In the evening of 6 June 2010 a Boeing 737-4B6 of Royal Air Maroc was en route from Amsterdam Schiphol Airport to its destination of Nador International Airport in Morocco. Flight AT-685 had 156 passengers and four crew members on board. The captain was Pilot Flying, first officer was Pilot Monitoring.

Timestamps and actions are recreated from the incident report. Direct quotes from the Dutch Safety Board report are indented with a grey background.

21:42 Pilot commences take-off on runway 18L.
21:42:54 Aircraft lifts off
21:42:58 At a height of 16 feet the gear retraction is initiated

At this moment, travelling 175 knots, the aircraft encounters a bird strike with multiple geese.

Effects:

• Immediate loss of almost all thrust on the left engine.
• Landing gear displays unsafe nose gear indication.

21:43 The first officer announces that engine one is damaged. The captain does not respond.

The captain said later that the aircraft was shaking violently and was difficult to control. He decided to return immediately. Good decision!

21:43:04 At a height of 140 feet, the aircraft pitch attitude is 12 degrees nose up and the engine RPM were 45.5% and 93.8% N1. The captain tells the FO to select the gear down and declare an emergency. The first officer selects gear down, contacts the runway controller with a mayday call.

The left engine speed remained at approximately 45% N1 until the engine was shut down approximately four minutes later.

However, the flight crew were not (yet) in a position to land. Why put the gear down immediately? The priority should be to get the plane climbing and stable. Once you are at a safe altitude, you have the chance to deal with the individual issues and even time to go over checklists. The flight crew appear to have been in a panic.

21:43:14 At an altitude of 280 feet, the captain initiates a turn to the right.

…the pilots initially believed both engines had been damaged by the bird strike. This conclusion, in combination with the vibrations, stench and unsafe nose gear indication lead the pilots to doubt whether the aircraft would remain airborne. Based on these assumptions, it is understandable that the pilots decided to return to the airport as quickly as possible.

Well, yes, I can understand wanting to return to the airport as quickly as possible. However, if both engines were out, he was making a suicide turn at under 500 feet. Even with the fear that the plane is extensively damaged, I have to think that the best response would be to attempt to glide to the open land in front of me.

The right thrust lever is retarded manually, decreasing engine RMP from 93.8% to 82.0% N1. I can’t come up with a good reason for reducing the power, I really can’t.

But more important is this turn to the right.

Take a look at the illustration from the accident report here:

They departed on runway 18. You can see grey dotted line, where the flight should have carried on south for the climb out and then a gentle left turn. The correct procedure would be to continue south, clean up the plane, and then plan your turn back to the airfield.

21:43:18 Mayday call transmission ends. Aircraft’s bank angle has increased to 21 degrees to the right.

The runway controller saw aircraft in the turn, instructed crew to continue the turn and roll out on a heading of 330 degrees. Full credit to the controller – he did not argue or try to ask what they were doing but simply adapted to their current route and tried to give them a sensible heading.

He then informed crew they’d receive further heading instructions for approach to runway 18R and halted the traffic taking off of Runway 24.

The first officer acknowledged ATC and states again in the cockpit that engine one is damaged. The captain does not respond.

During the aircraft’s turn the maximum recorded bank angle to the right was 37.5 degrees. Airspeed dropped from 179 to 156 knots.

21:43:26 Autothrottle disengaged. The aircraft continues in a slow climb.

21:43:27 At an altitude of 496 feet and a speed 161 knots, the aircraft enters a shallow descent.

21:43:44 The Ground Proximity Warning System activates: DON’T SINK DON’T SINK. The airspeed continues to reduce.

21:43:47 The aircraft slowly descends to 352 feet with an indicated airspeed of 150 knots.

The captain asks the first officer to repeat the information given by the runway controller. The first officer responds and notes that the nose gear is not up. Their discussion is interrupted by the purser calling the cockpit to inform the crew that the left engine is on fire. The captain tells the first officer to inform the purser that they will be returning to the airport.

The captain is not actually acknowledging any of the information he’s being given. Overload?

21:44:13 The runway controller calls the crew to ask whether they will be able to maintain their altitude and to give new heading instructions.

21:44:14 The airspeed drops to 145 knots. The aircraft rolls out from the right turn on a heading of 344 degrees.

The first officer speaks to the runway controller while the captain speaks to the purser. The captain is flying the aircraft manually now which is correct procedure: the autopilot should not be used under 1,000 feet.

The purser repeats that the left engine is on fire. The Ground Proximity Warning System triggers several times.

After the first officer finishes his conversation with the controller, the captain asks the first officer to repeat the controller’s instructions.

At this stage, finally, power to the (fully functional) right engine is increased and the aircraft begins to climb and build airspeed.

21:44:39 The aircraft is at an altitude of 500 feet with an indicated airspeed of 169.5 knots. The first officer states that the right engine has been at full thrust for two minutes since the start of the take-off roll.

21:44:41 The right thrust lever is pulled back again. The aircraft enters another shallow descent. DON’T SINK warnings sound continuously.

So, here we are, flying north, away from the open land and over urban areas. The minimum sector altitude (MSA) is 1,000 feet above the highest obstacle in the sector. For the area in which the flight of Royal Air Maroc took place, the MSA is 1,700 feet. They are at 500 feet, not only below the MSA but below the highest obstacle in the sector.

The autopilot is not to be used when flying under 1,000 feet so in addition to trying to navigate at low height in a disabled aircraft to a runway in an urban area, the captain is having to fly the plane by hand.

Air Traffic Control can’t do much to help: their minimum vectoring altitude is 1,200 feet. Below 1,200 feet, the captain is responsible for avoiding obstacles and to avoid flying over built-up areas. The controller can not give vectors.

The situation has gone from a simple emergency (bird strike, one engine out, unknown status of nose gear) to a complex one as they fly over the urban areas – in fact, they fly through the urban areas.

As a result of the immediate right turn and limited rate of climb, the crew members were under increased pressure as the autopilot may not be engaged at altitudes below 1000 feet. The pilots had to look outside to identify obstacles. The crew was also forced to deal with complications such as (system) warnings in the cockpit and an unstable flight path (variable heading, altitude, flight speed and rate of climb).

As a result, both pilots did not carry out their tasks – such as the execution of (follow-up) procedures and completion of checklists – according to procedure. This caused an increased risk to the aircraft, its occupants and the surrounding area.

21:44:57 The aircraft flies over Vijfhuizen at an altitude of 262 feet with an indicated airspeed of 160.5 knots. The GPWS warnings change to TOO LOW TERRAIN

I just just imagine standing on the street and seeing a 373 pass overhead at 262 feet…

Air traffic controllers supported the crew during the flight by providing headings for the landing. No information was provided regarding the presence of the aforementioned high obstacles, as these obstacles were not presented on the air traffic controllers’ radar screen.

The obstacles aren’t shown because ATC can’t navigate a plane through these areas at these heights. But the controllers can’t offer vectors at such a low level, they should be able to help the crew see and avoid tall buildings that they know are on the flight path.

21:46:14 The aircraft overflies Haarlem at an altitude of 348 feet with an indicated airspeed of 165.5 knots.

Their route takes them straight past a 479-foot tower which was located on the outskirts of Haarlem. They then proceed towards Amsterdam’s western harbour area, flying near obstacles up to 587 feet. They are flying below the tallest buildings in their area.

When the flight crew was asked if they received training for incidents like this they replied that an incident like this could not be trained and for that reason they did not receive such training.

The investigation revealed that the relevant Atlas Blue and Royal Air Maroc manuals contained all information needed for situations just like this serious incident. The training manuals contained general guidance needed to address the incident in a structured manner and the QRH and FCOM contained all relevant procedures that would have been needed to address the actual damage.

Despite this the flight crew was convinced that they had encountered a unique occurrence.

The captain had 7,540 hours and the first officer had 2,730 hours. Nevertheless, they both failed to follow standard procedure for the emergency with which they were confronted. Not only that, they were convinced that there was no procedure to deal with the emergency.

21:46:20 The GPWS warnings cease but are replaced with continous sound of the landing gear warning horn until 21:47:07

As the flight crew discuss the warning horn, the controller gives the crew a heading of 350 degrees as a downwind leg to runway 18R and asks if they are able to climb. The crew responded that they cannot.

Boeing performed a performance analysis, based on the flight data recorder data. This analysis showed that the aircraft’s performance was as expected both prior to and after the bird strike. Following the bird strike the crew extended the landing gear and allowed the aircraft’s airspeed to decay to near the V2 speed. Both of these actions contributed to the aircraft’s inability to gain significant altitude.

Up until this point, the crew have more or less followed the headings given by the controller.

The arrival controller then instructed the flight crew to follow a new heading of 100 degrees and reported they were four miles from touchdown. The crew concluded that they could not silence the landing gear warning horn. The captain turned the aircraft towards the new heading but rolled out on heading 065. At 21.47:17 hours the left engine was shut down according to the memory items 17 of the “Engine Fire or Engine Severe Damage or Separation” checklist (Quick Reference Handbook chapter 8.2). During this procedure the arrival controller informed the crew to fly heading 160 degrees. This information was not read back nor followed. A moment later the arrival controller gave a heading of 210 degrees which was not followed either. Only a very shallow right turn was initiated. By the time the flight crew had completed and confirmed the recall items of the checklist, the aircraft was positioned north of the airport, crossing the extended centre line of runway 18L.

21:48:03 The controller gives the crew a heading of 270 degrees to try to steer them back towards runway 18R. Crew completes the checklist and finish programming the flight management computer.

21:48:47 Airspeed fluctuates between 160 and 170 knots. As aircraft passes through heading 110, the first officer asks for further heading instructions.

The arrival controller repeated to fly heading 270. The flight crew asked the controller if it was possible to land on runway 18L. The controller indicated that this was not possible due to obstacles (a buildup area) just north of runway 18L. The crew discussed that the aircraft was difficult to control during this phase of the flight.

21:49:57 The airspeed drops to 156 knots. The first officer warns the captain that the airspeed is getting low. The captain adjusts the thrust lever and remarks that the right engine is at full thrust.

But he’s wrong. The engine was briefly at full thrust – for 5 seconds – as the captain made that statement. But just before and just after, it was not. He’s pulled it back.

Eventually, they manage the turn for a manual instrument landing (Category I) approach on runway 18R. Flaps are set to position 5. Flap positions 5 through 15 are used for take-off. Normal landings require flaps 30 or 40.

During the final part of the approach the first officer asked the captain if he should inform the purser that they would be landing shortly and that the cabin should be prepared. The captain replied that he did not want the cabin crew to start an evacuation procedure on the ground. Instead he told the first officer to inform the purser that they would be making a hard landing. The first officer did not pass this message to the purser as at that moment the aircraft started the final part of the approach. Instead he assisted the captain with monitoring the initiation of the descent. During the descent the first officer remarked that the auto brakes did not work whereupon the captain instructed to switch the auto brake system off. Just before touchdown the first officer suggested to the captain that he should try to keep up the nose wheel during the landing as long as possible.

21:52:06 The aircraft lands safely at a speed of approximately 175 knots.

The accident report confirms the bird strike as a causal factor but goes on to specify the flight crew management of the issue as equally a cause:

The deviations from the standard operational procedures after an engine failure were:

• The initiation of a (right) turn at 280 feet with a bank angle of up to 37.5 degrees instead of climbing to the prescribed ‘clean up’ altitude with retracted landing gear.
• Selecting gear down at very low altitude after it had first been selected up.
• Reducing the thrust on the undamaged right engine from 94% N1 to 83% N1 instead of selecting maximum thrust

.

These deviations from the standard operational procedures resulted in the aircraft only being able to achieve a limited rate of climb, causing it to be unable to achieve the required minimum safe flying altitude. The flight crew had difficulty controlling the aircraft and were distracted by various audio and visual warnings

My favourite comment from PPRuNe:

…the only concession I’ll give you is that he did have some piloting ability, which is what got the plane back in spite of his piss poor decision making.

This is a truly frightening incident. But, easy as it is to judge, we shouldn’t simply point at the pilots and tell them they handled it wrong. Pilots are the easy target, the scapegoat. If both pilots felt adamantly that the situation was so unbelievably rare that it could not be trained for, then it seems clear that they were not, in fact, adequately trained for it. Bird strikes are not a rare event and being able to analyse the symptoms and come up with a sensible plan is crucial. Understanding the situation and prioritising is the primary function of the flight crew in an emergency.

The accident report insists that Royal Air Maroc overhaul their entire training system and I agree. Something is wrong when two highly experienced pilots do not know how to deal with a situation that should be covered in training. They did not know (or had not been trained) to go for the books and check the procedure. Standard Operating Procedures exist because we know people are fallible. Going by the book is not a sign of weakness or inexperience. If an airline is not making that clear to their staff, it is the airlines’ job to work out where the failure is.

The recommendations as a result of the investigation are clear cut. Here’s my summary:

• Royal Air Morac must work on their training and their flight crew’s cockpit resource management skills as a matter of urgency.
• Schiphol ATC should be given the local information so they can see and warn about high obstacles in their control zone, so they can better help aircraft in distress.
• The Minister of Infrastructure and the Environment needs to take responsibility for doing something about the geese population and increasing number of bird strikes.

You can read the full accident report as a PDF in English for more information, including an in-depth analysis of the bird strike problem.

A Sukhoi Superjet 100 crashed in Indonesia last Wednesday. As always, there’s been a lot of confusing and conflicting reports in the media, so here is my attempt to document the factual aspects of this terrible accident.

The Sukhoi Superjet 100 is a fly-by-wire short-to-medium range jet with capacity for 75-98 passengers. The jetliner was the first new model to be produced in Russia since the end of the Societ Union.

The Superjet 100 entered commercial operation in June of last year, with five aircraft currently active in the Aeroflot fleet and one with Armavia.

The aircraft involved in the accident, the Sukhoi Superjet 100 MSN 95004, made its first flight in July 2009 and had accumulated over 800 flight hours in over 500 flights. It had no serious technical problems.

The Superjet was a part of a publicity road show to demonstrate the aircraft to Asian airline executives. Russian blogger Sergey Dolya posted a collection of photographs from the tour on his LiveJournal account. The aircraft photograph at the top of this post is also by Sergey Dolya and links to his gallery.

On the 9th of may, the aircraft, registration RA-97004, was at Jakarta’s Halim Perdanakusuma Airport in order to perform demonstration flights for media and airline representatives.

Here is a video of the aircraft coming into Halim:

The flight was crewed by two pilots with extensive flying experience. The Captain was the chief test pilot at Sukhoi with a military background and over 10,000 flight hours. He did the first test flight of the Superjet. His first officer was also a test pilot at Sukhoi. The Straights Times has reported that neither had flown in Indonesia before.

The aircraft took passengers on a demonstration flight that morning, which lasted 30 minutes and returned to Halim without incident.

The passenger list for the second flight was not updated although some of the invited guests did not arrive and others took their place. As a result, there have been conflicting reports regarding the souls on board. As of yesterday, Sukhoi’s statement says that there were 45 people on board.

Shortly after 14:00 local time, the flight departed for the second demonstration flight of the day. The aircraft was at 10,000 feet near Mount Salak. The peak of Mount Salak is at 7,254 feet however, there is a valley leading between the mountains that the pilots may have decided to fly through.

At 14:21, one of the pilots requested a descent to 6,000 feet, which was acknowledged.

That was the last radio call from the aircraft. Radar contact was lost between 14:21 and 14:33. The last track showed the aircraft in a right-hand turn descending through 6,200 feet.

The Emergency Locator Transmitter did not go off, leading aircraft personnel to hope that the aircraft was still in the air. After 3 hours, the maximum endurance for the flight, the alarm was raised.

The Indonesian Air Force was unable to start an immediate search and rescue as a result of the thick fog and bad weather. The wreckage was discovered the following day at 5,300 feet MSL and 6 paratroopers parachuted to the crash site, where they stated they had no hope of finding survivors.

The Air Force has stated that the initial impact was at 6,250 MSL into a sheer cliff, which the wreckage then slipped down.

The impact site appears to be just below the ridge line.

The Jakarta Post have reported that satellite surveillance shows that Mount Salak was obscured in thick cloud at the time of the crash.

Video footage of the crash site taken from one of the rescue helicopters has been posted to YouTube:

A pilot with local knowledge wrote about the area in the Jakarta Globe:

Superjet Disappears South of Jakarta: Notes From an Aviation Consultant | The Jakarta Globe

I’ve flown around that area a lot in the past. It’s nice and scenic in visual and meteorological conditions (VMC). But between Mt. Salak and Mt. Pangrango, one has to have their wits around and not have a lapse of situational awareness. Some very strange winds are up there, and conditions are unpredictable even in VMC, and in instrument meteorological conditions (IMC), it’s damn awful. I must thank my fortunes to not have to go through the pass between those two mountains anymore these days.
…
If these guys were only armed with Jepp approach, STAR, and en route charts, a simple “fly out along R206 to 30NM and turn back”, would be fine in VMC, but deadly in IMC and bad localized weather.

Meanwhile, an Aeroflot flight attendant posted to Twitter with commentary on the crash.

Aeroflot Fires A FA Over Superjet Crash Remarks — Civil Aviation Forum | Airliners.net

As soon as the news about the crash came through, she reportedly twitted with text roughly translated as “A Superjet crashed? (Devil Laugh)… Shit of a plane. Pity not at Aeroflot. Could do with one of the planes out or have them all sold back to someone…”

Aeroflot responded by posting her letter of termination on the corporate Twitter account.

The headlines have been full of the story of the Captain of a JetBlue flight who panicked on board and was locked out of the cockpit. In the interests of not arguing with everyone I meet, here is a run-down of what happened, unembellished by media excitements.

Let’s get this out of the way first:

No, there is no evidence at this time that the Captain was on drugs, was known to have a brain tumour, was a terrorist himself or was an alien from Mars. Please disregard any and all headlines of this nature. No, it is not true that “a passenger had to land the plane” – an off-duty Captain was travelling on the flight and assisted the First Officer, who was the Pilot in Command throughout.

Here’s what we know so far, primarily based on the federal affidavit released on Wednesday.

The captain of JetBlue Flight 191 was Clayton Osbon, 49 with twelve years service and described by the president of JetBlue as an old friend and consummate professional. He has no history of problems.

He was featured in Richmond Hill Reflections magazine last year.

Clayton Osbon: Flight Standards Captain for JetBlue Airlines

He’s flown in 35 different types of airplanes in general aviation and is approaching eighteen thousand hours. It was his job at Net Jets, where he was hired in January of ‘94, which allowed him to fly the Gulfstream IV, the predecessor of the G450 and G550, all over the world. During this time he lived, for a few years, in Lisbon, Portugal and Lyon, France.

…At home, Clayton is working on leadership coursework. “Putting it down on eight and a half by eleven sheets of paper,” he says. He wants to be a motivational speaker down the road. “It starts with a greater enhanced knowledge of one’s being…you know, I’d like to think the world is more than just getting up in the morning, making a cup of coffee, going to work, coming home, kissing your wife good-night and going to bed.”

Flight 191 was an Airbus A320 in good condition. The first officer was Jason Dowd.

On Tuesday, Captain Osbon was late arriving for the flight and missed the routine crew briefing. The flight departed half an hour late. However, there is no evidence that he was agitated or acting bizarrely at that point.

At 07:28 EST, JetBlue Flight 191 departed New York for its 06:55 scheduled flight to Las Vegas. There were 135 passengers on board, many of whom were attending a security convention in Las Vegas. As a result, there was a large number of police officers and prison guards on the flight.

As they were climbing out of JFK, the captain referred to being evaluated by someone. First Officer Dowd did not know what that meant. Captain Osbon spoke about religion and the FO stated that his statements were not coherent. He became concerned when the the captain stated that “things just don’t matter.”

Osbon apparently spoke on the radio, telling the air traffic controllers to be quiet. He then turned off the radios and admonished his First Officer for trying to use the radio. I’ve not been able to obtain the ATC recordings of this interaction.

Osbon continued to speak whilst dimming all the instruments and made a number of comments which concerned his first officer, including “we need to take a leap of faith” and “We’re not going to Vegas.”

First Officer Dowd said that Osbon tried to “correlate completely unrelated numbers like different radio frequencies” and then began a type of sermon.

An off-duty JetBlue captain was a passenger on the flight and at about 3½ hours into the flight, the FO suggested that they invite him to the cockpit.

Captain Osbon ignored the suggestion and left the cockpit, breaking JetBlue procedure, to use the toilet at the front of the plane. He found it was occupied and banged on the door, shouting that he needed to go.

First Officer Dowd alerted the flight attendants to the situation and asked them to bring the off-duty captain to the cockpit. The First Officer then locked the cockpit door and changed the security code.

Osbon paced the length of the plane, speaking about 150 souls on board, religion, September 11 and terrorists. He appears to have walked to the back of the plane and then shouted “guys, push it to full throttle” while sprinting back to the front of the plane with the flight attendants giving chase. The Flight Officer announced over the PA system that Osbon should be restrained.

Osbon then tried to re-enter the cockpit and realised he was locked out. That’s apparently when he began to scream that the plane was going down. You can the captain at the beginning of this passenger video:

Flight attendants and several passengers pulled him away from the cockpit door and held him down in the forward galley.

The passengers were justifiably confused.

U.S. charges screaming, incoherent JetBlue pilot – Yahoo! News Canada

Passengers who were on the plane described a chaotic mid-flight scene in which a man in a JetBlue uniform, apparently locked out of the cockpit, began banging on the door and demanding to be let inside. Passengers subdued him.

“People behind me, a bunch of big guys, started going up there and trying to help, and we found out that the guy banging was actually the pilot, and he was trying to get into the cockpit because the other co-pilot had locked him out,” passenger Grant Heppes told Reuters.

“Everybody seemed pretty nervous,” he said. “Nobody was sure that was going on.”

Several male passengers were able to subdue him in the forward galley and restrained him using seat belt extensions and zip-tie handcuffs. A passenger said that in the end there were six men holding him down, with more congregating in the aisle ready to jump on the pilot if he broke free.

Affidavit depicts drama on Flight 191 | Amarillo Globe-News

Passengers described Osbon as a large man, standing more than 6 feet, 3 inches tall and weighing roughly 250 pounds. They said that when they tried to apply zip-ties to his wrists, he snapped the restraints, forcing passengers to take off their belts to bind his arms. A passenger said they held Osbon for roughly 30 minutes as the plane diverted to Amarillo.

The ATC recording of the flight coming into Amarillo, Texas has been posted on YouTube. It is interesting in that it is unremarkable. The First Officer is calm and matter-of-fact as he diverts the plane and declares an emergency.

Flight 191 landed in Amarillo at 16:13 local time on Tuesday in Amarillo.

From the affidavit

The flight attendants elected to have the aircraft land without having the assisting passengers return to their seats, because the flight attendants felt they could not risk letting Osbon get up off the floor. The aircraft landed with passengers still restraining Osbon in the galley.

JetBlue stated that they are sorry that the passengers were put into the situation but are very thankful for their efforts. “What the customers did to help our inflight crew was amazing and we really appreciate their efforts, and also the cooperation of everyone on board – it contributed to the safe landing.”

Clayton Osbon has been charged with interfering with the duties of the flight crew which can bring a sentence of up to twenty years in prison. He is currently in a guarded facility at a hospital in Amarillo.

The NTSB have the cockpit recordings and are investigating.

BlueTales » JetBlue » Update on Flight 191

On behalf of the Crew of Flight 191, we would like to express our appreciation for the public’s kind words and well wishes for the crew. We understand and appreciate everyone’s desire to hear directly from the crew regarding their experience, but they have decided to decline all media opportunities at this time in order to spend time with their families.

I’m just glad that the airline isn’t arming their captains in case of emergency: now that could have been a real threat.

A round of applause for the passengers who helped to resolve the situation. Another reminder that it is everyday people — not technology, not air marshals, not airside security — that were able to respond. We can’t predict every situation but we can rely on people to do their best to resolve problems as they encounter them.

In 2010, Continental Airlines was convicted of involuntary manslaughter for the Air France Flight 4590 disaster in Paris a decade earlier.

Continental called the judgement “absurd” and vowed to appeal. That appeal has now started in Versaille this month. The crash, in July 2000, is described as “the beginning of the end” of Concorde’s commercial flights. Concorde was retired by both Air France and British Airways in 2003.

Air France Flight 4590 departed Paris at 16:42:17 local time. Witnesses saw the plane take off with flames coming out of the engine. At 16:44:30, the burning plane stalled and crashed into the Hôtelissimo Les Relais Bleus Hotel in Gonnese. All 100 passengers and nine crew were killed as well as four people in the hotel.

The French BEA (accident investigation bureau) determined that there was a strip of metal on the runway which punctured the Concorde’s tyre.

The tyre exploded and large pieces of flying debris struck the craft. The vibrations caused a fuel valve on the wing to burst open. The resulting fuel leak was likely to have ignited from the sparks from the landing gear wiring which had been severed when the tyre exploded. The crew began aircraft rotation (take-off) as the fire ignited. The flight engineer shut down engine two in response to the fire alarm.

The undercarriage (with severed/burning electrical wiring) would not retract. The report found that the resulting configuration meant that the remaining three engines did not have sufficient power to climb. The crew attempted to divert to Le Bourget; however engine one failed and the port wing began to melt, causing further destabilisation. Finally, engines three and four failed and the crew lost control as the plane stalled into the ground.

The strip of metal, a titanium alloy strip measuring just 435x29x34mm (approx 17x1x1.3 inches), had come from a Continental Airlines DC-10 which had departed for New Jersey five minutes before the Concorde.

The accident report concludes with the following:

The accident was due to the following causes:

• High-speed passage of a tyre over a part lost by an aircraft that had taken off five minutes earlier and the destruction of the tyre.
• The ripping out of a large piece of tank in a complex process of transmission of the energy produced by the impact of a piece of tyre at another point on the tank, this transmission associating deformation of the tank skin and the movement of the fuel, with perhaps the contributory effect of other more minor shocks and /or a hydrodynamic pressure surge.
• Ignition of the leaking fuel by an electric arc in the landing gear bay or through contact with the hot parts of the engine with forward propagation of the flame causing a very large fire under the aircraft’s wing and severe loss of thrust on engine 2 then engine 1.

The BEA found that the titanium strip had not been manufactured nor installed in accordance with manufacturer procedures. Titanium was not a suitable material to use for the repair.

French authorities began a criminal investiagion of Continental Airlines. On the 6th of December in 2010, Continental Airlines was found criminally responsible for the disaster and Continental mechanic John Taylor was given a 15-month suspended sentence for negligence. Continental was fined 200,000 Euros and ordered to pay one million Euros to Air France.

Continental stated at the time that Concorde was unfit to fly and that the aircraft caught fire before hitting the metal strip.

The appeal is based on the argument that Concorde’s design was flawed and it was structural vulnerabilities which allowed such an incident to happen. Continental’s lawyer stated “Air France, a civil party, could have been among the accused if some experts hadn’t been former Air France employees.”

The Concorde already had a reputation for burst tyres and the US NTSB had expressed concern about this issue as early as 1981. However, the French BEA determined that although a burst tyre “is not an improbable event on Concorde”, neither had it ever caused a fuel fire. The BEA believe that a burst tyre without external cause explodes into smaller parts and thus could not have triggered the effect that lead to the structural failure of the fuel tank.

Continental lawyers are no longer arguing the cause of the accident but have focused on the findings. They appear to be claiming that the metal strip should not have caused such a catastrophe and the design faults of Concorde are to blame.

PPRuNe poster cwatters has pointed out that this appeal may well be dismissed by the take the victim as you find him rule:

Eggshell skull – Wikipedia

This rule holds one liable for all consequences resulting from his or her tortious (usually negligent) activities leading to an injury to another person, even if the victim suffers an unusually high level of damage (e.g. due to a pre-existing vulnerability or medical condition). The term implies that if a person had a skull as delicate as that of the shell of an egg, and a tortfeasor who was unaware of the condition injured that person’s head, causing the skull unexpectedly to break, the defendant would be held liable for all damages resulting from the wrongful contact, even if

1. such damages were not reasonably foreseeable, or
2. the tortfeasor did not intend to cause such a severe injury.

The poster points out that there is at least one case where the rule was applied in shipping collisions (PDF) but I’m unsure if there is French precedent.

The trial is expected to continue until the 9th of May although the defence is hoping for a fast dismissal: they have argued that the retrial on the same charges is unconstitutional. The first day of hearings on Thursday was devoted to procedural questions.

Henri Perrier, former head of the Concorde program at Aerospatiale, did not appear at the hearing. His lawyer argued that his 82-year-old client is too frail to attend the proceedings and requested that the case to be dropped.

French court begins hearing Concorde crash case appeal – Monsters and Critics

The court rejected a request Thursday for the case to be scrapped. It came from a lawyer for one of the accused, Henri Perrier, former head of the Concorde programme at Aerospatiale, who argued that his client, aged 82, was too frail.

The court decided instead that Perrier and another Aerospatiale employee will face separate court proceedings in January 2013. They are accused of having known about the plane’s engineering flaw and not having done anything to prevent the accident.

Meanwhile, this short documentary about the Concorde still makes me well up:

Special thanks to reader RJ Wade for bringing this to my attention.

If you’ve flown a retractable, you’ve had it drummed into you: put the undercarriage down, check you put the undercarriage down and then check it once on short final.

I came close, once. I was doing a circuit to land at North Weald. I wanted to get around quickly and took a decision not to lower the gear just yet. The warning tone sounded, of course, but I’d done it intentionally, so I ignored it. On finals to land, I did my final check: red, blue, three greens. That’s the prompt to look at the fuel flow (fully rich) and the propeller (fully fine) and the landing gears (all three extended).

Needless to say, I saw nothing where my three green lights should have been and immediately went around. I felt sick to my stomach realising how close I’d come – all it would have taken was one further distraction and I could have written off the plane.

You may think it will never happen to you but then again, none of the pilots in the following clips thought it would happen to them!

Favourite statement on the video: “I said we were going too fast!”

We did not know, what will happen in the next 4 minutes. I was filming the approach for my personal video files, than it happens. The crash. Right after the crash, we don’t knew what was happening. We all survived. This video shows the approach to the altiport megève. Both, the pilot and the mountain rate teacher have several thousands of flight hours and a huge experience, but it happens, that the gear was forgotten. On the video you can hear the warning signal of the plane, that indicates, that the gear was not pulled out. No one was harmed by the crash.

After the crash, we tried to move the plane, but we had to get a tractor to pull the crashed plane from the runway. You can see this in the further video.

So I can give you the following advice: Check your gear twice or use a plane with a fixed gear.

I particularly like this comment by 1editor1 defending the pilots:

The gear up landing can happen to anyone who flies a retract. External pressure and life distractions will bite you at sometime, whether it‘s running a stop sign, leaving the iron on or car unlocked. The perfect storm for a gear up. You’ve booked that getaway with your buddies in the TB20 that you haven’t flown for 5 weeks. This has been a ball buster. Your wife has just served the divorce papers, the bank won’t refinance your home and your daughter is pregnant by your best friend. FOCUS!

A safety “squat switch” prevents the gear from raising when the weight of the plane is on it. The safety is there in case of inadvertent selection of GEAR UP while on the ramp or taxi. Once the weight of the aircraft is removed, the gear will operate as selected.
This pilot simply took off with the gear lever in the up position, as soon as the weight was removed, the gear raised as designed.

Landing a big plane with its gear up is a particular challenge (although I think quite a bit less likely to happen as a result of a missed checklist!).

Here’s a Boeing 727 doing it right:

The flight IR-742 from Moscow, Sheremetyevo was on approach to Tehran’s Imam Khomeini Airport around when the crew did not receive a down and locked indication for the nose gear and aborted the approach. Following unsuccessful troubleshooting the crew decided to divert to Tehran’s Mehrabad Airport where a low approach confirmed the nose gear was not extended. The crew subsequently performed a landing without the nose gear and came to a stand still on both main gear and the nose of the aircraft. The aircraft was evacuated, no injuries occurred.

And here’s a hang glider… sadly not quite doing it right:

100% pilot error. A $200.00 Landing. I should have landed at the lower lz.

And finally, the most beautiful gear-up landing I’ve ever seen was this King Air landing at Atlanta, Georgia, as shown on CNN:

I have to admit: that’s a smoother landing than I manage with the gear down!

It was an uneventful night. The crew went on duty on Thursday night at 20:40 for scheduled passenger flights on a Boeing 737-800 from Lanzarote to Glasgow and back.

Friday morning, on the return leg, their work is almost done. The First Officer is flying and the Captain has taken the opportunity to have a short rest. There are 74 passengers and six crew on board for this 4-hour and 19 minute flight to Lanzarote.

At 06:50 (UTC and local time) they are cruising at FL 390. The Lanzarote ATIS (recording giving up-to-date airfield information) looks good:

06:50 Runway in use 03. Transition level 70. Wind touch down zone variable 3 knots, variable between 200 and 270 degrees. Visibility 10km or more, clouds few at 1,800 feet, broken 9,000 feet. Temperature 18 degrees dew point 14, QNH 1014, QFE 1013. Report Lanzarote ATIS information A.

There is no mention that the runway is wet, which should be specified in the ATIS and by air traffic control, as wet runways can require a longer landing distance.

The First Officer has already programmed the Flight Management Computer for the 03 runway. He gives a detailed briefing of the approach. The briefing includes a review of the airport chart and the landing distances required. The captain mentions that the approach also includes Precision Approach Path Indicator (PAPI) visual aids to help incoming aircraft acquire the correct approach path.

They continue to descend. The Captain contacts the handling agent in Lanzarote with an estimated arrival time of 07:22.

“Just out of curiosity,” says the Captain to the FO, “ask him how the wind is for runway 21…I don’t think they’ll let us, but anyway…” He said later that runway 21 saved time when arriving from the north although it was a more difficult approach.

The FO makes the request and then comments, “The thing is, if we head for 21, I have nothing planned, so if they end up giving it to me, I’m going to laugh.”

Canaries Approach responds: “Europa 196 you may proceed to the 11 mile fix, runway 21 to land on 21, continue descent to 5,000 feet, QNH 1014.”

The First Officer now has to work out the new approach. He talks to himself as he inputs the new information into the Flight Management Computer.

From the final report (PDF):

The FO asks the captain in a troubled voice, “We’re going to here, to mile 11, right?” The captain replies, “Mile 11, yes.” The FO again asks “There?” and the captain replies, “I don’t know but descend.”

The FO states, “No, no, something’s not right here… we’re now heading for mile 11, ah … no…” The captain replies, “Set 4,000 for now,” adding shortly afterward, “Here, to this point.”

The FO once more asks, “What point are we going to? I’m not seeing this point at mile 10, mile 11, it has to be F.” The captain replies, “CD21” and the FO, in a relieved voice, says “CD21, OK, that makes sense! Of course, I thought something was off!”

The carefully set-up approach is in a mess. The Captain repeatedly requests a faster descent. The Flight Officer knows he’s not prepared for the runway change and clearly struggles to set up the Flight Management Computer fast enough. At 10,000 feet they are 21 nautical miles from the runway and going 315 knots. They are too high and too fast. The Captain requests “a bit of speedbrake” to alleviate the issue.

They continue the descent. The Captain reads the descent check list. The First Officer continues to express surprise at the indications of the Flight Management Computer.

Before the runway change, the descent had been planned at 300 feet per nautical mile. At the point of the runway change, they are suddenly 23 nautical miles closer to their runway and require an immediate increase in descent rate. The table below is from the accident report and shows the descent rate required to reach runway 21 as the flight progresses.

At 1,700 feet they are 3 nautical miles from the runway and travelling at 180 knots. The First Officer confirms landing in sight. The approaching minimums automatic call-out is sounded.

The First Officer asks for flaps 25 and then a few seconds later requests flaps 30. The Captain tells him to wait a couple of knots: they are going too fast to lower the flaps any further.

At 900 feet, they are descending at 2,000 feet per minute. The cockpit fills with a caution from the Enhanced Ground Proximity Warning System: SINK RATE, SINK RATE.

“It’s all right,” says the captain and lowers the flaps to 30°.

500 feet. They are going 177 knots and descending at 1,900 feet per minute. They have not achieved the glide slope. The warning system continues to sound: SINK RATE, SINK RATE, PULL UP, PULL UP.

Boeing’s Flight Crew Operations Manual states that the PULL UP warning requires an immediate go around, specifically because it is associated with an unstabilised approach.

The First Officer says “We’ll keep it there, OK?”

500 feet is the decision point, at which point the pilot monitoring should make a statement to continue the approach if stabilised and break off if it is not. The pilot monitoring, in this case the Captain, must demand a go-around if the approach is unstable. Reasons to interrupt the approach include confusion among the crew, checklists completed late, crew overloaded, and the approach altitude, speed, glide slope or configuration becomes unstable.

Top tip: if warning calls from the Enhanced Ground Proximity Warning System are filling the cockpit, the approach is not stabilised.

The captain did not make the 500-foot call out.

300 feet, 176 knots, descending 1,700 feet per minute and more warnings: TOO LOW TERRAIN, SINK RATE. TOO LOW TERRAIN, SINK RATE.

The Captain realises that the runway is wet and increases the thrust setting on the autobrake system to maximum.

According to Boeing 737 FCTM “Flight Crew Training Manual”, the maximum braking landing distances included in the QRH must not exceed the 60% of the real available distance, in order to provide adequate safety margins. Considering this, the minimum required runway length would be 1,712 m. Lanzarote runway is 2,400 m long, thus it exceeds by more than 700 m the minimum runway length required for this type of aircraft.

After a prolonged flare, the airplane touches down halfway down the runway at a speed of 157 knots. That’s 23 knots over the VREF – the landing reference speed at 50 feet above the threshold which is 1,300 metres behind them as they touch down.

Groundspeed 137 knots: Someone accidentally presses a brake pedal and the autobrake disengages five seconds after touchdown. The Captain calls out “Autobrake disarm!” immediately and both crew members engage manual brakes with full force.

Groundspeed 96 knots: The Captain calls for the reversers to be applied, 13 seconds after touchdown. They need time to spool up and thus have no immediate effect. The tower controller activates the alarm.

Groundspeed 51 knots: The next sound on the cockpit recorder is the sound of the aircraft colliding with the row of lights at the end of the runway.

Groundspeed 40 knots: Sounds of collisions with beacons.

The aircraft crosses the 60 metre stopway and slows to a halt just as the reversers finally kick in. It stops a metre away from the jet blast barrier for Runway 03.

The Captain transmits, “Lanzarote Europa 196…”
The Tower cuts him off, “Sending you firefighters Air Europa.”

There are no injuries and no damage to the aircraft other than the landing tyres. The Flight Officer is heard lamenting the event and blaming the reversers.

Cause:

The cause of the incident was a high-energy unstabilized approach followed by a landing with excessive speed, 1,300 m past the threshold, with a wet runway. In addition, neither the autobrake nor the reverser was used efficiently. A contributing factor to the incident was a combination of deficiencies involving several aspects of CRM (Crew Resource Management).

There’s more detail in the final report, including a long list of what went wrong.

In the end, it strikes me that the greatest problem here was the reluctance to break off the approach once things began to go wrong.

“The captain undoubtedly noticed that the FO could not adapt properly to the circumstances and that the situation was worsening, and yet he decided to maintain his role and not take control of the airplane himself. The captain made every decision. At no time did he ask the FO his opinion. He decided to request the runway change, he decided to have the FO continue flying and he decided to continue the approach in spite of the presence of a multitude of indications that suggested or required that the maneuver be stopped. He eventually decided to land, increasing the autobrake setting to MAX instead of ordering a go around when he saw they were landing too fast in the middle of a wet runway.”

Even if we accept that asking for Runway 21 at that late stage was reasonable, the approach should have been broken off based on the descent profile alone. It should have been broken off when the FO was clearly overloaded and it should have been broken off when the warnings sounded and it should at the latest have been broken off at the 500 metre call-out point.

Fatigue and operating in the low-performance phase of the circadian rhythm were brought up as possible contributing factors.

This is certainly a text-book example of bad decision making.

Source: Comision de Investigacion de Accidentes e Incidents de Aviacion Civil (CIAIAC) final report IN-041/2008 (in English)

Analysis: Incident: Air Europa B738 at Lanzarote on Oct 31st 2008, departed runway on landing

Photographs by Manuel Estévez, Erik Cabrera Jensen and Keith Hatfield.

The plane went missing on the 10th of August in 1984. It was a Cessna L-19E “Bird Dog” – a two-seater liaison and observation aircraft built for the US Military.

L-19 Crash Documents

[The pilot] had been offered a contract by the Colorado Dept. of Forestry to videotape a particularly nasty type of beetle infestation that had been ravaging hundreds of acres of Colorado forest in and around some of the higher-elevation foothills surrounding some of the Rockies. One thing that was unique about this particular flight was that the pilot had mounted a VHS video camcorder atop the instrument panel for the purpose of visually recording any beetle infestation that was observed along the flight route. The pilot started the camera shortly after takeoff and it ran until the aircraft crashed down through the trees – approx. 6-1/2 minutes later.

The tandem plane departed Granby (KGNB) with a passenger for the scenic flight over the Colorado mountains but never arrived at Jeffco (KBJC) as planned.

No one knew what had happened: the aircraft had tumbled into the trees and landed on the Emergency Locator Transmitter, cutting off the signal. Although there was a fire, it burnt out quickly and there was not enough damage to mark the crash site from the air.

The wreckage was discovered three years later, when backpackers hiking through the woods found the crash site, including a video tape hanging from tree branches. The video was released to the FAA who who were amazed to find that it had survived both the crash and three years of exposure with only minor damage.

Using the video as primary source data, the NTSB released an accident report.

NTSB Synopsis: Probable Cause

The airplane departed Grandby 8/10/84 and failed to arrive at its destination. On 8/23/87, it was found on the slope of a high tree-covered ridge. Video tape recovered from the wreckage provided a visual and audio record of the flight from takeoff to impact. Comparing the recording to a topographical map, the flight was climbing and its altitude above the ground was decreasing when it crashed at the 10,200-ft level. During the last few seconds of the tape, the terrain dominated the view through the cockpit window. The pilot made a 60-deg bank, and the stall warning horn could be heard 3 times during aprx 180 deg of turn. the airplane subsequently stalled, flipped over, and entered the trees. The density altitude was about 13,000 ft.

The pilot continued to fly into rising terrain until he was boxed in. He saw the ski slopes which are almost certainly on the leeward side of the mountain: mountain flyers know these can produce a severe downdraft and are trained not to fly straight into them. The pilot presumably panicked because he then compounded his worsening situation with the steep turn to the right. The plane lost lift and the stall warners sounded.

The altitude, temperature and humidity combined to create the density altitude of 13,000 feet when the aircraft was actually at 10,200 feet. The high density altitude, flying over Colorado mountains in August, meant that in the turn, the plane was as high as it was capable of flying and was no longer able to climb at speed.

L-19 Crash Documents

He makes a moderately steep turn to the right (in excess of 45 to 50 degrees angle of bank) in an attempt to turn around quickly – the plane loses considerable lift and initially stalls twice; then on the 3rd stall (with the stall warning horn blaring in the background), enters the traditional “stall/spin” syndrome and flips upside down as the left (up-wing) wing stalls completely and the plane, flipping over on its back, plunges straight down through the trees – but not before capturing the pilot’s last mournful cry to his friend in the back seat: “Damn, hang on Ronnie!!”; the plane smashes downwards through the thick tree branches (you can hear the heavy “thuds” as the plane’s wings smash into these while heading for the ground); it crashes & burns – killing both the pilot and back-seat passenger.

Improper in-flight planning/decision by the pilot in command and airspeed not maintained are cited by the NTSB report as the probable causes, with the high density altitude and mountainous terrain given as contributing factors.

The pilot’s family requested that the film not be released to the general public and a 20-year moratorium was placed on the footage. That expired in 2009 and the footage was released.

This is a hard video to watch. The plane is flying low and slow but there seem to be plenty of escape routes. I kept thinking, hey, there’s still room to get down, if he stalls now, he can head for that valley and get some speed back up. And every time, the aircraft got a little lower and a little slower, taking in the view. The pilot gets tempted down to look at the lake and never regains that height. When the mountains took over the horizon, he must have realised he was boxed in. And then that turn … I wanted to scream.

Such a damn shame.

(Before I start, I want to share some exciting news. You Fly Like a Woman appeared in Forbes this week! And it was reviewed – in Dutch and English! – on Aviationbookreviews. I would never have written the book without the support of the blog readers, so here’s a big THANK YOU to all of you. Now, on with the post!)

The 2008 viral video of an unregistered plane supposedly losing a wing and the brave pilot landing it safely is making the rounds again, much to my disgust and the advertiser’s excitement. The video is completely faked but seems to have done the job of getting people’s attention. To compare, you can see this real video of a radio controlled aircraft landing with one wing – ignoring everthing else, the tilting plane on the runway is what’s clearly missing from the viral video. I find it a little bit bizarre that the advertising clip is continuing to fool so many people. And once they have found out the truth, do they really go and buy clothes?

The reality is not so pretty. The following are true accidents – including video – of the wings falling off during flight. Be warned, the results aren’t pretty. The first two videos are very hard to watch.

In 1983, this light twin (the Italian Partenavia P68C which is not an aerobatic aircraft) was being flown by the owner who had apparently imported the planes and showed them off at local airshows. He began a rapid pull-up at high speed (above the aircraft’s VNE). With an estimated load of 8.3 Gs, the wings separated from the plane. The NTSB determined the probable cause as the pilot in command’s overconfidence in the aircraft’s ability.

Accident Report

No engine sounds were heard during the spin & the prop was observed not rotating before impact. The engine was not equipped with an inverted fuel system. The aircraft was prohibited from aerobatic flight. There was no evidence that the pilot had ever received any aerobatic instruction.

In 2002, this Hercules was hired as fire-fighting plane to combat a 10,000-acre fire in California. The incident occurred on the sixth run of the day, delivering fire retardant. Examining the wreckage, the NTSB discovered fatigue cracks in the right wing’s lower surface skin, originating from the rivet holes. The cause of the accident was metal fatigue with a contributing factor of inadequate maintenance procedures to detect fatigue cracking. All three crew were killed on impact.

Accident Report

Tanker T130 flew down the east side of the drainage valley and proceeded to make a ½ salvo fire retardant drop. Just prior to the completion of the drop, the nose of the airplane appeared to rise and the airplane started to initially arrest its descent and to level out. The nose of the airplane then continued to rise towards a nose up attitude and almost at the completion of the ½ salvo fire retardant drop, the airplane’s wings folded upwards and detached from the fuselage at the center wing box beam-to-fuselage attachment location.

I’ve linked to this before but it is still the most amazing aviation story that I have ever read. Test pilot Bill Weaver tells the story of his SR-71 Blackbird disintegrating around him – and how he survived although he never had a chance to eject.

LiveLeak.com – SR-71 Disintegrates Around Pilot During Flight Test

Everything seemed to unfold in slow motion. I learned later the time from event onset to catastrophic departure from controlled flight was only 2-3 sec. Still trying to communicate with Jim, I blacked out, succumbing to extremely high g-forces. The SR-71 then literally disintegrated around us.

From that point, I was just along for the ride. My next recollection was a hazy thought that I was having a bad dream. Maybe I’ll wake up and get out of this mess, I mused. Gradually regaining consciousness, I realized this was no dream; it had really happened. That also was disturbing, because I could not have survived what had just happened. Therefore, I must be dead. Since I didn’t feel bad–just a detached sense of euphoria–I decided being dead wasn’t so bad after all.

AS FULL AWARENESS took hold, I realized I was not dead, but had somehow separated from the airplane. I had no idea how this could have happened; I hadn’t initiated an ejection. The sound of rushing air and what sounded like straps flapping in the wind confirmed I was falling, but I couldn’t see anything. My pressure suit’s face plate had frozen over and I was staring at a layer of ice.

For an incident with a happy ending, AVweb produced a video showing a wing come off of an aerobatic plane (a Rans S-9 Chaos) during an airshow in Argentina. In this instance, a full-plane parachute saved the pilot’s life.

Real Aircraft Loses Wing, Lands Safely (Under Canopy) – YouTube

Comparing a ballistic ‘chute to a normal parachute worn on the body in this case it seems the full-plane parachute was a good choice. Due to the rate of roll induced by the loss of one wing, it appears questionable that the pilot could have escaped the cockpit and saved himself wearing a conventional parachute on his back. Conventional parachutes are not aided by ballistic deployment and may require more altitude to properly open. Had the pilot been wearing a parachute and managed to escape the spinning aircraft without being hit by it, he may have simply have impacted the ground under a partially opened canopy. In this case, full-plane parachute FTW.

Meanwhile, the University of Cambridge has released a video to show that the common explanation of how wings create lift actually goes against the laws of physics.

How wings really work – Research – University of Cambridge

“A wing lifts when the air pressure above it is lowered. It’s often said that this happens because the airflow moving over the top, curved surface has a longer distance to travel and needs to go faster to have the same transit time as the air travelling along the lower, flat surface. But this is wrong,” he explained. “I don’t know when the explanation first surfaced but it’s been around for decades. You find it taught in textbooks, explained on television and even described in aircraft manuals for pilots. In the worst case, it can lead to a fundamental misunderstanding of some of the most important principles of aerodynamics.”

Mind, a little bit of physics would go a long way towards stopping that viral video from being passed around as real!

Class dismissed.

I just discovered this great video footage of a US Coast Guard rescue in the Bahamas.

It happened just last week. Dr. Richard McGlaughlin and his daughter Elaine were flying his Cirrus SR22 to Haiti to do charity work, something Mr McGlaughlin has done regularly since the earthquake.

Dr. McG’s Haiti Chronicles – Cirrus Owners and Pilots Association

Dr. Dick “McG” McGlaughlin flew in with a Cirrus full of medical supplies because he “couldn’t stand to hear one more thing on the TV”. His first (short) report from ground zero said, “Everybody should come here- a great ameliorative for feeling put upon.” Interesting that McG ended up taking his own advice to heart. He has since flown his Cirrus to serve in Haiti more or less on a once-monthly basis.

They were a few miles out from Andros Island when they encountered engine trouble. The oil pressure dropped slightly and then within a few minutes it dropped to zero.

Elaine wrote about the experience in the COPA comments:

I’m writing this email from the Sheraton hotel in Nassau, after one of the most exhilarating days of my life. My dad and I took off from the smaller Tamiami-Executive Airport this morning, en route to Haiti after picking up his plane from a couple weeks of routine annual maintenance. I had bought a shiny new digital camera for the trip that morning, and was hungrily reading through the owner’s manual (something I never do) when I heard my dad speak into the headset, calling out to the nearest air traffic controllers that he planned to do an emergency descent because of an unexpected drop in oil pressure.

I thought that was kind of weird, but was mostly interested in organizing my granola bars and putting my travel sunscreen into MY backpack instead of his, and figured that if anything was really going on we would calmly make an unplanned landing on some dusty runway in the Bahamas, fix whatever was going on with the oil pressure, and be on our way. Then my dad’s voice became a little more pressured, and I noticed his hands were shaking.

They were at 9,500 feet. After the radio call, the engine seized and the propeller stopped. Dr. McGlaughlin configured the plane as best as he could and continued to speak to air traffic control. Elaine gradually became aware of the gravity of the situation.

My dad was obviously spooked, but mostly composed, adjusting whichever controls would respond at that point and continuing to communicate with air traffic controllers in various locations. They asked how many “souls” were on board, and I thought to myself that that particular word choice was decidedly morbid for a moment like this. As my dad’s voice became more gravelly, I sensed in him and began to feel myself what I now have the time and luxury to recognize as dread. Dread is sticky, humid; it fills the air and waits heavily, knowing and fearing, hating to have to know, but knowing all the same.

[...]

The air traffic controllers told us that the U.S. Coast Guard had been notified, and that we were four minutes from land. Four minutes was about three minutes too far, because we sank to 2200 feet at what looked to be a mile off shore, and my dad decided to pull the parachute. BOOM! We shot forward, I hit my head pretty hard on the dashboard– the energy of the parachute rocketing out the back of the plane caused us to pitch forward, and all of a sudden we were stopped still, dangling it seemed, looking straight down at so much flash-blue water. Just as quickly as it had careened over, the plane righted itself, the parachute slider doing its job, working the larger overarching parachute upright into the sky. Then we floated downwards, somewhat slowly, and hit the water HARD, a big firm collision right up your spine and down, but before I knew it water was rushing in EVERYwhere, and I couldn’t get my door open and whoa that water was pretty cold, aren’t we in the damn Caribbean here anyway?

Dr McGlaughlin stated separately that he was unsure of what would happen with a Cirrus Airframe Parachute System (CAPS) splash-down. He decided that he would pull at 2,000 feet above the ocean but then became impatient and deployed at 2,300 feet.

Early Reflections on CAPS Pull #32 by Dick McGlaughlin in the Bahamas – Pull early, pull often! – Cirrus Owners and Pilots Association

Dick vividly describes their splash down as a hard landing, harder than he expected. But both he and Elaine were uninjured. The cabin quickly began to fill with water through the fresh air vents, so they felt urgency to get out of the plane. While Elaine’s door would not open, the pilot door opened easily and both got onto the wing with their life vests and life raft.

As you can see, the plane did not break up on impact and they appear to be waiting relatively comfortably considering the 4-man raft looks about the size of a postage stamp.

Currrus have stated that this is the 28th save (making for a total of 53 survivors) since the Cirrus Airframe Parachute System was launched. Although having read the account, I’m sure Dr McGlaughlin could equally have handled a standard water ditching – he was perfectly in control and making decisions in what is for all of us a frightening possibility: engine failure during a water crossing.

Don’t you just love a happy ending?

The Air India Express 812 accident in May 2010 was a shocking reminder of how important cockpit management resources: the flight crew interactions and the adherence to procedures. There was nothing wrong with the plane. There was nothing wrong with the airfield. The weather was good. Everything that went wrong, went wrong in the cockpit.

The media is very focused on on fatigue at the moment and how it affects pilots. This 737 running off the runway, killing 158 people, is a reminder that fatigue is only one small piece in the puzzle.

Air India Express 812 was a quick-turnaround night flight, Mangalore to Dubai and back.

The captain, a 55-year-old Serbian national, had just returned from a few weeks spent at home. Air India Express employs a number of foreign captains, on a contract of eight weeks of flying duty followed by two weeks at home. The captain just had returned from two weeks in his hometown. This was his first flight since coming back on duty. He had over ten thousand hours flying experience as a Pilot in Command with 2,844 of those on the B-737-800.

The First Officer, a 40-year-old Indian national, was waiting for Command Training on the 737. He’d queried about the conversion six months before the accident but had received a generic response regarding company policy. He was a stickler for procedure and had previously complained about another foreign Captain who had not followed the company SOP. A note was made not to pair those two pilots together. It’s not hard to imagine his frustration at not being taken seriously.

The cockpit recorder has two hours of five minutes of the flight – the recording cycles over itself. I’m not sure why that might be, in this day and age of cheap storage. It would seem trivial to record twelve hours before recording over itself in order to give us a full picture of flight interactions. The result, in this instance, is that we do not know what interactions took place between the pilots that evening. We don’t know what conversation took place in the cockpit prior to the final descent.

The aircraft and crew departed Mangalore at 21:35 local time (Indian Standard Time, which I will use for all further times). No pre-flight medical check took place; however the crew interacted with engineering personnel at Mangalore who said both pilots seemed healthy and normal. It was a routine flight and they landed at Dubai on schedule at 01:14. They stopped at Dubai for just under an hour and a half and then at 02:36 they departed, on schedule for a 06:30 arrival in Mangalore. There were 160 passengers on board, including four infants. The take-off, climb and cruise appear to have been uneventful. There were many families in the cabin, quite a few first-time flyers. As the plane levelled off into the cruise, they probably dozed.

Certainly the captain did.

Our recording from the cockpit begins at 4am with the sound of the Captain snoring. He’s clearly deeply asleep for the first hour and forty minutes of the recording. He’s breathing deeply and is unaffected by the sounds of the First Officer making radio calls.

05:32:48 The first officer contacts Mangalore Area Control to say they are approaching reporting point IGAMA at flight level 370. He requests radar identification and is informed that the Mangalore Area Radar is out of service.

Mangalore Area Radar had been out of commission since the day before and a NOTAM had been issued. I would have expected the flight crew to have been made aware of this when they left Mangalore that evening.

05:33:20 The first officer reports position at IGAMA and asks regarding the approach. He requests descent clearance, which is denied to ensure safe separation with other aircraft.

Airlines that allow for controlled rest in the cockpit – that is to say, taking a quick nap while in the cruise – have specific regulations in place including this key point: a sleeping pilot must be woken at least 30 minutes prior to the beginning of the descent. This is to ensure that the pilot is properly awake before the critical phase of flight begins. Air India Express does not have a policy in place for controlled rest. It may not have occurred to the First Officer that he was obliged to wake the Captain with plenty of notice before the descent. There’s no evidence that he attempted to wake the Captain at all.

05:46:54 The first officer reports position and is cleared to descend to 7,000 feet. The aircraft begins the descent.

The cockpit recorder has some quiet mutterings from the Captain’s channel just prior to the descent. He’s woken up. There is no evidence of a descent and landing briefing.

From the accident report:

The crew had failed to plan the descent profile so as to arrive at correct altitude for positioning into ILS approach. The First Officer had said on the intercom to the Captain “RADAR NOT AVAILABLE, BUT I DO NOT KNOW WHAT TO DO.” This indicated that he was possibly not aware of procedure in case the radar was not available and in such a scenario, how to plan a descent and approach if not permitted by the Area Control to descend at the desired distance on DME.

Mangalore has a table top runway located at 337 feet above mean sea level. It is considered a challenging airport because of the surrounding terrain. Because of this, Air India Express standard operating procedure is such that only the Pilot in Command – that is to say the Captain – can carry out take-off and landings at Mangalore.

The Captain had done 16 landings at Mangalore. The First Officer had acted as co-pilot for 66 flights at Mangalore.

The flight is cleared to continue descent to 2,900 feet. The First Officer requests a direct route to radial 338 to join the 10 DME arc, which is approved.

The plane is high throughout this descent.

05:52:43 The aircraft is handed to ATC Tower at Mangalore. The tower is manned at this time of the morning specifically for the Dubai-Mangalore flight which is the first of the morning. ATC ask Air India Express to report established on the 10 DME arc for ILS runway 24. The First Officer acknowledges and yawns.

The airport reports the 10 DME arc and are asked to report established on the ILS.

The Captain selects Landing Gear DOWN at an altitude of approximately 8,500 feet, with speedbrakes still deployed in the Flight Detent position. This is clearly to increase the rate of descent. He’s too high and he knows it.

His configuration changes aren’t enough. The aircraft is still too high and fails to intercept the ILS glide path. In fact, it is at almost twice the altitude as it should be for a standard ILS approach.

06:03:14 The Captain selects the flaps at 40 degrees and completes the landing checklist.

06:03:35 At about 2.5 DME, the radio altimeter alerts the crew that their altitude is 2,500 feet.

06:03:33 The First Officer calls “it’s too high” and then “Runway straight down!” He’s just spotted the runway, coming up fast. They’re not on the approach path.

The Captain responds with “Oh my god” He disconnects the auto-pilot and increases the rate of descent.

06:03:53 The First Officer queries: “go around?”

They are in an unstabilised approach. The aircraft is too high and going too fast. It is absolutely correct that they should go around: break off the approach and circle around and try again.

06:03:56 The Captain responds with “Wrong Loc .. Localiser … glide path.”

So it is clear: the captain is not incapacitated. He is in control of the aircraft and comprehending at least some of the issues affecting the approach. However, he makes no move to go around. He’s still trying to get down to the runway in time.

The Extended Ground Proximity Warning System begins to sound an alarm: SINK RATE, SINK RATE. They are going down too fast.

06:04:02 The First Officer says “Go around Captain” and “Unstabilised!” but does not take any action to initiate a go-around.

There’s no question that they should go around. As a part of his training, the First Officer should have received very clear instructions as to when to take this decision. In most commercial airlines, the First Officer is expected to break off an unstabilised approach if the Captain is continuing despite a call to go around. This approach is clearly unstabilised. Assertiveness training is often offered in order to give the First Officer the confidence to override his captain in exactly this situation. A First Officer must have clear guidelines, confidence that his decision will not be held against him, and a good working environment within the cockpit. On Air India Express 812, the First Officer had none of the above.

The Captain does not go around. He makes visual contact with the runway and increases the rate of descent to almost 4,000 feet per minute.

This isn’t enough to cause screaming in the back. It’s unlikely that the passengers in the cabin even noticed that this is a more rapid descent than normal. They aren’t regular commuters and the rate of descent is not aggressive enough to feel like the plane is diving. Nevertheless, it is much greater than it should be for that approach.

The tower hasn’t heard from the flight and so they make contact: “Express India Eight One Two – confirm established.” Are you established on the ILS? Are you at the correct height going at the correct speed?

The First Officer doesn’t respond.

The Captain says “Affirmative” to him. When the First Officer doesn’t make the call, the captain barks it at him again: “Affirmative!”

The First Officer keys the radio. “Affirmative,” he says to the tower, even though he knows they are not established. They are too high and too fast.

Air India Express 812 is given landing clearance. Winds are calm.

For this flight, the target speed should have been 144 knots at 50 feet as they cross the threshold of the runway.

They cross the threshold at 200 feet with an indicated speed in excess of 160 knots.

06:04:38 Just before they touchdown, the Flight Officer calls out “Go around captain,” followed by “We don’t have runway left.”

From the accident report:

With the first Officer not showing any signs of assertiveness, the Captain had continued with the faulty approach and landing, possibly due to incorrect assessment of his own ability to pull off a safe landing. This violation of laid down SOP by the Captain can be attributed to fatigue, sleep inertia and the phenomenon of ‘GET OVER WITH IT’.

The captain continues the landing. Final touchdown is at 5,200 feet from the threshold of runway 24, leaving 2,800 feet of remaining paved surface.

Two thirds of the runway was behind them when the final mistake was made.

The captain selected the thrust reverser and commenced braking in order to stop as quickly as possible in the last third of the runway.

The full runway is 8,003 feet, more than enough for a 737 to land on. Boeing did tests simulating the conditions of the Air India Express 812 landing using the configuration of the aircraft. They came to the conclusion that if the Captain had applied maximum manual braking – that is, remained committed to the landing – the aircraft would have come to a halt at 7,600 feet beyond the threshold. The plane could and would have stopped before the end of the runway.

The only thing the Captain needed to do was continue braking.

But the Captain didn’t do that. He changed his mind. With two thirds of the runway behind him, having successfully landed and begun to slow the plane, he put full power on and attempted to take off again.

The last words recorded was one of the pilots saying, “Oh my God.” At this moment, 06:05:00 am on the 22nd of May 2010, the cockpit voice recorder went blank.

The 737 accelerated across the remainder of the runway and the overshoot. The right wing hit an ILS antenna mounting structure. The aircraft hit the fence and fell into a gorge.

INDIA Mangalore, survivor tells of air disaster – Asia News

Joel, a 24-year old native of Vamanjur, a town near Mangalore, was returning from a month spent in Dubai with his sister after completing a course of study on computer aided design in mechanical engineering. “I was in seat 23 – he tells AsiaNews – and we had barely touched the ground when it seemed that the pilot lost control of the aircraft.” He adds that “despite attempts by the pilot to stop the vehicle, it did not happen, the airplane crashed and the cabin was filled with a thick blanket of smoke. “Me and six others managed to escape – he confesses – and then we saw the plane break in two.”

The aircraft was destroyed in the impact and resulting fire. There were only eight survivors. All six crew members and 152 passengers lost their lives.

The DCGA cited the Captain’s persistence in landing as the direct cause, especially in light of the three calls from the First Officer to go around.

Even that was still survivable, if he’d just hit the brakes and done everything in his power to stop the plane. But there’s no question that continuing the approach was the primary factor.

Contributory factors:

1) Sleep inertia leading to impaired judgement. The Captain was in a prolonged sleep, waking at the top of the descent. The slowness of waking would be accentuated while flying in the Window of Circadian Low.

Quite honestly, I can’t see any other reason why he would make that bizarre choice to try to go around at the last minute, having successfully brought the plane to the ground. I can understand the desire to recover the approach. But having succeeded, and to the Captain’s credit, he had, it is beyond bizarre that he would then change his mind. This goes against all training and againt all standard operating procedures for the plane. It is crazy that an experienced Captain with over 10,000 hours in command would make such a reversal. I can only think that he was truly not quite awake and not actually understanding what was going on. Nothing else makes sense.

2) The aircraft was given a descent at a shorter distance than normal.

This should be a non-issue. However, it’s clear that the First Officer did not know how to deal with the last-minute change and the crew never planned the descent profile in order to correctly intercept.

3) The First Officer did not initiate a go around. Specifically: “the First Officer gave repeated calls to this effect, but did not take over the controls to actually discontinue the ill-fated approach.”

This strikes me as incredibly unfair. There is a clear training and cockpit resource management emphasis that needs to be in place at an airline in order to empower a First Officer to take control of the aircraft.

In this cockpit, the Captain expected the First Officer to do as he was told. This is clear from his insistence that the First Officer respond to ATC that they were established on the ILS when they most clearly were not. If ATC had been aware that the flight was not established, they would not have given the clearance to land.

But more importantly, the DGCA, even following this devastating report, has not clarified the issue in order to offer confidence to First Officers. In fact, going through their circulars, it seems clear that the Pilot Not Flying should not initiate a go around in a circumstance such as this.

The 15/2010 circular, still in effect now for Go-around following unstabilised approach is less than helpful:

Subtle incapacitation is associated with non-response to particular stimuli, as the crew is deeply involved in a particular maneuver. To assist in identifying subtle incapacitation, the PNF is expected to give two calls before taking any further action. In case the response is there from the PF towards the correction expected by the virtue of his action, it is taken as satisfactory. But the case where the response from the PF is absent or inadequate and the situation continues to deteriorate is something that needs to be addressed.

That is to say, it is up to the First Officer to decide that the response is “inadequate” and that the situation is continuing to deteriorate and to then consider addressing the situation. That’s not particularly inspiring for a First Officer who needs to be empowered to take control of the situation from an authority figure. But wait, it gets worse:

The action to take over controls by the PNF should only be in the case of total / subtle incapacitation. A situation of conflict in the cockpit is most undesirable for flight safety and would lead to a hazardous situation and needs to be avoided in all circumstances.

So rather than a straight-forward decision, such as “is my Captain continuing an unstabilised approach, yes or no?”, the Pilot Not Flying is told he shouldn’t take control unless the Captain is incapacitated, with a get-out clause of “subtle incapacitation”, in which case the PNF is expected to monitor to see if the situation continues to deteriorate.

Completely unreasonable to then allocate blame to the First Officer for not taking control, in my opinion, even as a contributing cause.

As the Ministry of Civil Aviation Court of Enquiry website appears to be timing out, I’ve included a PDF of the Report on Accident to Air India Express Boeing 737-800 Aircraft VT-AXV on 22nd May 2010 at Mangalore as a local file for your reference and convenience.