Archive for the ‘Safety’ Category

Clueless in Barcelona?

Wednesday, July 9th, 2014

Last week we discussed the effects of culture and automation confusion in the cockpit. This week an Airbus 340 crossed a runway in Barcelona, Spain while a B-767 was on short final. This kicked off a new media round on runway incursions and serves as a great reminder that while it doesn’t happen often, it’s one of those low probability, high consequence incidents that can go really bad, really quickly.

As usual, we speculate on cause, but the effect is clear. According to unofficial reports, the Boeing balked the landing at about 200 feet agl and was about 3000 feet down the runway. Based on the camera angle and the effect of foreshortening, it appeared perhaps a bit closer to the ‘Bus than it was in actuality. That said, this is a graphic depiction of what was almost a major accident and serves as a good example of how NOT to do things.

  • At this writing, we don’t know what role ATC played—did they direct the Airbus to cross?
  • Did the controller forget that the Boeing had been cleared to land?
  • What was going on in the Airbus cockpit?
  • We know that the Boeing crew reacted exactly as they should have.

The FAA has grouped incursions based on how close the collision nearly was. It’s worth perusing the definitions. My estimation is that this was either a category A (a serious incident in which a collision was narrowly avoided) or B (an incident in which separation decreases, and there is a significant potential for collision which may result in a time critical corrective/evasive response to avoid a collision).

On the ground there are several inviolate rules—especially for those of us that fly single pilot:

  • No programming while taxiing—either load the beast before leaving the ramp or after reaching the run-up block. No in-between unless one is devoted 100 percent to driving while the other is loading—split personalities are not allowed! I really like ground power switches which allow getting a clearance and loading it into the FMS without powering up the entire stack or starting the engine.
  • Always know where you are on the airport—duh. Airport charts are now universally accessible either in instrument approach chart booklets or electronically. Lost? Ask for progressive, especially after dark or in IMC.
  • Sterile cockpit while on the ground, especially with passengers until there are no more runways to cross. Operations take priority over friendly discussion.
  • Coming to the familiar runway entrance red and white sign? Default is to stop unless you’ve been cleared. Are you SURE? Verify if in any doubt. But—wait for it—if cleared, is the runway clear? ATC doesn’t make mistakes often, but it only takes once so Mom was right—always look both ways before crossing.

The cockpit voice recorder and ATC tapes will make clear what is or is not so obvious now. Distractions can be deadly—but you knew that.

GA pilots continue to account for almost 80% of runway incursions, so we’ve got some work to do…especially as single-pilot operators where the proliferation of cockpit automation fights for our attention. That’s why ASI offers a free online course about runway safety to anyone with Internet access.

Clueless Crews?

Tuesday, July 1st, 2014

OLYMPUS DIGITAL CAMERAHow much automation is enough? When is the line crossed between having something that’s really useful and doing so much that, like the Wizard of Oz with his hot air balloon, we have no idea how it works? What role does training play?

In the wake of the Asiana accident where the crew flew what appeared to be a perfectly functioning B777 into a seawall, inquiring minds are now wondering if the auto-throttle system was perhaps a bit overdesigned. My only experience with auto-throttles have been in simulators—Gulfstream IV and the Airbus 330. It was pretty easy. Push a mode button here, select a speed there, and then monitor the system for anomalies. “Monitor” is a key word.

The ease of flying a fully automated approach makes you wonder just how hard this could be? In primary instrument training there are roughly five or six instruments to be scanned to keep the localizer and glideslope (or was it glideslop?) somewhere near center scale. It’s a lot of plates to keep spinning simultaneously. When first introduced to the horizontal situation indicator (HSI) and the single-cue flight director, they significantly lowered my estimation of how hard it was to fly bigger aircraft.

One of the NTSB’s Asiana findings was that auto-throttle modes were confusing. Former NTSB Chair Debbie Hersman noted, “This crew was extremely experienced. They had a lot of hours, but they just didn’t have the ability to understand what was happening in the critical few seconds before the crash. It wasn’t just one person in the cockpit that didn’t understand. There were three experienced people in the cockpit that didn’t understand what was going on.” Really? Didn’t have the ability to see that the aircraft was not stabilized early in the approach and failed to take action when slowing below Vref? Hmmm.

I know nothing about the B777 systems which may be complex, but with several hundred thousand (or more) successful automated landings completed over the aircraft’s 20 plus year history, ya gotta wonder just how bad the system design was. Ms. Hersman and I both agree that engineers often overthink and overdesign systems. We diverge somewhat on the statement regarding this crew’s capability. Experience and competence are two different attributes.

The other two airline accidents that bear at least some similarity with somewhat clueless crews are the Colgan Q400 accident in Buffalo and Air France 447, the Airbus 330 that stalled over the South Atlantic. In all cases, a highly automated aircraft wrested control away from the crew. (Shades of Space Odyssey and the HAL 9000 computer… “I’m sorry, Dave. I’m afraid I can’t do that.” )

Lest you think I’m just picking on air carrier pilots, many more GA pilots demonstrate a lack of clue far more frequently. Automation doesn’t seem to trap us often although it’s becoming more prevalent.  It’s more often judgment. Lack of fuel, too much weather, too much wind, too little altitude, not enough runway—you know the list.

Black Swans and Checklists

Wednesday, June 25th, 2014

By HeartThe loss of a Gulfstream IV several weeks ago with all on board is tragic, and the cause seems obvious and yet a mystery. From what we now know or think we know, it appears that the big jet accelerated down the runway and reached rotation speed when the crew belatedly discovered that the flight controls were locked. There was no escape—no way to fly or to stop. They skidded for over half a mile on the remaining runway, into the overrun, through the localizer antenna, breached the airport fence, and down into a ravine where the G-IV broke up and burned.

The mantra about flight controls being ” Free and correct” MUST be done prior to every takeoff in every aircraft. It’s a killer item. So how could a professional crew with so much experience miss this most basic of before-takeoff checks? A friend brought up a key point point—that most factory checklists are absurdly long and too many pilots ignore them or significant parts of them. They are written to prevent lawsuits, not to help pilots prepare for flight.

With my usual caveat about speculation so early in an investigation, part of the answer may be perfectly obvious—complacency and/or distraction. It is present in almost every accident involving experienced pilots. We become complacent because we’ve seen or done this many times before and it’s always worked. One should never get too comfortable in an aircraft, which is never a totally benign environment.

Distraction means not putting first things first. Humans are no good at multi-tasking—it’s amazing that job-seekers still think this is a good buzzword to put on their resumes. In aviation, as in business, deal with the nearest biggest alligator first. If the first one gets you, everything else is irrelevant! Shorter, more relevant checklists perhaps?

Now to the mystery part. The G-IV designers, anticipating that humans make the most basic of errors, added a thrust lever interlock that would prevent engine thrust from being increased beyond taxi speed if the gust lock was engaged. That should have prevented takeoff power from being applied. Was there a “black swan event” (a one in a gazillion chance) that the interlock failed at the same time the crew failed to check the controls? Or, did the gust lock release mechanism fail to release the controls while releasing the thrust lever interlock?

How would a crew know if the interlock failed in routine operation because they always checked the controls and everything worked normally? Suppose a key human factors device became inoperative? And in the one in a gazillion times that the crew failed to verify flight controls “free and correct,” the safety backup would not be there to save them.

A good way to check flight controls: “Box them.” That means to move the yoke or stick all the way left, then pull it all the way aft, then all the way to the right, then full forward and finally back to neutral. Of course, you could go clockwise instead, if you’re of that political persuasion. Full control movement is needed, and please actually look to see that the controls did as commanded. There have been dyslexic mechanics who reversed rigged the system, and that will really mess your mind on takeoff. Let’s pare checklists down to essential items only and make it easy to check—there’s more to learn after this accident.