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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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    Cessna Crash in Sinaloa Mexico

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    Pilot Aaron Meza Martin del Campo, 21, and co-pilot Fortunato Ramirez Perez, 25 and two unidentified women died in the crash.

    The accident is under investigation. THe cause may have been pilot error.

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  • Getting Past Indifference

    In George’s Point of View

    When we are working on a case trying to get compensation for victims of a crash, we find that the court relies on friends and family to paint a picture of who the victim was, and how they used to fit in the world. Of course we all know that every human being is priceless; but it is the court’s duty oftentimes to put a numeric value on a person for the sake of compensation. Some courts can be remarkably indifferent to individuals. I was reminded of that truism when reading the word-pictures rendered by the boyfriend of one of the Kazan Airport Crash victims, Yana Baranova …” an incredibly focused and mature businesswoman. Her colleagues describe her as a “rising star” of their industry, and her drive would have doubtless carried her beyond her own expectations….” He barely glances over this description of her, but in his words, we do see the snapshot of a vital young woman lost in her prime.

    Yana’s boyfriend is unaccustomed to dealing with the Russian bureaucracy, and refers to “indifference and a lack of surprise boarding on apathy” and officials who write off that attitude with “This is Russia.” As this young man notes, my experience too has been that Russian courts that can be apathetic.

    It is true that the opposite of love is not hate; it is apathy. Elie Wiesel said that, and it is true. Apathy is the callus that has formed—like a healed blister over an injury— thickened, hardened, insensitive tissue formed over a wound to protect it. Over time, it may become expedient for an official not to stop and feel the pain, but it is a tragedy when that happens. Something of humanity is lost. When dealing with government and the courts, one has to remember that they have seen it all, not once but a hundred, a thousand times. Their souls are probably more blistered than your worst blistered feet in new shoes with no socks, worn day after day, in grueling conditions. No wonder they are calloused, insensitive, even hard. It is a grievous fact that too often robes of government, of jurisprudence, which should be worn to empower and embrace the rights of man and the rule of justice are often worn as shields and blades against the individual. For the law to work at its best, it should be objective, but never sacrifice sensitivity to the victims, or the families of the victims.

    Sometimes it is up to our lawyers to remind the courts that the best and brightest of the legal profession went into the field because they were idealists who love the law; who stepped into their professions because they wanted to spearhead change for good, rights of man; who probably had specific agendas where they wanted to affect change; who believed they would be more effective than they are; who ran into barrier after barrier and who may have given up; who may have substituted apathy for the appearance of objectivity.

    After consulting for forty years on a huge variety of cases, maybe I haven’t seen it all, but I’ve come pretty close. I can’t claim to have a crystal ball, but there’s not a whole lot that surprises me. I’ve developed a pretty good instinct about where and when courts go left instead of right.

    In the US, our “rights-based” ethics system means that we all have the right to be treated as equal to others. Other countries may have “utilitarian ethics based on “good outcomes” vs “bad outcomes”, often with the rights of the individual getting crunched somewhere under the wheels of the system.

    We can only hope to do our best to represent the individuals who were lost. We can only do our best to remind those who sit in judgement that underneath the armor and callouses we all wear to protect ourselves from being fragile in the face of all the storms of life, that we are all human, all deserving of hope, concern, and ethical treatment.

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  • Airworthiness Directive: Life

    In an aviation disaster, what happened is never a true mystery. A true mystery is something that baffles understanding and cannot be explained. We know there’s an explanation. We know something tangible happened. There is a tangible explanation. We just don’t know what it is. What happened. Or in what sequence. Or if one or two of the events in the sequence didn’t happen, could the disaster have been prevented.

    Most aviation disasters live in a realm of tragic mystery. We are always walking around, picking up the pieces of the puzzle. In fact, there are usually few pieces of evidence to pick up–and the ones we do find crumble in our hands, or they’re inexplicable or perplexing. So when we put the puzzle pieces together, they may fit a multiplicity of ways. There may be huge gaps. Or there may be no way at all to fit together the disparate elements. Oh, sure, we come up with a thousand theories–perhaps a different theory for each time we consider, each time we try to take another perspective, each time we speak to another expert. These experts agree; those experts disagree. Perplexing, an enigma, a riddle the answer of which remains forever out of reach. The alleged mystery—the answered question— remains, all the more tantalizing because we know there is an answer.

    As troubling as it is for those of us who look for the answer to “how” it happened, families struggle with fathomless questions a thousand times harder to deal with: why my loved one? Of all the thousands of trips, why this particular flight, why this particular plane, why this January, why this Monday?

    Families play the questions back in their heads, rewind their lives and replay the events as if somehow in the thinking of it, they could reach back through time, stop their loved one from boarding that plane, or otherwise change a single factor–make the pilot leave his phone behind. Make the mechanic give that lug nut an extra turn. Bless that plane designer—or the parts designer—with something extra so that on that long ago day when he came up that design, it was flawless. The thing that if it had been done just a little differently, would have kept the tragedy from ever happening. That magic something that could undo what has been done with such conclusive finality. As if the moment could be rewound as in a movie, and come out differently. These are the questions which are beyond inscrutable, profound questions heavy with the weight of life, of love wrenched away before its time.

    The answer may be elusive.

    But there’s always rigid hard reality behind a crash. There’s always an actual sequence of events that instigated the tragic event.

    So any time I see an airline being proactive, I think of lives that will be saved.

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    There are mysteries hanging about 737s such as ITEK & PERM and recently Ethiopia. In the first two it was determined that it was human error.

    I have always believed that pilot error alone will not bring down a plane.

    This vibration opens a whole new window of possibility of answers to our unanswerable questions. In some of these past crashes where we have not found the answers, is it possible these tragic flights encountered turbulence which was exacerbated by this vibration? Could this flaw have been instrumental in the Aeroflot-Nord B735 crash at Perm on Sep 14th 2008? or to Itek Air B732 at Bishkek on Aug 24th 2008? Or more recently, to Ethiopian Airlines B738 in the Mediterranean Sea on Jan 25th 2010?

    So I am glad to hear that Alaska Airlines begun inspecting their 14 Boeing 737 jetliners. I am glad to hear that Alaska Airlines is committed to safety. They should be commended for wasting no time in ordering an inspection.

    If only all carriers were so diligent, there might be fewer grieving families. And that wouldn’t be a bad thing, would it?

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    As famílias da TAM, três anos depois.

    As famílias da TAM, três anos depois.

    Às famílias que agora rememoram a tragédia com o voo JJ 3054 da TAM Linhas Aéreas – o Airbus A320 que se chocou ao pousar em uma noite chuvosa, em uma pista com problemas de pavimentação, em 17 de julho de 2007…

    Às famílias, muitas das quais são amigas minhas…

    Este mês de julho não pode passar sem que relembremos. Assim como cada primavera faz lembrar o inverno, e cada noite faz lembrar o dia, em17 de julho, nós lembramos.

    Espero que, a essa altura, vocês tenham criado algum tipo de tradição que ajude a família a se reunir e lembrar.

    É um privilégio recordar toda a virtude de suas vidas – quer visitando seu túmulo, acendendo uma vela, plantando uma árvore ou realizando atos de bondade em sua memória.

    Vela alguma brilha o suficiente ou por tempo o bastante; arvore alguma se ergue suficientemente alta ou dá sombra o bastante; nenhum ato de caridade é suficientemente generoso. Mas, ainda assim, fazer algo a cada ano que nos ajude a realmente lembrá-los traz em si um ato de vida. Fazê-lo traz a chama da lembrança, entrelaçando o ontem ao presente e ao amanhã.

    Um ritual que, a princípio, pode funcionar como uma muleta emocional, mas tarde dá asas à nossa alma. Um ritual que nos faz lembrar que cada vida é como uma pedra em um monumento, um alicerce que sustenta a todos nós que seguimos em frente.

    Que a perda não seja em vão.

    Lágrimas não nos podem devolver o ser amado, mas espero que o tempo tenha trazido cura e alívio para a dor, deixando apenas a ternura da lembrança.

    Amigos e amigas, celebrem a memória.

    George Hatcher

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    FAA Focuses on Fixes to Aircraft Collision-Warning Systems

    After looking back at near-collision data the FAA collected, the FAA has given U.S. airlines three years to install software changes to collision-warning systems, saying that the warning devices that have been installed in commercial airliners as well as private businesses need to be fixed.

    The FAA has known since 2009 that systems have been known to fail to monitor and track all the nearby planes, resulting in monitoring errors, a fact which could and may have already caused problems in 7000 commercial planes and 1800 business planes in the US.

    If a warning system fails, and is known to fail, why is a crash which may have been the result of a warning system failure being attributed to air traffic controller error or pilot error? That’s what I’d like to know. Do we need to be looking more closely at L-3 Communications?

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    Always the Last to Know

    In spite of reports to the contrary, Qatar Airways and Ethiopian Airlines deny emergencies that occurred during Sunday’s power outage at the Lagos airport. The rest of the world knew about the power outage even before power was restored. Apparently however, no one told Qatar Airways or Ethiopian Airlines.

    Even the brand-spanking new radar system installed at Murtala Mohammed International Airport will not function without power. And neither can communications.

    Of course, how do you communicate while in denial?

    Pilots coped by flying in a holding pattern or rerouting to other airports when they stopped receiving input from ATC during the power outage.

    Officials of Ethiopian Airlines and Qatar Airways can play all the semantic games of denial that they want. The game is up. Everyone knows. Newspapers got wind of the power outage forcing up to a dozen planes into holding patterns, some of them until they experienced a fuel crisis and had to land without official clearance. There’s nothing like a little journalism to clear the air.

    With enforcement bodies like IATA and EASA empowering the airline passenger and providing oversight, and the aviation industry taking advantage of the (practically) instantaneous communication the world enjoys, legitimate airlines have made it universal policy to be as “transparent” and honest as possible regarding the unavoidable multitude of mini-disasters that constantly creep up in the course of making the world safe for aviation. It is that kind of wide-awake, constant open trouble-shooting and problem-solving which makes flying as safe as it is. No one wants to be “caught with their pants down”– but when it happens, you can be sure most airlines do their best to be wearing shiny clean underwear when it happens.

    Except in countries where denial reigns over truth. Countries that have certain airlines on a banned list.

    Qatar Airways and Ethiopian Airlines say “none of their pilots complained about an enforced landing prompted by depleted fuel.” Maybe their pilots are scared to open their mouths, especially if they’re familiar with that policy of denial.

    One wonders if their pilots–or air traffic control, for that matter–had cell phones. Surely SOMEone in ATC called the main office and said, “Excuse me boss, but we have 12 planes circling, and no electricity. What do we do? What is the policy on that?” Surely SOME pilot used a cell phone, and told somebody somewhere, “Dude, we gotta land, we’re running out of fuel.”

    What did they say at headquarters? Pretend it’s not happening?

    To the folks in charge at Qatar and Ethiopian: Listen, nobody’s perfect. These things happen. Don’t deny it. Take responsibility. You examine what went wrong. You fix it so it doesn’t happen again.

    You don’t pretend it didn’t happen. You’re not a seven year old who broke Mama’s favorite cup or tracked mud on the carpet.

    You don’t fire the poor shmuck who happened to be on the duty that day.

    You admit the problem, own it, examine it in detail, and fix the mechanism, and make helpful policies for what to do if it happens again. And to go the distance, you award that poor shmuck on duty, because while you were sitting there with your head in the sand, denying any problem existed, somebody somewhere on the front lines—pilots and/or ATC—made some right decisions that kept people alive.

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