Posts Tagged ‘NTSB’

See & Avoid Doesn’t Work

Tuesday, November 10th, 2015

Contemplate the worst scenario that might confront a pilot during a flight. What comes to mind? Fire? Flight control failure? Engine failure? Perhaps it’s flight crew incapacitation, explosive decompression or severe structural damage.

No doubt about it, those all fall into the Very Bad Day category. But there’s one that can be even worse: a mid-air collision. That’s because it can involve all the problems listed above — at the same time. And since the parties involved aren’t aware of the impending crunch until it’s too late, the mid-air is usually accompanied by a violent element of surprise, confusion, and initial denial.

You might think fatal mid-airs are rare events, and from a purely statistical standpoint I’d have to agree. According to the 2010 Nall Report, a fatal mid-air occurs about once every 8 million flight hours. Think of it as the roughly the same odds as winning the lottery or being struck by lighting. Doesn’t sound so bad, does it? A typical GA pilot might accumulate but thousand or so hours over a full lifetime of flying.

So what’s there to worry about? Plenty. The “big sky” theory may sound good, but it doesn’t hold up very well under close scrutiny. It’s true that the navigable atmosphere over the United States alone is massive — about 20 million cubic miles — and there are relatively few airplanes in the sky. Even on those occasions where a collision is possible, modern tools such as radar, TCAS, VHF communication, and anywhere between two and four sets of eyeballs almost always succeed in averting the disaster. If aircraft were equally distributed throughout the atmosphere, the “big sky” idea would be pretty comforting.

But airplanes cluster near airports, large cities, and on thin slices of the sky known as “airways”. For the VFR types, airspace and terrain often crowd planes into small swaths of the air in places like the Santa Ana Canyon or Banning Pass. The sky is much like the ground: vehicles stick to relatively confined spaces and that makes collisions a serious hazard.

Since we’re on the topic of statistics, let me give you a few of my own: I personally know two people who have been struck by lightning, and a winning lottery ticket was recently sold not 300 feet from my front door. Hey, crazy stuff happens. But unlike lighting strikes and golden tickets, we’re not all facing the same odds. The risk profile varies widely depending on the type of flying you’re doing.

For example, flight instruction is frequently a factor; thirty-seven percent of mid-airs occur with a CFI on board. Many instructional flights happen near airports, and as previously mentioned, that’s where other airplanes tend to congregate. On the other hand, if you fly airliners, your risk of a mid-air is rather low because the aircraft itself is large and easy to see, you’re always flying IFR, and the most sophisticated traffic avoidance hardware available is always installed. Airliners also spend most of their time in cruise and are in constant radar contact with ATC.

Midair collisions are almost as old as powered flight itself.  This B-17 collided with a German fighter over Tunisia in 1943.

Midair collisions are almost as old as powered flight itself. This B-17 collided with a German fighter over Tunisia in 1943.

Think it can’t happen to you? Think again. Some very talented, capable, and well-respected pilots have been involved in mid-air collisions. I know a guy who was involved in one while flying a large-cabin, TCAS-equipped business jet under Instrument Flight Rules. Alan Klapmeier, the founder of Cirrus Aircraft, was in one too. Richard Collins, famed Flying columnist, was in a mid-air. Speaking of Flying, the recent Editor-in-Chief owns a very nice Cirrus SR-22 which was in a mid-air. And lastly, a decade ago I was in a mid-air collision myself.

I’ll save the blow-by-blow (no pun intended) on that for another day. The point I’m trying to make is that the odds of a mid-air are probably greater than you think, especially if you live in a populated metropolitan area and fly VFR. If you’ve ever had a close encounter with another airplane in flight, you were only separated from “those who have” by nothing more than a miniscule sliver of plain old luck.

Think about that for a moment.

This may be hard to believe, but there is some good news. For one thing, mid-airs are not always fatal. It seems intuitive that most collisions would involve fatalities, but all the people I cited above survived, including (obviously) myself. Also, technology is rapidly advancing, from cheap TCAD boxes to airframe parachutes to super-bright LED exterior lighting.

The question we should all be asking ourselves is how we avoid ending up in a mid-air, fatal or otherwise. If you refer to official guidance from the FAA, the answer is to simply look out the window and spot the other airplane before it hits you. This technique, referred to as “see and avoid”, is still considered adequate for preventing collisions. Here are a couple of passages from Chapter 1 of the Airplane Flying Handbook:

The “See and Avoid” concept relies on knowledge of the limitations of the human eye, and the use of proper visual scanning techniques to help compensate for these limitations. The importance of, and the proper techniques for, visual scanning should be taught to a student pilot at the very beginning of flight training.

Proper clearing procedures, combined with proper visual scanning techniques, are the most
effective strategy for collision avoidance.

Other FAA publications, ranging from the Aeronautical Information Manual, to Advisory Circulars like AC-90-48 (“Pilot’s Role in Collision Avoidance”) will give you the same spiel: “see and avoid will keep you safe”. And it will! Until it doesn’t.

From my perspective as someone who’s been in a mid-air and who was using proper clearing and scanning techniques at the time, I take it as gospel that “see & avoid” won’t always do the trick. I’m just one guy, of course. But many others — some institutional in nature — just happen to agree with me.

For example, a couple of years ago Canada’s Transportation Safety Board issued an accident report on a mid-air collision between a Beech V-35B Bonanza and a PA-28 Cherokee over northern Virginia. Canada was tasked with performing the investigation because the pilots of the Bonanza were employees of the NTSB while the Cherokee was piloted by an employee of the FAA.

I won’t keep you in suspense. The conclusion from the TSB was that the “see and avoid” concept was inadequate. They even quoted a 1991 report produced by the Australian Transport Safety Bureau which provides an overview of the major factors that limit the effectiveness of the see-and-avoid principle in preventing mid-air collisions, as well as a 2005 scientific study published in Aviation, Space, and Environmental Medicine which came to the same conclusions.

The main points:

  • Cockpit workload and other factors reduce the time that pilots spend in traffic scans, and even when pilots are looking out, there is no guarantee that other aircraft will be sighted.
  • Visual scanning involves moving the eyes in order to bring successive areas of the visual field onto the small area of sharp vision in the center of the eye. The process is frequently unsystematic and may leave large areas of the field of view unsearched.
  • A thorough, systematic search is not a solution as in most cases it would take an impractical amount of time.
  • The physical limitations of the human eye are such that even the most careful search does not guarantee that traffic will be sighted.
  • The pilot’s functional visual field contracts under conditions of stress or increased workload. The resulting ‘tunnel vision’ reduces the chance that an approaching aircraft will be seen in peripheral vision.
  • The human visual system is better at detecting moving targets than stationary targets, yet in most cases, an aircraft on a collision course appears as a stationary target in the pilot’s visual field.
  • An approaching aircraft, in many cases, presents a very small visual angle until a short time before impact.
  • Complex backgrounds such as ground features or clouds hamper the identification of aircraft via a visual effect known as ‘contour interaction’. This occurs when background contours interact with the form of the aircraft, producing a less distinct image.
  • Even when an approaching aircraft has been sighted, there is no guarantee that evasive action will be successful.
  • Because of its many limitations, the see-and-avoid concept should not be expected to fulfill a significant role in future air traffic systems.
  • Transportation Safety Board of Canada aviation investigation report A06O0206 identified that there is a high risk of mid-air collisions in congested airspace when aircraft are not alerted to the presence of other aircraft and rely solely on the see‑and-avoid principle.

There’s one more area of the TSB report which is worth of quotation. In it, they reference a British Royal Air Force study into mid-air collisions. If you’re keeping score, that’s the third sovereign agency to reach the conclusion that “see and avoid” is inadequate. Yet our own FAA, which oversees about 80% of the world’s aircraft and almost all of the high traffic density airspace, still officially proclaims that one can look out the window and see everything that needs to be seen.

This accident has demonstrated yet again that relying solely on the see-and-avoid principle to avoid collisions between aircraft operating under visual flight rules (VFR) in congested airspace is inadequate.

A number of international studies have addressed the overall issue of the effectiveness of the see-and-avoid principle, as well as the risks of collision associated with this principle. All acknowledged the underlying physiological limitations at play and that, when mid-air collisions occur, “failure to see-and-avoid is due almost entirely to the failure to see.”

One study stated that “our data suggest that the relatively low (though unacceptable) rate of mid-air collisions in general aviation aircraft not equipped with TCAS [traffic alert and collision avoidance system] is as much a function of the ‘big sky’ as it is of effective visual scanning.”

A British Royal Air Force study into mid-air collisions, which were deemed to be random, found that the probability of conflict is proportional to the square of the traffic density, and recommended avoiding altitude restrictions that concentrate traffic.

Measures such as improving aircraft conspicuity, pilot scanning techniques, and pilot traffic awareness can reduce risks, but they do not overcome the underlying physiological limitations that create the residual risk associated with a see-and-avoid method.

It’s obvious that “see and avoid” cannot, by itself, ensure our safety. If it could, there’d be no need for TCAS or most of our controlled airspace (both of which came about because of high-profile mid-air collisions, I might add!). I’m not necessarily in favor of mandating any additional equipment, airspace, or restrictions, especially on general aviation. But it’s clear that serious changes are needed in how collision avoidance is taught, especially as it concerns “see and avoid”. The concept has serious limitations which must be understood so the pilot-in-command can make educated decisions about how — or even if — they want to mitigate those risks.

I sincerely hope our nation’s regulatory and safety organizations will eventually acknowledge what we all know to be true: “see and avoid”, while a good start and certainly a vital part of collision avoidance, is simply not sufficient to ensure traffic separation.

Improving Your Stick and Rudder Skills: Seaplanes and Taildraggers

Monday, March 23rd, 2015
UPRT Photo

APS Training photo

In mid-January, the National Transportation Safety Board (NTSB) released some cold, hard facts. “Between 2001 and 2011, over 40 percent of fixed wing general aviation fatal accidents occurred because pilots lost control of their airplanes.” You might be surprised to learn that when The Boeing Company studied commercial jet accidents around the world between 2004 and 2013, the cause that resulted in more fatalities than any other – by a 2 to 1 margin actually – was Loss of Control Inflight (LOC-I). What we don’t know of course is why this keeps happening?

While the relationship between LOC-I precursors and actual loss of control is still being investigated, it’s clear that pilots of all categories are, at times, simply unable to fly their airplanes out of situations in which they find themselves. Cockpit automation has often been pegged as a likely culprit. Today, we’re going to do our part to slow the advance of LOC-I by turning off all the cockpit automation and hand-flying the airplane more often. Two ways I learned to be more closely tied to my airplane was to check out in a taildragger and earn my seaplane rating. Both require all hands on the controls from the moment you turn over the engine until shutdown. While flying both can be challenging at times, I’ve found the skills they build have truly made me a better pilot and instructor.

Dragging My Tail

I learned to fly a 7ECA Citabria many years ago after I bought it. I thought it was just an airplane with the steering wheel on the wrong end – although it used a control stick and not a wheel. Wrong again. For starters, the view out the cockpit window was different from the tricycle gear aircraft I’d flown Taildraggerbecause the taildragger’s nose sits high on the ground. That makes taxiing … interesting. Lots of rudder and brakes to turn the aircraft, or even keep it heading straight, especially when a strong breeze starts blowing. My first few hours with an instructor produced a great logbook entry … “N8300V 1.5 of crash and dash,” he wrote. I was mortified. After all, I already held a commercial pilot certificate. I’d pour the coals to it on takeoff and of course, with P-factor, torque and everything else, the Champ would head to the left side of the runway. Then I’d kick right rudder which brought us back toward centerline. Unfortunately, I waited until the nose began heading to the right edge of the runway to kick in left rudder and hence many zig-zag takeoffs were started and stopped. The key turned out to be calm days of partial power on takeoff, just enough so I could raise the tail and learn to steer before I pulled the throttle back and taxied back for another try.

It took me awhile to realize I needed to lead the nose around rather than allowing it to lead me. But of course during takeoff, the airplane is also trying to accelerate and I couldn’t see much over the nose. I also learned to raise the tail once there was enough airflow. But you have to do that gently or you’ll put the airplane on it’s nose. You might remember something in ground school called gyroscopic effect … well maybe not. Point is, when the tail comes up, that movement also makes the nose want to swing so you really need to be on the rudders there too … positively, but gently. During my first landings, all seemed normal until I realized this was simply a reverse crash and dash … keep on the rudders to keep the nose straight. Add a crosswind and it becomes a tad challenging until the tail comes back down.

Worst case scenario in my Champ was the inability of the airplane to turn downwind after landing in a 25-knot headwind. Too much brake and power and I could feel I’d put the thing on its nose. The solution turned out to be impossibly simple. Shut the engine down, get out and lift the tail myself to turn the airplane around. Then I restarted and moved it to my tiedown. While all of this sounds tough, after 10 hours or so, I was no longer zig zagging. I used my rudders often and cross winds no longer seemed to bother me as much. I’d become not only coordinated, but finely tuned.

seaplaneSplish Splash

Last fall I realized I craved a new learning challenge. That evolved into earning my seaplane rating in Traverse City, Michigan. The first hour in that Cub on floats reminded me of a few things from my days as a taildraggers student. When the pitch and power of the instructor’s voice is high and loud, danger is near. I also realized the airplane started moving the minute the propeller spun up and of course, there are no brakes. Like the Champ, the Cub had a control stick which I thought made aileron and elevator movements easier to plan and water rudders for improved steering on the surface. I just needed to remember to retract them before takeoff and landing. The seaplane rating is all about learning to taxi, takeoff and land on the water. The rest is like any other airplane, except that when the instructor pulled the engine on me at 1,000 feet AGL, those floats acted like barn doors that pegged the vertical speed indicator pretty fast. On takeoff, it’s all about finding a place on the water called, “the step.” It’s a spot where you have just enough forward pressure on the stick to raise the back of the floats out of the water, but not so much that you put the airplane on its nose. Like the taildragger, it was all about learning to fine tune my movements. I learned this piece of fine tuning the hard way however.

On takeoff, I shoved the stick forward in the Cub like I did to raise the tail in the Champ. WRONG! I learned that fine tuning means too much forward pressure on the stick and the floats bog down in the water. After a few takeoffs, I absolutely began to feel it. Too little back pressure on takeoff and we just mush along in the water like a boat. Finding the takeoff sweet spot meant power, a bit of forward pressure and after about three or four seconds, the airplane accelerated … no it actually jumped ahead. Then I had to finely oscillate the stick to keep the floats in the same place until liftoff speed. Then a bit of back pressure and I was climbing just like a regular bird. By the second hour or so of instruction I thought figured it out. My silent instructor in the back seat confirmed it. There is of course the issue of docking the airplane to contend with too, but I’m still working on that part.

The point of convincing you to give a taildragger or a seaplane rating a try is of course, both are fun. But both also require the pilot to control the aircraft very precisely at times. The first few hours will be real work, but after that you’ll be surprised at how much better you’ll fly these and any other airplane. BTW, when you see AOPA President Mark Baker at AirVenture this year, tell him you’re thinking about a seaplane rating. He has more great seaplane stories than any half dozen other pilots I know.

Data, Data … Who Has the Data … and What Will They Do With It?

Monday, January 26th, 2015

Whether an airplane slides off the side of the runway during takeoff or disappears behind some tall trees on final approach, the reaction is pretty universal. People want to know, “what happened?” In the heavy metal airplanes like Boeings, Airbus’ or Gulfstreams, the investigation of what went wrong begins by retrieving the flight data and cockpit voice recorders that typically survive almost every kind of mishap. The data on those recorders help investigators re-create the moments before the chaos began … what control was moved in which direction, where the power was set or what one pilot said to the other. The data becomes the basis for the Board’s final report that offers valuable insights to the industry, many that quickly make their way to the pilot training providers.

But on the GA side of flying, that kind data and analysis is almost non-existent. We need to fill that GA vacuum for the same reason large aircraft carry data recorders … to prevent the same accident from reoccurring.

Stratus 2Thanks to the glass avionics now standard on just about every production airplane in the U.S., the job of capturing operational data is becoming easier. Unknown to may pilots, both the Garmin and Avidyne avionics offer downloads of operational data by simply inserting an “SD” memory card in a front panel. ForeFlight users can also capture their flights on their iPad. Add a Stratus 2 from Sporty’s and pilots can download enough data to create a simulation in X-Plane. Imagine watching your performance as if you’d been flying alongside as your own wingman. Hook up an Iridium Go! to a Stratus 2 and you can download the data via satellite while the aircraft is still airborne. The University of North Dakota is already deep into testing data capture systems on its flight training fleet to better gauge both aircraft and pilot performance.

And not a moment too soon since the NTSB reminded us a few weeks ago that loss of control inflight (LOCI) is enough of a GA to land LOCI on the Board’s Top 10 List of Transportation worries for 2015.

Of course the real value in trend analysis evolves by analyzing thousands or even hundreds of thousands of flights. But will the GA industry take the steps needed to capture more data and, after scrubbing it clean of any identifying tags, share it with the world for analysis? The airlines and business aviation are beginning to learn the value of identifying these kinds of trends before an accident occurs.

A few stumbling blocks to using the data from today’s airplanes include worries about cost, privacy and enforcement. The cost issue is actually an easy one though, despite the huge requirement for ADS-B Out looming in 2020, because data capture isn’t required by the FAA. It’s just valuable information. The equipment is either already on board, or can be added pretty inexpensively. A Stratus 2 that sells for $899 and an Iridium Go! listing out at $799 represent the top of the line for data capture options. The Stratus also gives an aircraft ADS-B In capabilities at no extra charge. Many data capture options cost much less. The MITRE Corp. worked closely with the FAA to produce a handy app — called GAARD — you’ll find at iTunes store that is a pretty slick tool for basic data capturing just using your iPhone. Don’t be surprised when insurance companies begin offering discounts to pilots who monitor their data like auto insurers are trying right now.Iridium Go!

Certainly privacy and enforcement go hand in hand with everyone worrying about who might view their last flight and what action they might take. For the commercial and business carriers, service providers already exist that scrub the data of identifying information while they focus on the issues the data identifies pretty much the way we’ve grown accustomed to using the ASRS forms through NASA.

With the AOPA Air Safety Institute’s 2012-2013 Accident Scorecard chronicling 948 fixed-wing accidents in 2013 that cut short the lives of 165 people, I’d say we have our work cut out for us. The question is whether enough pilots will gather together to take advantage of a system that might help GA vanish from the NTSB’s list in the near future.

Time for a Shakeup

Wednesday, January 22nd, 2014

Last November the Federal Air Surgeon, Fred Tilton, unilaterally declared that mandatory screening for obstructive sleep apnea (OSA) in pilots would begin “shortly.”

The initial BMI threshold would be 40, with an ominous vow that “once we have appropriately dealt with every airman examinee who has a BMI of 40 or greater, we will gradually expand the testing pool by going to lower BMI measurements until we have identified and assured treatment for every airman with OSA.”

Tilton noted that “up to 30% of individuals with a BMI less than 30 have OSA”. Between the fact that people with normal-range BMIs have been diagnosed with sleep apnea and his apparent zest for uncovering “every” airman with OSA, logic dictates that the eventual threshold would be in the mid-20s, if not lower.

The aviation community was up in arms pretty quickly, and for good reason. For one thing, the mid-20s are the upper end of the normal BMI range. It’s also worth noting that even the World Health Organization acknowledges that the BMI scale was never designed for application to individual people, but rather for statistical modeling of entire populations. BMI is based solely on weight and height, so it does not account for differing body types. Nor does it obey the law of scaling, which dictates that mass increases to the 3rd power of height.

In plain English, a bigger person will always have a higher BMI even if they are not any fatter. This penalizes tall individuals, as well as bodybuilders and athletes who are in prime physical shape by assigning them absurdly high BMI numbers. Likewise, short people are misled into thinking that they are thinner than they are.

Nevertheless, Tilton declared his intention to press on anyway, without any industry input or following established rulemaking procedures despite the fact that this scavenger hunt would break invasive new ground in aeromedical certification.

Then, even the Aviation Medical Examiners objected to the new policy, noting that “no scientific body of evidence has demonstrated that undiagnosed obesity or OSA has compromised aviation safety” and that providing long term prognoses is not part of the FAA’s job. The medical certification exists soley to “determine the likelihood of pilot incapacitation for the duration of the medical certificate.”

Without the support of the civil aviation medicine community, Tilton was literally standing alone. At that point, Congress jumped into the fray on the pilot community’s behalf and eventually forced the Air Surgeon to back down… for now.

While the battle may have been won, the war is far from over. Mark my words, this is not the last you’ll hear about this bogeyman. Tilton may be forced to consult with the aviation community or follow a rulemaking procedure of some sort, but his zeal for the topic means OSA screening will be back in one form or another.

To effectively combat such overreach, we’ve got to attack the problem from its true source. In this case, the Air Surgeon’s ammunition came from National Transportation Safety Board recommendations issued in the wake of a 2008 regional airline flight which overflew its destination by 26 miles when both pilots fell asleep.

… the National Transportation Safety Board recommends that the Federal Aviation Administration:

Modify the Application for Airman Medical Certificate to elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder. (A-09-61)

Implement a program to identify pilots at high risk for obstructive sleep apnea and require that those pilots provide evidence through the medical certification process of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification. (A-09-62)

The NTSB serves a useful purpose in assisting transportation disaster victims and investigating accidents, but when it comes to safety recommendations, the agency operates in a kind of vacuum, divorced from some of the most pressing realities of the modern general aviation world. The reason is simple: their mission statement. It calls for the Board to “independently advance transportation safety” by “determining the probable cause of the accidents and issuing safety recommendations aimed at preventing future accidents.”

While there’s nothing objectionable about their mission, note how there’s no mention of the cost these recommendations impose on those of us trying to make a go of it in the flying industry. Since it’s not part of their mission statement, it is not a factor the Board takes into account. It doesn’t even appear on their radar. The Board’s federal funding and their lack of rulemaking authority negates any such considerations. So a sleep apnea study costs thousands of dollars — so what? If it prevents one pilot from falling asleep in the cockpit in next half century, it’s well worth the decimation to an already down-and-out sector of the economy.

That’s been the logic for the NTSB since it was conceived by the Air Commerce Act in 1926. It worked well when aerospace safety was at its nadir — but that was nearly ninety years ago. As air transportation evolved during the 20th century, attempts at increasing safety have reached the point of diminishing returns and exponentially increasing cost. At some point the incessant press toward a perfect safety record will make aviating such a sclerotic activity that it will, in effect, cease.

It’s a problem for any industry, and it’s especially so for one that’s teetering on the edge of oblivion the way ours is. The good news is that this can be fixed. It’s time to shake things up at the NTSB by revising their mission statement to make cost analysis a major part of the Board’s function. They should work with stakeholders to carefully study the long-term effect each recommendation would have on the health and size of the aviation industry before they make it.

For what it’s worth, the FAA needs this mission statement adjustment just as much as the NTSB. More, in fact, because the NTSB can recommend anything it wishes, but the regulatory power to act upon those suggestions is outside their purview and rests with the Federal Aviation Administration. From medical approval to burdensome aircraft certification rules, the FAA is the hammer. We have to start somewhere, though, and the NTSB is in many ways the top of the heap, the place where these ideas get their start. It would be nice to see the industry’s lobbyists in Washington, D.C. suggest such a bill to members of Congress.

One final thought: if government’s power really does derive from the “consent of the governed”, this should be an idea even the NTSB (and FAA) can get behind. Otherwise, they may convene one day and find that there’s not much of an industry left for them to prescribe things to.