Colgan 3407, Feb 2009, Buffalo: Is "Safety Delayed" in reality "Safety Denied"?:Why is the FAA so Slow to do its own Work?

The Buffalo Feb, 2009, Colgan Air mishap killing more than 50 people occurred nearly 3 years ago. In the past few days the FAA has come out with a proposed document that will address commercial pilots, flying and stall prevention. Hmmmmmmmm...

I seem to recall that stall recovery training occurred during my first few flights in a C-150 as a student to get my private pilot license, "a way back when."

What is the news? Why have almost three years gone by before this recommendation is being proposed? How long will the "comment period" be on this proposed recommendation? Did the mishap investigation somehow reveal something that we didn't already know? When did the FAA find out that Colgan may have been operating revenue passenger flights with flight crew members not sufficently trained in stall prevention, recognition and recovery procedures?

In the nearly three years since the mishap and in the next few years as the FAA goes through this excruciatingly slow legal, lawyer-based process to address what is in fact a SAFETY OF FLIGHT issue and not a legal issue, how many more revenue paying passengers will be subject to airlines operating with flight crew members not sufficiently trained in stall prevention, recognition and recovery procedures?

Is this senseless "lawyer-led" FAA process really just SAFETY DENIED? So, I ask the question on behalf of the traveling public, "Is not safety delayed really safety denied?" As readers of this blog, what do you think?

In my humble opinion and curiosity, I ask, "Should not the agency that leads, governs and regulates commercial aviation be led by someone trained and experienced in commercial aviation?"

It is wonderful that the agency has so many lawyers who went to law school and can handle all sorts of legal issues for this federal agency. I applaud their hard work and expertise in their field.

But, having acknowledged that, any commercial pilot knows that stall prevention, recognition and recovery procedures are part of the very basics of private pilot training, qualification and licensing leading to FAA CERTIFICATION. So now three years hence this senseless fatal commercial scheduled passenger US aviation disaster, why is the Federal Aviation Admin going in this direction? Did not Colgan have an FAA Principle Operations Inspector (POI) whose sole job was to ensure this?

So, I would ask who ever is leading the FAA at this time, do you think that the FAA should need a fatal commercial aviation mishap disaster of the first order in order to make a proposed recommendation that all commercial pilots be trained, qualified, licensed and certified in stall prevention, recognition and recovery procedures?

In my opinion, this aerodynamics lesson is something learned in the first few days of flight school and my guess is that it is not even in the syllabus of of any law school. (I haven't really checked and done the syllabus research on this claim, so please forgive this error if it is not true and in fact stall training is covered in law school.)

Again, just my humble opinion.

But again I would offer that perhaps with an experienced trained, qualified, licensed and certificated commercial line pilot in the leadership role of the FAA, this process would move along a little faster.






See reference of WSJ article by ANDY PASZTOR, from U.S. NEWS
DECEMBER 14, 2011, 4:35 P.M. ET

"The Wall Street Journal
FAA Proposal Targets Stall Recovery After Deadly Crash
Federal aviation regulators released draft recommendations detailing measures to prevent airline pilots from flying aircraft too slowly and risking the onset of dangerous aerodynamic stalls, such as the one that caused a much-publicized 2009 crash near Buffalo, N.Y., that claimed 50 lives."

Welcome to my readers from across the globe

If you are a safety manager for a commercial airline, I want to extend a welcome to you. I want to offer my ideas to you to help you make your own airline safer. I know that being a Safety Manager is a very hard job. You either have the choice of doing very little and waiting until a mishap (accident) happens and then you have 2-3 years of mishap investigating to do.

OR

You can work very hard long hours to prevent mishaps from occurring in the first place.

In either case, you will work very hard. The big difference?

In the case of prevention, you will enjoy the holidays with your family, your company will be profitable and all of the employees will enjoy happy careers.

In the case of mishap investigation, you will work so very hard and in the end, realize that all of this pain, suffering, damage and all this waste could have been and should have been prevented and you will have a stack of photographs, a larger stack of papers, a huge smoking hole and a lifetime of regret.

Please follow my blog so that I can give you some ideas on how to be a successful Safety Manager.

If you are an industry analyst or other gatherer of other people's work and writing, welcome as well. Feel free to correspond with me via my web site and email address below.

All my best regards, Paul Miller

If you would like to send me an email to ask a question or clarify the English language part of all of this, please do.

http://paulmiller@safetyforecast.com and I will answer you individually.

Mishap Prevention Theory

It is critical to understand the terms risk and hazard.

A hazard is a something that causes danger such as an incomplete or outdated procedure, an object such as a equipment, a malfunction or a human factor. The hazard is real, it is perceivable and most of all discoverable BEFORE any mishap, accident or incident occurs.

This is a CRITICAL part of safety theory. A Hazard is a real thing and certain people with a good safety eye can see it ahead of any accident. Some do not, but many do and can report that hazard to the safety manager, who if he or she is smart enough, can take steps to eliminate that hazard.

Why is it important to eliminate hazards?????

Safety theory says that mishaps, accident and incidents are the result of unresolved hazards. That is the sole purpose of safety investigations: identify the hazard and eliminate them.

But if you seek mishap free operations, then you have to go seek out hazards and eliminate them ahead of time. If you do that, you will enjoy mishap free operations.

A risk is defined as a product of two factors. First factor is the likelihood of the event occurring on a sliding scale from zero to 100. Think of this as a per cent of probability which could be measured from a low of very unlikely, at or near zero per cent, then all the way up to very likely, that is at or near 100%.
The second factor is the severity of the event if it occurs. This means if the hazard does occur, what are the consequences? How badly will a plane be destroyed if it crashes, how seriously will a person be injured or will they die, how severely will equipment be damaged or destroyed? You could assign a numerical value to severity as well on a sliding scale of zero to 100 percentage, meaning that none, some or all of the aircraft, person, property or equipment is damaged, injured, destroyed or killed.

When you multiply the two factors of probability per cent and severity per centage together, the product becomes RISK, which is a real number. Risk is a product of two factors, meaning that each is factor is multiplied together to form a number. As when multiplying any two numbers between zero and 100 together, the product increases rapidly and in a hyperbolic fashion.

So I have written a mathematical formula to describe this and it is called, MILLER'S FORMULA FOR RISK. RIsk is labled Z, Probability is labeled X and Severity is labeled Y. When you multiply probability by severity you come up with risk. So the formula looks like this Z=XY. Plotting this function gives you a three dimensional display of the full range of risks. Factor in several more factors such as time and resources devoted to mishap investigations, called factor N and take into account some level of periodicity by looking at the trigonometric sine function and MILLER'S FORMULA FOR RISK becomes Z= sine |X| N(Y). Miller's Formula uses the absolute value of X or |X| to denote that for these particular safety theory purposes interest is located on the positive section of the saddle curve of Z=XY. This means that MILLER'S FORMULA FOR RISK considers probability from 0 to +100% and severity from none to total or 0 to +100.

[Mathematically, there are three more sections of the curve, but logically for now, the other three segments of the hyperbolic curve are not considered. We will explore some of these segments at a later date, as well as explore the N factor of additional availabilities in upcoming posts.]

There is more in my paper published in the Flight Safety Foundation Proceedings of the 2003 Corporate Aviation Safety Seminar, entitled "Forecasting Hazards and Charting a Safe Course: How to Plan Changes in Flight Safety Programs to Meet Future Safety Issues, Decisions and Attitudes, and Keep Your Business Profitable!" copyrighted 2003.

If you have any problem getting a copy or a copy of the accompanying Powerpoint or would like me to come to your organization to speak more on this subject, contact me by Paulmiller@safetyforecast.com.

See other safety discussions on my web site: http://safetyforecast.com

Be safe. Remember that $afetyPay$
Thank you for reading my blog. Paul Miller

Yak 42 Sept 2011 Mishap, Hockey Team Lost

It is the experience of the commercial aviation industry about which I speak.
Airline operations today should be safe so that mishaps are a rarity, when in fact, not only do we see commercial aviation mishaps continuing unabated, but we see mishaps that are 100% preventable. I wonder if we have any mishap prevention included in the safety policy of many airlines? Sure, it is necessary to spend millions doing investigations, but how much do we spend in mishap prevention?
Safety is being absurdly left behind in many investigations for the purpose of blaming a party and seeking damages.
The concept of prevention today is about as foreign to many managers as east is from west. And yet, when a mishap occurs, there are expressions of incredulity that belie the understanding of hundreds of years of tort law.
BEA's investigation of AF 447 is an example of that, but I digress.
Can you name me one fact or idea in the September Yak 42 mishap investigation report that was either not already known or should have been known ahead of time?
Pilots should be trained in the aircraft that they are flying? What? We didn't already know that? Managers should keep correct records and maintain certified training? What? Is that a new idea? Customers should be protected by a layer of aviation safety regulatory bureaucracy? What, is that something new?

What occurred, that was not already known to be a problem, prior to starting engines? How can we move forward as a commercial industry, when so many want to move backwards?

Is this the Unregulated Three Step Dance, one step forward, two steps back?

new blog

See my blog and web site now at http://safetyforecast.com

More Questions Asked by Flight Crew Members Regarding AF 447

More questions have been raised by fellow safety minded pilots regarding AF Flight 447. Here are several:
1. Why were they flying through that nasty weather?
2. Why did the captain leave the cockpit just prior to the flight's arrival to this area?
With respect to the questions asked, here is my take.
1. The captain had at least a 2 hour old satellite pix by the time he started engines. The thunderstorm encounter occurred somewhere after about the 2nd or third hour of flight, meaning that the flight entered the thunderstorm area about four to five hours minimum after the sat shot was taken. This means that it is very possible that the sat pix that the captain received did not resemble the convective weather area that the flight eventually encountered. This is assuming of course that the crew got a satellite pix at all out of Rio. This is a very common problem for all airlines operating oceanic flights. Flight Control is not required to resend the latest satellite shots to the crew during the flight. Why is that???
A. Let's say that the captain was a cautious fellow and planned well. So he gets up a few hours before the hotel pickup, has a shower, checks his email, gets packed, dressed and meets the crew in the lobby. At the airport or maybe even at the hotel, he sees the sat shot prepared and sent by AF Flight Control Dispatch Offices.
I have not seen a satellite pix or a weather observation from the time from 4-5 hours before the mishap, but if I was investigating this incident, that is the first place that I would look. Why? Well that is the information that will inform the captain as to what lies ahead of him and will inform his game plan, sleep strategy, crew switch strategy for the flight. So my money is on a sat shot that shows widely scattered storms if any at all. He doesn't see a threat at this time and doesn't see any reason not to use his normal strategy of getting the oceanic clearance, getting the plane out onto the tracks and then retiring to get some rest and let the other crew members handle the routine of the crossing. This will allow him to get some sleep and be fresh when they get close to Europe and have to start their let down at CDG for landing. Maybe this is his normal routine.
B. Alternative scenario: The captain is a "show me" kind of guy- unless he sees the lightning flashes and is face to face with a thunderstorm, he doesn't worry about the metro stuff, because it is all 4-5 hours old data by the time they get out onto the tracks for crossing.
Either way, I do not think that the captain foresaw the 60,000 ft+ tropical convergence storms in his path as a real possibility.
Additionally, thunderstorms anywhere rise rapidly in height, developing at 2000-4000 feet per minute, even as much as 6000 feet per minute. Therefore, information such as “the previous flight got through this path” is not valid information for following flights, especially flights following by 10 to 15 minutes later. The fact that another flight transited this area 10-15 minutes prior is certainly and in my opinion most definitely not an endorsement for safe flight. Thunderstorms by their very nature are unstable. That is what makes them so dangerous to flight. Thunderstorms violate the very first principle of aerodynamics, which says, "assume a homogeneous airmass." For sure a thunderstorm is not a homogeneous airmass!
Thunderstorm development in the inter-tropical convergence zone (ITCZ) is even more dynamic than at other places on the globe, meaning that even more caution needs to be exercised in the ITCZ by commercial airline operations. This mishap occurred on a flight planned and operated regularly in the ITCZ.
C. Third scenario is this. This is the kind of fellow that does his own thing. He does the takeoff, then he does his nap, then he does his arrival. This is the way that he does things and this is his thing. This is how he does every oceanic flight and he figures the other crew can handle things. That is just the way he is.
D. Fourth possible scenario: The Air France Dispatch Office in CDG does not consider it their responsibility to update Air France flights with Air France passengers on board of dangerous weather that has developed and is now in the path of an Air France flight. They consider it their responsibility to get the preflight paper work prepared and delivered and then do no further duties other than to stay awake and answer any questions that come up during the flight.

My guess is that AF Dispatch Flight Control Standard Operating Procedure SOP is not to initiate any inflight communications unless directed to do so by "higher authority" or some similar version of that idea. The second place that I would look were I doing the BEA investigation would be the AF Flight Control Log for AF 447, the AF Flight Control SOP and all of the metro data that was available to AF Flight Control before the mishap.

I would further examine just exactly how AF Flight Control does business every day and night with respect to how much info is passed to airborne flights concerning dangerous weather occurring ahead of any AF flight.

Sorry to say this but more than a few commercial flight crew members are like B and C. I am even more sorry to say that more often than not, many flight control offices are like D. They send company flights on flight paths that intersect dangerous weather and do not change plans along the way. My guess is that this most likely remains "the way things are" at many airlines. How about yours?

So that is some thoughts on question one. But if you are a good captain and a good communicator, my guess is that you also have a few ideas and I would be very interested in hearing from you and reading your thoughts on this same question.

Now for question two, here is what I think. I do not think that the captain was fully aware of what was ahead of him. I also do not think that the captain expected a failure on the pitot static system due to icing to occur if the flight did go into clouds.

Remember that the pitot static equipment manufacturer, France's CAA, Airbus and AF all denied that the equipment was faulty, even though there had be several incidents of failure previously of this same equipment in this same scenario and that it had been reported in the industry press.

So that captain may have allowed himself to be informed by the "authorities" in lieu of informing himself through reading industry incident reports.
Again, there are plenty of crew members who allow themselves to be informed this same way, at airlines all over the world, pilots who do the same thing.

Those of us who doubt "authority" are few.probably less than 1/3 of all. My guess is that real doubters are even fewer than 1/3, more like 1/10!

So, here is a third question: Why didn't the captain jump back into his seat and take control as soon as he arrived back up front? I know that I would have. You? Sure things were confusing, alarms going off, icing, thunderstorms, panic-what better time for the captain to be in charge of the flight deck and the controls?


I hope that this mishap is eventually re-investigated by some board other than the BEA, a board that knows that they are doing a Safety Investigation and not a Legal Investigation for some future court proceedings..

In the meantime, I am blogging my thoughts to allow local safety managers around the world to think deeper about keeping their operation safe. That is my intent.

Keep in touch.

AF 447: Are any Airbus Airliners Certified to Operate in 60,000 ft Thunderstorms?

Are any Airbus airliners certified to operate in 60,000 ft thunderstorms? If so, where is that test data available?

If not, why was Air France operating Airbus aircraft inside 60,000 ft thunderstorms as in the case of AF 447?

Was this question addressed by BEA? If not, why not?

AF 447 Investigation Missed Many Important Facts

The key to success in any investigation, in my opinion, is to be right, to be correct with your analysis of the facts and testimonies collected. You have to be correct and logical with your conclusions and you have to make recommendations, recommended corrective actions based solely on the conclusions. I would say that somewhere between 90-95% of the time that accident boards get the form of the investigation incorrect. They list conclusions without logically supported analysis, they come up with recommendations out of the clear blue sky with no support from the conclusions and they do not even collect all of the facts.
Case in point?
Take BEA's investigation of AF447. I have not read a single fact, analysis or conclusion so far that leads me to believe that BEA considered the role of AF Dispatch Office in the mishap.

However, consider this important information: it was AF Dispatch Office that had all of the latest metro satellite data at their disposal. That data showed massive thunderstorms in the flight path of AF447, thunderstorms rising to altitudes well above the Airbus operating ceiling. While AF Dispatch had this data, they did not connect having this data and their responsibility to minimize the safety risk to the Air France passengers onboard AF447, nor the crew nor their own asset, that is the aircraft. Air France Dispatch took no action to warn AF447 even though it was their specific regulatory requirement to do so since AF is a scheduled airline and AF447 was a dispatched flight.

If for an aeronautical experiment, a test crew were to be sent with any current airliner into a 60,000+ foot thunderstorm at night, I doubt any aircraft or test crew would escape the encounter unscathed.

In fact Airbus is not required to send any of their passenger aircraft into 60,000 foot thunderstorm in order to be certified by the FAA or any other airframe regulatory body.
Plus consider the idea that passenger injuries are likely to be sustained even if the airframe makes it out the other side of a 60,000 foot storm in one piece. Plus few passengers will speak well of the flight experience if they manage to live through being inside a 60,000+ ft thunderstorm. Many will vow to never fly again and of those, many will never fly again.

In my opinion, political pressure on an investigation is not really so much an issue as is the poorly handled investigation, collection of the facts, poor analysis, poor conclusions and poor tie in of recommendations. Political and party pressures are a fact of life. They are afraid, under stress, and will do anything to survive. But the truth can not be hidden. If it is not found, the board wasn't looking hard enough.

AF 447 missed facts

The key to success in any of these investigations, in my opinion, is to be right, to be correct with your analysis of the facts and testimonies collected. You have to be correct and logical with your conclusions and you have to make recommendations, recommended corrective actions based solely on the conclusions. I would say that somewhere between 90-95% of the time that accident boards get the form of the investigation incorrect. They list conclusions without logically supported analysis, they come up with recommendations out of the clear blue sky with no support from the conclusions and they do not even collect all of the facts.
Case in point?
Take BEA's investigation of AF447. I have not read a single fact, analysis or conclusion so far that leads me to believe that BEA considered the role of AF Dispatch Office in the mishap. It was AF Dispatch Office that had all of the latest and current metro satellite data that showed massive thunderstorms in the flight path of AF447, rising to altitudes well above the Airbus operating ceiling. Even while AF Dispatch had this data, they took no action to warn AF447 even though it was their specific requirement to do so since AF is a scheduled airline and AF447 was a dispatched flight.

Send any current airliner into a 60,000+ foot thunderstorm at night and I doubt any will escape the encounter unscathed. Plus passenger injuries are sure to be sustained even if the airframe makes it out the other side.

So, in my mind, political pressure is not really so much an issue as is the poorly handled investigation, collection of the facts, poor analysis, poor conclusions and poor tie in of recommendations.

Human Error and Training

I certainly can see why airlines with good safety records have vigorous training programs, and in many if not in most cases of mishaps, if not in all cases, human error should be found as the cause of the mishap. Let's examine the AF Toronto mishap. Human Error: crew continued approach and landing during adverse wind field encounter. Crew did not brief a runway that had failed to have been grooved by the national airport authority contractor, presuming dry runway - like stopping performance.
I would bet dollars to donuts that the Toronto AF flight crew training program DID NOT include a segment of approach briefing covering whether or not the runway was grooved, porous friction coated or not grooved. [by the way this information is on the 10-9A page]. And yet wet runway stopping and control performance degradation is a commonly known hazard. Yet look at the investigation and you will see virtually all the blame heaped upon the flight crew, with little or no mention of this severe training deficiency. Also if the crew was trained and certified upon dispatch by AF and French CAA, why did they continue their approach to land into an adverse wind field generated by convective weather occurring in the approach corridor? Were they acting in accordance to the procedures for which they had been trained and qualified? Yet no where in the investigation do you see any questions raised about AF convective weather avoidance procedure training and why is that?

For a safety investigation to have any merit, it must identify what went wrong and what steps can be taken that will prevent the mishap from recurring. Why do so many airlines have their pilots "practice to proficiency" the windshear go around procedure, auto and manual?
Why do so many airlines require their flight crew, by procedure to brief whether or not the landing runway is grooved or not? How could any airline operating be oblivious to the notes on 10-9A about grooving? How could any airline not make this information an element of the approach runway briefing?

How could the Canadian national airport authority contractor make a decision to not groove their main instrument runway in their biggest city, or any runway in the country for that matter, and ICAO and not one other global safety authority object? How is it that ATSB could complete their investigation and not cover these subject areas? Is it possible that the humans on the ATSB made an error? Of what use is their report? What steps did they recommend to prevent the re-occurrence of this same mishap?

Is it possible, just possible, that what the ATSB really did was conduct a legal and administrative investigation where they found fault and laid blame for the damage and injury, but never really found the cause and recommended the actions to prevent a re-occurrence?

Lastly, the purpose of training is to put a crew together, working as a team, using standard operating procedures, designed to give crew members a pretty comprehensive set of well practiced actions to deal with whatever is expected to be encountered. The argument that no one can not make no mistakes is irrelevant. When you look at any and all of the major airline mishaps, the crew made massive errors, the crew did not trap the error and correct each other (two heads are better than one theory of CRM.)

I am not arguing the academic argument of purity from error. Rather I am arguing the very practical argument that a crew well trained in well written procedures will be able to handle just about anything that it encounters.

In the mishap reports that I have read, not only did one crew member make an error, but moreover other crew members did little or nothing to trap and correct the procedures in use. Take the Amsterdam B737-800 mishap where the crew allowed the aircraft to stop in the air and fall out of the sky. What kind of procedures were those? Where was the training to proficiency program for that airline?

Flawed Investigations?

I cite a flawed investigation as the cause for re-occurrence because in aviation you have one chance to get it right. If you connect coincidental events together but then label them as "causation" you will fool all the people some of the time. An example is placing pilot error as the cause, when in reality when the pilot reported for work, was assigned the flight and climbed into the seat, he/she was "fully qualified" according to the FAA, the company and any other regulator. If that pilot made a pilot error as gross as stalling the aircraft on final and not recovering, the pilot, a product of the company and FAA training and qualification program to me, appears to be untrained and unqualified in this area. Since most would consider this area of flight procedures to be a skill critical to safe flight it would appear to me that the training and qualification program was deficient. Failing to correct the training and qualification program in my mind would be an example of a flawed investigation, wherein I would expect a same or similar mishap to occur at some time in the future at that airline, or to similarly trained and qualified airmen.

If you miss this opportunity to get the investigation right, then you can pretty much expect that the next pilot, similarly trained and qualified, facing similar circumstances to make the same mistakes. The purpose of the investigation is to find these flaws and recommend training to overcome this skill deficiency.
Look at how we all do windshear recovery training to proficiency now. Too bad the pilots at Kenner, Kennedy, DFW, Charlotte and other places did not have that training. We are lucky that we had Dr. Fujita and the training that resulted from his models and those of NCAR in the 1980's.

Why is Jailing Pilots a surprise?

Does not the person in charge of any vessel or organization bear some legal responsibility? If so, why would anyone be surprised to see a pilot jailed following an accident? Are we really just seeing the terribly weak legal profession just beginning to realize how much work has gone undone in the past 70 years?

If in an accident, lives are lost and property is destroyed, why wouldn't victims, survivors and claimants seek some form of compensation?

Is it really the accident investigation profession which has been dropping the ball all these years? Has ICAO really taken all the action that it could to actually promote safety and promote learning from investigations?
Or has the case really been made year after year that it is the pilots who made the errors and that is all the blame that we need to know about?

So finally everyone is reading these atrociously poorly prepared and written accident reports and noting what was written so often.

For years airlines, the FAA and NTSB has been laying all blame on pilots, often those deceased in the mishap, and directing attention away from ATC, manufacturers, the weather guessers, airport operators, and everyone else. So here we are in 2011, surprised and complaining.

And yet even as we write this blog, the BEA has issued a scathing reproach of the AF447 pilots who could not decipher the cryptic puzzle presented before them, struggled to save their own lives for several minutes before perishing. No where in the report is any mention made of the responsibility of the dispatch office to advise of foul weather, of the manufacturer to sell good equipment, of the airline to verify that the equipment works, of ICAO and other agencies to keep updating all technology for the benefit of the flight crew. A passenger sitting in row 24 on that airbus could have accessed the internet and obtained the most up to the minute satellite pix, but the flight crew had on board pix probably over 4 hours old.
How fantastically ridiculously inaccurate weather data process could anyone ever invent? Make a copy of the last sat shot an hour before brief time, have it ready for the crew who show up an hour and a half before take off and give them one hour old data. By the time they take the runway, the data is 2 1/2 hours old. At three hours into the flight the data is 5 1/2 old.
But wait, isn't the entire life cycle of convective weather defined as a matter of minutes, may be an hour tops? Doesn't convective weather around the tropics often build at 4000 to 6000 feet per minute?
So how could 4-5 hour old weather ever be considered accurate or useful data for safety purposes? Wouldn't the airline and their dispatch office know this? Why would the official weather guessers not offer more accurate weather data, some form or method of updating that sat pix in flight to the flight crew????????????

Oh yes the passenger in 24E has the latest sat shot on his PC.

So I can easily see why ICAO and BEA and everyone else are so determined to blame the pilots and not give a seconds care about what might happen to passengers tomorrow who might be in similar jeopardy.

Do you not think that the same mishap cannot happen tomorrow, think harder. It can and it will.

AF447 Investigation Fails to Deter Future Mishaps

It is with great sadness that I note the issuance of BEA's recommendation for new data streaming requirements for all pax acft.
In other words, BEA is saying, "To help us reduce our costs in locating the next accident site, we would like all of you to stream your DFDR."

Well, that pretty much sums up what BEA expects- many more mishaps. This is a terribly failed approach to a Safety Investigation of such a serious nature.

Rather, BEA should be devoting themselves to ensuring that this mishap never happens again. Plain and simple.

AF 447: Proof of Incomplete, Possibly Incorrect Investigation?

What is the purpose of a Safety Investigation of an aviation disaster?

The answer is simple and singular: the purpose of a Safety Investigation is to determine what happened and what actions can be taken to ensure that the event does not reoccur?
This is the simple and singular purpose of a Safety Investigation of an aviation disaster.

Pilot associations and other line pilot advocates world wide have been asking the question, "Has the BEA's investigation of the AF 447 aviation disaster met the purpose of a Safety Investigation?"

Has the BEA's investigation asked and answered the question, "What happened and what actions can be taken to ensure that the event does not reoccur?"

It is the opinion of pilot associations and line pilot advocates that the BEA's investigation is incomplete in this regard and possibly incorrect as a result.

It appears that the question that BEA was asking and answering was, "Who was at fault and who is responsible for damages?"

Why is that important? Are the two statements of inquiry really just the different versions of the same question?

Well, actually no, not at all.

The question of "Who was at fault and who pays for the damages?" is not a safety question at all. Rather this is legal question. It addresses English Common Law negligence and compensation. The investigation does not seek to prevent further occurrences of the same event. Rather, it seeks damages for negligence.

Meanwhile the safety question, "How did this happen and what actions can be taken to ensure that the event does not reoccur?" actually does not appear to be addressed completely by BEA.

Why is this statement important? The answer is simple. Every other airline flying an aircraft manufactured by this manufacturer has been reading the BEA report over and over again. But have they found anything in the report that they can take action on to prevent this event from occurring to their operation?

If the answer is not totally and completely yes, then the investigation is incomplete and possibly incorrect.

Prevention by Investigation vs AF 447 Blame Game

If prevention of a mishap similar to the one being investigated is not the purpose of the safety mishap or incident investigation, then what is the purpose of the investigation?
If the purpose is to level blame, for one party to escape blame, to shift blame to someone else, to share blame with other parties, well then that investigation is a lawyers investigation, a damages investigation, an insurance investigation- but it is not a safety investigation. Remember that a safety investigation is purposefully tasked with determining the cause so that a prevention process can be developed to keep the event from reoccurring.
Where has the AF 447 investigation taken us in terms of prevention?
Is the investigation really living up to its purpose?

Is Your Safety Investigation Local?

The information gathered from a local investigation to determine 'what went wrong and how do we prevent it from recurring' needs to be local.

There is a tendency to defer investigations to higher authority, most likely because the local safety managers just do not have the equipment to analyze the DFDR and other technical records.

Yet the more that the investigation is centered locally, the more likely it is that the investigation will address the local safety issues involved with the mishap. Most often mishaps are the result of human error on the part of crew or others involved in operations or some other local element of the operation.

Yet hull and engine complete reconstruction often takes place at great expense but at no level of contribution to the prevention of future mishaps. Again the local investigators become intimidated by the metal smiths, but to what avail? How does all of that expense and effort profit us when the mistake was made elsewhere? Are some investigators really trying to conduct a belated administrative investigation of the air line operation in lieu of focusing all efforts on human error, the most common reason for aviation mishaps?

As a local safety investigator, it is most likely that the greater burden of determining what went wrong will fall eventually squarely on your shoulders.

This is why I believe strongly that all safety investigations contain a strong local component with a great focus on human error.

AF 447 again?

If no one at the AF Dispatch office is tasked with flight following, that is looking ahead of the flight path of a dispatched flight to see if any weather hazard is in the path of a dispatched AF flight and then tasked with coordinating a new and safer path diverting around the hazard, and coordinating that path with flight planning, metro, ATC and the crew, then I would expect a 100% probability that this mishap will occur again, at AF and at every other airline that fails to complete the tasking required to ensure safety of its flights and its embarked passengers.

The subsequent spending of tens of millions of dollars investigating any such mishap, will in the end not change the disastrous outcome, and in that sense will be money not spent to promote safety, but only rather to satisfy subsequent law suits. Remember, that is a legal function, not a safety function.

Safety's goal is to PREVENT THE MISHAP FROM OCCURRING IN THE FIRST PLACE, FROM OCCURRING AT ALL.

The job of lawyers is to just pick up the broken pieces and dead bodies and sit around with a pile of money and dole it out to whom they determine is the victim. How does that bring back the dead? How does that make anyone whole? Where is the prevention of loss in all of that?

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Who Was at Fault & Who Pays versus How Did This Happen & How Can We Prevent a Recurrance

1. If you are investigating an aviation mishap and asking the question, "Who was at fault and who pays," then you are doing a legal investigation.

2. If you are investigating an aviation mishap and asking the questions, "How did this happen and how can we prevent a recurrence?" then you are doing a safety investigation.

3. In either case, what is written on the door of your office, the door of your truck or car, the name tag you wear or the title of your agency is not as relevant as which question begins your investigation.

4. If the title of your agency says mishap investigation, but the purpose of your investigation is fault finding, the safety purpose remains unfulfilled.

Why Did 44 Die in Russian TU 134 crash near Petrozavodsk

Again, why? Fog does not cause a plane to crash. If a plane is in fog and not able to descend to the runway, the procedure is for the crew to execute a missed approach and try another approach, hold for the weather to improve or divert to an alternate field nearby with better weather.

Sounds like this crew was quite a distance away from the field when they hit the ground. Nothing here in this report makes any sense. Did the crew try to get below the overcast and strike an obstacle? Did the crew miss-set the altimeter and go too low inadvertently? Did the crew set in the incorrect navigation radios and wind up somewhere other than their planned approach route?

There are so many questions that should be asked immediately but to wait 1-2 years to hear the answers seems to most people a very long time and somewhat counter intuitive for a safety investigation.

AF 447: Basic Instrument Training

The second issue seems to be flight crew training when in heavy turbulence and when the pitot-static system is not operating.
Basic Instrument flying procedures in convective turbulence recommend a shift of instrument scan to attitude instruments and a disregard for pitot-static instruments, such as airspeed, vsi and altimeter. The procedure is to keep the wings level and the nose level with the attitude instruments. As the acft bounces along through the area of heavy turbulence and as the pitot-static system is affected by rain, ice and the pressure variations encountered in heavy turbulence, scan on the attitude instruments allows the crew to keep the acft straight and level.

Also, the power is monitored so that it remains at cruise power settings, neither more nor less and this keeps the airspeed relatively constant.

The crew should have slowed the acft to turbulent penetration airspeed prior to penetrating an area of turbulence or upon penetration. This speed allows the wings to accept g loadings due to turbulence but not be moving fast enough to over stress the wing g limits.

I wonder if in fact AF training covered these areas and if they allowed flight crew to practice all of these procedures?

Getting into heavy turbulence is to be avoided, but knowing these procedures is critical to survival in the event that convective weather is encountered.

Other procedures include all of the various heaters and engine ignition circuits should be placed on.

Using automation in these circumstances is not a good idea because the programming for automation usually involves smooth air and one g flight.

Could reliance on automation in these circumstances indicate a weakness in training proficiency on the part of this airline and this crew? Is this the second issue for AF, AB, BEA and all other airlines following this investigation?

AF 447 Investigation Flawed itself?

1. Air France Flight Control Dispatcher in Paris should have been monitoring AF 447. Flight Control should have been monitoring all hazards impacting the flight such as severe convective weather and rerouted AF 447 around the hazard.

A. Scheduled passenger airlines that operate under both US and European regulations control all flight operations from a central office known as "Flight Control" or "Dispatch." Despite the name "dispatch," (meaning to send out or send off) the office uses the radio and data call sign of "Flight Control." By US and European aviation regulations Flight Control must be in continuous communications and control of all dispatched flights. By US and European aviation regulations Flight Control is legally in control of the flight from before engine start and taxi out until the flight parks in its final parking spot at the completion of the flight. This is known as "block to block."

B. Flight Control plans the flight route prior to flight and files this flight plan with international aeronautical agencies that control the airspace through which the flight is planned to proceed. The agency determines the actual flight route and provides this authorization to Flight Control and the flight crew just prior to the flight departing its origin. During the flight, when entering oceanic airspace, this agency is coordinated through agreements between international civil aviation organization member states (ICAO) and is handled through radio calls in a non-radar environment.

C. Flight crew members, especially the captain, must be authorized to move the flight by Flight Control and must remain in constant communications with Flight Control during the flight, by regulation. This regulation is in place so that Flight Control is able to pass along information materially and directly affecting the flight, such as weather enroute and at destination and remain in control of the flight for all sorts of reasons affecting international authorizations for airspace entrance and transit.

2. No modern jet passenger transport aircraft in service then or today are certified to penetrate and fly into severe thunderstorms with tops above 50,000 feet, such as those in the tropical convergence zone near the equator.

A. Modern jet passenger transport aircraft are capable of flying high enough to be above much if not all of severe convective weather in the US, in Europe and over much of the non-tropical oceanic routes between Europe, the US and Asia. As a result, most of the time pilots can handle enroute weather with the information available on on-board weather radar and by looking out visually during day light and at night if in the clear. But at night, especially if the flight is operating in the clouds or at lower altitudes and in the vicinity of heavy, severe convective weather, weather radar might not be powerful enough to display the full extent of severe convective weather ahead on the flight path.

B. In the areas near the equator, severe convective weather very often occurs with heights much greater than modern jet passenger transport aircraft are capable of flying. This is a known meteorological phenomenon and these storms occurs routinely day and night. (Repeat these two statements in your mind.) They are observable by satellite with both optical, infrared and other technologies. In many cases they are exceed the ability of onboard radar to determine their size, severity, and height. On board radar in these cases is only useful for defining the edges of the storms for circumnavigation if the aircraft is outside of precipitation.

C. Oceanic navigation areas where modern jet passenger transport aircraft operate and are authorized to operate routes, such as from Brazil to Europe and to North America lie outside ground based weather radar coverage and therefore are not observable by ground based radar.

D. Weather information in these areas are obtained by weather imaging from a wide range of both photographic, infra red and other technology satellites. This information is made available from government agencies to airline Flight Control offices and other subscribers through commercial services by way of the internet. This internet facilitated information is not now accessible in the cockpit (although current technology would allow it and it is accessible in some cases onboard passenger aircraft in the cabin where on board internet is provided). Therefore the only way that flight crew can be advised of this critically important weather data is by Flight Control advising them by radio and data communications from the Dispatch or Flight Control Office.

E. It does not appear that the lack of action on the part of the Air France Flight Control Office in Paris is being investigated as a relevant factor in the loss of AF 447. Rather the attention of investigators and journalists is being redirected towards equipment manufacturers such as Air Bus and the flight crew.

3. Sophisticated weather data is accessible at Flight Control. Managing this information is the direct legal responsibility of Flight Control. US and European aviation regulations thereby give Flight Control the direct responsibility and authority to keep dispatched flights informed of weather hazards along the route of flight and at destination. (Repeat that to your self.)

A. Flight Control is fully equipped with all internet facilitated current satellite based meteorological information. Flight Control has the current and up to the minute information about severe weather phenomenon and the ability and the responsibility to communicate that information to the flight crew.

B. Flight crew graphic information, such as satellite images of photographic or infrared data are provided only at the time of preflight briefing, which can be as much as 1 ½ hours prior to departure. Very often the briefing itself is prepared an hour before the flight crew arrives to receive their briefing, because Flight Control may be dispatching multiple flights at or about the same time. A flight crew that is three hours into a flight for example, could possibly have therefore weather data that is five and a half hours old, in other words, not current.

4. Since severe weather, such as tropical convergence zone thunderstorms can routinely develop at a build-up rate of 4000-6000 feet per minute, new severe convective weather with heights of 60,000 feet, and higher, can develop in a very short period of time. Areas and lines of these thunderstorms can and do develop in the space of less than two hours and can build to heights well above the flight capability of modern jet passenger transport aircraft and pose severe hazards to flight such as hail, severe turbulence, lightning, icing and heavy precipitation.

5. No modern jet passenger transport aircraft are or have been certified to operate in severe thunderstorms, although many have been strengthened, equipped with electrical bond wiring and some level of engine, wing and windscreen deicing in the event that they encounter these severe convective weather conditions of a thunderstorm inadvertently.

6. Actual US and European aviation regulations require flights to be dispatched and while airborne to remain miles away from severe convective weather activity.

A. Yet in this case, the Air France Flight Control did not reroute AF447 around a known area of severe convective weather, that had heights above the possible service ceiling of the Airbus 330.

Why not? Why has the investigation not asked this question?

AF 447 pitot tubes iced up?

1. For many commercial aircraft, there is an emergency procedure for when pitot static based flight instruments become inoperable.
Pitot static based flight instruments include airspeed indications, altimeters and rate of climb instruments.

2. The scenarios encountered that might render these systems inoperative include a blocked pitot tube or a blocked static port.

A. In the past safety investigations found the following factors involved in pitot tube blockage:
1. loss of pitot tube heater allowing ice to build up or precipitation to clog the tube and/ or the associated plumbing.
2. a protective maintenance cover left on the pitot tube
3. insect, bird or other debris or object entering the pitot tube.

B. In the past, safety investigators have found the following factor most commonly involved in static port blockage:
1. Masking tape place over the static port by crews washing, waxing or painting the plane, where the tape was not removed prior to flight.

3. Since from what has been reported in the media that the flight was proceeding normally, it can be deduced that the problem with the pitot and static system was most likely due to the pitot tube icing over due to lack of heat.

A. Since most pitot heat systems are electrically powered, it is possible that there was some interruption in that electrical system.
B. When the loss of pitot static powered instrumentation occurs, the flight crew is directed by emergency procedures to use instruments which indicate flight attitude, that is pitch, roll and yaw.
C. The attitude instrument most often found in jet powered tranport aircraft is the attitude indicator. It will simultaneously indicate pitch, roll and yaw.
D. Attitude instruments are most often powered on commercial jet transport aircraft electrically and therefore will provide valid data in the event the pitot static system is inoperative. Their source is either laser ringed gyros, mechanical gyros or other similar systems.
E. Laws of aerodynamic performance state that pitch-attitude controls airspeed and engine power controls altitude. So as long as the flight crew maintains the cruise pitch attitude and the cruise power settings on the engine, the aircraft should stay relatively level in flight and the airspeed should remain at the speed required for cruise flight. The crew is often directed to seek an area of clear sky outside of icing conditions or precipitation in an attempt to regain use of the pitot-static system in the event icing caused the problem.

4. This is an emergency procedure which is successful and will allow the flight crew to maintain control of the aircraft through all flight regimes. I can speak from experience that this procedure works just fine. I can also state that this procedure is practiced in training simulators at many US airlines and I would suspect at many European airlines as well.


5. If the investigators state that the aircraft stalled, there are many scenarios by which this could have taken place. One common scenario is that the pitot tube ices up decreasing the dynamic pressure input to the airspeed indicator and rate of climb indicator. The static pressure port may not be blocked so it continues to show static pressure. If the crew does not cross check the pitch-attitude indicator, and only looks at pitot-static instruments, they may see an increasing airspeed and react by increasing pitch and reducing power. This could lead to as stall within a short time at altitude with an aircraft heavily laden with fuel, passengers and cargo.

6. To prevent this type of mishap, many airlines employ training in emergency procedures for the loss of pitot static instruments. The procedure includes disconnecting the auto pilot from control of the aircraft and hand flying the aircraft, again using pitch attitude and engine power settings from a chart. The charts carried on the aircraft include variables such as flight altitude and aircraft weight.

7. If the loss of pitot static system occurred while in a severe thunderstorm, the crew would have had to deal with both the severe turbulence, icing, possible lightning as well as the disconnecting of the autopilot. That would have been a handful for any crew to handle, but that is why most major airlines have strong training programs.

Safety or Accident Investigations?

Does your organization focus on prevention or investigation?

Reliving Colgan 3407 in Buffalo

What has changed at smaller airlines who contract with major airlines in terms of flight crew training since the 2009 crash that killed all in the aircraft and one on the ground?

Anything?