Tam Familes, 3 Years Later

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    Buffalo: Haunting Questions

    George’s Point of View

    When it is all over, after the crash, after the investigation, after the finger-pointing, after all the intangible blame has been assigned to corporeal cause, and the reproachable have been reproached, it is important to remember that one of the objectives of a crash investigation is prevention.

    Accidents happen. It is a fact of life. Because accidents happen no matter what we do, it is crucial that we do everything possible to reduce their likelihood. When we hear contributing factors of the Buffalo New York crash included that one pilot’s training lacked the procedure of how to handle the particular crisis (how to “respond to a warning system designed to prevent the plane from going into a stall”), and that the co-pilot was sick, we need to look at every factor. We should recognize opportunities to make procedural changes that reduce the accident factor.

    I am sure that inclusion of this training is going to be the most obvious solution.

    Regardless of training, is anyone is considering that sending those pilots flying under the weather conditions of that night is a reckless policy that dumps administrative blame on pilots who can no longer defend themselves, and whose jobs are simply to follow orders?

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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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    No Mayday, then Gone

    I could speculate here about what caused the disappearance of Malaysia Airlines Flight MH370, but that is all it would be: speculation. One can look at the type of plane, the weather, and various circumstances, but the truth is that the devil is in the details, and we just don’t know the details. The investigation will turn them up; the investigation can be a long road down a circular path.

    It makes it more difficult when there was no distress call. No mayday. Think of this: if something happens and you’re on a plane rapidly losing altitude—or with catastrophic issues which could be anything on a plane from a drunk grandpa to a bomb on board to a bad repair failing, to a sudden system failure due to frozen pitot tubes, what is the first thing that you are going to do if you’re part of the flight crew? That’s right—the first thing will be to fix the issue, and stay in the air. The last thing to do after the crisis is handled is to call ATC and let them know what’s going on.

    But because there was no distress call, we can assume that whatever happened happened fast. And now the wildest speculation of all is that the two people with fake passports were terrorists carrying a bomb. Do we need to go down that thought path? There are plenty of things that could have gone wrong although the 777 has a a stellar safety record.

    Now too, there is even speculation where the plane went down, apparently. There’s an oil slick approximately where the teams are searching. Maybe they’re right. Maybe under that slick, there’s a beacon to hear.

    Still, I keep hoping there’s a raft somewhere full of survivors.

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    The Greatest Threat to Aviation Safety

    According to the people who ought to know—the NTSB, Flight Safety Foundation, Boeing—recent studies indicate that the biggest threat to aviation safety is pilots not doing go-arounds.

    Excuse me?

    Apparently,pilots need to recognize and respond faster to unstabilized approaches (approaches that need correction in heading, speed and/or altitude.)

    Pilots tend to want to land when they come in for a landing; and surveys indicate that although airline requirements are to abort landings if their approaches are unstable, go-arounds happen proportionally less often than they should. The Director of Global Programs at Flight Safety Foundation, Rudy Quevedo, “The physics of landing mean that the plane should be centered, on the correct trajectory, the correct descent rate and the right speed.”

    In George’s Point of View

    This conclusion seems to me a major oversimplification of the multitude of aviation problems.

    I would not presume to say that I know if weather, mechanical failures or human failures are most frequently responsible for aviation disasters. I do know that problems tend to occur together.

    I know, for example, that there are countries (like India where a recent aviation school scandal revealed the licensing of pilots who cannot fly or pass flying exams.) When a pilot who couldn’t pass his flying exam has an accident, a go round would not have helped.

    And as for a crash like the Boeing 777 operated by Asiana Airlines that crash landed at San Francisco International Airport–the plane flown by someone unfamiliar with the airport and the plane he was flying came in too low and hit the seawall (among other things.) How can one say that failing to make a go around was the problem–when the plane was too low and at the wrong angle even before reaching the runway.

    It is easy for a statistician to say some of these accidents could have been prevented with a go-around; but in how many of these accidents was a go around actually an option? Planes hit seawalls, encounter wake turbulence, strike cables, have flat tires, flap failures, bird strikes, suffer wind shear, idiots who attempt to open doors in mid-flight, and hundreds of other problems. A go-around is not always an option.

    Undoubtably, especially on small planes, a second or even third shot at landing will correct minor landing physics issues. It’s probably somewhat easier on a small plane than a 777, And if you ask a pilot that had a runway overrun, he will probably tell you the exact instant when he should have gone for the go-around, and knew when it was too late.

    It should be noted that sometimes when the plane is on a wrong trajectory, incorrect descent rate, and wrong speed, it might not be possible to manage a go-around; there may well be a factor like a bird strike, mechanical failure, faulty flight indication, or icing crimping the physics.

    It’s very easy for a guy with a pencil in his hand to say pilots should have aborted their landings at the first sign of trouble. Sometimes we should look at surveys and statistics like Mark Twain, and realize that “There are lies, damned likes and statistics.”

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  • Putting Aviation Out of Biz, Breaking the Camels Back: Walk Softly and Build a Massive Deficit

    We don’t usually talk about politics here, but it is hard to completely ignore Obama’s proposal to eliminate a tax break for business-jet owners. (The proposal extends the tax-depreciation schedule for business jets to seven years from five years.) I am not anti-Obama, at all, but it is what it is.

    We believe the consequences of that tax break will not make much money for the government, but it will have repercussions in the aviation industry. Catch phrases have cropped up, terms like “demonizing private aviation” and “engaging in class warfare.” Obama does not seem to be aware of that (to use an old catch-phrase) “trickle down” economics. The tax break is incentive for corporations and private owners to purchase new jets. The proposal does attack aviation, which * employs 1.2 million people and generate $150 billion in economic activity.

    How can a depreciation allowance for private jets prevent the rich from paying enough taxes to finance government child safety programs? Where is the logic behind the theory? It is obvious if you look at the results: what is actually involved is a politician courting public opinion, because the majority of Americans can’t afford jets, and will gladly agree to a tax on rich folks, i.e. them. Most Americans aren’t going to take a long view of how a tax will affect an entire industry. They’re just relieved that there are taxes coming out of some other guy’s pocket.

    But the tax will affect an entire industry, those 1.2 million people working in aviation, building planes and buying them. Those unbought private jets don’t get built, don’t get sold, don’t get flown, don’t get maintained, don’t get stored in aviation hangers. That means a lot of jobs for a lot of pilots, a lot of small charter lines, mechanics and support crews.

    With tax proposals like this one, one wonders if Obama’s long range goal is gunning for the aviation industry to look like Detroit after the exodus of the automotive industry.

    How can business owners stay in business and create jobs when the government is steadily chipping away at the foundations of business?

    *Statistics according to General Aviation Manufacturers The General Aviation Manufacturers Association represents over 65 of the world’s leading manufacturers of fixed-wing general aviation airplanes, engines, avionics, and components. In addition to building nearly all of the general aviation airplanes flying today, GAMA member companies also operate aircraft fleets, airport fixed-based operations, pilot training, and maintenance facilities worldwide

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    Door Switch Oops Rolls Nippon Flight


    Click to view full size photo at Airliners.net
    Contact photographer Andrew Bowden

    What: All Nippon Airways Boeing 737-700 en route from Okinawa to Tokyo Haneda
    Where: Hamamatsu
    When: Sep 6th 2011
    Who: 2 crew injured
    Why: While en route, the co-pilot accidentally activated the rudder trim switch instead of the door mechanism.

    The plane descended 6000 feet and rolled, injuring a couple of flight attendants. The first officer—2400 hours— leveled off, and was able to admit the captain who was stuck outside the cockpit, waiting to get in.

    The flight continued without incident.

    In George’s Point of View

    If there is a problem, it comes out, eventually. My pilots tell me that after there is some kind of incident, we need to keep an eye on new incidents, reports, recalls, and especially advisories, directives and safety alerts. There can always be a relationship, no matter how obscure it seems at first glance.

    You know how everyone has been looking at Air France Flight 447 with a new eye, ever since examination into the Air France Flight 471 on July 22 apparently fooled the autopilot into quitting with a swift descent. And Airbus investigators looked at this event twice because you have two the same plane types doing something similar?

    Well, on the surface, this Nippon incident reminds me of Ethiopia Flight 409. It only reminds me because I saw a line drawing of the route of the plane as it spiraled out of control. It also was a 737.

    I’m not calling the situation identical. Certainly if one of the pilots were locked out on a bathroom break—not that a pilot would do this on takeoff!—it would turn up on the voice recorder.

    What if on Ethiopia Flight 409, someone had needed admission into the cabin?

    It just makes me wonder if it is possible that the cabin crew accidentally activated the rudder trim switch. The Ethiopian Airlines plane had just taken off; it would not have been high enough to drop 6000 feet before recovery.

    I know this thought is right out of the blue, and probably has no basis in anything but my wild imagination, but I am told by my pilots that although the switches are dissimilar, the door unlock switch is right next to the rudder trim. So, is it possible the trim switch could have been inappropriately engaged by accident on Flight 409?

    Some airlines rectify this by requiring a third party to open the door if someone leaves the cockpit, but I have to wonder if this could be a design problem.

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