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.

I really like the Avidyne PFD, MFD, and autopilot in my Cirrus. 

In a nutshell, the Avidyne PFD and MFD tell the pilot flying in instrument conditions which way is up and how to steer a course that keeps you from hitting a mountain.  The Avidyne autopilot is loaded with great safety features that can save your bacon if for some reason stuff hits the fan in the cockpit. 

A few days ago, Avidyne offered me its new “AeroPlan” extended warranty for my equipment:  pay $2000 per year and any repairs are free.  If that sounds like a lot of money, keep in mind that without a warranty Avidyne charges a flat rate of $5900 to fix anything that might go on the fritz.  (Ouch!) 

Offer expires July 1.

All in all, it seemed like a deal that I couldn’t refuse. 

Then I read the fine print.

Avidyne won’t sell owners the warranty unless they sign a “Waiver, Release and Indemnification.” At first blush, that document seemed like just another boilerplate form designed to protect Avidyne fromt frivolous suits. But when I read the form closely, I realized that by signing it, an owner puts his entire net worth on the line should Avidyne screw up and hurt someone that the owner may have never even met. 

By signing, the owner agrees that he won’t sue Avidyne if he crashes, regardless of whether the crash was Avidyne’s fault.  Hmmm.  You’d think that if I could prove that I crashed solely because Avidyne’s product was defective, Avidyne would agree to at least pay my medical expenses

But it gets worse. By signing the agreement, the owner agrees that if one of his passengers is injured in a crash, and his passenger sues Avidyne, the owner will pay Avidyne’s attorneys fees in defending the case in court.  Same goes for suits brought against Avidyne by anyone who is injured on the ground.

Furthermore, by signing the owner agrees to pay any court judgment that is awarded against Avidyne — even though the accident turns out to be entirely Avidyne’s fault and not the owner’s. 

And there is no end date to the owner’s obligation.  So even after I sell the aircraft, I’m still on the hook.  If the new owner crashes, and then sues Avidyne, I agree to pay for Avidyne’s attorneys and for any judgment that the new owner (or his passengers) obtain against it.

In short, anyone who signs this agreement becomes Avidyne’s insurance company.  Forever.  All to save a few bucks on repair work.  

Who would agree to that?  My understanding is that owners are rushing to beat the July 1 deadline. But I don’t think those folks know what they are getting themselves into.

 

A flight attendant placed a cup of hot coffee on passenger Lourdes Cervantes’ tray table.  Then the passenger in the row ahead of her reclined.  That caused the coffee to spill on Cervantes lap. Cervantes suffered second degree burns.  She sued Continental. 

Does she have a case? 

Domestic travelers can hold the airline liable only if their injuries are caused by the Continental Coffee Suitairline’s negligence.  In other words, the airline is not responsible unless it was careless.  So if Cervantes was on a domestic flight, it’s hard to see how she could win.

But Cervantes was flying on a flight from Madrid, Spain, to Newark, New Jersey.  Because she was traveling internationally,  the Montreal Convention applies. Under the Convention, whether the airline was negligent is for the most part irrelevant.  All that matters is whether the passenger was injured by an "accident."

The U.S. Supreme Court has defined “accident” to mean “an unexpected or unusual event or happening that is external to the passenger.”  Does Cervantes’ situation meet the definition? Yes, according to a California federal court that ruled on a nearly identical case involving hot tea rather than hot coffee: 

The slide of the tea off of the tray table was unusual and unexpected. Although it may be common for an airline seat to shake when its occupant moves around, it is not common for beverages placed on the tray table behind that seat to be so jolted by the movement that they fall onto another passenger. It is the failure of the tray table to hold beverages securely despite passenger movement in the seat in front that is unexpected.

Looks like Cervantes’ case is a winner.

A jury in Washington state handed down a $26 million verdict against Avco Lycoming as a result of a fatal Cessna 172 crash that killed three people in 2008.  The  jury’s award included $6 million in punitive damages, designed to punish Lycoming for consciously disregarding the safety of the flying public.

It’s the second time a jury has slammed Lycoming with punitive damages for its carb floats. In 2010, a jury awarded $89 million, including $64 million in punitive damages, as a result of 1999 Cherokee 6 crash that killed four and injured one.

This case, however, was a bit different. It was the judge who ruled that Lycoming was responsible for the crash before the case ever reached the jury.  All that was left for the jury to decide was how much to include in its verdict.  The judge ruled against Lycoming because it refused to turn over relevant documents in the case.  Apparently, the documents were so incriminating that Lycoming felt it was better to suffer a certain jury verdict than to allow the documents to see the light of day. 

[I]n December 2005, Lycoming participated in a series of emails discussing the leaking Delrin Float issue, none of which Lycoming produced during discovery. The series of emails informs Lycoming of the significance of the Delrin float leaking problem. In the emails, Lycoming employees state that it is clear that hollow plastic carb floats can leak, allowing fuel to enter the interior of the floats. The emails reflect that there was also a recent inflight [engine] stoppage. The email also recognized the danger of discussing the defects in writing: “It is too bad that we have to answer in writing on such a touchy issue.”

Plaintiffs asked Lycoming to turn over the rest of the emails on the subject, including those that went to upper managment.  The emails would have been important evidence that Lycoming knew the floats leaked and could cause engine failure. But Lycoming refused. So the court ordered Lycoming to turn them over. Lycoming still refused. 

Lycoming’s  willful and deliberate refusal to follow the court’s order prevented plaintiffs from proving their case. So the court did the only thing that was fair and ruled that the floats were defective and caused the accident.

The Judge’s order is an interesting read. 

Judge’s Sanctions Order Against Lycoming

This Robinson R44 crash was in Australia. 

Witnesses said that nearby restaurant staff “grabbed every fire extinguisher in the building, but there were too many flames . . . There was nothing anyone could do.”

No occupant of a properly-designed helicopter should be burned in an otherwise survivable impact. Unfortunately, the fuel tanks installed in all Robinson R44 helicopters manufactured before 2010 are not properly designed. 

On Friday, the ATSB (the Australian equivalent of the NTSB) confirmed that the accident helicopter was equipped with the all-aluminum fuel tanks, rather than the bladder-type tanks Sydney Robinson R44 Explodes on Impactnow available for retrofit.  The ATSB urged all R44 owners to get their tanks retrofitted after the February 4, 2012 R44 crash that killed noted Australian filmmakers Andrew Wight and Mike deGruy. But less than half of the 4000 Robinson Helicopters with the defective tanks have been fixed.

Passengers killed in this latest crash included a couple who were checking out their wedding venue.

Other low-impact R44 helicopter crashes that have resulted in fires since the new tanks have been made available:

 

The FAA allows Boeing to certify its own design work.  That means that, at least to some extent,  Boeing now regulates itself.  That never seemed like such a great idea to me.  Afte787 batteries - melted down (left) and undamaged (right)r all, isn’t it the FAA’s job to make an independent determination that an aircraft design is safe?  Does it make sense for the FAA to allow Boeing — or any manufacturer — to grant FAA certification to itself?

Now, the NTSB seems to agree.  In discussing whether the FAA’s "self-certification" policy played a role in Boeing’s 787 battery problems, NTSB Chair Deborah Hersman hinted that maybe the FAA isn’t doing its job:

This is an issue when you have a regulator with limited resources. . .You can delegate some of the action, but you can’t delegate responsibility.”

A regulator that allows a manufacturer to certify its own designs isn’t a regulator at all.  

The Jet Airliner Crash Data Evaluation Center (“JACDEC”) is an airline safety think-tank in Germany. Last week, it rated the safety records of 60 air carriers worldwide. It considered the number of crashes and fatalities each airline has experienced – regardless of cause – since 1983.  Its “time-weighted”China Airlines methodology placed the greatest emphasis on recent crashes. 

The safest airline: Finnair. The least safe: China Airlines.

Over the past few years, most fatal crashes have been attributable to foreign airlines. Nonetheless, under JACDEC’s methodology, the US carriers didn’t fare all that well.

United Airlines was ranked 31st, American 42nd, US Airways 44th, Alaska 45th, and SkyWest was ranked one of the ten worst at 51st. Worse even than Aeroflot, the notoriously dangerous Russian airline.

The entire list is here. The translations for the German column headings is here.

An Fixed-Base Operator will sometimes tell the pilot to whom it rents an aircraft that, in the event of an accident, the pilot may be held responsible for the FBO’s deductible.  From that, pilots sometimes conclude that their liability will be limited to the amount of the deductible, and that everything else is "covered."

Not so.  Not only can the FBO pursue the pilot for the deductible, but the FBO’s insurance company can (and often does) pursue the pilot for the full amount it pays to the FBO for the damage to the aircraft.  In other words, the renter pilot can be held responsible for the entire loss.

But more importantly, the FBO’s policy doesn’t necessarily cover the renter pilot for any injury or death he may cause to others. That was the recent holding in Knezovich v. Hallmark Insurance, an Illinois case arising from a fatal midair collision between a Cirrus and a Cessna in Wyoming. The families of those killed in the Cirrus sued the estate of Cessna pilot, claiming the Cessna pilot caused the crash. The court ruled that the FBO’s insurance policy didn’t protect the pilot at all (or, more accurately, his estate) and that the insurance company didn’t even have to hire the renter pilot’s estate a lawyer to defend against the wrongful death lawsuit brought against it.  In short, the estate was on its own.

Aviation lawyer Greg Reigel sums it up:

Although this is an unfortunate situation for the deceased pilot’s estate, this case serves as a reminder to anyone who rents aircraft to confirm that insurance coverage is in place that will protect the renter. It isn’t enough to simply ask the FBO or aircraft owner whether they have insurance. You need to be sure that coverage is in place to protect you, the person renting the aircraft. If the aircraft owner’s or FBO’s insurance doesn’t provide coverage, you need to know that so you can understand your risk and either obtain coverage elsewhere or go without.

Of course, not only was the situation unfortunate for the estate of the Cessna pilot, but it was unfortunate for the families of the others killed in the accident.  Even assuming that they prove the crash was caused entirely by the Cessna pilot, unlike the FBO, its unlikely they will ever be fully compensated.

The plaintiffs’ attorney in the Lidle case told the press that, once the judge ruled that certain key evidence would be kept out of trial, a defense verdict was a foregone conclusion.

The plaintiffs wanted to tell the jury about an incident where, according to a Cirrus flight instructor, a Cirrus’ controls locked up in flight without warning in March 2006. That evidence, according to the plaintiffs’ attorney, would tend to prove that there was a problem with the Cirrus flight control system, just as plaintiffs had alleged. And typically such evidence of “other similar incidents” is exactly what persuades a jury that a product is indeed defective.  But the trial judge kept that evidence out of trial. In an opinion issued earlier today, the federal court of appeals for the second circuit ruled that the judge’s decision was within her discretion — in other words, it wasn’t wrong.

Plaintiffs argue that the district court erred by excluding evidence of a March 2006 incident involving another Cirrus Model SR20 G2 aircraft (the "Doremire Incident") to prove [Cirrus’] negligence and notice of a defective condition.

Evidence of prior accidents may be admitted at trial only if the proponent "establish[es] their relevance by showing that they occurred under the same or substantially similar circumstances as the accident at issue." Whether a prior accident occurred under "substantially similar" conditions necessarily "depends upon the underlying theory of the case, and is defined by the particular defect at issue."

The [trial judge] . . .concluded that the Doremire Incident did not occur under substantially similar circumstances because plaintiffs had not "provide[d] evidence that the Doremire incident involved [a rudder-aileron interconnect] lockup where the Adel clamp crossed over and locked on a bungee clamp."

 . . .  We see no abuse of discretion here. Accordingly, we affirm the [trial judge’s] ruling.

Plaintiffs also wanted to tell the jury about an Airworthiness Directive the FAA issued after the Lidle crash concerning the Cirrus’ rudder-aileron interconnect, again to prove that the design of the aircraft’s control system was defective. The judge kept that from the jury too. Again, the court of appeals ruled that the decision was within the trial judge’s discretion.

Federal Rule of Evidence 407 generally prohibits a plaintiff from introducing evidence of [a manufacturer’s] subsequent remedial measures "that would have made an earlier injury or harm less likely to occur" to prove the defendant’s "negligence; culpable conduct; a defect in a product or its design; or a need for a warning or instruction. Nevertheless, evidence of such measures may be introduced for other purposes, such as impeachment or — if disputed — to prove ownership, control, or the feasibility of precautionary measures. 

Plaintiffs argue that the district court erred by excluding. .  .a March 2008 . . . Airworthiness Directive mandating certain adjustments to the rudder-aileron interconnect on all Cirrus aircraft . . .Plaintiffs contend that Rule 407 does not apply to the Airworthiness Directive because it is a subsequent remedial measure taken by the government, not by Cirrus.

The . . . Airworthiness Directive incorporated by reference a 2007 Service Bulletin issued by Cirrus, which the [trial judge] excluded as a subsequent remedial measure and which exclusion plaintiffs do not challenge on review.  The [trial judge] concluded that allowing plaintiffs to introduce the Airworthiness Directive would function as a "back door" to introducing evidence of Cirrus’s own subsequent remedial measure, which was squarely prohibited by Rule 407. Further, the [trial judge] explained that "in the circumstances of this case where the [Airworthiness Directive] was issued as a direct response to [Cirrus’ Service] Bulletin, it is covered by Rule 407. . . because to determine otherwise might discourage manufacturers from issuing service bulletins as part of voluntary compliance procedures.

The second circuit’s ruling finally brings the Lidle case to a close.

(All citations omitted, full opinion here.)

American Airlines Flight 587 encountered wake turbulence. The pilot countered with rudder inputs. The rudder inputs were excessive, the tail assembly failed, and the aircraft crashed, killing 265 people.

The NTSB determined that the Airbus’ rudder controls are unduly sensitive and make it easy for a pilot to overstress the aircraft’s structure, causing a catastrophic failure.  Now, eleven years after that crash,the FAA has issued an Airworthiness Directive against the A300 Airbus to remedy what it considers to be a problem with the aircraft’s design. 

Originally, the FAA was going to require that all the A300’s be modified to limit the rudder pedals’ travel.  The FAA felt that such a modification would make it much more difficult for a pilot to overstress the aircraft. That modification would have cost about $200,000 per aircraft. But Airbus convinced the FAA to allow a cheaper fix.  So for about half of that cost, the FAA will allow the A300’s simply to be equipped with a warning light on the glareshield directly in front of each pilot and an associated "stop rudder inputs" aural warning.

A Warning is a Last Resort

Any engineer will tell you that when a hazard is discovered, the best option is to design out the hazard. If that can’t be done, then the hazard should be guarded against. If that isn’t feasible, the last resort is to warn against the hazard. That’s what’s known as the engineer’s “Safety Hierarchy.”

Here, there was a feasible way to change the design to eliminate the hazard – limit the travel Stress Performance Curveof the rudder pedals. Thus, a warning is the wrong way to go.

A Warning Is Not Always Appropriate.

Warnings work well in some situations. A warning system that alerts a pilot to low fuel is great. A warning system that alerts the pilot that some system is overheating is also useful. But warning systems that activate in emergency situations are often useless.

The problem is that under stressful situations, a pilot’s performance can degrade rapidly. The pilot is unable to comprehend a warning’s meaning in an emergency and respond appropriately. That’s what the BEA (Europe’s NTSB) concluded happened to Air France Flight  447. Confronted with an emergency, the crew could not comprehend and react to the Airbus’ aural warnings. As summed up by Paul Marks:

Despite a stall warning sounding continually, it was ignored and the pilot kept the plane’s nose pointing upward – while the plane was in fact plummeting toward the ocean. All the crew needed to do was push the nose down to regain lift – but they didn’t.

In the first minute after the autopilot disconnection, the failure of the attempt to understand the situation and the disruption of crew cooperation had a multiplying effect, inducing total loss of cognitive control of the situation," the BEA says.

The combination of the [Airbus] warning system ergonomics, and the conditions under which [Air France] pilots are trained and exposed to stalls during their professional and recurrent training, did not result in reasonably reliable expected behaviour patterns," the BEA adds with massive understatement.

Stress Performance Curve

Why would a trained crew essentially ignore the aircraft’s warning systems in an emergency? A little stress helps people focus, and they tend to perform better.  But after a point, stress makes it difficult, if not impossible, to think.  A Vietnam fighter pilot used to tell me: “The first thing that happens in an emergency is your IQ gauge goes to zero.” 

The Airbus’ rudder pedals can be feasibly redesigned to eliminate the hazard. That makes a warning system the wrong solution.