual segment to Tollgate where it was still visual.

The reports made to the CAA were made by the general public. Neither the control tower nor Pacific Blue filed an incident report.

The case continued. In March 2012, the defence counsel told the Judge that his client was “probably the absolute top of the tree in terms of aircraft qualifications”. He had over 16,000 flying hours at the time of the incident.

Accused Pacific Blue pilot ‘is highly qualified, not careless’ – National – NZ Herald News

Yesterday defence counsel Matthew Muir, of Auckland, said there was a “significant danger” in elevating an alleged breach of Pacific Blue’s exposition to “criminality”. The flight was scheduled to depart at 4.30pm, but took off at 5.25pm, meeting the “basic daylight requirements” by taking off 20 minutes before the advised Evening Civil Twilight (ECT) time.

However, it was a potential breach of the company’s exposition, so it had to be proven “there was such a failure and the pilot decided in a manner that was not reasonable and prudent” to take off. Pacific Blue’s exposition required take-offs to occur “at least 30 minutes prior to Evening Civil Twilight to allow for visual manoeuvring”.

“The defendant will say given the range of exposition requirements, a breach of Pacific Blue’s exposition at the time … can’t in itself be equated with carelessness.”

He said the captain and first officer formed a departure plan “which did not involve a return to Queenstown” and the only visual manoeuvre required was between the airport and a reference point, which took about two minutes’ flight time to reach.

“It had completed, we say, all the visual manoeuvres it was going to do that day … still with 18 minutes running before Evening Civil Twilight.”

Further, a “return to land scenario” would not only represent “very poor professional judgement” but it was prohibited in Pacific Blue’s exposition, given there was an “alternate airport” available and suitable in terms of weather conditions.

“We are saying that the pilot was faced with conflicting messages in the Pacific Blue exposition,” Mr Muir said. The hearing continues.

A Captain brought in as expert witness defended the pilot:

Pilot competent: witness testimony | Otago Daily Times Online News : Otago, South Island, New Zealand & International News

Captain Stuart Julian, who has more than 13,000 hours’ flying experience, told the Queenstown District Court yesterday that despite confusion among the crew, weather conditions and cockpit warnings, the pilot passed a test used by air-pilot examiners – “Would I put my daughter on that flight? ” – a measure he said was used to assess whether a pilot was competent.

Prosecution lawyer Fletcher Pilditch, at the end of his cross-examination of Capt Julian, asked whether he would “still put your daughter on that flight”.

“Yes, I would,” Capt Julian replied.

Capt Julian spent the day in the witness stand, addressing issues about the crosswind, cockpit warnings and the figure-of-eight contingency plan chosen by the pilot, who faces charges dating back to June 22, 2010.

He told the court and Judge Kevin Phillips the crosswind limits set by an airline can be broken, contrary to evidence previously given during the case by the Pacific Blue pilot, who has name suppression.

Capt Julian was of the view the 16-knot wet-runway crosswind limit set by Pacific Blue was an expectation of pilots; it was a guide and had little to do with the safety of the flight in question.

The New Zealand press reported that Pacific Blue supported the pilot throughout the courtcase, apparently funding his legal fees. Certainly, Pacific Blue did not deal with the pilot at the time and they did not report the incident. Eye-witnesses on the ground reported the incident to the CAA.

‘Feared for passengers’ – flight witness – Queenstown News

Alan Kirker, giving evidence in Queenstown District Court today (Thursday) during the fourth day of a Pacific Blue pilot’s defended hearing, recalled watching it from his Larch Hill Place home: “My first thought was I was afraid a wing was going to clip a tree, that’s how low I thought it was.”

The Sydney-bound plane left Queenstown Airport towards Frankton Arm before it disappeared behind Deer Park Heights.

Kirker told the court: “It was flying level. I saw it flying at what appeared to be a constant height all the way through till it got to Kelvin Peninsula, then I saw it bank very heavily, probably at a 45-degree angle.

The same article shows the problem with reports from the ground, however:

Earlier today Skyline Gondola operator and eyewitness Malcolm Officer was grilled under cross-examination by defence lawyer Matthew Muir.

Officer, a prosecution witness, says he saw low-lying cloud that covered Deer Park Heights and maintained his certainty despite being shown CCTV footage from Queenstown Airport that indicated the hill was in full view at the time of take-off.

Officer says he saw the aircraft disappearing into cloud as it turned above Deer Park Heights.

Muir suggested Officer’s observations could be wrong after he was presented with official data that conflicted with his accounts.

The courtcase has been going on for over two years but the judge finally handed down his decision a few weeks ago:

Pacific Blue pilot found guilty – Yahoo! New Zealand

A pilot has been found guilty of careless operation of a passenger jet, following a takeoff incident in Queenstown in 2010.

Fairfax Media reports the decision was handed down in a written judgement on the charge that the 54-year-old pilot, who still has name suppression, operated a Pacific Blue Boeing 737 in a careless manner.

During a trial, the defence said the pilot’s actions were correct and any breach of requirements was “below the level of carelessness”.

However, Judge Kevin Phillips’ ruling today said safety margins at that time were “seriously impacted”.

“I am satisfied that no reasonable and prudent pilot … would have commenced the takeoff roll,” the judge said.

“I am satisfied the defendant was careless in his manner of operating the aircraft. The defendant ignored the mandatory requirements and, in their place, used his planning and self designed contingency.”

The pilot was sentenced this week:

Captain Roderick Gunn: Pilot Keeps Licence | Stuff.co.nz

The pilot sentenced yesterday for careless operation of a passenger jet with 64 passengers aboard was allowed to keep his airline licence but ordered to undergo extensive rehabilitative training.

Judge Phillips, who said the pilot’s actions had all the ingredients of an “absolute disaster”, did not disqualify Gunn but imposed conditions including undertaking ground-based training, a safety management course in the United States and not to act as pilot-in-command on any Queenstown flights for 12 months.

He was also fined $5100.

Prosecutor Fletcher Pilditch said in his closing submission the court was obliged to disqualify the pilot to denounce and deter the offending.

The court was presented with a case where the pilot elected to exercise his own policies and his actions lay somewhere between arrogant and cavalier.

“What the court is presented with is offending conduct which is not just mistakes but a product of deliberate decision-making and a wilful departure from the rules.”

Disqualification sent the correct message and it was difficult to assess any degree of remorse as there seemed to be an absence of contrition or accepted wrongdoing.

Defence lawyer Matthew Muir said the conviction itself was an exceptionally high deterrent and a lifelong commitment to aviation was imperiled if the court elected to disqualify his pilot’s licence.

His client’s mistakes were subject to the full glare of public scrutiny, he had lost face and was humiliated.

“He has made a 30-year investment in excellence in all facets of his career. He asks that he be left some foothold with which he can try to rebuild some future for himself and his family.”

The judge said the pilot’s references were excellent but on the day it was all thrown to the wind.


This really seems like a storm in a teacup, were it not that the Captain of that flight has had his entire career turned upside down over it.

I’m not a fan of litigation in these kinds of cases in the first place (it does little to promote safety) so maybe I’m biased.

NZ TV made a incredible sensationalist video. Warning: may cause head-desk moments!

Relive the infamous Pacific Blue flight out of Queenstown – Campbell Live – Video – 3 News

The more we learn about Pacific Blue flight DJ89 out of Queenstown, the more relieved we are we weren’t on it.

Well, I would have put my son or daughter on it. What do you think?