Expert Opinion: Fatigue and Bad Choices

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    Spatial Disorientation-in the pilot, or in the head of the investigator

    Donald Estell attempted to land the 21-year-old, single-engine Piper aircraft in challenging conditions, (on its second approach to St. Louis Downtown Airport in Cahokia) but instead, struck a house. The crash that ended the life of 65-year-old Estell of Clayton, Mo., and Robert Clarkson, 77, of Belleville has been attributed to pilot error by a June 27 report by the NTSB. The crash occurred on Feb 21, 2010, and it happened (according to the NTSB) because of spatial disorientation.

    A pilot who loses his orientation, and whose proprioception (perception of direction) is compromised is described as suffering from spatial disorientation. Most useful for maintaining orientation is an external visual horizon, which helps maintain the sense of “up and down.”

    We know that spatial disorientation is a real condition. It is also one of several “pilot error” causes that officials point to when they can not figure out why an otherwise airworthy (or supposedly airworthy) plane crashes.

    There are cases rightly or wrongly attributed to spatial disorientation, for example, the Ethiopian Airlines Boeing 737 that spiraled into the sea off Beiruit; the May 12 2010 Afriqiyah Airlines Flight 771 crash where the pilot undershot the runway on approach to Tripoli; and the July 28 2010 Airblue Flight 202 which crashed in the Margalla Hills on an ILS approach to the opposite runway 30.* There are events attributed to spatial disorientation when it may or may not be a factor, and may or may not be the only cause. Even when it does occur, it is usually in combination with something else, such as foggy weather which obliterates the horizon, radar failure, cabin pressure loss (the sudden loss of pressure can cause a pilot to lose consciousness.)

    Families who have lost loved ones in airline crashes rely on investigations to determine what systems failed, and what went wrong that caused the crash. It is the solemn duty of investigators (like those in the NTSB) to sort through the wreckage, and analyze the black boxes to determine to the best of their ability what went wrong. The final report is usually the result of a year or several years of intensive study and research. It is usually the more responsible or determined investigators who do not settle for a spatial disorientation cause blaming the pilot, but who look beyond it to find the underlying factor—the radar failure, or system failure, or pressure leak or faulty automatic pilot—that instigated the disorientation.

    *See Comment

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    Raising the Bar on Pilot Training

    Whether one looks at what happened in US cockpits on the Colgan Air flight (49 aboard killed, 1 on the ground, 4 injuries on the ground), or at Air France Flight 447 (228 killed), or if one looks at foreign crashes such as in Mangalore (166 aboard, 8 survivors), it appears that pilots need better tools to indicate when they are in trouble; and better training on how to respond in emergency situations such as when components fail, or flight is becoming unstable for whatever reason. It does little good to be warned that something is wrong if the warning comes at a point when it is too late to do anything about it.

    One wonders if the Thales pitot tubes are equipped to warn when there is a heating failure; or if there is a backup heating system for the tubes; if that backup system were equipped to give a warning. One wonders if there might not be an additional set of pitot tubes installed, one that might be stored internally, but that the pilot might be able to engage automatically if the tubes fail; or barring that, one wonders if there should not be some other mechanical (as opposed to digital or mathematic) “speedometer device” alternative on board for emergency situations… in case pitot tubes again happen to fail in the dark of night over an unlit ocean hurtling for the duration of a four minute stall to an inevitable watery grave.

    I do not advocate reverting everything to fly-by-wire. The best way I can express this is with a simile: Forcing pilots to use fly by wire is like forcing a healthy person to always ride in an electric wheelchair because there is a possibility they might trip.

    If you do this, the person stuck in the wheelchair becomes less able to walk. Their leg muscles will atrophy and their walking skills will deteriorate. They become a passive passenger rather than an active participant. Thus ultimately, relying on a mechanical device to perform what the human being should be doing actually cripples their abilities rather than enhances them. Fly by wire should only be a tool an otherwise competent pilot can use on occasion, not part of the status quo.

    It seems ironic that the automatic pilot quit at the point that it was most needed. But face it–the automatic system was as confused and disoriented as the pilots were at the incoming faulty data.

    We will never know, whether, if the AF447 data crash occurred during daylight hours, if the pilots would have known better how to deal with the situation. Or if the notification of approaching flight crisis was a death knoll rather than a warning, i.e. a warning that came too late for any corrective measures to be applied. But we can be fairly sure that if there were better training and better warning, the catastrophe would not have occurred.

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    Blackhawk Lawsuit


    Photographer Clark Moody

    Benjamin Franklin-Poor Richard’s Almanac
    For want of a nail the shoe was lost.
    For want of a shoe the horse was lost.
    For want of a horse the rider was lost.
    For want of a rider the message was lost.
    For want of a message the battle was lost.
    For want of a battle the kingdom was lost.
    And all for the want of a horseshoe nail.

    I’m not a pilot or a helicopter designer. I’m not an aviation engineer, or an aviation mechanic. Not an Aeronautical Scientist, Aerospace Engineer or Aviation Safety Inspector.(Although I do have the resources of 500+ experts in my Anonymous Experts database. I don’t consider myself an expert but I quote the experts.) I’m not even a farrier who pounds nails into horses’ hooves. What I am is a guy who works with people who were in aviation crashes; and I haven’t a clue what a “yaw boost servo” is, but that’s what failed in a Black Hawk crash, injuring two people and killing two. The Sikorsky UH-60 Black Hawk was owned by the US Army and crashed in Texas A&M College Station, TX.

    Someone in the Army performed a tedious and detailed technical readiness assessment to make the decision to purchase this Black Hawk in good faith.

    Someone was trusting that Sikorsky Aircraft Corp., Sikorsky Support Services, United Technologies Corp., Parker-Hannifin Corp. and Parker Aerospace Group had all their ducks in a row, all the T’s crossed, all the i’s dotted. That is to say that all the helicopter designers, aviation engineers, aviation mechanics, Aeronautical Scientists, Aerospace Engineers and Aviation Safety Inspectors (and all the unnamed professionals of the aforementioned companies) who had brainstormed to create this marvel of engineering, then pushed it to its limits and found it to be without flaw. The helicopter was conceived by, designed by and built by companies who have convinced the world that they know helicopters better than anyone else alive. No one knows more than they how important those tests are.

    There were indications of problems long before the flight. I glanced online 2005 notices of the coast guard seeking sources for the servos repair—servos to be used on the Sikorsky H-60 class helicopter. One match does not a conflagration make, but I only looked online for about ten seconds.

    The short story: the crew took off in the helicopter, and then it spun to the left until it wrecked. Can you imagine how helpless the pilot and copilot felt? How helpless the two crew who could do nothing? There was that moment aboard when some of them or all of them realized the helicopter was probably going to kill them.

    So the “yaw boost servo” contributed to the pilots being unable to control the helicopter. The loss of control and crash were due to the failure of a part. It’s that old thing—kingdom lost for want of a nail.

    A couple of people on that helicopter survived. One of them, Matthew J. Smith filed a lawsuit Jan. 14 in the U.S. District Court for the Southern District of Texas against Sikorsky Aircraft Corp., Sikorsky Support Services, United Technologies Corp., Parker-Hannifin Corp. and Parker Aerospace Group, citing negligence, seeking damage over $100,000. That’s a lot of money for want of a nail. But our armed forces are risking their lives. They need the most reliable equipment—100,000 will not be nearly enough.

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    Fatigue for one-Fatigue for all

    George’s Point of View

    Remember that old Herodotus misquote inscribed on the James A Farley Post Office Building: “Neither snow nor rain nor heat nor gloom of night stays these couriers from the swift completion of their appointed rounds.“?

    The iconic postman is viewed as being the superman of civil servants, intrepid deliverers, come what may. (For those of you born after 1997, the mythos of the intrepid postal carrier predates the movie. Bless Kevin Costner’s heart)

    That iconoclastic perspective will stand unchallenged by pilots if the FAA goes ahead in its move to impose stringent regulations limiting pilot flight time. The bill includes some $8 billion for airport construction and pilot scheduling limitations designed to lessen the incidence of accidents related to pilot fatigue.

    However the effectiveness of this bill may be challenged by an amendment exempting some pilots (those flying for nonscheduled carriers and charter flights carrying commercial cargo) from the amendments intended “fatigue protection.”

    Are cargo pilots and charter pilots built of sterner stuff? Are they eating their Wheaties and consuming super-charged vitamins? Are they really supermen who are not affected by the debilitating fatigue of lesser men? Is the biology of this select group of pilots different from all other pilots so that they are immune?

    What do you think?

    Maybe, just maybe, this new amendment is designed to sacrifice safety concerns in favor of profit.

    No kidding.

    There is no place for exemptions in this bill.

    However, that said, one hopes common sense will be applied in military situations. Say, for example, it is wartime. Can you see some 2011 era John Wayne pilot watching the second hand on his stopwatch and scrubbing a mission based on a peacetime standard? Is some squad somewhere going to have to stop in mid-mission due to a peacetime regulation? How doubly stupid would it be to give any faction opposing us the foreknowledge of such controlling factors. It’s the 2011 equivalent of the British sending their troops out in formation, to be picked off by guerilla fighting Americans. Are we the stupid ones with targets on our chests now?

    Let pilots flying commercial aviation have their reasonable hours, and leave the heroism and exemptions up to the military.

    And to mailmen too, of course—long may they be by snow, rain, heat and gloom of night, “unstayed.”

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    Hawaii, Cleveland, etc…

    I should note at some point that every day there are dozens of small events that occur that we don’t talk about. For example, there was the event on the 7th when a 65 year old pilot beached his Cessna 310 (flying out of Monteray) in the ocean when he ran out of gas. He had notified authorities of his fuel situation, so the Coast Guard was on hand to rescue him…

    Or the fiasco 22 year old Jason Laurence Delta University student (Cleveland Mississippi) survived when the 1972 Cessna 150 he was flying failed, and flipped during an emergency landing in a groove in a cotton field, rolling end over end.

    Or the Piper PA-32 Saratoga went missing heading to Johnstown, Pa, and in which Michael Garrone of Allegheny Township, Pa., 52-year-old Chas Armitage Jr. of Parks Township, Pa., and his girlfriend, 49-year-old Laura Stettmier lost their lives when it crashed 12 miles southeast of the Grant County Airport in Petersburg.

    Or the United Express flight from Chicago to Omaha which landed in Des Moines on Friday with an undesignated engine problem.

    Or Thursday’s Pia birdstrike in Pakistan that ended with an engine shut down and a return to Islamabad.

    Or the fatal crash thursday of an experimental Rand Robinson KR-2 which took off from Mountain Empire Airport and killed the pilot a mile north of the airport at 1:10 pm.

    Or the experimental Quickie Q200 which crashed and burned when 60-year-old Gerald Brinkerhuff from Gobles was practicing touch and goes in Holland Michigan. Brinkerhuff did not survive.

    Every day there are numerous events that happen, and sometimes there’s just not enough detail available, or sometimes conflicting accounts make it difficult to determine what happened.

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    Airblue 202: July 28, 2015

    Love letter and rose on wooden background,close up
    Love letter and rose on wooden background,close up

    Our dead are never dead to us until we have forgotten them.

    Those are words by another George—the Victorian novelist Mary Anne Evans whose pen name was George Elliot.

    “Our dead are never dead to us until we have forgotten them.” No truer words were ever spoken. But there are so many dead to remember in the world of plane crashes. In the world of plane crashes, some disasters manage to make it into the spotlight

    Like MH370, where more money has been spent on looking for the wreckage than the families will ever receive;
    Like MH17 the casualty of a civil war that looks like it might split the world;
    Like Germanwings 9525 whose memorial this weekend in the French Alps leaves so fresh a wound, I wonder how the families will ever heal.

    Some disasters, big or small, just as tragic, manage to bypass the attention of the world stage. Or people just forget. It is the calendar that calls me to remember this flight, these families, that the world seems to have forgotten. Because it is July 28. The calendar forces me to remember another July 28 back in 2010 when I first heard that Airblue Flight 202, an Airbus 321 with 152 souls aboard, had crashed into the Margalla Hills of Pakistan.

    I have heard news that is troubling. That there are families who lost loved ones on Airblue Flight 202 that have still not received compensation. This does not seem just to me, but I am only one man. One man looking at the names of 152 dead, 152 souls whose families, whose lives were abruptly and violently changed. 152 souls multiplied by their families and loved ones. That is a wide reach, a lot of injured hearts and lives.

    This is one of those corners of the world I have mentioned before, where life seems to be held cheaply. I grieve for the families‘ loss, the loved ones whose candles were snuffed out, whose birthday songs will never again be sung. Six crew; 119 men. 29 women; 5 children; 2 babies. I say to the victims, the world may have forgotten you. Pakistan, and Airblue may be sweeping you under the rug as if your lives never happened. But you are remembered. Your families have not, and will not forget you. Nor have I.

    It is the duty of the living to cry out for justice. So I say this here and now, and hope that someone is listening. Let there be justice and compassion for the families of Airblue202. I never knew you, but I knew some of your families; and on this day of remembrance, this July 28, I will remember you. I will never forget you.

    Sincerely,

    George Hatcher
    Consultant

    Final PDF

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