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.

 

Another Look at "The Impossible Turn"

When the engine quits just after takeoff, the pilot has few options. One is to attempt to turn around and try to land at the airport. It's such a difficult maneuver that it's often referred to as "the impossible turn." I've written about the "impossible turn" before. AvWeb's Paul Bertorelli takes another look at the turn in the video below. Bertorelli suggests that the turn is an option that a pilot should not write off. But it does require practice.

My advice is to practice with plenty of altitude. I've had two cases involving fatalities resulting from turning back after simulated engine failures during flight training.  One is here.

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.

EMS Night Vision Goggles: FAA Incompetence Exposed

Stephen Stock, an investigative reporter for NBC, talks about the hazards posed by night vision goggles improperly installed in much of the nation's EMS helicopter fleet. I was happy to offer Stock my thoughts. The FAA refused to comment on camera.

Imagine how difficult it must be for Rand Foster to go to work each day.

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More Proof That Post-Crash Helicopter Fires Are Unnecessary

There was no fire.  That allowed both occupants to survive.

No, not a miracle.  Just a properly designed fuel system.

No post-crash fire in Arizona Helicopter Crash

And everyone walked away.

The video is proof that if it has a properly designed fuel system, a helicopter need not catch fire after an otherwise survivable accident.

Hope the folks at the Robinson Helicopter factory take note. 

 

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.

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.)

NTSB Boots American Airlines Off Jackson Hole Investigation

I often write about the NTSB's "party system." That's the NTSB's practice of asking airlines and manufacturers for help in determining an accident's cause.  If you ask me, it's a bit like asking the fox for help in figuring out what happened to the chickens. The party system allows industry participants to bias NTSB probable cause findings in their favor.

The NTSB allows party participants to handle evidence and perform certain engineering tests.  But one thing the NTSB insists on doing all by itself is downloading the data from an aircraft's black boxes.  The NTSB's labs in Washington DC are well equipped for that job, and it doesn't require any "help" from the airlines. 

But when it received the black boxes from the American Airlines 757 that ran off the runway at Jackson Hole, the NTSB quickly figured out that one of the black boxes had already been tampered with. The culprit turned out to be the trusted "party participant," American Airlines:
The Safety Board learned that the recorders were flown to Tulsa, Okla., where American Airlines technicians downloaded information from the DFDR. . .
That was too much industry "help" for even the NTSB to tolerate.  So the NTSB kicked American off the investigation.
Because maintaining and enforcing strict investigative protocols and procedures is vital to the integrity of our investigative processes, we have revoked the party status of American Airlines and excused them from further participation in this incident investigation.
Revoking a participant's "party status" is the NTSB's equivalent of the death penalty.  It is the harshest punishment the NTSB has the power to dole out. Still, it doesn't seem like much of a deterrent for next time.
 
Narrated video of landing shows spoilers, thrust reversers failing to deploy: 
 

Summer Means High Density Altitude Airplane Accidents

Many airports in the western United States are located at altitude.  In the thin air, a departing aircraft's propeller and wings are less aerodynamically efficient.  And without a turbocharger, the aircraft's engine won't be able to produce full power.  All of that hurts the aircraft's ability to climb. Unless the aircraft is handled properly, after lifting off the runway it may travel for a distance

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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.  

 

 

Mike Danko Honored As 2009 California Attorney of The Year Finalist

Burdett v. Teledyne Continental Motors involved the forced landing of a Beech Bonanza after the Teledyne Continental IO-550 engine installed in the aircraft came apart in cruise flight. The passenger was severely injured.

The National Transportation Safety Board blamed the engine failure on the mechanic who last worked on the engine, and cleared the engine manufacturer, Teledyne Continental, from any liability. 

We suspected that the NTSB's determination had been influenced by Teledyne's engineers, who the NTSB had allowed to assist in the investigation, despite the obvious conflict of interest that presented.  We thus conducted our own, independant investigation.  We concluded that, contrary to the NTSB's findings, Teledyne Continental was to blame.  After a six-week trial, the jury agreed.

At its annual convention in San Francisco, the California Trial Lawyers Association, known as the Consumer Attorneys of California, honored aviation accident attorney Mike Danko as a Trial Lawyer of the Year finalist for 2009 in recognition of our work in the Burdett case. The Trial Lawyers Association showed this video presentation during the ceremony.

 

 

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. 

 

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. 

 

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.

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.