Weight and Balance Issues in Riverside Cessna Crash?

The Cessna T310Q crashed shortly after takeoff.  For clues into the cause of the crash, the press has focused on the fact that the pilot, Nouri Hijazi, had difficulty getting the engines started. 

But what one witness had to say suggests that the plane was improperly loaded – specifically, it had too much weight in the back. According to the San Jose Mercury News, the witness watched the plane head off to the runway and saw something odd: 

[The witness] said she watched uneasily as the plane slowly taxied for takeoff.  As it did, the plane rocked back and forth, front to back, its tail nearly touching the ground. 

That can happen when there is too much weight in the back of the plane. And when an aircraft is loaded such that is isn't in proper balance, it can become uncontrollable shortly after takeoff and enter an aerodynamic spin or stall, even with the engines developing full power.  That is, though there engines are running fine, the aircraft will stop flying and simply fall out of the sky.  Judging from the security camera footage of the crash, something like may have happened. The video show the aircraft "falling" rather than "flying."  

Bogus Airplane Parts and a Cessna 182 Crash

A courageous client speaks to Stephen Stock about the risks to the flying public. 

 

Miracle on the Hudson Immersive Video

It was seven years ago that Kas Osterbuhr put together a nearly courtroom-ready reconstruction animation of Flight 1549. At the time, there really was nothing else like it. With the movie coming out, Kas went back and updated his work.  Next worst thing to being there.

 

No Mayday Call from Egypt Air Flight 804

Aviation expert Clive Irving suggests that, because the Egypt Air pilots made no mayday call, they must have been killed before the aircraft crashed.  In other words, the crash was the result of terrorism rather than a mechanical issue.

Normally in a fire and smoke emergency the pilots would have time to don smoke masks with microphones in them, and would be able to send a Mayday, and describe the problem. The Egyptian pilots clearly were never able to do this, suggesting the possibility that they were either disabled or killed at the onset of whatever overcame the airplane so rapidly.

I'm guessing Mr. Irving never experienced a significant in flight emergency.  Those who have understand that the last thing a pilot facing an emergency feels the need to do is broadcast a mayday or “describe the problem” to some air traffic controller sitting in a warm dark room hundreds of miles away, sipping coffee.  And calling air traffic control to “describe the problem” is a task that appears on few, if any, emergency checklists.   Sure, pilots in distress broadcast “Mayday! Mayday!” all the time – in the movies.  But that’s about it.

“Mayday” is from the French, “m’aidez”, meaning “help me.”  When you are 6 miles over the ocean and dealing with smoke in the cockpit there is nothing an air traffic controller can do to help you.  Nothing at all.  The smoke is entirely your problem.  In an emergency, communicating with an air traffic controller is most often a distraction to be avoided or at least deferred until time and bandwidth permits. 

We don’t yet know whether the flight 805 crashed due to a mechanical problem or a terrorist act.  But the fact that the pilots made no mayday call suggests nothing.

Pearl Harbor Helicopter Crash: Settling with Power?

Today a Bell helicopter crashed into Pearl Harbor near the Arizona Memorial.   Reports are that everyone survived.  

 

 

Some are saying the helicopter experienced engine failure.  Unlikely.  Instead, the pilot probably experienced "settling with power."  That's when the helicopter is forced down by the downdraft it   creates with its own rotors.  To avoid crashing, the pilot must ease up on the power.  In the video, you can hear power increasing.  Adding power (or torque) just makes things worse.   

Settling with PowerFrom the FAA's Rotorcraft Flying Handbook:

When recovering from a settling with power condition, the tendency on the part of the pilot is to first try to stop the descent by increasing collective pitch. However, this only results in increasing the stalled area of the rotor, thus increasing the rate of descent. Since inboard portions of the blades are stalled, cyclic control is limited. Recovery is accomplished by increasing forward speed, and/or partially lowering collective pitch. In a fully developed vortex ring state, the only recovery may be to enter autorotation to break the vortex ring state. When cyclic authority is regained, you can then increase forward airspeed.

Piper Turbo Lance Crash in Bakersfield: Icing?

Piper N36402 departed Reid-Hillview Airport for Las Vegas as it was getting dark.  The pilot had his wife and three children on board.  Though the weather was challenging, the aircraft was turbocharged, which would have allowed the pilot to climb above at least some of the clouds.  

The plane's flight path, speed, and altitude changes can be followed on FlightRadar24.  The radar track shows that thePiper Turbo Lance N26402 aircraft made at least one 180 degree turn, but then resumed its course.  

It wasn't long too long after that the pilot found himself in trouble. The radar data shows the aircraft's speed building excessively and its altitude dropping fast.  The made two mayday calls (recording below) before the aircraft crashed, killing all aboard.

The flight conditions were ripe for airframe icing.  The Piper Lance lacked deicing equipment.  Airframe icing changes the aerodynamics of the wing and tail and can bring an aircraft down in a matter of minutes.  The loss of control can be especially dramatic when it is the tail surface that ices up first.

 

SkyLife HEMS Crash and Weather

The SkyLife Bell 407 air ambulance helicopter departed from Porterville Airport at 6:52.  It crashed minutes later, halfway into its 50 mile flight to San Joaquin Hospital in Bakersfield.  The four aboard SkyLife Helicopter Crashwill killed, including the patient being transported.

The flying conditions at Porterville were acceptable.  Though it was dark, the weather was 3300 overcast, with light rain, light winds, and 9 miles visibility.  Under those conditions, the crew could fly “VFR,” meaning they could avoid terrain and other aircraft by simply looking out the windscreen.  Were the conditions significantly worse, the pilot would have had to fly “IFR,” and would have had to rely on instruments and help from air traffic control.

The helicopter crashed east of McFarland.  The airport nearest the crash site does not have weather reporting equipment.  But first responders say that by the time they arrived it was raining hard. Photos of the crash area show dense ground fog. 

 Heavy rain, by itself, does not necessarily pose a safety risk.  But the restricted flight visibility that generally accompanies heavy rain or fog, does.  A helicopter pilot who inadvertently wanders into clouds, fog, or heavy rain can quickly become disoriented and lose control of the aircraft . 

One challenge of night flying is seeing and avoiding poor weather conditions before you wander into them.  Inadvertent flight into clouds is called “continued VFR into IFR conditions.” Sometimes pilots, trying to stay out of the clouds, will fly lower and lower until they strike hillsides or power lines that are hidden in the darkness.  The results of that sort of “CFIT” accident are almost always fatal.

It’s too early to say if weather was even a factor in this case.  After all, the first responders who reported the poor conditions didn’t get to the site for more than an hour after the crash.  But ground scars should provide clues to whether the helicopter might have crashed because the pilot lost control or whether, instead, he struck the ground, wires or a radio tower that he could not see while in controlled flight.  

Investigators will also want to know whether the air ambulance crew had night vision goggles available to them.  Night vision goggles have been a hot button for the NTSB for some time. 

Russian Flight KGL9268: Former NTSB Investigator Says Missile Brought Airbus Down

A few days ago, most were saying it's too early to tell what brought down the Russian Airbus that crashed on Egypt’s Sinai Peninsula, killing all 224 aboard.  Now, there's talk of the aircraft being downed by a bomb.  

Why a bomb?  The best explanation comes an article written by former NTSB investigator Doug Herlihy, appearing in the Goldendale Sentinel:

First, it’s likely that the aircraft came apart in flight.

The pieces of aircraft and persons on board are being found spread over 20KM (over 15 miles) in the mountainous region of the southern Sinai. The spread of wreckage is the most critical piece of the accident puzzle.    

When aircraft break up in flight, the parts are spread by two phenomena: the “ballistics” of the pieces and the wind.  “Ballistics” refers to the shape and weight of the object (like bullets or feathers) and how they will fly to earth.  The second factor is the wind at various altitudes as the parts fall to earth.  Like tearing a pillow in the wind, the parts are widely spread.

Second, aircraft seldom blow up because of a defect lurking within.  History shows that they almost always blow up because of an outside force.

Rarely, have any system or fuel supply or tank ever exploded a modern airplane.  Jet aircraft jet fuel, like kerosene and diesel fuel is not prone to explosion.  And, though it is not uncommon for an airliner to be hit by lightning, it’s almost unheard of that it has caused an explosion. Investigators know that either an on-board bomb or a hit by an explosive device is very high on the list of clues to search for.

Ella Lake Crash: NTSB Report Points to Weather, Possible Controlled Flight Into Terrain

NTSB preliminary reports do not draw conclusions as the cause of a crash.  But the NTSB’s preliminary report of the Turbine Otter crash that killed 9 near Ketchikan on June 25 suggests a weather-related “CFIT” crash, exactly as described here.

First, the report indicates that the flight was conducted under Visual Flight Rules.  That means that that pilot was supposed to stay out of the clouds and avoid the terrain by looking out the window rather than by relying on instruments.Chelton disply

Second, the report indicates that the closest reported weather was “marginal” for flying under visual flight rules.    (“The closest weather reporting facility is Ketchikan Airport (KTN), Ketchikan, AK, about 24 miles southwest of the accident site. .  .  few clouds 800 feet, broken clouds 1,200 feet, overcast clouds 2,700 feet. . .”) 

Third, and most significantly, a helicopter pilot searching for the aircraft minutes after the crash was unable to get to the crash site because the terrain was obscured by clouds and fog.  

The NTSB noted that the Otter was equipped with a moving map display that is designed to depict the aircraft’s position with respect to hazardous terrain.  When first introduced, such displays were seen as a boon to safety, making it easier for pilots to avoid terrain that they might not otherwise be able to see.  But some argue that such technology doesn’t increase safety at all, because pilots use the technology to fly closer to the edge than they otherwise would.  The phenomenon coming into play is called “risk homeostasis.” And in fact, the NTSB has previously found that aircraft equipped with moving maps and the other technology comprising modern "glass cockpits" have a higher rate of fatal accidents than those that aren't.

Ella Lake, Alaska Crash Looks Like Another CFIT Accident

We don't know much yet about the plane crash in Alaska that killed the pilot and 8 tourists from the MS Westerdam.  But the crash looks eerily similar to the Alaskan crash that killed Senator Ted Stevens and three others in 2010.

Like the plane that was involved in the Westerdam crash, the plane that crashed with Stevens Otter Senator Stevens Crashaboard was a de Havilland Otter retrofitted with floats and a turboprop engine. Both tour pilots encountered adverse weather that is common in Alaska:  Low Ceilings. Fog. Gusty winds.  

In the Steven's crash, instead of turning around when he encountered the low clouds, the pilot pressed on.  Unable to see where he was going, he inadvertently flew into the side of the mountain. (The local papers were calling the pilot a "hero" because not everyone aboard was killed. I had to disagree.)

In last week's crash at Ella Lake, the weather conditions were similar.  It looks as though the pilot,Promech Air Otter employed by tour operator Promech Air, inadvertently flew into the clouds and struck the side of a cliff.  

This sort of accident is not uncommon, particularly in Alaska and Hawaii.  The type of accident is called "controlled flight into terrain."  It is almost always due to pilot error. 

Blue Hawaiian helicopters was probably the last tour operator that flew a perfectly good aircraft into the side of a mountain due to low clouds.  Compare the photo of the weather conditions that contributed to the Blue Hawaiian crash (left) with the photo of the weather conditions that the Promech Air pilot tried to fly through.  Note how, in both photos, the clouds obscure the mountain tops.

Otter Crash near Ella Lake Alaska weather

 

 

Video Interview: Discussing AirAsia QZ8501 with LXBN TV

Following up on my recent posts on the incident, I had the opportunity to discuss the crash of AirAsia QZ8501 with Colin O'Keefe of LXBN. In the interview, I share my thoughts on the potential cause of the incident and what that might mean as far as compensation for families. 

AirAsia Flight QZ 8501 and Turbulence

Let's get it out of the way: there is little in common between the apparent loss of AirAsia Flight QZ 8501 and the disappearance of Malaysia Airlines Flight MH 370.  

But Flight 8501's disappearance does have at least some resemblance to the 2007 loss of Adam AirAirAsia A320 Flight 547.  Both Indonesian airliners disappeared shortly after contact was lost in bad weather. Both disappeared in Indonesian airspace -- the AirAsia flight over the Java Sea; the Adam Air Flight over the Makassar Strait.

Bad Weather vs. Pilot Inputs

The speculation after the Adam Air crash was that the flight was brought down by severe weather -- weather that the crew had been warned about.  But that turned out to be wrong. Adam Air Flight 547 went down because the crew fixated on troubleshooting a problem with the aircraft's navigation system, not because of weather.  The crew became so preoccupied withthe navigation system that they allowed the aircraft to slowly roll into a steep bank.  They allowed the nose to point down and the aircraft to build too much speed.  When the pilot figured out was going on and tried to recover, his control inputs broke the wings.

But the AirAsia Crew Had Requested a Deviation for Bad Weather

Unlike the Adam Air crew, the AirAsia pilots had requested from Air Traffic Control a clearance to climb to a higher altitude but didn't immediately get it.  A short time later, all contact with the airliner was lost. Isn't that a strong indication that rough weather may have been a factor?  

First, while small aircraft are often brought down by rough weather, it's extremely rare for an airliner to be.  Airliners avoid rough weather largely for comfort rather than for safety.  Second, although Air Traffic Control delayed in giving the AirAsia flight a clearance to climb, the pilots were free to do so immediately in the unlikely event the weather posed a risk to the aircraft's safety.

But while it's rare for an airliner to be brought down by turbulence, it's quite possible for an airliner to be brought down by a pilot's reaction to that turbulence.  

Airbus Rudder System

That's exactly what happened to American Airlines Flight 587 in 2001.  The aircraft encountered turbulence climbing out of JFK.  The co-pilot tried to correct by pushing on the rudder with his foot. He pushed too hard and the aerodynamic forces caused structural failure.  The airliner crashed and killed all 260 aboard and 5 on the ground.

American Airlines 587 was an Airbus A300. More then 10 years after that crash, the FAA required all 300 series aircraft to be modified to warn the pilot to "stop rudder inputs" when structural damage becomes a risk, a modification that I felt was inadequate.  Flight 8501 was an Airbus A320.  That's the same model which the NTSB called flawed because its rudder system was too sensitive:

The Airbus A320 family is . . .susceptible to potentially hazardous rudder pedal inputs at higher airpeeds. 

Eddie Andreini Accident: Air Force Documents Reveal Travis Officials Confused by Air Force Regulations

Airport fire trucks must get to a burning plane within three minutes if they are going to save any lives. That's the maximum response time allowed by the National Fire Protection Association, the organization that sets the standard for airport firefighters, including those working at U.S. Air Force bases. 

The survivable atmosphere inside an aircraft fuselage involved in an exterior fuel fire is limited to approximately 3 minutes if the integrity of the airframe is maintained during impact. This time could be substantially reduced if the fuselage is fractured. . . rapid fire control is critical. . .

Aircraft flown in air shows are usually smaller and less fire resistant than transport category aircraft.  At air shows fire trucks need to get to crash sites even quicker – within 60 seconds or less.

The key to getting fire trucks to a crash quickly is to station the trucks near to where an accident is most likely to occur.  Normally, that might be the end of the active runway.  But most air show crashes occur at “show center” rather than the end of the runway.  As one Travis Air Force witness put it, show center is where ‘the majority of dangerous events focus.”  At air shows, that's where fire trucks should be waiting.

Eddie's Accident

On May 4, Eddie Andreini was flying a routine at the Travis Air Force Base open house.  He was attempting a stunt known as an inverted ribbon cut.  Something went wrong.  Eddie's Stearman slid upside down along the runway, coming to a stop at smack dab show center. Eddie was uninjured but was trapped inside.  A fire started almost immediately.  Air Force personnel say that they saw Eddie struggling to get out as he waited for the fire trucks to save him.  One minute passed, then two, then three.  But the crash trucks didn't come.  When they finally did, it was too late. 

What happened?

The Air Force refused to explain why it took so long for its fire trucks to reach Eddie.  So we sued it under the Freedom of Information Act.  We now have internal Air Force documents showing that the brass didn’t understand the Air Force’s own regulations.  They mistakenly believed regulations prohibited them from stationing fire trucks near show center.  So instead, the Air Force positioned the fire trucks more than a mile and a half away. 

The Travis speed limit for fire trucks is 45 mph.  So it took the first fire truck (a “Rapid Intervention Vehicle”) more than four minutes to get to Eddie.  Had the Air Force positioned even one truck at show center--as it was supposed to--firemen would have gotten to Eddie within a minute and Eddie would have been saved.   

Regulations can be confusing. Was the Air Force’s mistake understandable?  Not really. The manual that Travis show organizers had in hand--and agreed to follow--makes clear that fire trucks belong at show center.  According to that manual, the personnel who were permitted in the “aerobatic box” (the area in which performers fly) included “demonstration teams and fire/rescue.” (Page 28.) The manual goes on to direct that fire trucks should be located “with immediate access to the show line” (page 34) – not a mile and a half away. 

To the extent the Air Force brass was confused, the FAA cleared things up for them when, a week before the air show, it told Travis that crash trucks did indeed belong “in the box” near show center.   

Our team, specifically the air ops staff, was led to believe that we could not put an emergency vehicle (or anything else) inside the Show Box at Show Center, because it was sterile and protected.  We learned that this was not correct about a week before the show after [name redacted] discussed it with [name redacted] of the FAA.  We learned that we could place airshow official vehicles or people in the aerobatic box."

Travis had time

The Air Force's own documents prove that Travis officials had a week before the show was to begin to correct their mistake and arrange for the trucks to be stationed at show center. But the Travis officials had already decided that the fire trucks were going to be positioned where they couldn't be of any use to a performer.  Having made a plan, they weren't going to change, even if it put lives at risk unnecessarily.

"I'll say it again, I need the trucks on the runway!  I need the trucks on the runway now!"

The Travis Command Post recording is difficult to listen to. After hearing it, it's hard to believe that Travis still tells the public that its fire department responded to the crash in an "exemplary" fashion.

(Notes:  At 2:14, one of Eddie’s crew tried to fight fire with a hand-held extinguisher.  The extinguisher was too small and was expended in seconds.  By that time, the Rapid Intervention Vehicle had not yet even left its station.  The Air Force documents do not explain why it took so long for the truck to roll.  It finally arrives on scene after the 4 minute mark.  The time stamps were placed on the photos by Air Force.)

Asiana Admits Pilots Allowed Aircraft To Get Too Slow But Blames Boeing

Asiana now says the autopilot confused the crew of Asiana Flight 214, and blames Boeing for the crash of Flight 214.  ABC Channel 7 asked me to comment.

 

Malaysia Airlines Must Compensate Families Regardless of Whether Flight 370 was Diverted by Crew or Hijacked

Someone changed the course of Flight MH370 and turned off the aircraft’s transponder.  Turning off an aircraft’s transponder makes it more difficult for the plane to be tracked by radar.  A hijacker with even minimal flight training would have known that. 

But there is one wrinkle.  The transponder was reportedly turned off when air traffic control was in the process of a “handoff” from Malaysian Air Traffic Control to Ho Chi Minh City Control in Vietnam.  At that moment, the aircraft was in the shadows: on the outskirts of Malaysian radar coverage and just entering Vietnam radar coverage.  The crew had said goodbye to Malaysian air traffic control, but hadn’t yet established contact with Ho Chi Minh City Control.  If a crew wanted to disappear, that would be an ideal time to pull it off.  Only the most sophisticated hijacker would know that.

Airline’s Obligation to Compensate Family Members

An airline’s obligation to compensate the families of those lost in the crash of an international airliner is governed by an international treaty known as the Montreal Convention.  The Montreal Convention requires the airline to compensate the families of those lost whenever the crash was the result of an “accident.” An “accident”  is defined as “an unexpected or unusual event or happening that is external to the passenger.”  Whether the crash was caused by a pilot’s wilful misconduct, a hijacking, or even a terrorist attack -- it doesn’t matter.  The crash counts as an accident and the airline is liable.   

Cap on Airline Liability

An airline is strictly liable for a family's loss up to 113,100 “Special Drawing Rights,” an amount equal to about $175,000. The airline can avoid liability for sums exceeding that amount only if it can prove it was totally “free from fault.” That is usually an impossible task for an airline, even if the crash was caused by a terrorist.  The air carrier can seldom show that there was nothing it could have done to avoid the accident.  It’s the problem of proving a negative.  Thus, if in fact flight 370 was lost in a crash, it’s unlikely the Convention’s “cap” on liability will come into play. 

More in my interview appearing in the Malaysian press

Asiana 214 Animation Shows What Went Wrong

This animation compares what Asiana 214's approach should have looked like to what it did look like. From the data we have, the animation appears to be fairly accurate, except the audio is not properly synchronized. (The initial transmissions are from when the aircraft was 7 miles from the runway, not several hundred feet.)

If the audio were fixed, would this animation be admissible in court?  

Not in it's current state.  It relies too much on guesswork. But once the data from the black boxes is available and the animation modified accordingly, it's exactly the type of thing the lawyers would want to show to a jury.

Not All Asiana Airlines 214 Claims Governed By Montreal Convention

As described here, passenger claims against Asiana Airlines are limited by the Montreal Convention.  But any claims the victims’ may have against a manufacturer of the aircraft or its component parts are not.  

NTSB Chairman Deborah Hersman reported that evacuation slides opened inside the passenger cabin. The slides are, of course, designed to open outside the cabin.  Passengers (or crew) who were injured by the slides may be entitled to compensation for those injuries from the appropriate manufacturers, if it is proven that the slides malfunctioned because of a defect rather than an error on the part of the flight crew.  Those sorts of claims would be governed by U.S. product liability law, not by the Montreal Convention.  

Asiana 214 and Runway Mismarkings

The markings on a runway are there to help the pilot aim for the proper touchdown point.  Shortly before the Asiana 214 crash, SFO moved the touchdown point for runway 28L several hundred feet down the runway. SFO was thus required to remove the old markings, and paint on new ones that matched the new touchdown point. The airport was not permitted to simply paint over the old markings with black paint. It was supposed to remove the old markings entirely. According to the FAA:

Pavement markings that are no longer needed are not to be painted over but instead are to be physically removed. Removal of markings is achieved by water blasting, shot blasting, sand blasting, chemical removal, or other acceptable means that do not harm the pavement. The FAA does not endorse painting over the old marking because this practice merely preserves the old marking, which is some cases have misled pilots . . .

Look at the photo at right from the New York Post. It is clear that SFO did exactly the wrong thing – when they moved the touchdown point, they painted over the old markings instead of removing them.

Was this yet another factor that the crew of Asiana Flight 214 had to deal with?

So far, the NTSB has not mentioned the improper runway markings. We’ll see if it comes up in today’s briefing.
 

Suing United Airlines for the Crash of Asiana Flight 214

Because Asiana Flight 214 was international, lawsuits against the responsible airline are governed by the Montreal Convention. The Montreal Convention strictly limits where a passenger may bring suit. To bring suit against an airline in a U.S. court, the injured passenger must be a U.S. resident, the passenger’s ticket must have been issued in the US, or the trip must have had a final destination in the US. As discussed here, that means that many of the tourists who were victims of Flight 214 may not qualify to sue Asiana in the US.

The Montreal Convention also permits victims to sue the responsible airline in the country in which the airline’s principal place of business is located. In this case, that doesn’t help the victims because Asiana Airlines' principal place of business is in Korea.

But some foreign passengers may have purchased their tickets through Asiana’s code-share partner, United Airlines. The Montreal Convention allows a passenger to sue not just the “actual carrier” (Asiana), but also the “contracting” carrier (the code share partner who issued the ticket). For some passengers, the "contracting carrier" may have been United Airlines.  United Airlines' place of business is in the U.S. That means that passengers who purchased a ticket from United may sue in the U.S. regardless of whether they qualify to sue Asiana here.

Montreal Convention Governs Asiana Airlines' Obligation to Compensate the Passengers of Flight 214

Asiana Airlines Flight 214 was an international flight between Seoul and San Francisco.  That means the airline's obligation to compensate its passengers for their injuries is governed by an international treaty known as the Montreal Convention. Here are some of the Convention's important points, as they apply to Flight 214:

  • The Airline must compensate its injured passengers as long as the crash was caused by an "accident." The Convention defines "accident" to include any unexpected event; from an encounter with bad weather, to poor planning on the part of the pilot, to mechanical failure. This crash certainly qualifies as an "accident."  The exact cause of the accident doesn't matter. The passenger does not need to prove that the airline was negligent, or that the airline did anything wrong at all. The airline is automatically required to compensate any injured passenger.
  • A passenger who was physically injured is entitled to compensation for his or her emotional distress as well as for the physical injuries. However, a passenger who was not physically injured is not entitled to compensation for emotional distress, no matter how severe the emotional distress may be.
  • The cap on an Airlines' automatic liability under the Montreal Convention is US$170,000. Asiana Airlines may avoid liability for amounts exceeding US$170,000 only if it proves that it was not in any way "negligent or at fault."  In this case, it appears that it will be impossible for Asiana to make such a showing. Therefore, there will be no artificial "cap" on Asiana Airline's obligation to compensate the passengers who were physically injured in the accident

Asiana 214: What Was So Hard About Making The Runway?

A pilot needs to reach the end of the runway at the right height and speed. Too slow and the aircraft could stall and crash. Too fast and the aircraft will run off the far end.

As an approach to landing progresses, the pilot watches the runway and constantly reassesses whether the aircraft is going to come up short or, instead, float too far down. The pilot needs to adjust his power settings and pitch all along the way to end up in the landing zone at the right speed and height. Things work out best if the pilot flies down a gradient of about 3 degrees. That profile allows the pilot to keep his speed and altitude in check.

So where did Asiana Flight 214 go wrong? We don't know yet but here’s what the pilot had working against him:

Surrounded by water. San Francisco airport is surrounded by water. The lack of visual cues impairs depth perception and makes it a bit tricky to tell whether the approach is going to work out properly. Not impossible by any means. Just a little tricky.

Slam dunk. Air traffic control kept the aircraft higher than normal as it neared the airport. The approach, sometimes called a “slam dunk” approach, requires the pilot to descend more steeply than he might otherwise be comfortable with. Again, just a little bit more difficult approach than normal.

ILS inoperative. In bad weather, the pilots use instruments in the cockpit to guide the aircraft down the proper glidepath. In fact, the autopilot will generally keep the aircraft on the proper descent – not too shallow, not too steep. Yesterday, the weather was nearly perfect and the aircraft had not been instructed to fly the electronic glide path. The crew was to fly by looking out the window. Nonetheless, most pilots keep the electronic glide path tuned in and engaged, just for additional help.PAPI's were inoperative Unfortunately, the electronic system (called an “ILS” or Instrument Landing System) was not operating at the airport yesterday. Certainly, it wasn’t needed given the weather, but it would have helped.

No PAPI lights. At the end of the runway is a series of colored lights. If the aircraft is too low, the lights turn red. Too high, and they turn white. The lights (called Precision Approach Path Indicators or "PAPIs") are an aid to flying the proper glide path when making a visual approach. Unfortunately, those lights weren’t working.

So the pilot made a slam dunk approach into an airport that can be a bit tricky. He had no ILS to help him, and no PAPI. He had one other thing working against him:

43 Hours. The co-pilot had only 43 hours of 777 time. With so little experience, it’s unlikely he would have felt comfortable telling the pilot that things just didn’t look right.

"Slam Dunk" Approach for Asiana 214

A poster on another forum notes that air traffic control kept Asiana 214 higher than the same flight from Seoul that landed the day before, requiring the aircraft to make a steeper descent to the runway.  This is sometimes called a "slam dunk" approach.

The top illustration is the descent profile for the accident flight.  The bottom is the profile from the Asiana flight that landed safely the day before.

Asiana 214 Slam DunkAsiana 214 Normal Approach

Ice Crystals Not Likely Cause of Asiana 214 Crash

In January 2008, a Boeing 777 crash landed just short of the runway at London Heathrow Airport. Ice crystals had formed in the fuel. The ice crystals restricted the fuel to the aircraft's two Rolls-Royce engines, causing a power failure just before landing.

Could the same thing have happened to Asiana Airlines Flight 214?

No.Ice clogging fuel oil heat exhanger

First, after the crash at Heathrow, the Rolls Royce engine components that had iced up were re-designed so that it could not happen again.

Second, Asiana 214's engines were not Rolls Royce Engines. Rather, they were Pratt & Whitney engines. Pratt & Whitney engines heat the fuel before passing it through the components that would otherwise be susceptible to icing up.

Finally, witnesses on board the aircraft report that the pilot increased throttle to what seemed to be full takeoff thrust just before the crash. If ice crystals had somehow restricted the fuel flow, that would not have been possible.

Why Did Asiana Flight 214 Land Short?

The picture to the right makes it clear that Asiana Flight 214 hit the berm just short of the runway 28L threshold.  But why?

Sometimes, an aircraft lands short because of a mechanical problem. For example, British Airways Boeing 777 landed short at Heathrow in 2008 when ice crystals in the fuel caused the engine to lose power during its approach to landing.

But more commonly landing short is the result of pilot error.  And I've listened to the tower tapes and didn't hear any indication of an emergency.  (Admittedly, that doesn't necessarily rule out a problem in the cockpit.)  

Here's an animation of Korean Airlines Flight 801 that landed short and crashed in 1997 in Guam. The cause was pilot error. The crew allowed the aircraft to get too low and then waited too long to add power and go around.

Paint Job a Clue to Brentwood Glasair Crash?

The owner of the Glasair III had finished painting the aircraft just before the fatal flight that killed him and his passenger near Byron, according to his ex-wife.

[Behne] had just finished painting the plane at his private airstrip when he and a friend went on the ill-fated flight. "He wanted to get it up and running," said Shelley Rose, whose marriage to Behne ended in divorce in 2009."

When an aircraft is painted, the painter must mask holes in the aircraft's exterior, called static ports, as well as the aircraft's pitot tube.  The pitot tube and static ports sample air pressure exerted on different parts of the aircraft during flight.  That information from the pitot static system drives the aircraft's airspeed indicator, altimeter, and vertical airspeed indicator.

Forget to remove the masking tape, or allow tape residue to clog the tiny static ports, aPitot tubend none of the instruments will work properly.  Masking tape is what brought down a Boeing 757 in 1996, killing 70.   A problem with the pitot-static system (unrelated to masking tape) was also implicated in the crash of Air France flight 447.

Years ago,  I picked up my plane after it was repainted by a reputable shop in Northern California.  During my pre-flight inspection, I found tape residue clogging the pitot tube.  The tape residue would have prevented the airspeed indicator from working properly, and could have caused problems in controlling the aircraft, especially on takeoff.

An inoperative pitot-static system always presents challenges.  But the challenges are greatest at night or in bad weather, not during the nearly ideal flight conditions the Glasair pilot experienced.

NTSB Cites Flutter As Cause of Reno Air Race Crash

The NTSB has determined that the probable cause of the Galloping Ghost’s crash at last year’s Reno Air Races was flutter. No surprise there -- I wrote about flutter within hours of the accident. At its presentation, the NTSB even showed the same NASA video demonstrating flutter that I had posted last year.

Flutter can occur whenever an aircraft is flown faster than it is designed to fly. As it turned out, Jimmy Leeward, the pilot of Galloping Ghost, exceeded by nearly 40 mph the aircraft’s previous top speed without any previous testing to determine if the aircraft would be able to resist flutter at the new speeds. As it turned out, it couldn’t. Board member (and pilot) Robert Sumwalt was highly critical of Leeward’s decision to fly the aircraft in competition without first testing it at race speeds:

If you want to go out and fly fast and try to win, that's one thing. If you're modifying an aircraft without fully understanding how the modifications can affect the aerodynamics, you're playing Russian roulette.”

A loose trim tab assembly contributed to the flutter’s onset. The assembly came apart because the lock nuts that held it in place had been reused multiple times. That’s a no-no. Each time locknuts are removed and then re-tightened, they lose a bit of their ability to grip. That’s why once removed, locknuts should always be replaced with new.

What was surprising was the NTSB’s sentiments concerning “assumption of risk”.  According to the NTSB board chair Deborah Hersman:

At the heart of the tragedy was the fatal intersection in transference of risks from participant to observers. One moment, spectators were thrilled at the spectacle of speed only to have it followed by inescapable tragedy. The pilots understood the risks they assumed. The spectators assumed that their safety had been assessed.”

Those sentiments echoed what I wrote here.  Judging from readers’ comments to that post, many disagree.

Transcript of the NTSB presentation here.

All this blog's Reno Air Crash posts here.

Piper Comanche Crash at Truckee-Tahoe: Density Altitude or Bad Fuel?

At first glance, one might expect that high density altitude was the cause of last week’s fatal Comanche crash at Truckee-Tahoe airport.  The pilot first attempted to depart with three aboard, but aborted the takeoff.  He then offloaded his two passengers and tried again.  It was on the second attempt that the pilot crashed into hangars.

No doubt about it:  Because of its altitude, Truckee is a difficult airport, especially in the summer whenTruckee-Tahoe Airport the air is thinnest.  In fact, last week’s crash was the ninth at the airport in the past four years.  High density altitude played a role in a number of those crashes, including the Karen Trolan crash.

But the facts don’t quite add up on last week’s accident.  The pilot flying the accident aircraft (Piper N8218P) was very experienced – he reportedly had in excess of 6000 flight hours.  And though a departure with three aboard may have taxed the abilities of the plane and its pilot, with only the pilot aboard, there shouldn’t have been much of a problem.

Whenever an aircraft crashes on takeoff, the NTSB tests the fuel supply at the departure airport.  It’s always possible that an engine failure contributed to the crash, and one possible cause of an engine failure is contaminated fuel.

Today word is out that the fuel supply at Truckee did not meet the standards.

From an email I received from San Mateo County Airport: 

After a fatal accident at Truckee (KTRK) on the 2nd of August, the industry-standard practice of halting fuel service and testing the fuel in all tanks and trucks revealed that the 100LL fuel stored at KTRK did not meet the American Society for Testing and Materials (ASTM) standards for 100LL.  As a result of these tests, 100LL fuel service at the airport continues to be suspended pending new fuel and testing of its quality.

Truckee Airport has been trying to get in touch with all pilots who purchased fuel between July 20th (the last fuel delivery) and August 2nd (the day of the accident) and have asked us to pass along this information to pilots at San Carlos/Half Moon Bay.  Questions about the above-mentioned issue should be directed to World Fuel Service's area representative Mike Montalvo at: 510-604-6511.

The test results don't prove that bad fuel caused the Comanche crash but, at this point, bad fuel can't be ruled out.

 

Reno Air Crash: NTSB Critical of Race Organizers' Tracking of Aircraft Discrepancies

No conclusion yet as to exactly what caused the Galloping Ghost to crash last September at the Reno Air Races. But the interim report the NTSB issued today disclosed that the Galloping Ghost experienced an “upset” 6 seconds before it lost its left elevator trim tab. That, in turn, caused the aircraft to go out of control.  None of that  information is really new, and was discussed shortly after the accident in this post and in the post's many thoughtful comments.Galloping Ghost vs. Unmodified P-51D

The NTSB also issued safety recommendations that specifically questioned whether the Galloping Ghost had been properly tested at race speeds or otherwise evaluated for resistance to “flutter;” an aerodynamic phenomenon that can destroy an aircraft in seconds. But that’s not news either -- flutter and its possible role in this crash was discussed the day after the crash here.

There is one fact, however, that we didn’t know before. Race officials inspected the aircraft just before the race and determined that the aircraft’s trim tab’s screws were too short. But the NTSB could find no documentation that the screws had been replaced and the discrepancy resolved before the race started. Though the race inspector stated that he verified that all the aircraft’s discrepancies had been resolved, the NTSB recommended that, in the future, race organizers develop a system that tracks discrepancies found during pre-race technical inspections and ensures that they have been resolved before an aircraft is allowed to race As the NSTB put it:Trim Tab - Reno NTSB

without a method to track discrepancies to resolution, conducting pre-race inspections is of limited value.

The NTSB’s interim report doesn’t say whether the screws were, in fact, replaced. For that, we’ll have to wait for the NTSB to issue its factual report. But even without a system for race officials to track discrepancies, whenever a mechanic performs any work on an aircraft, he is supposed to record that work in the aircraft’s maintenance logs.  If there’s no entry in the Galloping Ghost’s logbooks showing that the screws were changed, that’s evidence that the work wasn’t done, or at least wasn’t done properly.

Besides recommending that race officials establish a better system of ensuring that aircraft discrepancies are repaired before race time, it issued recommendations that would, among other things:  

  • Require race pilots to be trained to tolerate or avoid high g-loadings;
  • Revise the mathematical formulas used to lay out the race courses;
  • Require aircraft to be tested at race speeds before they be allowed to compete; and
  • Require pilots to practice on the actual race course before being allowed to compete.

 

Related Content:

 

Robinson R44 Fuel Tank Design Implicated in Filmmakers' Crash?

Robinson Helicopter Company likes to say that its helicopters are safe in crashes. According to an excerpt from Robinson Safety Notice SN-10:

The R22 and R44 have demonstrated excellent crashworthiness as long as the pilot flies the aircraft all the way to the ground . . .The ship may roll over and be severely damaged, but the occupants have an excellent chance of walking away from it without injury.

As it turns out, that’s not quite true. When they roll over, Robinson helicoptdeGruy/Wright R44 Wreckageers, in particular R44's, have a tendency to catch fire and explode.  That makes walking away from a crash pretty much impossible.

Robinson fixed the problem beginning with helicopters it manufactured in 2010 by installing better fuel tanks.  But that didn't help Mike deGruy and Andrew Wight, who were aboard VH-COK, a 2004 model that crashed February 4 in Australia.

A photograph of the aircraft (above) shows that the ship rolled over on its side, just as Robinson says.  There's little crush R44 Wreckage at Mammothdamage to the cockpit and so the crash looks survivable.  Except for the devastating post-crash fire.

The photo of the deGruy wreckage looks remarkably similar to the wreckage of the September 2010 R44 crash in Mammoth, California (left).  That helicopter rolled over and burned as well.

There's no reason for anyone to be burned in an otherwise survivable helicopter accident. Looks as though deGruy and Wright may be added to the list of those who died needlessly due to the dangerous and defective Robinson fuel system.

Scruggs' Accident: Was Pilot's Warning Adequate?

The pilot says he warned Lauren Scruggs away from his propeller.   According to the NTSB's preliminary report:

After [the pilot] opened the door, [Scruggs] started to get out of the airplane.Aviat Husky Upon noticing that she was exiting in front of the strut, the pilot leaned out of his seat and placed his right hand and arm in front of her to divert her away from the front of the airplane and the propeller. He continued to keep his arm extended and told [Scruggs] that she should walk behind the airplane. Once he saw that [Scruggs] was at least beyond where the strut was attached to the wing, and walking away, he dropped his right arm and returned to his normal seat position. The pilot then looked to the left side of the airplane and opened his window to ask who was next to go for a ride.

The pilot then heard someone yell, "STOP STOP," and he immediately shut down the engine and saw [Scruggs] lying in front of the airplane.

While the pilot apparently tried to keep Scruggs from the propeller, it wasn't enough.  Sadly, the accident likely would have been avoided had the pilot followed the the general safety guidelines set forth here.

  • The aircraft engine should be shut down before boarding or deplaning passengers. This is the simplest method of avoiding accidents. Unfortunately, the pilot elected to keep his engine running.
  • The pilot should instruct passengers, before they exit an aircraft with an engine(s) running, the path to follow to avoid the propeller or rotor blades. The pilot apparently failed to instruct Scruggs of the path to follow before she exited the plane.  Once she had exited the airplane, given the noise, he was left to rely on crude hand signals to get his message across.
  • When it is necessary to discharge a passenger from an aircraft on which an engine is running, never stop the aircraft with the propeller in the path of the passenger's route from the aircraft. Apparently, in this case, the propeller was in the path of the deplaning passenger's travel.

 

Propeller Safety and Lauren Scruggs' Accident

Investigators aren’t sure why Scruggs didn’t see the propeller” she walked into last night. 

Um, maybe because a spinning propeller is pretty much invisible? Especially at nightLauren Scruggs?

News reports are that incidents such as Lauren Scruggs', who is a model and fashion blogger, are rare. Maybe, but it would depend on what one means by “rare.”  Seems that someone is killed or seriously injured by a spinning prop every year. Some reports of incidents from my local area alone are here and here.

During the day, spinning propellers have a mesmerizing effect. People have been known to see them, yet walk right into them. 

Of course, at night, propellers can be virtually invisible.

In almost all prop-strike cases, pilot error plays a role. A pilot needs to think carefully before allowing a passenger to deplane with the engine running. Here, apparently, theAviat Husky pilot allowed Scruggs to exit the aircraft with the engine running so that another passenger could take her seat. Certainly it would have been safer to shut down the engine of the Aviat Husky he was flying before allowing passengers to leave or approach the aircraft. “Hot loading” – allowing passengers to get into the aircraft with the engine running -- is safe only when the passengers have been carefully briefed on procedures.  Even then, it's best permitted only with the help of a trained spotter who walks one passenger away from the aircraft and then walks the next passenger in.

Here are some common guidelines for propeller safety:

  • The aircraft engine should be shut down before boarding or deplaning passengers. This is the simplest method of avoiding accidents.
  • Boarding or deplaning of passengers, with an engine running, should only be allowed under close supervision. The pilot in command should have knowledge that either the company or the airport operator has ground attendants fully trained in their specific duties to board or deplane passengers from an aircraft with an engine(s) running. The pilot should instruct passengers, before they exit an aircraft with an engine(s) running, the path to follow to avoid the propeller or rotor blades.
  • When it is necessary to discharge a passenger from an aircraft on which an engine is running, never stop the aircraft with the propeller in the path of the passenger's route from the aircraft.

 

Blue Hawaiian Helicopter Crash: Photo Tells the (Same Old) Story?

The NTSB blamed the pilot for the last Blue Hawaiian helicopter crash into the side of a mountain. The NTSB concluded that while flying near bad weather, the pilot inadvertently entered clouds, became disoriented, and lost control of the helicopter. According to the NTSB, the probable cause of the accident was:

The pilot's inadequate decision by which he continued visual flight rules flight into instrument meteorological conditions. Also causal was his failure to maintain terrain clearance resulting in a collision with mountainous terrain. A contributing factor was the low ceiling.

One need only look at the low clouds in the photo taken shortly after TBy Joey Salamon/Molokai Dispatchhursday's Blue Hawaiian crash on Molokai to wonder if weather and pilot decision-making played a similar role in this latest crash. 

Hawaii’s micro-weather makes helicopter tours dangerous. We've written about it before here, and hereSpoken about it too.  Yet, year after year, tour operators opt to collect the fares and fly when weather conditions dictate that they really should stay on the ground.

Did the pilot involved in Thursday's crash try to squeeze his Eurocopter between the weather and the terrain and lose control?  Time will tell whether this accident should be added to the list of crashes caused by "improper VFR."  But without significant changes in the industry, Hawaiian tourists will continue to lose their lives in completely avoidable weather-related helicopter accidents. 

Plaintiffs' Lawyers Uncover Smoking Gun that NTSB Missed in Colgan Air Crash

The NTSB is underfunded and understaffed. So it investigates accidents using the "party system."  That means the NTSB relies on those who may have caused the accident for help in investigating the accident's cause. Unfortunately, the "party participants" seldom point the NTSB towards evidence in their files that would tend to incriminate them. As a result, NTSB reports go easy on the industry players.

From time to time, I've offered examples of cases (like the ones here and here) where the real cause of the accident was found by plaintiffs lawyers -- sometimes well after the NTSB report is published.

Here’s yet another example, this time arising out of the crash of the Continental (Colgan) Flight 3407. According to a recent CBS News report, lawyers for the families uncovered emails showing that Colgan Air knew the captain was not qualified to fly the Q400, but put him in the left seat anyway.   

According to an ABC report, in one of the emails a Colgan Vice President states that the captain

had a problem upgrading” and, taking that into consideration, “anyone that does not meet the [minimums] and had problems in training before is not ready to tackle the Q.”

The “Q” is a reference to the Bombardier Q400. Despite Colgan's concerns about the captain's ability to fly the Q400, they promoted him anyway.  Just five months after that, the new Q pilot crashed his aircraft in Buffalo, killing 50.

This wasn't merely a case of "pilot error," it was the result of an airline that didn't take safety seriously enough. The newly released emails are critical to understanding why the accident happened, and how similar accidents can be avoided in the future. Yet, an NTSB spokesman confirmed that Continental did not provide these emails to the NTSB at any time during its year long investigation of the crash.

It looks like the company's emails tell the story of why Continental Flight 3407 crashed.  And it was the plaintiffs' lawyers, not the NTSB, who found them. 

Reno Air Race Disaster No Freak Accident

Hall of Fame aerobatic champion Patty Wagstaff says that it was just bad luck that Jimmy Leeward's accident involved spectators.

At the speeds Leeward was moving, had the malfunction occurred four seconds earlier or later, or almost anywhere else on the course, it would have terminated in the desert.  This was not an accident waiting to happen – this was a freak accident.

Patty, this was not the first time that flutter sent a highly modified warbird out of Patty Wagstaffecontrol during the Reno Air Races.  It happened in 1998, when flutter ripped a trim tab from a P-51 called "Voodoo."  Bob Hannah, the pilot, immediately found himself heading straight up, just as Jimmy Leeward did.  Hannah lost consciousness from the high g-loading, but regained his senses as the aircraft rolled over the top.  Unlike Leeward, Hannah landed safely.

So, though it's too early to say for certain, it looks like Leeward's precise airframe failure -- or something pretty darn close -- actually happened before.  And sure, Leeward's failure could have just as easily occurred somewhere else along the nine mile course, and not at show center. But that doesn't make it a "freak accident," any more than losing at Russian Roulette can be considered a freak accident. 

Nope. This was an accident waiting to happen.

The warbird pilots push their aircraft to their limits and beyond.  That's why it's called "Unlimited" racing.  No one would deny pilots, fully aware of the risks they are taking, the right to fly their aircraft to the point of destruction.  It is, after all, their own lives that they are risking over the Nevada desert.  But they should not be permitted to place spectators at risk.  Pilots might be willing to flirt with death.  But that's not what spectators bargain for.

Sorry, Patty.  Leeward's crash was no "freak accident."  And suggesting it was is not fair to the victims.

 

Related content on this blog:  

Reno P-51 Pilot a Hero?

That's what some press reports are saying.  Had Jimmy Leeward not maneuvered the stricken plane as he did, things could have been much worse.

"The way I see it, if he did do something about this, he saved hundreds if not thousands of lives because he was able to veer that plane back toward the tarmac,” Johnny Norman, who was at the show, told the Associated Press.

That's a nice thought.  But it's probably not true.  Leeward likely was unconscious for most of the accident sequence, unable to veer the aircraft anywhere.

This isn't the first time a P-51 lost its trim tab at the Reno Air Races.  It happened once in 1998, when flutter ripped a trim tab from a P-51 called "Voodoo." Bob Hannah, the pilot, immediately found himself heading straight up, just as Jimmy Leeward did.  Hannah lost consciousness from the high g-loading, regained his senses as the aircraft rolled over the top, and saved the aircraft.  

As reported by AvWeb,

You OK Bob?" called Hinton. "Yea, this thing just popped big time," replied Hannah. What Hannah didn't mention is that the g-load from the quick pull-up had caused him to black out. He finally managed to reach the throttle and reduced Voodoo's power. At that point Hannah radioed that he "(wasn't) out of it yet," but he wasn't thinking clearly. Later, he declared a mayday and made a perfect landing. . . . On the ground one could see what cause Voodoo's problems during the race. The left elevator torque tube failed when the elevator trim fluttered and departed the plane.

It's quite possible that Leeward blacked out just like Hannah did in 1998 but, unlike Hannah, never regained consciousness. 

TGalloping Ghost Cockpitake a look at the two pictures of Leeward's aircraft, the "Galloping Ghost."  The photo on the left is the cockpit before takeoff.  Leeward's helmet is clearly visible.  The frame on the right is the cockpit during the dive, a second before impact.  Leeward is nowhere to be seen.  Perhaps he is slumped over, unconscious.  Regardless, it's hard to imagine that Leeward was in any position to control the aircraft's flight path.

Galloping Ghost/Jimmy Leeward

 

 

 

 

 

 

Related content on this blog:

Reno P-51 Mustang Lost Elevator Trim Tab

This photo, taken moments before the crash, shows that the P-51 had lost its left elevator trim tab. (I've circled the spot where the trim tab should be.) Without the trim tab, the aircraft may have been uncontrollable.

AP Photo/Grass Valley Union/Tim O'Brien

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Original Photo by Tim O'Brien, Grass Valley Union (AP).)

Why did the aircraft lose its trim tab?  One possibility is "flutter," an aerodynamic phenomenon that can, once it starts, damage a control surface quite suddenly.  Here's a NASA video of flutter in action.

 

 

 

An aircraft is at risk of flutter when its airspeed pushes up against or exceeds its design limits.

 

Related content on this blog

The "Impossible Turn" and Three Mooney Crashes in Two Weeks

Three Mooneys have crashed in two weeks.  Each aircraft crashed on takeoff.  Sadly, seven people were killed.  Two of the accidents may have involved the "impossible turn."

First Crash: On July 5, a 1974 Mooney M20F (N7759M) crashed shortly after taking off from Watsonville, California.  All four aboard were killed. 

Second Crash: On July 17, a nearly identical Mooney M20F (N3524X) crashed taking off from Winslow-Lindbergh Airport in Arizona, killing two aboard.  

At first glance, the Watsonville crash and the Winslow crash seem eerily similar.  The same model aircraft was involved in each.  Each crashed just moments after takeoff. 

But the two accidents are entirely different. The Watsonville crash is consistent with the pilot climbing too steeply to avoid a fog bank. There doesn't appear to be any evidence of an engine problem, at least at this point. Rather, as the pilot pitched the nose up, his airspeed bled off, and the wings (not the engine) stalled.  According to one witness:

He was heading toward the coast and tried to climb . . .From the time he took off, he was going too steep, too slow. ... He spun to the left and you can see where the impact was.

In contrast, the pilot in the Winslow crash appears to have attempted to turn around and glide back to the runway after his Lycoming engine quit.  

A Mooney departed then called with engine problems [saying he was] returning to the airport [from the] opposite direction. My friend circled giving the Mooney the right of way. .  Later he asked the Mooney for a position, no response to a couple of calls. He circled for a while longer then landed. Rolling out he saw the Mooney off the departure end of the runway on its back. He said it looked like the typical return to the airport stall spin accident.

The attempt to return to the airport after an engine failure is often called "the impossible turn," because it so frequently ends in the aircraft stalling during the turn and spinning in, with fatal results.

Plots are trained never to turn back to the runway after an engine failure unless they have adequate altitude.  Instead, land straight ahead, or slightly to the right or to the left.  Better to land in the trees, but under control, then lose control of the aircraft and spin in.  While a crash landing in rough terrain may result in serious injury or even death, spinning into the ground is almost always fatal.  Losing control of the aircraft after engine failure must be avoided at all costs. Unfortunately, the temptation to try the "impossible turn" and make it to the runway can be irresistible.

This video shows a Mooney pilot attempting the impossible turn after engine failure near Sacramento, California in 2009.  Both he and his passenger were killed when the aircraft spun in.

 

 

Third Mooney Crash: Finally, on July 18, a 1979 Mooney 20K (N777CV) crashed at Augusta Regional Airport while taking off, killing the pilot and sole occupant, a Mooreville doctor. That aircraft also came to rest within the airport boundaries.  It appears this pilot also experienced engine failure, and also may have attempted to turn back to the airport, stalled, and spun in.  Too early to tell.

Pilatus Crash at Butte: Reader Beats NTSB By Eight Months

Initially, the NTSB thought it might never determine the cause of the Pilatus crash at Butte, reporting to the press that it had no working theories. But this week, the NTSB concluded that the 2009 crash was caused by icing in the aircraft's fuel system.  According to the NTSB, the pilot failed to add an ice inhibitor to his fuel before takeoff.  Then, when his fuel started to solidify at altitude, he failed to immediately land.  Fuel in one wing tank began to freeze.  With fuel draining to the engine from other wing tank only, a fuel imbalance developed and grew worse and worse.  The fuel imbalance ultimately rendered the aircraft uncontrollable, and the pilot crashed.

Interesting analysis. But a blog reader provided us this analysis eight months ago, in a comment to this post.  Looks like "Pilatus Person" was spot on:

Pilot didn't take on Prist. Without Prist, the fuel the pilot had on board would freeze at -40F. It was colder than that at pilot's altitude. So fuel in one tank turned to jello. Despite the transfer pump's best efforts, it couldn't move fuel from that tank to the other side to balance the load. Pilot asked for a lower altitude because he wanted warmer air. But by then, the tanks were seriously out of balance. Pilot had to hold one wing up with aileron. As he approached the field, he was cross-controlled. Then he turned in the "wrong" direction. A cross-control stall flipped the aircraft on its back. . . .All of that fits with the information in the docket. Check it out.

 

Senator Stevens Crash Looking Like "Controlled Flight Into Terrain"

Early news reports described the pilot in the Senator Stevens crash as a hero. According to the reports, the fact that there were any survivors at all is a testament to his flying skills.

I disagreed. (See Pilot in Senator Stevens Crash a Hero?)

As I saw it, the pilot took off in poor weather. When the weather deteriorated, instead of returning to the safety of the lodge, he pressed on, bobbing and weaving around low clouds, until he slammed into the side of a mountain. Nothing particularly skillful about that.  Terrain Avoidance "Inhibit" Button

Opting out of the instrument flight system, the pilot had to stay under the clouds. He couldn't go through them because once inside, he wouldn't be able to see and might bump into something hard and pointy. So he had to stay in the clear and visually pick his way around the terrain in his path. But as he maneuvered under the low clouds and around the fog, he suddenly came upon a mountain's steep up-slope. He shoved the throttle forward, pulled the nose up and began a climb. But the terrain rose faster than could his aircraft. He bellied onto the rising slope while in full control of a perfectly functioning aircraft.

Sadly, the new information that the NTSB just released suggests that my analysis was correct.

  • The aircraft was equipped with a terrain awareness warning system (TAWS).  The pilot had turned the TAWS off.  He probably turned it off because, as he picked his way through the mountains, he found the frequent audible warnings annoying. 
  • One survivor recalled seeing only "white-out conditions outside the airplane."  That probably means the pilot was in clouds or fog.   Of course, the pilot was supposed to stay out of the clouds, so that he can see the terrain ahead and avoid it.
  • The fact that the ventral fin located beneath the aircraft had broken from the aircraft first, followed by impact by the left float, suggested to investigators that the aircraft impacted at a pitch attitude of 17° nose up and 30° roll to the left.  Most likely, as the pilot came out of a cloud or fog, he saw the mountainside ahead of him and pulled up and to the left in an attempt to avoid it.  But by then it was too late.

 Debris Field Suggests Aircraft Impacted Nose Up in a Left Turn

Unfortunately, there doesn't appear to be anything particularly heroic about the pilot's actions in this case.  Rather, it seems he flew a "perfectly good airplane" into a mountainside.  Looks like a classic case of controlled flight into terrain.

Video Shows Open Door in Deer Valley Cirrus Crash

I wrote here that the door on N146CK, the Cirrus SR22 that crashed August 4 at Deer Valley, opened in-flight.  Yesterday, Fox News in Phoenix aired video from a security camera that captured the impact.  Here are frame grabs from the video showing the open door. 

Cirrus Open Door

Cirrus Open Door 2

Usually, when a door pops open in flight, aerodynamic forces keep the door from opening more than an couple of inches, as depicted here.  The door on N146CK was open much more than just a couple of inches.  Of course, the aerodynamic forces operating on this aircraft were far from normal.

Full video here. (Note: the video is disturbing.)

EMS Helicopter - Airplane Mid-Air at Shenandoah Valley Airport

The EMS helicopter was returning to Shenandoah Valley Regional Airport in Virginia, having dropped off a patient in nearby Charlottesville.  Reports differ on whether the Cessna was departing the airport or returning to the airport for landing.  The Cessna and the helicopter collided.  Though the helicopter landed safely, both occupants in the Cessna were killed.

No Control Tower

There’s no control tower at Shenandoah Airport. The primary means of preventing collisions at airports like Shenandoah is called “see and avoid.” That means that pilots are supposed to look out their windows, see other aircraft, and avoid them. 

Helicopters and Airplanes Don’t Mix Well

Though the "see and avoid" method may sound primitive, over the years it has worked well, and mid air collisions are relatively rare.  But helicopters don’t mix well with airplanes in a "see and avoid" environment.  Helicopters tend to fly slower than airplanes and, because they have a small cross section, they are hard for airplanes to spot -- especially when viewed from directly behind. 

Because of that, when near an uncontrolled airport, helicopter pilots are supposed to "avoid the flow" of airplane traffic.  In other words, as best they can, helicopters are supposed to stay out of the way of airplanes.  Sometimes that’s easy enough. For example, if the airplane traffic flies on one side of the airport (see below), the helicopters generally should fly on the other side. Or, the helicopter can fly at an altitude that is lower than the altitude at which the airplanes are flying.

 Fixed wing traffic pattern

The above diagram depicts a left-hand traffic pattern for fixed-wing (airplane) traffic similar to the pattern used at Shenandoah Airport.  Airplanes typically fly the traffic pattern at 1000 feet.  To avoid the flow of that traffic, helicopters might fly a right-hand traffic pattern on the other side of the runway, and fly no higher than 500 feet.

One question will be whether the Cessna was operating within the "flow" of fixed wing traffic when the collision occurred and, if so, why the EMS helicopter did not avoid that flow. 

Cessa Crash Site

Robinson R44 Design Defect Leads to Post-Crash Fires

Robinson Helicopter Company has long touted the crashworthiness of its helicopters. An excerpt from Robinson Safety Notice SN-10, which dates back to 1982:

The R22 and R44 have demonstrated excellent crashworthiness as long as the pilot flies the aircraft all the way to the ground . . .The ship may roll over and be severely damaged, but the occupants have an excellent chance of walking away from it without injury.

That’s turned out to be not quite true. Sure, occupants may survive the initial rollover without injury. But because of the way it is designed, the helicopter is prone to catching fire and burning the occupants before they have a chance to get out.  There has been a string of such R44 N2153Saccidents, the most recent being the September 16 Robinson crash at Mammoth, California.

The R44 helicopter involved in that accident, N2153S, experienced a problem on takeoff.  The pilot "flew the aircraft all the way to the ground," just as he was supposed to. When the helicopter touched down, it rolled over.  As advertised, the two occupants survived the rollover uninjured.  But almost immediately, fuel rushed into the cabin, a fire erupted, and both occupants were badly burned.

As I explained here, there is no reason for an occupant to be burned in that sort of mishap. Technology has existed since the 1970's that can almost completely eliminate post-crash fires in otherwise survivable helicopter accidents.  The technology is not particularly expensive, fancy, or heavy.

In the case of the Robinson helicopter, the biggest problem is the aircraft's transmission. In any type of rollover accident, the transmission can puncture the fuel tank. The fix is simple: replace the rigid fuel tank with a soft bladder tank that won't rupture. 

Robinson has known about the problem for years.  But instead of fixing it, Robinson tried to dodge liability by putting the problem back on the owners. While continuing to tout the aircraft's crashworthiness, in 2006 it posted on its website a "safety noticeNo Nomex On Robinson Websiteadvising that anyone flying in one of its aircraft should wear fire retardant clothing head-to-toe.

To reduce the risk of injury in a post-crash fire, it is strongly recommended that a fire-retardant Nomex flight suit, gloves, and hood or helmet be worn by all occupants.

Robinson didn't seriously expect any occupants to wear that kind of clothing.  It's hot, uncomfortable, and generally inconvenient.  The "strong recommendation" was strictly a "CYA" move.  If Robinson was serious about it, it wouldn't have posted on its website pictures of people flying Robinson helicopters in shorts and t-shirts. (One such picture right.)  Rather, it would show everyone wearing head-to-toe Nomex. But that sort of "advertising" would kill sales.

The unnecessary burn injuries continued. Finally, in December 2009, Robinson conceded that there was indeed a better way and announced that all new R-44’s will be equipped with bladder tanks.

In a continuing effort to improve the R44 fuel sytem’s resistance to a post-accident fuel leak, current production R44s now feature bladder-type fuel tanks, flexible fuel lines and other modifications.

Great news. But what about the thousands of Robinson helicopters produced before last December without bladder tanks?  They are, without a doubt, defective.  The defect has caused, and will continue to cause, needless burn injuries.  The defect and the resulting injuries are Robinson's responsibility.

Pilatus Crash at Butte: New NTSB Reports Show Pilot Under Stress

The NTSB hasn't yet released its probable cause finding concerning the Pilatus crash at Butte, Montana that killed the pilot and his 13 passengers.  But it has just made public its “docket.”  The docket sheds some light on what may have been happening in the cockpit in the minutes leading to the crash.

The flight was bound for Bozeman. Suddenly, the pilot diverted to Butte, which was only marginally closer.  Though the pilot never explained the reason for the diversion, the docket suggests that the

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Cirrus Crash Near Agua Dulce: Pilot Not Instrument-Rated

An instrument rating entitles a pilot to legally navigate an aircraft when the weather is bad enough that he can't see outside.  A pilot who is not instrument-rated must always stay out of the clouds. If the weather is such that he can't do that, he must stay on the ground.  

The training required to obtain an instrument rating is extensive.  In most cases, it takes a pilot longer and costs him more to obtain the rating than it did for him to get his pilot's license in the first

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Witness to the Final Flight of Queen Air N832B

I was sitting in my aircraft at the approach end of the runway at San Carlos, waiting to be issued an instrument clearance. A Beech BE65 Queen Air taxied down to the runway and took off ahead of me. Sadly, it crashed 30 seconds later into a lagoon north of the airport, killing the three aboard. 

Some questions raised in the various news accounts:

Why was the aircraft headed north on the “Bay Meadows” departure, when its ultimate destination was to the south?

I heard the pilot – or whomever was handling the radios -- tell the ground controller that he was going to fly along the ridge line west of the airport and then to South County airport. The

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Pilot in Senator Stevens Crash a Hero?

The pilot of the Otter that crashed in Alaska on Monday, killing Senator Stevens and three other passengers, encountered some very bad weather.  Low ceilings.  Fog and rain.  Gusty winds.

Rugged terrain only complicated things.  Fortunately, the pilot had tons of experience  -- tens of thousands of hours.  According to the Alaska Dispatch, had any less talented pilot been at the controls, the death toll surely would have been higher.

The fact there were four survivors is testament to [the pilot's] skills. [He] maneuvered that plane like no other mere pilot to save lives.

So is the pilot a hero?  No.  Not quite.

There's an old saying in aviation: "a superior pilot is one who exercises superior judgment so as toN455A by jkero avoid having to exercise his superior skills."  In this case, a pilot exercising superior judgment might have turned around before tangling with the worst of the weather.  Or, better yet, never left the comfort and safety of the lake lodge in the first place.

The Weather was Bad 

When the pilot took off from the lake where the lodge was located, the weather was bad.  It was bad at nearby Dillingham airport.  It was bad at the river camp that was to be their destination.  And it was bad everywhere between.

A pilot who flew the same valley where the crash occurred confirmed to the LA Times that it was bad there too.  "It was just awful weather. . .I came through that valley at about 100 feet off the ground with about a mile of visibility."

Now, bad weather doesn't mean a good pilot must stay on the ground.  For example, the airport at Dillingham has various instrument approach procedures that will allow planes to land safely in some pretty crappy weather. No undue risk. No sweat.

But this pilot wasn't headed to Dillingham.  He was headed to a fishing camp on a nearby river.  No instrument approach procedure would guide him through the clouds.  If this pilot was going to get there, he’d have to do it without instruments. He’d have to do it by looking out the window.  Seat of the pants stuff.  All perfectly safe, as long as the weather is good enough for you to see where you are going.

Controlled Flight into Terrain

So what exactly happened?  What we know about the accident is consistent with "controlled flight into terrain."  Opting out of the instrument flight system, the pilot had to stay under the Senator Stevens Plane Crash Wreckageclouds.  He couldn't go through them because once inside, he wouldn't be able to see and might bump into something hard and pointy.  So he had to stay in the clear and visually pick his way around the terrain in his path.  But as he maneuvered under the low clouds and around the fog, he suddenly came upon a mountain's steep up-slope.  He shoved the throttle forward, pulled the nose up and began a climb.  But the terrain rose faster than could his aircraft.  He bellied onto the rising slope while in full control of a perfectly functioning aircraft.

At least that how it looks.

According to John Bouker, the pilot who found the wreck: 

The Otter had plowed into the hill. He bounced up the mountain. He looked like he was in a full-power climb. . the plane appeared mostly intact.

That’s a classic "controlled flight into terrain” scenario.


Poor Decision Making   

This morning a pilot who used to fly search and rescue out of Dillingham called me to talk about the crash.  He pointed out that the state of Alaska accounts for more than a third of all commuter and air taxi crashes in the entire country.  That's right: one state accounts for a third of all the nation's crashes.  And more than 80 percent of those crashes are due to poor decision-making.

Alaskans seem to accept aviation tragedies as part of life in the wilderness.  My caller suggested that poor decision making seems to be not just tolerated, but sewn into the very fabric of Alaskan aviation community. 

The question is not the whether the pilot had the skills to “maneuver” the aircraft around difficult terrain. Or whether he had the experience necessary to pick his way around the obstacles along the route. Or whether he brought the aircraft down with the least impact possible.  The question is whether, given the weather, he should have attempted the flight at all.

I can easily imagine that a nice fire was burning in the lodge fireplace when the pilot loaded up his passengers. If ever there was ever a flight that didn't need to be made, it was this one. 

Yet it was.  

Cirrus Crash at Deer Valley, Arizona: Door Opened (Yet Again. . .)

Cirrus N146CK crashed on August 4 at Deer Valley, Airzona.  The pilot was killed.  Just before the accident, the aircraft's door popped open.  We know that because the pilot reported to air traffic control that his door was open and that he needed to return to the airport to close it.  Plus, surveillance cameras confirmed that the pilot's door was indeed ajar. 

The plane's door popped open? What's with that? 

The Cirrus doors are poorly designed.  It's that simple. They just don't stay shut in flight.  

The plane flies okay after a door pops open.  But the distraction can be dangerous, and can lead to a loss of control, as demonstrated by this 2009 Cirrus crash.  Following the 2009 accident, John

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Manufacturer of Lancair IV-P Engine Not Immune From Suit for Jogger's Death

The NTSB has released its preliminary report of the off-airport landing of Lancair IV-P N9JE at Hilton Head.  The accident killed a jogger but left the plane’s two occupants uninjured. According to the preliminary report

Further examination of the airplane revealed that the propeller assembly separated from the crankshaft flange and was missing.

In other words, the crankshaft failed.

One wouldn’t expect a crankshaft to break absent some sort of defect. If that proves to be the case, could the manufacturer of the crankshaft be held liable to the jogger’s family?

The aircraft was built from a kit and was thus "experimental." The engine, however, was not. Rather, according to FAA records, it appears that the engine was an FAA-certified, turbocharged piston engine manufactured by Teledyne Continental Motors, a company that has had its share of lawsuits related to its engines coming apart in flightTeledyne TSIO-550-C

The General Aviation Revitalization Act, or GARA, protects aircraft engine manufacturers from liability for defective engine parts older than 18 years.

We don’t know how old the engine was in this case.  However, the Lancair builder had reportedly taken the engine from a Piper Malibu.  Piper stopped using the Teledyne Continental TSIO-520 engine in its Malibus due to reliability problems. In 1988, it switched and began installing Avco Lycoming engines instead. Thus, if it turns out that the engine was an original equipment Malibu engine, then it had to be at least 20 years old -- 2 years beyond GARA's age limit.

So is Teledyne Continental Motors off the hook, regardless of whether the jogger's family can prove that the engine was defective

No.

There is one important but little-known exception to GARA.  Regardless of the defective part's age, GARA doesn’t protect its manufacturer from lawsuits brought by the families of those killed on the ground.  

Morton, Washington Cirrus Crash: Should the Pilot Have Deployed the Parachute?

That's the number one question I've been asked about this accident.  Not "why did the accident happen," but "why didn't the pilot use the parachute?"

As I note here, most Cirrus pilots would say that the parachute should be deployed in the event of engine failure, unless there is a long, paved runway beneath the aircraft such that a safe on-airport landing is assured.  But that doesn't mean that, if there is no airport within range, a pilot who opts to glide to a field rather than pull the chute is negligent.

Pulling the parachute has serious risks.  The aircraft's rate of descent under the parachute is high.  Ground impact forces are severe. Cirrus warns that the decision to deploy the parachute should

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Cirrus Crash at Morton, Washington

A Cirrus SR-22, N224GS, crashed yesterday in Washington state.  The pilot was killed.  The passenger was critically injured.  The aircraft departed Concord, California (CCR) in good weather, bound for home.  It crashed in Morton, 60 miles from its destination, which was presumably Renton (RNT).

The accident appears to have been the result of engine failure:

Facts suggesting that the engine failed because it ran out of gas:

  • Fuel exhaustion is the leading cause of engine failure.
  • The pilot reported to his wife that he was battling a "stiff headwind." Unexpected headwinds are common to many fuel exhaustion accidents.
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NTSB Preliminary Report on Saratoga Crash at Pine Mountain Lake in Groveland, California

The NTSB released its preliminary report on the Pine Mountain Lake crash.  As usual, the preliminary report contains no conclusions concerning the cause of the crash. For that, we'll have to wait up to 4 years.  The preliminary report does, however, hint that the NTSB's investigation will focus on whether the pilot pressed on into weather beyond what the regulations allowed.

The full text of the report is here.  Some excerpts:

Instrument night meteorological conditions prevailed at the accident site, and no flight plan had been filed.

Instrument weather conditions are those that require a pilot to fly by reference to his instruments rather than by looking out the window. To fly in instrument conditions, a pilot must be instrument-rated, his plane must be properly equipped, and he must have a clearance from air traffic control.  He is not necessarily required to file a flight plan.  For example, instead of filing a flight plan, the

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Piper Saratoga Crash at Pine Mountain Lake Airport in Groveland, California

The runway at Pine Mountain Lake is oriented east-west, and is surrounded by rugged terrain.  In poor weather, pilots are permitted to execute instrument approaches to the airport.  The approach procedures guide pilots as they descend through the clouds to the runway.  The procedures, flown properly, will place the pilot in a position to land straight ahead without having to maneuver.  When the pilot pops out of the clouds after flying the instrument approach to Pine Mountain Lake, his view out of the windshield should be something like this:  

 Final Approach Runway 27 Pine Mountain Lake - Photo by austinpilot  

The procedure the pilot must follow when approaching from the east is set forth below.  A pilot may descend in the clouds no lower than 770 feet above the runway.  To descend further, the pilot must

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Cessna 310 (Tesla) Crash at East Palo Alto: NTSB Probable Cause Investigation

The initial investigation was conducted by local law enforcement in conjunction with the FAA. Now the National Transportation Safety Board will take over.

The NTSB’s job will be to examine the wreckage and attempt to determine if the crash was caused by a defective aircraft part, negligent maintenance, or pilot error. The NTSB concedes, however, that it lacks the manpower, the technical expertise, and the funding to do that job properly on its own. Therefore, as a matter of long-standing policy, it will seek engineering assistance from the companies that manufactured the aircraft components in question. In this case, the NTSB will recruit the help of Cessna Aircraft, which manufactured the aircraft involved in the accident, Cessna N5225J, and Teledyne Continental Motors, which manufactured each of the aircraft’s two 260 horsepower C-310 File Photo by Kensavition.comengines. The NTSB will exclude members of the victims’ families and their technical representatives from the investigation, feeling that they have nothing to offer. (Sad but true.)

Of course, the NTSB’s practice of asking the manufacturers for help – a practice it calls “the party system” -- presents a conflict of interest.  After all, the manufacturers themselves might be the ones responsible for the accident. Some say that the NTSB’s party system is akin to asking the suspects for help in solving a crime. Nonetheless, the conflict – discussed further here – is ingrained in all NTSB investigations.

It’s no surprise that most NTSB final reports often favor the manufacturers who have “assisted” the NTSB investigators in their work. But perhaps it doesn't make any difference because, by federal regulation, the NTSB’s probable cause findings are not binding on anyone. The families are free to conduct their own investigation, and in the event of a lawsuit, the NTSB’s conclusions are given no deference whatever. In fact, in the event of litigation, the NTSB conclusions are not even admissible. Aviation attorneys who conduct their own independent investigations find that the NTSB’s conclusions are wrong about 50% of the time.

In one recent example, a Teledyne Continental engine similar to those installed on N5225J quit

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Tesla Cessna 310 Crash at East Palo Alto: The Paradox of the Twin

One might think that a twin-engine aircraft is safer than a single-engine aircraft.  After all, if one engine fails, you still have the other to bring you home safely.  That's the whole point of the second engine, right?

If one of the twin engines fails in cruise flight, maybe that's true.  But if it quits right after takeoff, the twin can be extremely difficult to handle.  When the aircraft's landing gear is down, its flaps set, and its airspeed just above the minimum flying speed, the asymetric thrust generated by the operating engine can flip the aircraft onto its back and out of control.  A "Vmc roll", as it is called, is

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Cirrus - Pawnee Mid-Air Collison Near Boulder, Colorado

Updated February 12:

A Cirrus SR-20 single engine aircraft collided with a Pawnee tow plane that was pulling a glider. The Cirrus reportedly ran into the Pawnee's tow line. The Pawnee crashed and the pilot was killed.  The occupants of the Cirrus were also killed.  The glider pilot, however, recognized the impending collision, released his aircraft from the tow line, and landed without injury to himself or his two

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NTSB Finds Probable Cause of Crash of Continental (Colgan) Flight 3407: No Surprises

Icing or pilot error?

Last April, the NTSB released the data from Flight 3407's FDR.  I blogged about that here.  Despite wide spread speculation that icing brought down the aircraft, it looked to me like pilot error -- not weather --  was to blame. 

Then, in May, the NTSB released an animation derived from the aircraft's flight data recorder, its cockpit voice recorder, and ATC transcripts.  I blogged about that here.  The animation, like the raw data from the FDR, made a strong case for pilot error.  From the animation, it appeared to me that an inattentive pilot allowed the aircraft to get slower and slower, until it became dangerously close to the speed at which the aircraft would stop flying altogether and simply fall from the sky.  Then, when the critical moment came, the pilot pulled back on the control yoke instead of pushing it forward, thereby inducing an aerodynamic stall.

The NTSB made public its official probable cause finding at a hearing yesterday.  No surprises to anyone who has studied the data.  According to an article in today's Buffalo News, the NTSB summed it up as follows: 

The plane got so slow that the "stick shaker" — a device that helps to prevent stalls — activated. But Renslow [the pilot] mistakenly pulled back on the plane's controls at that point, which is exactly the opposite of what he should have done.

In total, Renslow pulled back on the controls three times in response to the stick shaker and "stick pusher," forcing the nose upward. That caused and then exacerbated the stall.

It's almost unimaginable that a professional pilot would make the series of mistakes that the pilot did in this case.  Even a new student pilot would know better.  But that's what he did.

The NTSB played its animation for those who attended the hearing.  The animation shows the pilot's errors mount.  The activation of the "stick shaker" is depicted 2 minutes and 8 seconds into the animation. The shaking control yoke was a final warning to the pilot that he must immediately push the yoke forward.  But instead of pushing forward, the pilot pulled back. Three times.  After the third time, the aircraft stalled and crashed. 

There were countless points at which this aircraft could have been saved but, inexplicably, the pilot failed to take appropriate action.  

 

 

Mountain Lifeflight EMS Helicopter Crash Update

The NTSB's preliminary report on the crash contains little more than what was in the news accounts. The report does, however, offer one bit of new information.  The helicopter impacted on a magnetic heading of 230 degrees.  That heading is not in line with the route from Reno to Susanville.  While that might ultimately prove to be important, little can be made of that information without a careful examination of the layout of the terrain near the accident site and the roadway that the pilot might have been using to aid in his navigation.     

Though the information in the NTSB's official report is sparse, an NTSB spokesman did offer his expanded comments to Mary Pat Flaherty, a reporter for the Washington Post who has been following the poor EMS safety record during the past months. The NTSB's Ted Lopatkiewicz told Flaherty that the Mountain Lifeflight helicopter didn't have certain important safety equipment.  Lopatkiewicz was referring to the helicopter's lack of an autopilot, a ground proximity warning system, night vision goggles (discussed in this post), and other equipment necessary to navigate in poor weather.

But in this case the pilot was flying in good weather.  He did not collide with the ground because he could not see it.  Rather, as discussed here, it appears that the pilot crashed because of some type of mechanical problem with the helicopter.  It's unlikely the helicopter's lack of advanced equipment played any role in the accident at all. 

Related Posts:

Compensating the Families of the Mountain Lifeflight EMS Crash

Mountain Lifeflight EMS Helicopter Crash at Doyle, California

EMS Helicopter Safety: NTSB Pushes the Envelope

OSC: FAA Ignoring EMS Helicopter Dangers For Fear of Negative Publicity 

Mountain Lifeflight EMS Helicopter Crash at Doyle, California

An A-Star AS350B air ambulance helicopter crashed November 14 at Doyle, California, killing the A-Star Helicopter that Crashed Saturdaythree crew members on board.  According to an article in the Reno Gazette Journal, the pilot made a distress call before the crash. That indicates that the pilot was likely experiencing a mechanical emergency. The photographs accompanying the article show that the wreckage was spread over a fairly large area.  That indicates that the pilot lost control of the helicopter well before he was able to attempt an emergency landing.

Under the circumstances, the NTSB will be looking at the helicopter's

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Exosphere3d's Animation of US Airways Flight 1549: Courtroom-Ready

I blogged about Scene Systems' animation of Flight 1549's landing in the Hudson here back in March.  Great effort, but I noted that it would take hundreds more hours of work before it could be used in court.  That's because it did not appear that the animation accounted for and synchronized all the available data for the flight.  For example, the flight path depicted in the animation could not have been true to the information from the flight data recorder, because the flight data recorder had not yet been downloaded and made available by the NTSB.  As a result, Scene System's finished product involved too much guesswork to ever be shown to a jury.

Just for fun, Kas Osterbuhr of Exosphere3d in Denver has been working on perfecting an animation ever since.  He emailed me the link late last night.  Kas, whose firm creates animations for use in court, explained to me that his animation is pretty much technically perfect.

Among the datasets utilized are: audio transcripts and recordings, digital flight data recorder, raw radar data, NEXRAD weather, witness statements, satellite imagery, elevation maps and several of the NTSB reports published in the docket. . .All aspects of this animation are based on actual data, whether from the NTSB docket or otherwise. The entire 3D reconstruction is built into a single environment where every piece of information can be aligned in position and on a timeline.

Tons of work went into this animation and it shows.  Aviation accident animations don't get any better than this.

One question, Kas.  The animation depicts flames coming from the aircraft's engines at certain times.  On what data is this based and what would happen if the judge ultimately determined that that evidence for this aspect of the animation is insufficient to allow it to be shown to a jury?  

November 9 Update: Kas' response is in the comments.

Hudson Mid-Air: NTSB's Comments Supported by Audio Recording?

NTSB Chairman Deborah Hersman's recent testimony before congress concerning the mid-air collision over the Hudson raises more questions than it answers.  She stated that  the Teterboro controller instructed the Piper pilot to switch to frequency 127.85 to contact the Newark controller.  But before leaving the Teterboro frequency, according to Hersman, the pilot read back to the controller "127.87,"  which was wrong.  Thereafter, the pilot was in contact with neither Teterboro nor Newark, and so neither facility could warn him of the impending collision. Hersman's remarks are here.

Hersman's implication is that the Teterboro controller failed to correct the pilot, and so the controller contributed to the pilot's getting "lost in the hertz" (out of radio contact) at a crucial moment.  However, the animation that the NTSB released on the same day that Hersman testified does not appear to back Hersman up.  It just doesn't sound as though the pilot read back "127.87" as Hersman states.  You can listen to the audio yourself beginning at minute 2:25. 

 

Helicopter - Airplane Mid-Air Collision Over the Hudson: NTSB Boots It

We count on the NTSB to get the facts right. That confidence is, unfortunately, sometimes misplaced. The truth is that the NTSB gets it wrong. A lot. I’ve written about that herehere, and here.

The NTSB has now given us further reason to question whether it deserves the confidence weATC Radar place in it. On Friday, the NTSB came out with a block-buster press release condemning the Teterboro air traffic controller who had cleared the Piper airplane for takeoff. According to the NTSB's report, the Teterboro controller could see on his radar screen that the Piper pilot was on a possible collision course with the Liberty Tours helicopter. In fact, according to the NTSB, the controller could see the conflict before the Piper pilot switched off from the Teterboro controller’s frequency. Yet, according to the NTSB, the controller failed to warn the Piper pilot.

At 1152:20 the Teterboro controller instructed the pilot to contact Newark on a frequency of 127.85. . . At that time there were several aircraft detected by radar in the area immediately ahead of the airplane, including the accident helicopter, all of which were potential traffic conflicts for the airplane. The Teterboro tower controller, who was engaged in a phone call at the time, did not advise the pilot of the potential traffic conflicts.

That was wrong. True, the controller was on the phone when he should not have been.  But the helicopter did not appear on the controller’s radar screen until after the Piper pilot was supposed to have switched to a new frequency. Of course, by then it was too late for the controller to advise the pilot of anything. In other words, it appears that there was nothing the controller could have done -- whether he was on the phone or not.

Over the weekend, the air traffic controllers’ union privately asked the NTSB to correct its error. The NTSB refused. So today the union issued its own press release setting the record straight.  The press release claims that the NTSB's account, which implies that the controller should have prevented the accident, is "outright false" and "misleading."  Worse, it charges that the NTSB knows it, but refuses to correct its error.

This afternoon, after the controllers' union went to the press, the NTSB finally conceded that it was, in fact, wrong. It thus issued a new press release, explaining that the controller could not have seen the helicopter after all.

The accident helicopter was not visible on the Teterboro controller's radar scope at 1152:20 [when the controller instructed the Piper to change frequencies]; it did appear on radar 7 seconds later - at approximately 400 feet.

The NTSB offered no apology for its error. Nor did it offer an explanation. Rather, despite that the union was right, and the NTSB was wrong, the NTSB’s only reaction was to kick the union off the investigation.

The NTSB’s blunder was a whopper. It laid blame for the accident where it does not appear to belong.  The NTSB's only interest is supposed to be in getting the facts right. If that’s so, why did it not correct its error when the union asked it to?  Why did it require the union to force the issue? 

Mid-Air Collision Over The Hudson: Airplanes and Helicopters Don't Mix Well

Compared to pilots in other countries, pilots in the US have extraordinary freedom. Of course, to keep commercial airliners safe from collisions, pilots of small aircraft are excluded from certain Author Over Statue of Libertyairspace near major airports unless they have first obtained a clearance from air traffic controllers.  If a pilot obtains the necessary clearance, controllers will dictate the pilot's path and use radar to monitor the pilot's every move. 

But that still leaves many places where pilots are permitted to fly without being supervised or controlled in any way.  One such area, appropriately enough, is near the Statue of Liberty.  As long as the pilot stays below 1100 feet -- outside the airspace used by airliners -- the pilot doesn't need a clearance, doesn't need to have filed a flight plan, and doesn't need to communicate with any tower or other air traffic control facility. The pilot is totally on his own.

Many non-pilots are surprised to learn that the method used to prevent collisions in such uncontrolled areas is called "see and avoid."  The pilot is supposed to look out his window, "see" the other aircraft, and "avoid" them.  Pilots talk about having to "keep their head on a swivel" when flying in uncontrolled airspace. Though this method of collision avoidance may sound primitive, over the years it has worked well.

There is one problem.  Helicopters and airplanes don't mix well in a "see and avoid" environment.  Helicopters fly slower than airplanes.  And because they have a small cross section, they are hard to spot -- especially when viewed from directly behind. That puts them at risk of being rear-ended.  It doesn't help matters that helicopters tend to manuever in a fashion that most airplane pilots find to be unpredictable. 

Because of all that, helicopter pilots are supposed to "avoid the flow" of airplane traffic.  In other words, as best they can, they are supposed to stay out of the way. Unfortunately, when both a helicopter and airplane are headed to the same spot, or are both looking at the same feature on the ground, that can be difficult to do.

We don't know what factors combined to result in the midair over the Hudson.  But the NTSB has long recognized that when it comes to uncontrolled airspace, helicopters -- especially tour helicopters -- don't mix well with airplanes.

More on the Hawthorne Plane Crash

The G36 Bonanza's closest competitor is probably the Cirrus SR22. Would the outcome of this accident have been different had the Beechcraft been equipped with a ballistic parachute system, like the system installed in the Cirrus, depicted here?  Probably not.  For the Cirrus' ballistic parachute to work, the plane needs at least 400 feet of altitude.  Although we don't know how high N618MW climbed before its engine quit, it's unlikely it reached 400 feet.  That's an altitude the aircraft probably wouldn't have achieved until well after crossing the end of the runway. As this illustration shows, the Bonanza never made it that far.

The NTSB has now released its Preliminary Report.  The report can be found here.  There's no new information in the report, and certainly nothing that causes us to rethink the analysis we wrote about here.  

As usual, the NTSB report contains no conclusion concerning the cause of the crash.  For that, we have to wait until the NTSB issues its Probable Cause report.  Some news sources, such as the one here, are reporting that the probable cause report will be issued in the next 6 to 9 months.  That's doubtful. Except in the simplest of cases, it takes the NTSB at least 18 months to issue its probable cause report.  Sometimes, it can take as long as four years.    

Beechcraft G36 Bonanza Crash At Hawthorne

Bonanza N618MW, a Beechcraft like the one pictured below, was doing "touch & goes" at Jack Northrop field in Hawthorne.  "Touch and goes" are practice landings where the pilot does not stop on the runway.  Instead, after the wheels touch down, the pilot advances the throttle, takes off again, and then circles around for another landing.  Everything appeared to be fine until, on one of

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NTSB Releases Animation of Crash of US Airways Flight 1549

Two months ago, Scene Systems -- a litigation support firm -- released its animation of Flight 1549's crash into the Hudson. I posted here that, in all likelihood, the animation would not be admissible in court. The legal objection would be that the animation "lacked foundation." For example, without information from the Airbus' black boxes, Scene Systems couldn't confirm the aircraft's flight path or guarantee that the Air Traffic Control audio was properly synchronized to the aircraft's path of travel.  Therefore, the animation involved too much guesswork to be shown to a jury.

The National Transportation Safety Board has now released its own animation. Having retrieved the black bloxes, the NTSB was able to plot accurately the Airbus' position, speed, and altitude at each point along the aircraft's short flight.  The NTSB then properly synchronized the Air Traffic Control audio to the aircraft's flight path.

The only audio on the NTSB's animation is the radio transmissions between the crew and Air Traffic Control. As is typical, the NTSB did not make public the audio of the cockpit conversation between the captain and the first officer. The NTSB did, however, prepare a written transcript of that conversation. The NTSB superimposed the transcript on the animation. (HOT-1 is the pilot, HOT-2 is the first officer.)

Would this animation be admissible in court?  While Scene System's animation would not pass legal muster, the NTSB's work probably would. 

 

Pilatus Crash at Butte Montana and Occam's Razor

The pilot's original destination was Bozeman, Montana.  But the pilot amended his flight plan and diverted to Butte.  The pilot did not tell air traffic control why he was diverting.  About 25 minutes later, as the aircraft approached for landing at Butte, it went out of control and crashed. 

The NTSB is now investigating two things: (1) why the pilot diverted to Butte, especially when he was so close to Bozeman, and (2) why the pilot lost control and crashed so near the runway at Butte.

Some possible explanations for diverting include:

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Weather Analysis Suggests Air France Flight 447 Penetrated Thunderstorms

Tim Vasquez is a meteorologist with Weather Graphics in Oklahomoa.  He has plotted Flight 447's flight path against GOES-10 satellite and other weather data. Vaquez' work suggests Flight 447 penetrated two thunderstorm cells.

The image below, according to Vasquez, is similar to what the Flight 447 crew would have seen on its weather radar screen, assuming its radar was working. The black line in the image represents the aircraft's flight path.  "ACARS Position" represents the aircraft's position when it sent it's last ACARS message.

 Vasquez Figure 12

This next diagram is a cross section of Flight 447's track through the thunderstorm cluster.  According to Vasquez, instead of fying around these two cells, Flight 447 flew through the top of the first cell and then continued on through the middle of the second.

Vasquez Figure 13

 

Not surprisingly, Vasquez concludes the aircraft encountered severe turbulence that may have damaged the aircraft.  The question of why Flight 447 failed to avoid the storms (theories discussed in a previous post) remains unanswered.  Vasquez's full report can be found here.

 

Air France Flight 447: Lightning, Thunderstorms, and the Airbus

Did the Pilots Attempt to Fly Through a Thunderstorm Intentionally? That's very unlikely. Pilots avoid thunderstorms at all costs, because they know a thunderstorm can destroy any aircraft. Pilots use the aircraft’s on-board weather radar system to make sure they keep a safe distance. During the day, they can see the towering thunderstorms rising up to 50,000 feet and avoid them that way as well.


Did Lightning Destroy the Aircraft? Probably not. Lightning strikes are common. On average, each airplane is the US commercial fleet is stuck by lightning once per year. To protect against strikes, airliners are designed to route the electrical charge along the aircraft’s outer skin from one end of

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NTSB Animation Suggests Continental Flight 3407 Pilot Error

I blogged here on whether it was icing that caused the crash of Flight 3407, or whether the pilot simply pulled back on the yoke when he should have pushed forward.  The NTSB's animation, using data gathered from the aircraft's black boxes, makes a strong case for the latter. 

The video is 2 minutes 39 seconds long.  Watch the airspeed drop dangerously low by 2:04 and the stick shaker activate at 2:07.  The pilot should have immediately pushed the yoke forward, which would have pointed the nose down and allowed the aircraft to regain airspeed.  Instead, he pulls the yoke back.

Is Lidle Suit against Cirrus Frivolous?

Cory Lidle's wife and Tyler Stanger's family are suing Cirrus Design, alleging that a problem with the plane's flight controls caused Lidle and Stanger's plane to crash into a Manhattan hi-rise.

Miles O'Brien, a former CNN correspondent, calls the lawsuit frivolous, because the NTSB concluded the cause was pilot error.  According to O'Brien, "in our litigious society, the facts don't matter for much."

O'Brien is missing the fact that the NTSB's conclusion is marred by a built-in conflict of interest.

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Continental (Colgan) Flight 3407: Law Firms Take Different Tacks

Right after the crash of Flight 3407 at Buffalo, investigators  focused on the aircraft's deicing system. The question, as explained by former CNN reporter and pilot Miles O'Brien, was whether ice had accumulated on the plane's wings faster than the de-icing system could remove it, leading to an aerodynamic “stall,” or loss of lift. 

But as the investigation progressed, it began to look as though, just before the pilot lost control of the aircraft, the nose of the plane pitched up  -- not down as usually happens when ice overwhelms an aircraft.  That raised an almost unthinkable possibility:  gross pilot error.  When an aircraft gets

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US Airways Flight 1549 Animation

Scene System's animation of the crash of US Airways Flight 1549 is a viral hit.  The litigation support firm combined available ATC audio tapes, flight track information, and an on-scene photograph into a great recreation.  This is the exactly the type of animation used in court to help juries understand the details of an aviation accident.  

But would this particular animation be admissible in a lawsuit?  Probably not. It incorporates too much guesswork.  For example, Scene System overlays the animation with audio from Air Traffic Control tapes.  Are the movements and positions of the aircraft properly synchronized with the audio? To do that right, you'd most likely need information from the Flight Data Recorder , which isn't yet available. Without that data, the animation is objectionable as "lacking foundation."  It's safe to say that, before it could be shown in court, the animation would require hundreds more hours of work and refinement. 

Of course, Scene Systems wasn't out to produce a recreation that was admissible in court. It was just trying to show the type of product it is capable of. And it did that very nicely.