AF447 will undoubtedly reoccur again and again because the aircraft mishap investigation board failed to discover the cause of the mishap and instead blamed the mishap on the crew. Not only is this an inaccurate and unsubstantiated conclusion, it is also a conclusion that is misinformative. No airline reading this report will be able to use the report to take steps to prevent a similar mishap from occurring again. That is a very large error on the part of the company and the country.
The sole and critically important purpose of an aircraft mishap safety investigation is to determine the cause of the mishap. Period. By accurately determining the cause of the mishap, the safety investigation informs all of us on how to prevent this mishap from occurring again.
Instead, the board doing the investigation has chosen to take their license to do a safety investigation and use the investigation as a legal tool to attempt to lay legal blame for the mishap on flight crew. This is a total aberration of the legitimacy of the entire process of safety investigations.
While companies and countries have the right to do a legal investigation to protect their legal interests, it is not their place to take the safety investigation and abscond with it for their own legal purposes. The public deserves and the industry deserves an unbiased safety mishap investigation.
What has been publish so far is not that at all.
This is a terrible miscarriage of safety and a great example of why the fox should not be guarding the hen house.
Monday, August 8, 2011
Thursday, July 21, 2011
Go Arounds, Missed Approaches and variations?
I would like to suggest that each reader spend a few minutes thinking about how many different procedures that their airline or aviation organization has for conducting a missed approach and/or a go around.
Your first reaction might be "Just one." But take another minute and consider the variations. Each aircraft type has a slightly different set of procedures. How about the case when an engine is inop? What if the weather is IMC and tower is using IFR procedures in the ATA?
What if the weather is VMC and tower is using VFR procedures in the ATA? How about the case of the flight executing a cleared IFR approach procedure, but when handed off to tower, the clearance reads, "Cleared for a visual approach to land?"
What if the terrain for the runway in use dictates immediate maneuvers, the weather is IMC and tower assumed that you would have broken out and is taken by surprise that you are going around and a large thunder storm is in the missed approach path?
Does your training program give line pilots training and sufficient sim practice to be superbly proficient in all types of MA/GA's?
What if the weather is so bad that the airframe is icing up with mixed clear and rime during the last 1000 feet and the previous aircraft has not cleared the runway and now tower orders a GA? Has the crew practiced and become proficient in this scenario?
I hope that each reader considers all of the variations on MA and GA for a while and feels free to post a comment on this subject.
Thanks and more to follow on this subject.
Your first reaction might be "Just one." But take another minute and consider the variations. Each aircraft type has a slightly different set of procedures. How about the case when an engine is inop? What if the weather is IMC and tower is using IFR procedures in the ATA?
What if the weather is VMC and tower is using VFR procedures in the ATA? How about the case of the flight executing a cleared IFR approach procedure, but when handed off to tower, the clearance reads, "Cleared for a visual approach to land?"
What if the terrain for the runway in use dictates immediate maneuvers, the weather is IMC and tower assumed that you would have broken out and is taken by surprise that you are going around and a large thunder storm is in the missed approach path?
Does your training program give line pilots training and sufficient sim practice to be superbly proficient in all types of MA/GA's?
What if the weather is so bad that the airframe is icing up with mixed clear and rime during the last 1000 feet and the previous aircraft has not cleared the runway and now tower orders a GA? Has the crew practiced and become proficient in this scenario?
I hope that each reader considers all of the variations on MA and GA for a while and feels free to post a comment on this subject.
Thanks and more to follow on this subject.
Tuesday, July 12, 2011
Safety Forecasts More AF Mishaps
Safety Forecasts and Plans has determined that since AF has devoted so many resources towards trying to prove that they were not legally at fault for the deaths of their AF 447 passengers, that AF has not devoted sufficient resources to preventing future mishaps of all kinds, and therefor should plan on more mishaps for the future.
The statistical review of the past 10 years shows that AF mishaps were preventable, yet AF took steps insufficient to prevent them. Since AF has seemingly now devoted enormous resources to the trying to defend themselves, such as spending as much as $35 million to recover a DFDR by submarine, when all that they had to do was to walk into their own dispatch office and witness supervisory personnel not taking preventative steps to advise line captains about weather hazards in their path.
Example? AF 358 flew into a thunderstorm upon landing. Was the thunderstorm present prior to approach? Did dispatch, flight ops or anyone at AF have a thunderstorm avoidance policy? Did the policy undergo scrutiny, study or in anyway become part of flight operations procedures subsequent to AF 447 departing?
It appears that the thunderstorm avoidance procedures at AF was not change after AF 358 crashed in Toronto. Remember that this crash happened in August of 2005.
AF 447 occurred June 2009. So four years occurred and AF 447 flew into a thunderstorm. So once again the same mishap occurred all over again. And Why?
Very simply because no one in AF, or Canada or any other body determined that the cause of the mishap was flying into a thunderstorm. Blame was placed legally at the hands of the flight crew. Legal blame, legal blame was the product of the Canada Aircraft Safety Mishap Board. In fact it appears that the board didn't complete the safety task at all.
Should not have the board instead of assigning blame, determined the cause to be an encounter with a thunderstorm? Who claims that the aircraft can fly in thunderstorms? Does the manufacturer? Who does?
And yet less than 4 years later, AF flies another aircraft into a thunderstorm and the various mishap boards are all focusing on the actions of the crew once inside the storm!!!!!!! How absolutely ridiculous and illogical can any attempt be?
The manufacturer of no commercial aircraft and the regulator of no civil aviation authority anywhere in the world builds or certifies any commercial aircraft to operate inside of a thunderstorm.
So why does AF continue to do so? Why does any board expect to find any differing result in the event of an encounter?
The statistical review of the past 10 years shows that AF mishaps were preventable, yet AF took steps insufficient to prevent them. Since AF has seemingly now devoted enormous resources to the trying to defend themselves, such as spending as much as $35 million to recover a DFDR by submarine, when all that they had to do was to walk into their own dispatch office and witness supervisory personnel not taking preventative steps to advise line captains about weather hazards in their path.
Example? AF 358 flew into a thunderstorm upon landing. Was the thunderstorm present prior to approach? Did dispatch, flight ops or anyone at AF have a thunderstorm avoidance policy? Did the policy undergo scrutiny, study or in anyway become part of flight operations procedures subsequent to AF 447 departing?
It appears that the thunderstorm avoidance procedures at AF was not change after AF 358 crashed in Toronto. Remember that this crash happened in August of 2005.
AF 447 occurred June 2009. So four years occurred and AF 447 flew into a thunderstorm. So once again the same mishap occurred all over again. And Why?
Very simply because no one in AF, or Canada or any other body determined that the cause of the mishap was flying into a thunderstorm. Blame was placed legally at the hands of the flight crew. Legal blame, legal blame was the product of the Canada Aircraft Safety Mishap Board. In fact it appears that the board didn't complete the safety task at all.
Should not have the board instead of assigning blame, determined the cause to be an encounter with a thunderstorm? Who claims that the aircraft can fly in thunderstorms? Does the manufacturer? Who does?
And yet less than 4 years later, AF flies another aircraft into a thunderstorm and the various mishap boards are all focusing on the actions of the crew once inside the storm!!!!!!! How absolutely ridiculous and illogical can any attempt be?
The manufacturer of no commercial aircraft and the regulator of no civil aviation authority anywhere in the world builds or certifies any commercial aircraft to operate inside of a thunderstorm.
So why does AF continue to do so? Why does any board expect to find any differing result in the event of an encounter?
Thursday, July 7, 2011
AF 447, Safety Forecasting and Planning
Did the AF dispatch office fail to fulfill their duty to look at satellite data?
Did AF flight ops management have a procedure to get the information about recent bad weather enroute passed to transoceanic flight crews, especially those transiting the tropical convergence zone?
When you who are safety managers look at these questions, do you wonder why this lack of procedure was allowed to occur when so many lives are at stake?
If you who are safety managers are able to see that this could be a problem for your airline, then you have created e forecast of things to come.
Did AF flight ops management have a procedure to get the information about recent bad weather enroute passed to transoceanic flight crews, especially those transiting the tropical convergence zone?
When you who are safety managers look at these questions, do you wonder why this lack of procedure was allowed to occur when so many lives are at stake?
If you who are safety managers are able to see that this could be a problem for your airline, then you have created e forecast of things to come.
Friday, June 10, 2011
Did AF 447 use correct Turbulent Penetration Procedures?
The second issue seems to be flight crew training when in heavy turbulence and when the pitot-static system is not operating.
Basic Instrument flying procedures in convective turbulence recommend a shift of instrument scan to attitude instruments and a disregard for pitot-static instruments, such as airspeed, vsi and altimeter. The procedure is to keep the wings level and the nose level with the attitude instruments. As the acft bounces along through the area of heavy turbulence and as the pitot-static system is affected by rain, ice and the pressure variations encountered in heavy turbulence, scan on the attitude instruments allows the crew to keep the acft straight and level.
Also, the power is monitored so that it remains at cruise power settings, neither more nor less and this keeps the airspeed relatively constant.
The crew should have slowed the acft to turbulent penetration airspeed prior to penetrating an area of turbulence or upon penetration. This speed allows the wings to accept g loadings due to turbulence but not be moving fast enough to over stress the wing g limits.
I wonder if in fact AF training covered these areas and if they allowed flight crew to practice all of these procedures?
Getting into heavy turbulence is to be avoided, but knowing these procedures is critical to survival in the event that convective weather is encountered.
Other procedures include all of the various heaters and engine ignition circuits should be placed on.
Using automation in these circumstances is not a good idea because the programming for automation usually involves smooth air and one g flight.
Could reliance on automation in these circumstances indicate a weakness in training proficiency on the part of this airline and this crew? Is this the second issue for AF, AB, BEA and all other airlines following this investigation?
Basic Instrument flying procedures in convective turbulence recommend a shift of instrument scan to attitude instruments and a disregard for pitot-static instruments, such as airspeed, vsi and altimeter. The procedure is to keep the wings level and the nose level with the attitude instruments. As the acft bounces along through the area of heavy turbulence and as the pitot-static system is affected by rain, ice and the pressure variations encountered in heavy turbulence, scan on the attitude instruments allows the crew to keep the acft straight and level.
Also, the power is monitored so that it remains at cruise power settings, neither more nor less and this keeps the airspeed relatively constant.
The crew should have slowed the acft to turbulent penetration airspeed prior to penetrating an area of turbulence or upon penetration. This speed allows the wings to accept g loadings due to turbulence but not be moving fast enough to over stress the wing g limits.
I wonder if in fact AF training covered these areas and if they allowed flight crew to practice all of these procedures?
Getting into heavy turbulence is to be avoided, but knowing these procedures is critical to survival in the event that convective weather is encountered.
Other procedures include all of the various heaters and engine ignition circuits should be placed on.
Using automation in these circumstances is not a good idea because the programming for automation usually involves smooth air and one g flight.
Could reliance on automation in these circumstances indicate a weakness in training proficiency on the part of this airline and this crew? Is this the second issue for AF, AB, BEA and all other airlines following this investigation?
Thursday, June 2, 2011
Does FAA even do safety correctly?
Why does the FAA not take immediate and rapid action on safety issues when a flight crew member, the NTSB or anyone else for that matter brings the issue and a solution to their attention? Quite a simple answer really: the FAA is run by lawyers and not safety professionals. Lawyers deny that there is a problem of their own origin, because to "admit a problem" ( lawyerspeak, not safetyspeak) would be to admit fault and therefore legal liability in a tort court.
Instead of safety resolutions, the FAA maintains deniablity until pressure from the press and the public is so great that they cannot deny "something has to be changed!", usually the result of a press grabbing major air disaster, such as Continental/Colgan 3407.
A safety professional, on the otherhand, would have been looking at the problem, in this case, flight crew training, as soon as the first evidence of a problem was revealed.
The sad part about the lawyer approach of the FAA is that hundreds of innocent people have to die and grab headlines in order for a change to be made.
If the FAA were instead run by safety professionals, changes would occur without a lot of needless loss of life.
As far as comments such as, "Regulation created in a knee jerk reaction can do more damage to the commercial air industry than the industry (or passengers) can afford. Is it worthwhile to ground perfectly safe aircraft and aircraft operations on the basis that if there are no aircraft flying or no-one can afford to travel by air no crashes can happen..." frankly, I do not even know where to categorize this illogical line of reasoning.
As far as I know, there has never been a recommendation by a safety professional that said no aircraft should be flying or make flying so expensive that no one can travel. These kind of statements are known as "make up an outlandish course of action, pretend that a safety professional said it, and see how many people you can fool," type of statement, also know as "red herrings."
Safety on the other hand is good for business.
Paul
Instead of safety resolutions, the FAA maintains deniablity until pressure from the press and the public is so great that they cannot deny "something has to be changed!", usually the result of a press grabbing major air disaster, such as Continental/Colgan 3407.
A safety professional, on the otherhand, would have been looking at the problem, in this case, flight crew training, as soon as the first evidence of a problem was revealed.
The sad part about the lawyer approach of the FAA is that hundreds of innocent people have to die and grab headlines in order for a change to be made.
If the FAA were instead run by safety professionals, changes would occur without a lot of needless loss of life.
As far as comments such as, "Regulation created in a knee jerk reaction can do more damage to the commercial air industry than the industry (or passengers) can afford. Is it worthwhile to ground perfectly safe aircraft and aircraft operations on the basis that if there are no aircraft flying or no-one can afford to travel by air no crashes can happen..." frankly, I do not even know where to categorize this illogical line of reasoning.
As far as I know, there has never been a recommendation by a safety professional that said no aircraft should be flying or make flying so expensive that no one can travel. These kind of statements are known as "make up an outlandish course of action, pretend that a safety professional said it, and see how many people you can fool," type of statement, also know as "red herrings."
Safety on the other hand is good for business.
Paul
Monday, May 23, 2011
AF447 Pitot Tubes Issue
1. For many commercial aircraft, there is an emergency procedure for when pitot static based flight instruments become inoperable.
Pitot static based flight instruments include airspeed indications, altimeters and rate of climb instruments.
2. The scenarios encountered that might render these systems inoperative include a blocked pitot tube or a blocked static port.
A. In the past safety investigations found the following factors involved in pitot tube blockage:
1. loss of pitot tube heater allowing ice to build up or precipitation to clog the tube and/ or the associated plumbing.
2. a protective maintenance cover left on the pitot tube
3. insect, bird or other debris or object entering the pitot tube.
B. In the past, safety investigators have found the following factor most commonly involved in static port blockage:
1. Masking tape place over the static port by crews washing, waxing or painting the plane, where the tape was not removed prior to flight.
3. Since from what has been reported in the media that the flight was proceeding normally, it can be deduced that the problem with the pitot and static system was most likely due to the pitot tube icing over due to lack of heat.
A. Since most pitot heat systems are electrically powered, it is possible that there was some interruption in that electrical system.
B. When the loss of pitot static powered instrumentation occurs, the flight crew is directed by emergency procedures to use instruments which indicate flight attitude, that is pitch, roll and yaw.
C. The attitude instrument most often found in jet powered tranport aircraft is the attitude indicator. It will simultaneously indicate pitch, roll and yaw.
D. Attitude instruments are most often powered on commercial jet transport aircraft electrically and therefore will provide valid data in the event the pitot static system is inoperative. Their source is either laser ringed gyros, mechanical gyros or other similar systems.
E. Laws of aerodynamic performance state that pitch-attitude controls airspeed and engine power controls altitude. So as long as the flight crew maintains the cruise pitch attitude and the cruise power settings on the engine, the aircraft should stay relatively level in flight and the airspeed should remain at the speed required for cruise flight. The crew is often directed to seek an area of clear sky outside of icing conditions or precipitation in an attempt to regain use of the pitot-static system in the event icing caused the problem.
4. This is an emergency procedure which is successful and will allow the flight crew to maintain control of the aircraft through all flight regimes. I can speak from experience that this procedure works just fine. I can also state that this procedure is practiced in training simulators at many US airlines and I would suspect at many European airlines as well.
5. If the investigators state that the aircraft stalled, there are many scenarios by which this could have taken place. One common scenario is that the pitot tube ices up decreasing the dynamic pressure input to the airspeed indicator and rate of climb indicator. The static pressure port may not be blocked so it continues to show static pressure. If the crew does not cross check the pitch-attitude indicator, and only looks at pitot-static instruments, they may see an increasing airspeed and react by increasing pitch and reducing power. This could lead to as stall within a short time at altitude with an aircraft heavily laden with fuel, passengers and cargo.
6. To prevent this type of mishap, many airlines employ training in emergency procedures for the loss of pitot static instruments. The procedure includes disconnecting the auto pilot from control of the aircraft and hand flying the aircraft, again using pitch attitude and engine power settings from a chart. The charts carried on the aircraft include variables such as flight altitude and aircraft weight.
7. If the loss of pitot static system occurred while in a severe thunderstorm, the crew would have had to deal with both the severe turbulence, icing, possible lightning as well as the disconnecting of the autopilot. That would have been a handful for any crew to handle, but that is why most major airlines have strong training programs.
Pitot static based flight instruments include airspeed indications, altimeters and rate of climb instruments.
2. The scenarios encountered that might render these systems inoperative include a blocked pitot tube or a blocked static port.
A. In the past safety investigations found the following factors involved in pitot tube blockage:
1. loss of pitot tube heater allowing ice to build up or precipitation to clog the tube and/ or the associated plumbing.
2. a protective maintenance cover left on the pitot tube
3. insect, bird or other debris or object entering the pitot tube.
B. In the past, safety investigators have found the following factor most commonly involved in static port blockage:
1. Masking tape place over the static port by crews washing, waxing or painting the plane, where the tape was not removed prior to flight.
3. Since from what has been reported in the media that the flight was proceeding normally, it can be deduced that the problem with the pitot and static system was most likely due to the pitot tube icing over due to lack of heat.
A. Since most pitot heat systems are electrically powered, it is possible that there was some interruption in that electrical system.
B. When the loss of pitot static powered instrumentation occurs, the flight crew is directed by emergency procedures to use instruments which indicate flight attitude, that is pitch, roll and yaw.
C. The attitude instrument most often found in jet powered tranport aircraft is the attitude indicator. It will simultaneously indicate pitch, roll and yaw.
D. Attitude instruments are most often powered on commercial jet transport aircraft electrically and therefore will provide valid data in the event the pitot static system is inoperative. Their source is either laser ringed gyros, mechanical gyros or other similar systems.
E. Laws of aerodynamic performance state that pitch-attitude controls airspeed and engine power controls altitude. So as long as the flight crew maintains the cruise pitch attitude and the cruise power settings on the engine, the aircraft should stay relatively level in flight and the airspeed should remain at the speed required for cruise flight. The crew is often directed to seek an area of clear sky outside of icing conditions or precipitation in an attempt to regain use of the pitot-static system in the event icing caused the problem.
4. This is an emergency procedure which is successful and will allow the flight crew to maintain control of the aircraft through all flight regimes. I can speak from experience that this procedure works just fine. I can also state that this procedure is practiced in training simulators at many US airlines and I would suspect at many European airlines as well.
5. If the investigators state that the aircraft stalled, there are many scenarios by which this could have taken place. One common scenario is that the pitot tube ices up decreasing the dynamic pressure input to the airspeed indicator and rate of climb indicator. The static pressure port may not be blocked so it continues to show static pressure. If the crew does not cross check the pitch-attitude indicator, and only looks at pitot-static instruments, they may see an increasing airspeed and react by increasing pitch and reducing power. This could lead to as stall within a short time at altitude with an aircraft heavily laden with fuel, passengers and cargo.
6. To prevent this type of mishap, many airlines employ training in emergency procedures for the loss of pitot static instruments. The procedure includes disconnecting the auto pilot from control of the aircraft and hand flying the aircraft, again using pitch attitude and engine power settings from a chart. The charts carried on the aircraft include variables such as flight altitude and aircraft weight.
7. If the loss of pitot static system occurred while in a severe thunderstorm, the crew would have had to deal with both the severe turbulence, icing, possible lightning as well as the disconnecting of the autopilot. That would have been a handful for any crew to handle, but that is why most major airlines have strong training programs.
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