07 February 2014

The Sordid Story behind the Cork Fatal Accident : Manx2, Air Lada and Flightline

This is an in-depth look at the operations behind the crash that I wrote about last week: Manx 2 Fatal Accident at Cork: Below the Required Minima.

This might take a while, so get comfortable.

On the 10th of February in 2011, the Fairchild Metro III attempted to land at Cork in low visibility conditions.

The aircraft carried out two ILS approaches, both of which were continued beyond the OM equivalent point with conditions below required minima. On both of these approaches, descent was continued below [Decision Height], followed by a missed approach. The aircraft then entered a holding pattern following which a third ILS approach was made with conditions below required minima. This approach was continued below DH and a missed approach was initiated. Approaching the runway threshold, the aircraft rolled to the left, followed by a rapid roll to the right during which the right wingtip contacted the runway surface. The aircraft continued to roll and impacted the runway in an inverted position. The aircraft departed the runway surface to the right and came to rest in soft ground.

To understand the situation, we will have to untangle the complex relationships between the companies.

A Spanish bank owned the physical aircraft and leased it to Air Lada. In the accident report, Air Lada is referred to as the Owner. Air Lada subleased the flights to Flightline S.L., referred to in the report as the Operator. The service was sold by Isle of Man company Manx 2, referred to in the report as the Ticket Seller.

The Captain held a Commercial Pilot Licence issued in Spain and had a total flying time of 1,801 hours with 1,600 on type.

Records show that he had operated as a co-pilot (first officer) into Cork on 61 occasions and he flew in on seven occasions as Captain. There’s no records of any diversions on any of these flights. In addition, he’d never operated into Waterford or Kerry, which could have increased reluctance to divert.

He was promoted to Captain on the 6th of Feb 2011, four days before the accident.

Flightline’s Chief Instructor was involved in the training of both the Captain and the First Officer of the accident flight. He stated that although all the pilots were considered to be Flightline pilots, the pilots who flew the Metro III were paid by Air Lada.

He was the sole Class Rating Examiner at Flightline and it was his decision as to how many training sectors a candidate for captaincy would receive. The other Class Rating Instructor at Flightline had left the company shortly before. This meant that he both trained and checked the Captain. He agreed that there should be a separate Class Rating Instructor and Class Rating Examiner, but in the Captain’s case, this was not possible. He felt he would be able to objectively evaluate the Captain. He agreed that the command training of the Commander was very disrupted and thought it was possibly because they were tight in numbers and because the Captain had to travel from Belfast to Barcelona for training. He described the commander as enthusiastic with good crew resource management.

The First Officer held a JAA CPL issued in the United Kingdom and had a total flying time of 539 hours with 289 on type. He was employed as a co-pilot by the operator just three weeks before the crash. He went through a thirty-minute Operator’s Proficiency Check at that time. Flightline’s Chief Instructor described him as ‘was okay for his hours‘.

Flightline did not have any restrictions for newly qualified flight crew, so it was possible for newly qualified commanders and co-pilots to operate together.

The First Officer did not complete the line training and should only have flown with a training captain until he had completed his line training and passed a line check. The Flightline SL records show that all of First Officer’s flights were with line captains who were not instructors.

His CV indicated that he had studied Italian but there was no evidence of Spanish language competency.

It was quite clear that the duty and rest periods of the crew were not correctly documented.

The Co-pilot’s roster for February showed him ‘Libre’ (‘free’) between 8-12 February 2011. As another co-pilot requested a change of duty on 9 February, the Co-pilots duties were changed and he was required to operate the scheduled flights on 9 and 10 February 2011. The identity of the co-pilot was not noted in the flight paperwork of the short positioning flight between EGAA and EGAC on 9 February 2011. The Investigation is satisfied that the Co-pilot operated this flight and subsequently the two return flights to Cork. The two other possible candidates forwarded copies of their personal logbooks to the Investigation which showed they did not operate the sector.

The partner of the First Officer stated, “He did not have very much rest. He was working on a defined route incorporating some night-time flights carrying post.” She last spoke to him at 23:00 on 9th of February, the night before the crash.

Flightline, as the operator, was responsible for the flight crew, including ensuring staff competence and rest periods. The Quality Manager at Flightline stated that Air Lada produced a draft roster for flight crew, which Flightline would monitor and and amend as needed to ensure that flight time limitation rules were followed. Any roster change after the roster was published had to be approved.

However, none of the flight changes prior to the accident flight had been approved and Flightline were unaware that the co-pilot was on the flight until after the accident. The flight crew instruction regarding making a roster change request was in Spanish and no English translation was found. As a result of unofficial roster changes, neither the Captain nor the First Officer were fully rested at the time of the accident flight.

The aircraft had been involved in two previous significant events.

In the early mornings of 21 May 2004, EC-ITP was involved in a take-off incident at Palma de Mallorca Airport (LEPA). On take-off, the aircraft accelerated normally to 60 knots when the nose wheel steering (NWS) system was deactivated the aircraft veered to the right. The take-off was abandoned and reverse thrust applied but the aircraft departed the runway and incurred minor damage which was later repaired.

On 8 November 2009 EC-ITP suffered a heavy landing at Barcelona. As a result, the aircraft was ferried to an overhaul facility in Cologne for repair. This work was completed and the aircraft returned to service in October 2010, four months prior to the accident.

The repair for the heavy landing in November 2009 revealed that the left-hand engine installed in the engine was a loaner – meant for temporary use. It was removed and another loaner engine installed on 15 July 2010. The right-hand engine was removed from the aircraft on 27 April 2010 “for access to repair area” and re-installed on the right-hand side on 13 July 2010.

Despite the change of engine, a full Engine Ground Run check was not run. Instead, the checklist for engine adjustments was used. The engine ground runs did not include power lever split checks at Flight Idle.

On the last approach into Cork that day, the Captain, who was Pilot Not Flying, took control of the power on the last approach. At the decision height, he pulled back the power and called to continue, clearly hoping to spot the runway in the fog.

From last week’s blog post:

They once again descended below the decision height of 200 feet above the ground. However this time, the aircraft reduced power and at the same time experienced a roll to the left.

Terrain Awareness Warning System: ONE HUNDRED
Captain: Go around!
First Officer: Round.
Terrain Awareness Warning System: FIFTY
Terrain Awareness Warning System: FORTY

The Captain applied go-around power which is when they lost control of the aircraft. The aircraft rolled rapidly to the right and the right wingtip contacted the runway surface. The aircraft continued to roll.

It is likely that the First Officer, the pilot flying, did not realise what his Captain was doing with the power and made a control wheel input to the right to correct for the left roll.

The investigation cites three principle factors contributing to the loss of control:

The uncoordinated operation of the power levers and the flight controls, which were being operated by different Flight Crew members.

The retardation of the power levels below Flight Idle, an action prohibited in flight, and the subsequent application of power are likely to have induced an uncontrollable roll rate due to asymmetric thrust and drag.

A torque split between the powerplants caused by a defective Pt2/Tt2 sensor, became significant when the power levers were retarded below Flight Idle and the No. 1 powerplant entered a negative torque regime. Subsequently when the power levers were rapidly advanced during the attempted go-around, this probably further contributed to the roll behaviour as recorded on the FDR.

The Flight Data Recorder was recovered with 106 hours of data leading up to the accident. It showed that there as a mismatch between the torques being delivered by the two engines.

In general, the data showed that the torque being delivered by No. 2 engine exceeded that being delivered by No. 1 engine by up to 5%. It was also noticed that, as the power levers for both engines were being advanced prior to take-offs, the torque response for the No. 2 engine was faster than that for No. 1 engine.

The data showed that the pilots were adjusting the power levers to compensate for the engine torque differential. As the aircraft was descending towards the runway shortly before impact, the No. 1 engine was at 20-23% and the No. 2 engine was at 25-27%.

Then, 8 seconds before impact, a negative torque value was recorded. The next recorded values show the torques on both engines increasing but not in sync.

The next recorded values for this parameter [the No. 1 engine), following at intervals of one second, were +22%, +10%, +7% and +36%. Thereafter, recorded torque values for No. 1 engine rose rapidly. In a similar timeframe, the No. 2 engine torque values were recorded at +8%, 0%, +3%, +5% and +25%. Thereafter recorded torque values for No. 2 engine also rose rapidly to values in excess of 90%.

The negative torque the No. 1 engine caused the left roll. Then as both engines started to increase rapidly, the aircraft rolled to the right to 115° bank before the aircraft impacted.

The issue turned out to be a faulty sensor on the No. 2 engine. The defective engine intake air temperature and pressure sensor was caused by a crack in the side coil of the sensor bulb. The fracture surface was corroded, showing that the crack had been there for some time.

The effects of this fault were

  • Slower engine speed response when the speed lever was advanced
  • Faster engine torque response when the power lever was advanced
  • Higher torque for a given power level angle

Manx 2, based at Ronaldsway Airport on the Isle of Man, is referred to in the report as the "Ticket Seller". They did not have an operating licence or an Air Operator's Certificate, which is the approval required for an aircraft operator to use aircraft for commercial flights.

Instead, Manx 2 had contractual relationship with four AOC holders, including Flightline.

Flight crew on the flights wore a Manx 2 uniform and aircraft were painted with Manx 2 livery. However, the company did not want to have the "regulatory complexity and crewing problems associated with holding an AOC". Manx 2 didn't need an Air Travel Organisers Licence to sell the tickets, as none of the aircraft had in excess of 19 seats.

The UK Civil Aviation Authority was concerned that Manx 2 gave the impression that it was a licensed airline, at which point Manx 2 updated the website to state that it was a Marketing Group and acting as an agent for the four AOC holders.

In 2006, Manx 2 had made an arrangement with Air Lada (the owner of the two Metro IIIs) to use the aircraft using an Air Operator's Certificate held by Eurocontinental Air. In 2009, the UK Department for Transport suspended Eurocontinental's AOC following a series of safety incidents in UK airspace.

Agencia Estatal de Seguridad Aérea (AESA), the Spanish aviation safety and security agency, suspended Eurocontinental's AoC and then revoked it completely in 2011.

Manx 2 stated that it was unaware of the number of safety occurrences reported because they were not included in the occurrence reporting list.

In November 2009, Air Lada and Flightline agreed to the operation of the two Metro IIIs under Flightline's Air Operator's Certificate. Operations and scheduled maintenance of the aircraft were to be conducted under Flightline's AOC while Air Lada would arrange commercial arrangements and flight scheduling. All maintenance costs were met by Air Lada.

AESA accepted the transfer of the two Metro IIIs from a suspended AOC to a new AOC holder as Flightline had different procedures and management structure. The application provided no details regarding how the aircraft would be used. AESA had no knowledge of Air Lada or Manx 2's history with the aircraft, nor that Air Lada were the owners of the aircraft. They were also unaware that the two former Eurocontinental Air pilots had moved with the aircraft to Flightline.

Thus, AESA approved the request to include the two aircraft on Flightline's AOC. The AOC approval forms did not approve low visibility operations for Take-Off, Approach and Landing for either plane. This means that both aircraft were only permitted to operate in CAT I limits.

Once the transfer was complete, in 2010, the two Metro IIIs resumed flying for Manx 2 under Flightline's AOC, offering the new service between Belfast City and Cork as well as night cargo flights for the Royal Mail. Manx 2 worked directly with Air Lada and there is no evidence of any direct contact between Manx 2 and Flightline. Although there were various documents which referred to the operator, the Operations Manager worked for Air Lada and the address and contacts used were all for Air Lada's office in the Isle of Man.

The Isle of Man has its own Civil Aviation Administration and a flight to or from the Isle of Man and the UK by a non-UK AOC holder requires permits from the UK and the Isle of Man. The permits were applied for by the Operations Manager of Manx 2 on behalf of Flightline, with Flightline named as the airline.

A new operational procedures document still in draft had only contacts for Manx 2. The Operator's Quality Manager named in the document was one of the pilots supplied by Air Lada. There was no evidence that Flightline appointed him to this position.

Flightline audited the operation on the Isle of Man two weeks after the new operation started in Ireland. The audit comments include the following:

4. Flight

The meteorology of the Isle of Man in particular, with strong winds and low minimum temperatures, and of England in general, necessitates a different approach to the operation. Both the commander and the co-pilot must be experienced and have a good level of English. Our company should guarantee this. Pilots who are currently operating do not have any problem in this sense.

5. Operational aspects

They must change the normal checklist and adapt it to our company, carry out the pre-flight inspection, sign it and apply the anti-icing system before entering the clouds. It is important to study the [Standard Operating Procedures] well, as well as clearly specifying in its list who is responsible for what and when…

The audit clearly states that experienced crews were required for the scheduled flights. Eight months later, the crew comprised of a Captain with questionable training who had been promoted four days earlier and a First Officer who had not completed his line check.

No further audits were done by Flightline.

Over the three months prior to the accident, there were no pilot reports, defects or maintenance entries made in the Technical Log. The Technical Log for the other Metro III included only two entries in its period of operation, both relating to an ignition problem.

Not a single normal maintenance issue over three months: no lights burned out, no oil top-ups, no defects at all. And no reference to the fact that the pilots were having to manually adjust the power levers to compensate for the engine torque differential. Scheduled maintenance was performed on the plane but, without a report, it’s very unlikely that the crack in the sensor coil could be spotted.

Flightline should have questioned the suspicious lack of defects in two of their aircraft. But for all intents and purposes, operations for the two aircraft were based on the Isle of Man and controlled by Air Lada and Manx 2, while using the operator’s certificate from Flightline in Spain.

Meanwhile, continuing oversight of the operator and its operation fell under the remit of AESA.

In the year before the accident, AESA performed eight audits and inspections were carried out on Flightlines flight operations. The evaluations included how the airline monitors and controls its operations.

However, they were unaware that the two aircraft were operating in the Isle of Man. There’s no obligation for an operator to inform the Authority regarding remote operations, although AESA did state that, had it known that the operation was remote and such a small number of people were involved, they would have taken a greater interest.

In the twelve months leading up to the accident, both Metro IIIs were subject to SAFA (Safety Assessment of Foreign Aircraft) ramp checks in Germany and Ireland. Both inspections included findings and, in one instance, the aircraft was not allowed to depart until the crew cleared the baggage/cargo which was blocking the emergency exits.

During the Eurocontinental Air operation, AESA had sent inspectors to the Isle of Man to carry out an extended ramp inspection. However, as they were unaware that the two aircraft had resumed operations there, no inspectors were sent.

AESA further informed the investigation that ‘in order to have better tools/procedures for proper oversight of a remote operation, EU regulation should require the operators to provide the certifying Authority with a formal declaration stating which are the organizations that ultimately decide the flight’s schedule, routes, crew roster, etc.’

After the accident, the EU Air Safety Committee met with AESA to clarify whether AESA’s surveillance activity of Flightline had provided the evidence that Flightline was capable of adequately supervising its remote operations. AESA stated that ‘they decided to limit the AOC of Flightline to prevent operation of the Fairchild Metro 3s, and that they had initiated the process to suspend the AOC.’

Commission Implementing Regulation (EU) No 390 of 2011 (establishing the European Community list of air carriers which are subject to an operating ban within the Community) stated the following:

Flightline explained that they had entered into a business arrangement with the company Air Lada, not a certified air carrier, to operate two Fairchild Metro 3 aircraft, registrations EC-GPS and EC-ITP, using pilots provided by Air Lada. The Commission pointed out to Flightline that the same aircraft had previously been operating within the AOC of Eurocontinental, another air carrier certified in Spain and that as a result of SAFA inspections and significant safety incidents with the operation of these aircraft, AESA had suspended Eurocontinental Air’s AOC.

The Commission invited the air carrier to make a presentation to the Air Safety Committee and noted that AESA had decided to limit the AOC of Flightline to prevent operation of the Fairchild Metro 3s, and that they had initiated the process to suspend the AOC.

At a meeting on the 19th of October 2011, AESA briefed the Commission on ‘the actions taken to date to address the identified safety issues with Spanish air carriers in a sustainable manner’. Flightline’s AOC was renewed, following corrective actions, but limited to exclude the aircraft of the type Metro III.

In 2010, Welsh ministers working with Manx 2 and FLM Aviation to provide a scheduled air service between Cardiff Airport and RAF Valley on Anglesey. However, the AOC of FLM Aviation, one of the four other operators working with Manx 2, was revoked by the German regulatory authority. Manx 2 continued to sell tickets for the route, replacing FLM Aviation with an air carrier operating under a UK AOC.

In late 2012, Manx 2 informed the investigation that its assets were being sold to a new company as a part of a management buy-out. The new company commenced operation on the 2nd of January 2013 and continued to sell tickets on the route.

The Manx 2 website was updated on 28th of January 2014 with a full statement regarding the final report.

Manx2.com statement on AAIB Final Cork report

Manx2 contracted all the flying to EU airlines licensed and required, as was the Operator, to operate in compliance with the stringent standards and controls of the European Aviation Safety Agency (EASA), recognised to be among the most stringent in the world, under the oversight of their national aviation safety authorities. Unfortunately, the report is clear that the prime causes of the accident were decisions made by the Flightline crew in adverse weather conditions, compounded by inappropriate crew rostering by the Operator and a significant lack of oversight by the Spanish air safety authority.

The investigation concluded that the the commercial model of a ticket seller providing an air service is not in the best interests of passenger safety, as the ticket seller has “an inappropriate and disproportionate role with no accountability regarding air safety”. It’s sad to note that in the end, they didn’t take responsibility and the new company that was formed uses the exact same model.

31 January 2014

Manx 2 Fatal Accident at Cork: Below the Required Minima

Last week, the Final Report covering the accident of Fairchild SA 227-BC Metro III EC-ITP at Cork Airport was released by the Air Accident Investigation Unit in Ireland.

In order to completely understand all the factors that come into play in this 244-page report, I am going to split my analysis into two parts. Today, we’ll look at the specifics on the day of the crash. Next Friday, I will focus on the organisational factors which directly led to this fatal incident.

Over the night of the 9th/10th of February, the aircraft served as a night cargo charter for UK Royal Mail from Belfast to Edinburgh to Inverness.

On the 10th of February at 05:10, the aircraft was repositioned back to Belfast, ready for the scheduled flights of the day.

06:15 The accident flight crew commences duty.

They downloaded flight documentation and meteorological information for Belfast City, Cork and Dublin.

Cork had been operating under Low Visibility Procedures since 15:50 on the 8th of February, two days prior.

06:40 The aircraft, EC-ITP, departs Belfast to reposition at Belfast City.

07:15 EC-ITP arrives Belfast City, leaving the flight crew with a 35 minute turnaround.

The scheduled flight was Belfast City to Cork and back to Belfast City. Waterford Airport was specified as the alternate airport for Cork. No second alternate was nominated.

They fuelled with enough total quantity for the planned round trip to Cork and back to Belfast City with required reserves.

Boarding of passengers was delayed due to the flight crew working on the passenger seats in the cabin.

07:50 The doors closed with all ten passengers on board.

No cabin crew was on the flight, nor was one required, as there was only a limited number of passengers.

The First Officer gave the safety briefing and the flight crew prepared for departure.

08:10 The aircraft is reported as airborne and climbing to Flight Level 120.

08:34 Flight crew establishes communications with Shannon Air Traffic Control.

08:48 Communications handover to Cork Approach Control.

At that time, the Cork Automated Terminal Information Service (ATIS), which offers the latest actual meteorological conditions, broadcast that Runway 35 was active and Low Visibility Procedures (LVP) were in operation.

Cork Approach also informed the flight crew that Runway 35 was active but the visual range at Cork at that time were below the required minima for CAT I operations. They informed them that a CAT II approach was available for Runway 17.

A Category II instrument landing system is used in low-visibility conditions.

08:58 Aircraft establishes on the ILS approach to Runway 17 and contacts Cork Tower.

09:00 Cork Tower relay the Instrument Runway Visual Range, which is below the required visibility of 550 metres for the CAT II approach.

The decision height (or decision altitude) on a precision approach is the point where, if you do not have visual contact with the runway, you must discontinue your approach and climb (a missed approach).

It is the job of the Pilot Not Flying to monitor the approach and act as look out. He’s expected to call attention to deviations from procedure and watch for the decision height. It is his job to call when the approach lights or runway is clearly in sight. The decision height at Cork for the ILS approach to Runway 17 is 200 feet.

In this flight, the First Officer was the Pilot Flying and the Captain was the Pilot Not Flying.

09:03 The First Officer carries out a missed approach. The lowest height recorded by the Terrain Awareness Warning System on the aircraft was 101 feet.

Cork Approach offered radar vectors and the flight crew requested an approach to Runway 35, hoping that, with the sun behind the aircraft, they might be able to make visual contact with the runway.

09:10 The flight crew speaks to Cork Tower, reporting that they are eight nautical miles from the runway. Cork Tower informs the aircrew of the Instrument Runway Visual Range, which is again below the required minima for the approach. The aircraft continues with the approach.

09:14 The First Officer carries out a missed approach.

The lowest height recorded on this approach was 91 feet.

09:15 The flight crew request to enter a holding pattern for “fifteen to twenty minutes” to see if the weather conditions approve.

They maintained the holding pattern at 3,000 feet and requested weather for Waterford Airport, their alternate airport. Waterford was also below the required minima for an approach, so the flight crew requested weather information on Shannon. Conditions there were also below the required minima and Cork Approach offered to get weather for Kerry Airport. Kerry Airport conditions were good, with visibility in excess of 10 kilometres.

09:33 The aircraft is still in the hold when the Instrument Runway Visual Range at Cork shows a slight improvement.

Cork Approach (to a different aircraft): Surface wind zero nine zero degrees seven knots, ah…visiblity three hundred metres in fog, broken at one hundred, IRVR runway one seven now is four hundred metres all round.

Captain: See, it’s improving a little bit now, it’s four hundred.

The required minima is 550 metres.

The flight crew discuss their alternates and agree to hold a bit longer and see if visibility at Cork improves.

First Officer: Kerry’s alright.
Captain: It’s alright okay, so… In case we’ll proceed in the beginning there.
[sound of a bag being zipped or unzipped]
Captain: I always bring with me—brought with me—some notes about the alternative and all this kind of things and I never use it and now I don’t have it here.
First Officer: Is that the thing that’s pinned up on the board in the office?
Captain: Yeah, exactly.

09:39 The conditions improve again slightly and the flight crew decide to attempt a third approach into Cork, although the conditions are still below the required minima.

The Captain briefed the go-around procedure and that although he will be the Pilot Not Flying, he will apply power.

The First Officer by this time has done the flight, two missed approaches in bad visibility and a fifteen minute hold in an aircraft with no autopilot and no flight director. He must be beginning to feel the strain.

Captain: ….Okay go-around in case I apply power, flap one quarter. Okay, go-around flap positive rate gear up, okay, four hundred feet we clean the plane and that’s it.

09:45:22 Flight crew reports established on ILS Runway 17.

09:45:26 Cork Approach reports that the Instrument Runway Visual Range has improved to 550 metres, the required minimum.

09:46:00 Flight crew report to the Tower passing 9NM from the DME, that is, they are nine nautical miles from the runway.

Tower: Flightavia four hundred Charlie, good morning to you again. You are cleared to land runway one seven; the wind is zero nine zero degrees niner knots.
Commander: Cleared to land one seven, Flightavia four hundred Charlie.

09:46:15 The final Instrument Runway Visual Ranges reported by Cork Tower were now below below the required minima of 550.

Tower: Touchdown RVRs five hundred midpoint four hundred stop end four hundred.
Captain: Copied, thank you very much.
First Officer: It’s gone down, woah. I want the other guy’s RVRs, they were better.
Captain: Yeah, fifty feet less.

The RVR is measured in metres not feet, and the RVR was actually fifty metres less, not feet.

As per the briefing, the Captain operated the power levers during the latter part of the approach. This is important because the First Officer, who is the Pilot Flying, is now potentially missing input as to what is happening with the power.

The Captain, as Pilot Not Flying, is also counting down to the minimum descent height of two hundred feet, at which point they must either have the runway in sight or break off the approach.

Here’s what the Pilot Not Flying actually said.

“Okay minimum. Continue.”

Captain: Okay, capture again very good….sorry it’s eh, six hundred for minimum.
First Officer: Thank you.
Captain: Okay, five hundred for minimum. Three hundred for minimum. Watch out, glideslope. Two hundred for minimum. Localiser…yeah. One hundred for minimum.
Terrain Awareness Warning System: FIVE HUNDRED
Captain: Okay….[unintelligible]
Terrain Awareness Warning System: FOUR HUNDRED
Terrain Awareness Warning System: THREE HUNDRED
Terrain Awareness Warning System: MINIMUMS, MINIMUMS
Captain: Okay minimum. Continue.
Terrain Awareness Warning System: TWO HUNDRED
First Officer Okay

They once again descended below the decision height of 200 feet above the ground. However this time, the aircraft reduced power and at the same time experienced a roll to the left.

Terrain Awareness Warning System: ONE HUNDRED
Captain: Go around!
First Officer: Round.
Terrain Awareness Warning System: FIFTY
Terrain Awareness Warning System: FORTY

The Captain applied go-around power which is when they lost control of the aircraft. The aircraft rolled rapidly to the right and the right wingtip contacted the runway surface. The aircraft continued to roll.

One of the surviving passengers was able to describe the moment of impact.

“I do remember looking out and the ground was just feet from below us and it was grass, it was definitely not tarmac. And the pilot then gave the plane thrust, to come up out of the cloud. And at that stage, the cloud was right to the ground. I feel that the plane … immediately after the thrust, veered to the right and tilted…the right hand of the wing caught the ground first and after that it was just mayhem… I couldn’t breathe because all the mud had come up into the fuselage… I do remember pushing the mud away and then being able to breathe…”

09:50:34 The aircraft, inverted, impacts the runway. The recording ends.

09:56 The Instrument Runway Visual Range improved to 650/550/550 on Runway 17. By 10:08, 18 minutes after the accident, the visibility exceeded 2,000 metres.

The two flight crew and four passengers suffered fatal injuries. Four other passengers suffered serious injuries and the two remaining passengers had only minor injuries.

The final report gives the following primary cause:

  • The crew did not give adequate consideration to the weather conditions in Cork.
  • The crew breached the minimum decision height (DH) during all three approaches.
  • The captain applied reverse thrust which caused the aircraft to roll to the left due to the No.1 engine retarding to -9% torque, the No.2 engine stayed at 0% (idle). The power difference was due to a differential in power in the right engine, which was not corrected in maintenance checks. The AAIU believes the co-pilot applied right control inputs to counteract this, subsequently the application of full power to commence the go-around at 100ft coincided with the commencement of a rapid roll to the right and loss of control resulting in the subsequent accident.

How did this happen? Next week, we’ll look at the human factors in play here and untangle the complex relationships between the companies which led to the lack of regulatory oversight specified as a direct contributing factor.

24 January 2014

Suicide by Plane

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

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

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

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

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

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

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

The departure time was noted as 16:51.

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

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

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

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

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

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

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

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

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

They called Tampa.

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

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

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

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

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

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

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

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

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

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

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

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

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

17 January 2014

Last Words Air France 447

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

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


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

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

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

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

Translated from French

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

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

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

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

Reprinted with permission from Plane Crash Info.com.

10 January 2014

Memorial in the middle of the Desert: UTA Flight 772

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

It was originally featured in Google Sightseeing in 2009.

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

Here is an embedded map showing the memorial in satellite.


View Larger Map

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

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

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

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

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

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

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

Guillaume de Saint Marc

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


Le mémorial du Ténéré (film documentaire) by Familles_du_DC10_UTA

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

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

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

Guillaume de Saint Marc

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

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

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

Guillaume de Saint Marc

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

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

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

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

03 January 2014

Live Footage of Accident from 1910

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

A review from IMDb:

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

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

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

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

Wishing all the best for all of us in 2014!

27 December 2013

2013 In Review

Hard to believe another twelve months and fifty-two blog posts have gone past. One of my favourite things to do every year is to go over the statistics and see what the top posts were. I laughed a little bit to see that FAA Approved? is in the top ten again for the fifth year in a row.

Some other fun facts:

82,242 people visited the site over the year from 187 different countries for a total of 128,113 page views. One person visited from Vanuatu, which I had never heard of before reading the annual stats report but I now desperately want to visit. Chrome is the most popular browser. Least popular browser is the Playstation Vita Browser with just one single access. Fastest average page load time is Opera followed by Chrome with Internet Explorer in third place. Slowest is Safari. Most popular mobile device was the Apple iPad.

Most users come directly to the site. The most popular single referrer is Reddit. Users referred to the site from Stumbleupon spend the longest time exploring the site (9-12 pages).

The most popular search phrases were: boston john, tipsy nipper, fear of landing and red arrows. Most predictable search: do air hostesses have sex with pilots and variations there of. Most specific search: while you are flying to miami for spring break, the pilot announces that the altimeter on the plane indicates you are cruising at an altitude of 30,000 feet. how does the pilot know your altitude? Most worrying search: why are there police airplanes at night sending some kind of laser light in my bedroom when im sleeping. Most intriguing search: reason for the crash of the dragon plane flying out of the scillies in the 60′s (I will look into this).

The most popular category is Incidents and Accidents followed by History.

And with that, let’s look at the most popular posts of the year.

Number Ten: FAA Approved?

I found this on an aviation forum and I just can’t stop staring at the photographs.

Number Nine: The Amazing Story of the B-17 Flying Fortress

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

Number Eight: Boston John

Air Traffic Controller John Melecio, also known as “Boston John,” is one of the most famous ATC controllers today. When he was controlling from Boston Tower, he was always lively and humourous, gathering a following all over the world. Listeners on LiveATC.net posted to the forums whenever he was on air so fans could tune in and hear him live.

Number Seven: Loss of Control – Collision with Water

The first thing that struck me about this TSB Canada report was the title. Loss of control seemed an odd description and certainly isn’t a cause in itself. The title fits the report, though: loss of control was the key factor in this investigation because to start, that was all the investigators knew. How did the pilot lose control and why did he fly the aircraft into the water at a 45° angle? That took longer to work out.

Number Six: 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.
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.

Number Five: Six Exclamations You Never Want to Hear in the Cockpit

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

Number Four: The Story Behind an Unbelievable Photograph

Jim Meads is the man who took the picture. He was a professional photographer who lived near the airfield, next door to de Havilland test pilot Bob Sowray.

So, the story goes: Bob Sowray mentioned to Jim Meads that he was going to fly the Lightning that day. When Meads took his kids for a walk, he took his camera along, hoping to get a shot of the plane.

His plan was to take a photograph of the children with the airfield in the background as the Lightning came in to land. They found a good view of the final approach path and waited for the Lightning to return.

Number Three: How Not to Become a Police Pilot

Apparently, the man became friendly with some pilots at the East Midlands Police Air Support Unit. He told the staff that he was a freelance helicopter pilot and owned his own helicopter. He clearly loved helicopters and was interested in a ride-along with the Air Support Unit, but as no passengers are allowed on police operation flights, it wasn’t possible.

Then they received a brand new helicopter, The Eurocopter 135.

Number Two: How Far Did She Fall? The Amazing Story of Vesna Vulović

This blog post started, as so many do, over a general conversation at the pub. We were actually talking about Felix Baumbartner, the man who jumped from the edge of space last year and made numerous records, including the highest freefall ever.

I remembered there was a woman who held the record for the longest freefall without a parachute, who fell for 33,000 feet and survived. Funnily enough, I could remember the distance but not her name or how exactly she’d managed to survive this unbelievable fall from an aircraft. We had an amusing round of guesses (“She fell into jungle canopy which broke her fall in stages?” “She landed in very soft powdery snow?”) and when I got home, I looked it up.

Number One: Sequence of Events in the Cockpit on Asiana Flight 214

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

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

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

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


So there you have it, another year with Fear of Landing. I hope to see plenty more of you in 2014!

20 December 2013

Amazing Aviation Videos

As we run up to the holiday season, here’s a couple of amazing aviation videos to brighten up your day! If you are reading this on the mailing list, I’m afraid you’ll have to click through to see these as I can’t embed them into the mail for you!

Anyway, these are all stunning new videos, I’m sure you will agree.


LiveLeak.com – Breathtaking Boeing 747 Cockpit Scenes


Air Tahiti Nui behind the scenes footage


Painting the WestJet Magic Plane


I hope there’s plenty of food and drink in your plans over the next week. Merry Christmas!

13 December 2013

Sequence of Events in the Cockpit on Asiana Flight 214

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Precision Approach Path Indicator (PAPI) is a visual display next to the runway which provides vertical guidance for the approach path. In a normal approach, the PAPI would show two whites and two reds. More whites means that the angle of the approach is too high. More reds than white means that the angle of the approach is too low. The PAPI shifted to three reds and one white and then to four reds.

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

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

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

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

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

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

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

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

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

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

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

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

06 December 2013

Banner Planes in Action

I’ve long been obsessed with banner planes. They are fascinating and amazing to watch. When I did my PPL in Spain, I was lucky enough to see them in action every weekend.

All excerpts from You Fly Like a Woman:

The weekends were busy at Axarquía now that high summer was here. Broad-shouldered young men with their hair clipped short invaded the airfield. They never spoke, they shouted, laughing and clapping each other on the shoulders as they checked their planes and fueled up. They flew the banner planes: advertising discothèques and cheap restaurants across the beaches of the Costa del Sol.

A young pilot at the fuel pump glanced over at me and then shrugged: crazy foreign lady. The banner pilots had never seen me fly. I retreated when they arrived, watching jealously from the distance. I listened to them on the radio — jokes, maybe insults. The Spanish was too fast and too dialectal for me to follow. They scared me: the energy, the easy-going laughter, as comfortable with the planes as an old bicycle kept in the garage. The airport held no secrets for them, the aircrafts were not a mystery. It’s a culture I would never belong to, even if I spoke the language, even if I were the same age. They must have been born in the cockpit, I thought.

After take-off, the aircraft circles back around in the circuit. Someone on the ground sets up the pick-up point. The banner is laid flat and the towline is strung between two poles across the runway.

The aircraft returns, flying low (about 10m) over the runway. He hooks the towline with a hook mechanism on the back of the plane and then flies straight up into a stall.

OK, not quite but that’s what it always felt like when I was watching. The pilot applies full power and goes into a steep climb. The tow-rope unfurls and then the banner lifts off the ground, in a way that literally seems like it is going to jerk the aircraft back down to the ground. The aircraft levels out and magic, the banner is flying behind it gracefully.

The following Saturday, I asked to use the radio so I could listen in. The first banner plane took off and made a left turn. He didn’t make any standard calls, it was chitchat, the roaring of the engines in the background. I watched the plane in the circuit when I noticed the man in the long-sleeved shirt was unfurling the banner, rolling it out centered along the runway. The plane came around, low and fast, just a few feet above the runway. On the back of the plane was a hook and as he came over the edge, it swooped down and hooked the banner. I felt vaguely sick as I watched. Having seen the weight of the banner, it seemed like it would jerk the plane backwards towards the ground as the hook tugged it. There wasn’t even a shudder, not a flinch, and he was away, an advertisement for Star-Spangled Disco fluttering behind. The next plane was already entering the runway, ready to follow the same sequence. Finally, all three circled with their banners on proud display before they called that they were leaving the station and the radio went silent.

They flew towards the coast. I dialed in the Málaga frequency on the radio. They would be flying through Málaga airspace and I wanted to hear how they sounded, once talking to air traffic control, once they had to be professional. But there was no call. It was as if they’d left us and disappeared. I waited a few more minutes and then changed the frequency back for local flights. Where had they gone?

Rick Witt, a banner pilot on the BeechTalk forums, describes what it’s like in the cockpit.

“Banner towing is 1 minute of adrenaline rush (the pick up) followed by hours of boredom followed by 30 seconds of fun (the drop).

If it weren’t for the fact that you’re in a 0g push at the moment the banner lifts, the plane would surely stall (more adrenaline). In a perfect pickup, the airplane is directly over the banner when it starts to lift, meaning you have climbed 100 ft while covering 100 ft across the ground.

I never had any passengers except for training. For towing billboards, we were at the limit of the plane’s capability. If we had excess power, they made the sign bigger!”

Somehow my explanations have always seemed rather flat compared to the reality, so I was thrilled to have found this video by C172skyhawk2 posted on /r/aviation showing banner pick ups in action.

(Note: if you are reading this on the mailing list, you’ll need to click through to view the videos on the Fear of Landing website)

We got back before the banner pilots arrived. The banner planes flew out to the coast and turned right, making their way to Marbella and then turning around to glide over the beaches, adverts trailing behind them.

I couldn’t face all of them together, that maelstrom of easy virility that flattened everything in its path. But I spotted one of the pilots on his own, sipping cold water at the bar. “Where do you go, when you leave?”

My Spanish was unsteady but he waited patiently for me to find the words. “When you leave the radio frequency, where do you go? You don’t speak to Málaga. I was listening on the radio.” I knew I sounded like a stalker but I wanted to know.

He laughed. “Es un secreto.” I scowled, feeling made fun of, but he kept on. “It’s true, it’s a secret channel. We fly low across the coast, low enough that Málaga does not even know we are there and we talk to each other.”

I was shocked. This was, well, against the rules! “So you just say nothing?”

“We say nothing to Málaga. We stay out of their way, and they are just as happy not to have the distraction,” he said. “We talk to each other, so we know where everyone is.”
Where “everyone” meant “banner fliers” only. I made a mental note to stay away from coast on weekends, at least until I found out their secret channel.

That would have been a fun way to learn more Spanish!

Here’s one more set of banner planes (picking up and dropping) video’d by C172skyhawk2 with obligatory aviation-video-music:

See you next week!