It is time again for Thanksgiving. In my heart, I feel Thanksgiving every day, perhaps because in my business I am constant touch with families of victims. I work closely with people in all stages of loss. I have to admit, it takes a toll. Even the news of the day takes a toll-the deaths of children abroad in bombings, this bus crash in Tennessee, the latest crash: they all take a piece of me. There are so many times that I can bring hope or help; I can’t help but wish I could always do so. There are so many who have so much. I feel deeply for those who are struggling to get their lives on track, and those who have to scratch for meals wherever they may be.
As this day of Thanksgiving approaches, I extend my condolences to all those who have suffered loss or deprivation. I pray that this season, everyone has everything they need, peace of heart, peace of mind, and tables full of blessings. At the same time, I give thanks for every moment, for my friends, family and health, and all the blessings of those close to me. Have a happy Thanksgiving.
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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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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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On July 28, Air Blue Flight 202 crashed in the Margalla Hills north of Islamabad. It was the last flight ever for 146 passengers and six crew. The accident happened during a July rainstorm six years ago, I believe the people aboard should be remembered.
The only survivors were the family members. No one aboard lived.
That means that the families of 152 people have had to learn to live with the memories of their loved ones. Most of them have probably traveled to the memorial to see their loved ones names written in stone. Stone will remember what people may forget.
The accident has been labeled pilot error, but those are just words. Some called the fatal flaw CRM, which is an acronym referring to how well the crew inter-managed resources, i.e. themselves. The final report has been completed and filed and put away.
And the victims are still dead. I could wish for a world of magic reality where the investigation would solve some thing, and somehow put the passengers back in their lives. Or even better, change the events of the past so that the flight never happened.
But magic reality does not exist. All that exists is the truth of what happened, the lessons of the past, and the hope that the aviation industry learned whatever it could to prevent such accidents in the future.
The tragedy is a stain on 2010, and forever a wound in the hearts of the families of those whose lives were pointlessly lost. Families, please know that even if the accident is no longer in the global eye, we are so sorry for your loss. No one can say it better than John Donne:
Any man’s death diminishes me,
Because I am involved in mankind,
And therefore never send to know for whom the bell tolls;
It tolls for thee.
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Irrational could be changing, now, what was had claimed before.
Like the NTSB saying in the 1989 NTSB Sioux City Final Report, the ‘probable cause’ to their references in their earlier National Airlines Final Report. That National Report found no probable cause but suggested ‘not understood vibrations’. That Report also drew in three earlier fan explosions as references and citing these as so similar, they were used for “comparison purposes”. That Report also expressly ruled out engine over speed as “pure conjecture”.
But now, in the Sioux City Report, and where the probable cause was a metallurgical defect, the NTSB listed just the National accident, and relabeled the National’s probable cause to be “engine over speed”. Daring not to also re-label those three other references, they now were simply left out. Presto ! – by doing so, the NTSB could now present the Sioux City accident as a ‘once-off’ (only happened once) when – in fact – it was 5th fan disk uncontained explosion (National, and the three others there having ‘no probable cause’ were now not relevant, separated and with no connection to Sioux City).#Irrational could be claiming as factual what scientific testing had ruled out.
In the NTSB’s ValuJet 592 Report, the NTSB claims “one or more” of the oxygen canisters carried in the cargo hold self-ignited and flooded the compartment with oxygen and thus started, and made that fire possible. They didn’t test their theories of self-ignition and the quantities of oxygen released, they had the FAA Technical Center do it. Contrary to all of this, the Tech Center tests said that, even if self-ignited, the canisters heat was only 400 degrees (525 degrees is needed to ignite the packing materials said to have ignited) and that the actual oxygen released is ‘insignificant’ (“local hot spot”). Lest they discredit the NTSB theory, neither of these FAA findings found their way into the NTSB’s Report. The Report also ignored another letter buried in the Docket, a oxygen manufacture’s statement that such self-ignition was unheard of, and “highly unlikely”, and thus the NTSB’s probable cause holds. Lost too was that four months after the loss of ValuJet, the aircraft manufacturer (Douglas) issued a warning to remove the fuselage insulation blankets (keeps the cabin areas warm) because of two earlier Douglas product (MD-88, MD-11) fires and that because of this, the Douglas method for fire testing was now deemed invalid. Four years later the FAA issued an airworthiness directive (AD) saying to check for burning below the cargo area (electric heaters for the static pressure sensors) and then issued yet another saying what Douglas said four year earlier – to remove the (acoustic) insulation blankets because of in-service fires and that the earlier flammability tests were invalid. Simply, ValuJet flight 592 was the precursor and warning to the coming loss of Swissair flight 111 in 1998 but the NTSB’s probable cause with ValuJet served to obscure, or hide, the long-known problems of insulation blankets that failed the flammability tests. Whose tests were these ? – Douglas and Boeing’s – the FAA had taken the manufactures’ word for it all. Now, and years after these two horrific losses, the FAA has just created it’s own flammability standards – ones that none of these two most used insulation blankets could pass. Oh yes ! – the FAA is giving the industry to 2016 to get these flammable materials out because, as they said, ‘of cost considerations to the industry’.
Irrational could be claiming a scenario as unique when dozens of other reports exist.
In the NTSB’s Report on the loss of American Airlines flight 587, the NTSB blamed the American Airline’s pilots aggressive use of the rudder pedals in American’s A-300 model aircraft. But the Report doesn’t address 20 other rudder incidents (largely from the SDR database) where the pedals and rudder where reported to be moving on their own (uncommanded rudder). A few reports called the movements ‘sudden’, and another “violent”. The words “violent” seen in the SDR and also in a Aviation Safety Report filed by pilots was missing in the NTSB in their Accident/Incident database report. “Sudden ” and ‘Violent’ described the scene as the American pilots fought with the aircraft for seconds and then losing all control. Worst yet, 3/4th of these other 20 reports weren’t on American Airline or on the A-300s but rather four other carriers including United, Fed Ex, America West, Air Canada and on different models, A-319s and A-320s.
Irrationally yours,
ANON
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Pitot tubes use external air temperature and pressure to calculate changes in speed. Ice crystals that get caught in pitot tubes are considered a contributing factor in a dozen significant events, and the crash of Air France flight 447. As a result of ice crystal accumulation, air temp and pressure readings are false, autopilots shut off, pilots lose altitude readings and receive false warnings. In a fly by wire plane, this is disastrous. In Air France Flight 447, it killed everyone aboard the plane.
Today’s news is full of aviation-safety experts looking for changes in procedures and more-precise checklists. There’s a lot of buzz out there about a new study. I hope that the study, as it has been explained, is not just about adapting to broken technology. I hope this is not the only study out there.
Air France and Boeing are now examining how these ice crystals function (or more correctly, malfunction.) That seems wise.
But one questions why the next step of the anti-icing drive will be to get consensus on how pilots should respond to pitot tube failure.
George’s Point of View
This is like figuring out the best way to drive on a flat tire, instead of making a tire that doesn’t go flat. Sure, pilots should have procedures, but shouldn’t a study be designed with the ultimate goal being to give the pilots a dependable speed sensor, not methods how to mitigate an oncoming disaster? Are designers afraid to trade a known quantity, even though it is flawed, for something unaffected by ice crystals? Even if it is cheaper for airlines to figure out how to muddle on with existing systems than to devise an alternative technology to pitot tubes, shouldn’t the focus of studies be on creating technology that is not disabled by ice crystals?
Not being an engineer myself, I have no ideas on the subject—but somewhere there’s an aviation engineer with a brilliant idea of either a safe design of reconfigured pitot tubes or a completely different system. Let us hope that engineer is able to step up, and be recognized. But it may not be so simple. Apparently Airbus and Air France had been aware of chronic pitot tube problems for years and were content to continue using the same design anyway.
Come on engineers. It’s time for a better mousetrap.
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They say that time heals all wounds. And in a sense that may be true even for the families who lost loved ones in a plane crash, as long as we can interpret “healing” to mean that time eventually eases the sharpness of the pain of loss. And while that degree of healing is something that happens with people because our nervous systems are built for survival and allow us to adapt to even agonizing loss, the same thing is not true of mechanical equipment. While people bathed in time may get a little better, black boxes, radar components and computers that sit in salt water for a long period of time do not get better. In fact a scientist could present us a ratio of the time an item spends in ocean water : accessibility of evidence in terms of a diminishing ratio of accessibility. Or in other words, the longer evidence soaks in salt water, the more diminished our capacity to analyze it. Not that the same ratio applies across the board, of course–the frailty of paper in salt water is not the same as metal. And rice paper would differ from bond which would differ from cardstock. But in general, one can certainly say the longer evidence sits in the ocean, the more degraded that item will be. Ocean-time won’t heal evidence; but it sure helps damage or destroy it. So any evidence that we find now has been quietly degrading for almost 2 years.
So now we have the news that the fourth search for the black boxes has turned up something even more stupendous–they found identifiable remains. Great hosannas and praise by the submarine-load is being lavished by the audience of a world who is transfixed by the news. How amazing it is that on this fourth search for a needle in a haystack, after two years time and ocean currents, and countless storms and tides, with each passing moment making discovery that much less likely, after all this, a needle is found. But who is the world praising? The searchers, certainly. The searchers have as they say these days “mad” skills. But let’s not praise the sponsors of the search.
If not for the sponsors quitting, this discovery would have been found two years ago, or sometime between then and now. Because let us not forget the sponsors of the search, Air France and Airbus—both of whom could well afford to continue—have THREE TIMES quit. Quit the search, leaving key questions unanswered. Quit the search, the black boxes with their priceless knowledge, unfound. Quit the search, and left the families dissatisfied, and without closure.
Nevermind that this is such a timely find. Days after a judge takes the high road of French law and declares Airbus and Air France open to a criminal investigation for the crash of Air France 447, suddenly we have such a “feel good” media moment. Bodies found. Good job, searchers. Bad job Air France. Bad job Airbus.
If you had not given up, (and let’s face it, your reasons were purely financial,) what is lost would have been less dispersed by currents and time. And perhaps what is more important, the families would not be having their wounds reopened. Because these are not live family members found. This will not be true joy and true relief. This is just re-opening that sense of grief and pain, which is torturous after the anesthetic of two years. For those families whose lost are still lost. And for those families now able to receive their two lost loved ones, the grief and pain will be renewed. It will force them to relive the deaths all over again. Because even when they’re found, they’re still lost.
The question remains, why did you ever quit the search? This Pandora’s box of pain could have been closed and laid to rest by now, if you had not quit. Shame on you.
Costuma-se dizer que o tempo cura todas as feridas. Em certo sentido, isso até pode ser verdade para as famílias que perderam entes queridos em acidentes aeronáuticos, contanto que interpretemos essa “cura” como um alívio à agudeza da dor e do sofrimento. E embora esse nível de cura seja algo possível às pessoas porque nosso sistema nervoso é projetado para sobreviver, permitindo que nos adaptemos à mais agonizante perda, o mesmo não é verdade para equipamentos mecânicos. Ainda que pessoas banhadas pelo tempo possam ficar um pouco melhores, caixas-pretas, peças de radar e computadores abandonados em água salgada por um longo tempo não ficam nem um pouco melhor. Na verdade, um cientista poderia nos apresentar uma relação em função do tempo que um item permanece em baixo d’água, demonstrando uma taxa decrescente de acessibilidade das evidências. Em outras palavras, quanto mais tempo uma evidência fica submersa, menor é nossa capacidade de analisá-la. Isso não significa que uma mesma taxa se aplique a todas as evidências – é claro que a fragilidade do papel na água não se equipara à do metal. De modo geral, contudo, pode-se afirmar que quanto mais tempo um item permanecer no mar, mas degradado ele ficará. O tempo no mar não trará cura às evidências, mas certamente ajudará a danificá-las ou destruí-las. Logo, qualquer evidência que encontremos agora terá enfrentado uma lenta degradação por quase dois anos.
Agora somos surpreendidos pela notícia de que a quarta busca pelas caixas-pretas encontrou algo ainda mais estupendo: corpos que podem ser identificados. Graças e louvores pelas descobertas submarinas têm sido dadas pelo público mundial que se mantém atento às notícias. Como é incrível que nessa quarta busca de uma agulha no palheiro, já após dois anos, com correntes oceânicas e diversas tempestades e marés, e com o passar do tempo tornando qualquer descoberta cada vez mais improvável, uma agulha tenha sido encontrada. E quem está sendo saudado pelo mundo? As equipes de busca, com certeza. Elas demonstraram habilidades verdadeiramente fenomenais. Mas não vamos enaltecer os patrocinadores das buscas.
Se os patrocinadores não tivessem desistido, essas descobertas teriam sido feitas há dois anos, ou em algum momento entre a data do acidente e hoje em dia. Por isso, não vamos esquecer que os patrocinadores das buscas, Air France e Airbus, que bem podiam ter arcado com sua continuidade, abandonaram-nas por três vezes. Abandonaram as buscas, deixando importantes perguntas sem resposta. Abandonaram as buscas, deixando perdidas as caixas-pretas e suas valiosas informações. Abandonaram as buscas, deixando famílias insatisfeitas e sem uma conclusão.
Não importa que essa descoberta seja tão oportuna. Dias após um juiz aplicar os rigores da lei francesa e declarar que a Airbus e a Air France podem ser investigadas criminalmente pelo acidente com o voo 447 da Air France, temos de repente um “agradável” momento na mídia. Corpos são encontrados. Bom trabalho, equipes de busca. Grande falha, Air France. Grande fracasso, Airbus.
Se vocês não tivessem desistido (e, sejamos francos, seus motivos foram puramente financeiros), as perdas teriam sido menos dispersadas pelas correntes marítimas e pelo tempo. E talvez, ainda mais importante, as famílias não teriam suas feridas reabertas. Como não estamos falando do encontro de sobreviventes, essas descobertas não trarão verdadeiro alívio e verdadeira felicidade. Elas apenas servirão para recrudescer aquela sensação de dor e sofrimento, que é uma tortura após dois anos de anestesia. Para aquelas famílias cujos entes queridos não serão encontrados, e para as demais que agora receberão os restos de seus familiares, a dor e o sofrimento serão renovados. Isso as forçará a reviver as mortes mais uma vez.
Porque, mesmo encontrados, eles continuam perdidos.
A dúvida permanece: “Por que vocês desistiram das buscas?” Se vocês não tivessem desistido, essa Caixa de Pandora de dor já poderia ter sido fechada e enterrada a essa altura. Vocês deviam se envergonhar!
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