Advice from Good “Friends”

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  • Pilot Fatigue Increases Flight Risk

    George’s Point of View

    Right now, the European Union allows pilots and cabin crews to work up to 14 hours straight, a situation which the president of the European Cockpit Association says is “a dangerous gamble with passengers.” A U.S. National Aeronautics and Space Administration pilot survey said 80% of pilots admit to have fallen asleep during a flight. Easa’s Moebus Report recommends lowering the max time to 13 day hours day and 10 night hours.

    I would no more want to be in a plane piloted by an exhausted pilot than I would choose to drive myself when I’m sleepy. 14 hours straight is simply too long a time-span to be entirely safe.

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    India: Civil Aviation Safety Advisory Council

    Air India Airlines did not single-handedly inspire the newly formed Indian separate body to investigate air accidents, but as the committee was formed immediately after the Air India Express crash in Mangalore that claimed 158 lives, it certainly was a major catalyst. It remains to be seen if the new investigatory committee will be as efficient or reliable as the US’s NTSB/FAA which investigates all major air events in the US and some outside of the US (when requested by foreign agencies or when American pilots, citizens, service or goods are involved).

    Certainly the DGCA needs help. We have already pointed out in a prior editorial that the DGCA’s report on the Mangalore crash is overdue. The Times of India quoted the DGCA’s own statutes:

    According to Civil Aviation Requirement (CAR) Section 5 (Air Safety), Series C, Part I issued on 13 October 2006, “preliminary report by the inspector of accidents/inquiry officer should be finalized within 10 days of the accident.

    We have also located a source that claims that * all of Air India Express managerial positions are “part-time.” Does this mean that the company was deliberately set up to have no key personnel who can be targeted as decision-makers? Though why should that matter? Air India Express is the budget branch of a larger company; Air India Express is a wholly owned subsidiary of Air India which is now part of National Aviation Company of India Limited (a merger between Air India and Indian Airlines.) Someone is in control.

    Those who fly India and have high expectations of the new safety committee being effective may be in for a let down while the newly formed body finds its footing. The new, separate Civil Aviation Safety Advisory Council which has been set up to handle air crashes has no experts from Air Traffic Control (ATC) nor expert pilots. Along with the Directorate General of Civil Aviation (DGCA) chief, Dr Nasim Zaidi, the 28 member body includes Aviation CEOs including Air India Chairman Arvind Jadav, Spicejet CEO Sanjay Aggarwal, managing editor of Centre for Asia Pacific Aviation, Kapil Kaul.

    If you take a look at how the NTSB handles an investigation, you will see that a team of experts are engaged and all interested parties, including pilots, are represented, including some you might not expect. Without such input, investigation is a waste of time.

    The NTSB team of investigators handle individual aspects of the individual investigation, allocated by expertise. Each expert is responsible for a specific and sometimes overlapping portion of the investigation. Specialization like this helps develop and apply expertise in each area and prevents key points from being overlooked. Also, bear in mind that the experts involved in investigating each crash will differ, depending on the parties involved; and most of these parties are on site within hours of the crash.

    SomeAreas of investigation/investigators

    • Structures investigators (who also usually takes responsibility for the crash site, ensuring that all the wreckage (e.g. wings, fuselage, and undercarriage) is accounted for and that proper trails of evidence are followed)
    • Engines investigators
    • Systems investigators such as flight controls
    • Airline’s Operations investigators (also studying crews’ training and suitability)
    • Black box investigators
    • Accident flight’s relationship with air traffic controllers
    • Meteorologists who analyze the weather at the time of the crash to determine if it had a bearing on the accident.
    • Metallurgists who analyze the condition of the plane’s metal and the forces on it
    • Sound specialists (for eg, identifying sounds on black box tapes)
    • Fire and Explosions experts
    • Simulation experts who reproduce the events
    • Flight survival experts who analyze the forces the passengers were subjected to. (These are the people who can tell you the safest place to sit on a plane.)
    • Maintenance experts who analyze the plane’s condition–and how it got that way
    • Psychologists may examine procedures to determine if airline practices exist that cause the pilot to make mistakes, like flying different types of planes. (e.g. Different types of cockpit controls make switching planes an unsafe practice.)
    • Manufacturers representatives who study and analyze their product’s performance
    • Pilots (representatives from the pilots’ union) may be attached to many or all groups; just as…
    • Labor Unions such as the International Association of Aircraft Machinists may attach representatives to multiple groups.
    • Cooperating “foreign specialists” in wreckage reconstruction, black box decoding or interpretation. (Countries who develop special expertise in various fields are often called to join the investigation, just as the NTSB is frequently asked to join foreign investigations.)

      Plane manufacturers have their own investigative teams experienced in this type of analysis, and they stand ready to work on any event that needs their expertise. And the investigation is networked so that if and when they need additional specialists, they can tap into their own company resources.

      One should note that in the case of the Mangalore Crash investigation, the wreckage sat out in the elements for 50+ days before being collected and warehoused. In my opinion, this is carelessness; and furthermore, this carelessness is just one visible aspect demonstrating where the existing procedures are obviously not up to par. While I am sure that experts combed the wreckage, including Boeing, (they always dispatch a team when one of their planes is in a crash,) leaving the wreckage out in the elements is not a best practice for conservation/preservation of evidence. One can only wonder how all other aspects of procedure including those behind closed doors-stand up to Aviation Industry’s internationally expected best practices.

      The industry calls this massive joint investigation the “party system.”

      The parties involved include all parties affected. The more parties involved, the faster the investigation may go.

      Chairmen of each group make their report; and any groups who discover any failures or unusual effects of machinery make note in the final report given to the primary investigator. The investigator invites the individual groups to provide their angle on what caused the crash and how it might be prevented.

      If all the probable causes line up neatly, then it is a simple thing to complete the final report. When theories conflict, the final report takes longer, and tension develops.

      All of this information is supposed to remain confidential until the final report is published.

      In this “party system,” the various opposing parties tend to keep each other “honest”. Unfounded attempts at blame by one party will be met with rebuttal by another–so it is obvious that if there is no pilot representation in this new committee, pilots may end up the “dumping ground.” Let’s say, for example, that a pilot in a crash went in with bad input like an outdated map. Is this committee set up to pursue the investigation to the source of the bad input? A pilot’s association representative would be instrumental in getting to the cause, whether it might be inadequate training, or materials.

      The international community and the people of India are waiting to see how this new committee manages to regulate and oversee all aspects of civil aviation in India, and whether it helps keep India’s DGCA and the safety of India’s aviation systems on track.

      * Need separate body to probe air crashes: Patel; Economic Times, The (India), May 25, 2010

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  • Thoughts on Human Error

    George’s Point of View


    Humans are amazing inventors, capable of envisioning a “possible” for every “impossible,” creating incredibly complex feats of engineering, in the name of Hughes and Learjet and McDonnell Douglas and Lockheed and a hundred others whose names won’t be forgotten. Even amazing inventors can engineer lemons, or fail to see every possible contingency. But the possibility of error goes beyond human error. Humans are not responsible for the fact that rust exists. Do you blame Einstein for the fact of relativity? It’s the dichotomy of reality: for every up there’s a down. Everything creates its own opposite. “Fixed” allows the possibility of “broken” to exist.

    Thinking logically along those lines…we can speculate and plan, study and test, polish and revise, but does that make our planning and scheduling invincible? Even if it were perfect (and I’m not saying it is, because I am speaking of things in general), things fall apart. The nature of reality is change. Change happens. Plan for contingencies 1-3000 and the one that will happen is contingency # 3001.

    We have to be careful sometimes when we start talking about human error. Unfortunately the container where the human error begins is life itself, because in theory EVERY thing can be blamed on human error. The patient died, blame the doctor. Nevermind that the patient was 112 and suffered every illness known to man.

    In aviation, gunnysacking the humans happens too. Maybe they didn’t cause the lightning but they flew through it. We humans are pretty amazing creatures but we don’t control nature. We can plan and schedule all we want, but if you are going to fly during rain, you’re going to encounter thunderstorms. So let us say that the storm is responsible for the event. Do we blame the pilot for flying through the storm? Do we blame the arrogance of the plane manufacturer who claims the plane is invincible and can fly through anything?

    Pilots are human. We have the full range of the spectrum, from the sublime, Sully, to the ridiculous (Colgan Air’s Marvin) Renslow. The problem that a hero like Sully presents to the rest of us is that he creates the philosophy that well trained pilots should be able to solve any emergency.

    But take for example Air France 447… could the pilots have been able to cope with flight speed problems caused by the performance of flawed parts?

    Is the failure to recover from an unexpected event (wind shear, potential conflicts with other planes, broken planes) pilot error? If we put human beings in an easy chair of an automated job in some point-and-click fly-by-wire captain seat, when the crisis happens, the built-in redundancies in flight systems fail and the pilot can’t snap out of humanness to turn into Superman when the wire breaks, is that pilot error?

    Our pilots now have to deal with cost-cutting industry practices causing fatigue and poor training.

    Even if the ultimate safety device in the airplane is the well-trained pilot, guess what? Pilots are human. Humans are capable of mistakes. They are capable of mistakes when operating planes.

    Let us not forget that pilots fly planes that were crafted by humans, maintained by humans, orchestrated by human ATC, landing on airports designed by humans.

    There is no one single answer. I have seen it a hundred times, and each case is unique unto itself, with one generality that can apply.

    Human error occurs at all levels, and rarely alone.

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  • Memorial Day

    Happy Memorial Day weekend, everyone. It’s time honor those who made the ultimate sacrifice in service to our country, to gather together, to remember the ones who need remembering, to thank the ones who need thanking, and to pull out the barbecue tongs and feed everybody else.
    May 27, 2013

    “The secret of Happiness is Freedom, and the secret of Freedom, Courage.”
    Thucydides

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    Flying in the face of Fate

    George’s Point of View

    Sometimes heroes do things that are counter-intuitive.
    Police break up riots.
    Soldiers enter battle.
    Firemen run into fires.

    Our natures are designed to have the urge to run away from harm. It only makes sense.

    There are thrill seekers who defy that urge:
    race car drivers
    parachutists
    The Evel Knievils of the world.

    Pilots are trained to do whatever is necessary to avoid thunderstorms. Serious storms are taken seriously–especially if routed through the “inter-tropical convergence zone.”

    It is counter-intuitive to fly into a storm.

    Maybe the storm crept up out of nowhere. Engineers can claim new planes are safely flown into storms but some things that are counter-intuitive are that way for a reason.

    We humans are solvers by nature. We like to see what the problem is, analyze it, and fix it. But what we find, while doing our fixing, is that there’s never just one thing wrong.

    This is true for any airline event. When is it ever just one thing? It’s not just the rain; the runway is too short. And part of the brakes are down. It’s not just that the pilot is landing on the wrong runway–the runway isn’t long enough, and it’s on a collision course. Plus when there are maintenance issues, they snowball. Maintenance crews get fluids on the engine that burn and send fumes in the cockpit, which causes the crew to have an emergency landing with a fuel-filled plane that stresses the landing gear and explodes the tire, and damages the nose wheel…

    It’s never one thing.

    So this time, it looks like it’s turbulence, hail, lightning strike, rapid decompression, storms, and electrical failure in the desolate oragious Atlantic. The controversy will keep going for a long time.

    What we decide is futile. Ultimately the only thing you can call a tragedy is a tragedy. This is a tragedy.

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  • FAA Standards Tested

    George’s Point of View

    I hope that all of St George’s licensees have been retested.

    Anthony St. George was convicted and sentenced to prison on 15 counts of conspiracy and submitting false statements on Federal AviationAdministration (FAA) certifications. At the time, St. George was a designated mechanical examiner for St. George Aviation whose job was to administer FAA tests air-frame and powerplant tests to mechanics after mechanics took the prescribed class.Not only did St. George provide test answers, he skipped segments of the tests and issued certifications when the office was closed.

    See the Official Whistleblower Press Release

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