Sorry Charlie

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Recently an aircraft from a major airline experienced runway excursion.  Failing to negotiate the turn onto a taxiway during a snowstorm the aircraft left the pavement and came to rest in the adjacent soft ground.  There were no injuries and only minor damage to the aircraft.  This is the latest in a series of runway excursions for this airline.  I can recall four since 2000, KBUR March 2000, KMDW December 2005, KMDW April 2011 and the most recent KDEN November 2012.

My focus of these runway excursions is not intended to be on one the airline, but to point out that all of them took place in the same type aircraft from the same operator.  What was significant with these flights and shat can we learn?

The excursions listed above are anecdotally significant for three reasons.  First of all, the aircraft were from the same operator (i.e. same procedures?).  I will comment more about procedures later.  Second, they were the same aircraft type, Boeing 737.  Third, the excursions occurred with the same conditions that other aircraft encountered and landed successfully.

The latest issue of Flight Safety Foundation’s AeroSafety World has an excellent article explaining a Boeing analysis of 29 runway end excursions.  Click HERE for the article.  The analysis divided the incidents into three categories, landed long, landed fast and deficient deceleration.  “Only three primary factors….govern the stopping of any airplane”, said A. Thomas Stephens, Lead, aero accident/incident analysis, The Boeing Co.  The study looked at touchdown point, touchdown speed and deceleration capability.   The study also pointed out that all flights were “capable” of making a full stop with the conditions present when they landed.

What were the differences?  What were the characteristics of the operations that resulted in these runway excursions?  More importantly, what were the significant factor(s) about the flights that did not have an excursion? 

I submit that there is a fourth factor, as important as the laws of physics, that can exploit or negate safety margins built into procedures and performance data.  That factor is crew effectiveness.  By crew effectiveness I mean decision-making capability and the ability to operate the aircraft in a manner that is consistent with the manufacturer’s performance data.  The aircraft in the Boeing study were capable and the crews were trained. But, trained for what objective?  Is the ultimate goal to robotically follow procedure or to operate safely?

Threat and Error Management (TEM) principles have been available to operators for approaching two decades.  Its concepts have been in use by effective pilots since the Wright Brothers.  Some airlines have chosen to embrace it from a foundational perspective while others as an afterthought.  For a few operators and their pilots it is the essence of what they do.  They approach every situation with the mindset of threat identification and mitigation.  Unfortunately, for many others they see Threat and Error Management as a set of platitudes and graphics that look good in presentations and sound good in training syllabi.  It is the same difference that exists between those who see volunteerism as helping your friends and neighbors and those who use volunteerism to enhance their image and to feel better about themselves.

Applying very simple threat analysis and simple mitigation strategies may have prevented all 29 runway excursions in the Boeing study.  Acknowledging threats and developing effective strategies before attempting to land is essential for a safe operation.   The crews involved did not either acknowledge the threats or employ mitigation strategies. 

Were the procedures in place at the time of the runway excursions ineffective?  Or, can we simply assume the crews were intentionally non compliant?  Were the crews adequately trained to operate safely (the outcome of the maneuver not in doubt) in the environment they were faced with?  The only true measure of a flight crew’s training is their performance on the line.  I submit that the crews were not trying to be unsafe, but rather were not effectively trained to identify and avoid or mitigate the threats. I believe the Boeing study along with runway excursion statistics in general point to a need for more effective training in this area.

Crews and operators that embrace Threat and Error Management principles see procedural compliance as a threat mitigation tool to maintain safe operations.  Those who think of TEM as an add-on tend to make procedural compliance the primary goal and believe safe operations will therefore follow. Training in judgment and decision-making requires a comprehensive approach over a long period of time. It is far easier and more efficient to write and publish a procedure than to train decision-making skills.   However, the more operators try to proceduralize safe operations the more crews tend to emphasize procedure over outcome.  The decision-making process can become “Can we do this?” rather than “Should we do this?”.   For example, effective training would produce crews that are trained to acknowledge and effectively mitigate the threats associated with landing downwind on a short runway with decreased braking action, not just trained to ask, “Can we do this?”.  Crews that have been conditioned to the reasoning that says,  “if it is allowed it is safe” are being unknowingly exposed to many threats.  Standard procedure cannot and should not be expected to cover all threats all the time.  The environment is too complex and too dynamic.

Technical knowledge, procedural compliance and good piloting ability are all essential tools for maintaining a safe operation. Threat and Error management skills are responsible for ensuring the tools are applied in an effective manner for a positive outcome. The most effective operators don’t just talk about Threat and Error Management; it is fundamental to their entire operation.

“Sorry Charlie, Starkist wants tunas that taste good, not just tunas with good taste. “

“But what’s happening?”

"….determines that the probable cause of this accident was the loss of control of the aircraft because the flight crew failed to recognize and correct the aircraft's high-angle-of-attack, low-speed stall and its descending spiral. The stall was precipitated by the flight crew's improper reaction to erroneous airspeed and atmospheric icing……"
 
The final report from Bureau d’Enquêtes et d’Analyses, BEA, the European agency tasked with the investigation and analysis of Air France flight 447, June 1, 2009, was issued this week. Most of the details of the accident had been previously disclosed with the exception of the unabridged voice recorder transcript. There were many thoughtful conclusions and recommendations in this report, but it still seemed that there were deeper issues surrounding this crash. As I read the report I asked myself, “What is THE takeaway here? What is THE fundamental lesson we need to learn?”
 
As with all fatal aviation accidents, we need to respect and value this tragedy by not allowing the passengers and crew to have died in vain. Fortunately, from the genius of Dr. David Warren (see my post The Vacuum Salesman and the Black Box, March 4, 2011) we have everything we need to place ourselves in that airplane that night and experience what the crew was faced with. We, all of us in the aviation community, must listen to what the crew and airplane told us as it “fell” into the dark equatorial Atlantic that night. The entire incident lasted less than 4 minutes and 30 seconds. I’m sure it seemed a lot longer to them. We must be strong enough, wise enough and vulnerable enough to look into the mirror that is this report to ask ourselves, “Are we them? Why?”

The flight displays of a modern airliner such as the A330 that crashed provide lots of information to the crew. Heading, altitude, airspeed, pitch, roll, vertical speed as well as computed data together. Computed data being targeted pitch and roll values to achieve the programed parameters entered into the flight guidance computers. In addition to flight data, the A330 displays provide printed status, caution and warning messages to the crew as well as numerous audio signals and messages to draw the crew’s attention to specific parameters, events or values.

After reading the AF 447 accident report it would be easy to classify it as simple loss of control following the unexpected auto pilot disconnect exacerbated by the intermittent, unreliable and inconsistent flight displays. The attitude and engine information remained valid. The pilots had been trained in the simulator for an unreliable airspeed event, but the indications were not the same as encountered by the crew of AF 447. The simulator scenario was certainly not practiced in conjunction with high altitude weather and turbulence. The flying pilot was startled and confused by the autopilot disconnect warning and the many sensory inputs being received, including comments from the other pilot, as well as the requirement to manually fly the aircraft. This crew thought, like many experts until the data recorders were recovered, that turbulence and an unstable atmosphere likely initiated the events that ultimately allowed them lose control of the aircraft.

The crew of Air France 447 never gained awareness of what happened. However, after the recovery of the flight data and cockpit voice recorders, we knew what happened. We had seen this before.

The opening quote in this post is not from Jean-Paul Troadec, head of the Investigation and Analysis Bureau, and Alain Bouillard, investigator-in-charge of the BEA (pictured above), rather it is from the NTSB report following the crash of Northwest 6231, December 1, 1974. There was only the crew of three on the Boeing 727-251 that departed JFK for Buffalo, NY. This flight was a reposition of the aircraft to pick up the Baltimore Colts football team. The aircraft weighed about 147,000 lbs. Although empty, was a moderate weight for the Boeing 727 carrying 48,500 lbs. of fuel.

The First Officer had only 46 flight hours in the right seat at Northwest, having upgraded from Boeing 707 Second Officer six weeks earlier. Prior to takeoff the crew did not ensure the pitot heat was turned on as called for on the checklist. Unlike the very sophisticated flight management displays of the Air France A330 manufactured in 2005, the 5-year-old Boeing 727 built in 1969 had only analog “round dial” instruments for each pilot. The aircraft was also fitted with the typical attitude and horizontal situation indicators found on that vintage 727. There were only 4 aural warnings on the B-727 back then, over-speed, stall, gear warning and cabin altitude. Nevertheless, like the Air France crew, the crew of Northwest 6231 faced some very confusing and illogical information from their flight instruments.

Along with other flight in the area, NW 6231 encountered icing conditions on their departure from JFK.   At 16,000 feet on their climb the First Officer said, "Do you believe that we're going 340 knots and I'm climbing 5,000 feet a minute?" The Second Officer commented, "That's because we're light."  At 23,000 feet their indicated airspeed was 405 knots and the over-speed warning sounded. The following exchange took place. Captain: "Would you believe that #." First Officer: "I believe it, I just can't do anything about it." Captain: "No, just pull her back, let her climb." Then over-speed sounded again. 5 seconds later the altitude was 24,800 feet and the pitch was 30 degrees nose up. The stall warning (stick shaker) activated and the First Officer commented, "There's the Mach buffet, guess we'll have to pull it up." The Captain then commanded, "Pull it up." The landing gear warning horn sounded indicating the thrust levers had been reduced to idle.

The crew desperately reported they were in stall in a "Mayday" call to air traffic control, however, they never utilized any effective recovery procedures as the airplane rapidly descended in a tight spiral. Flight recorder data indicated a pitch of minus 50 degrees and roll of 70-80 degrees. At about 3,500 feet the elevator failed at about +5g. The aircraft descended from 24,800 feet to the ground in 83 seconds.

In contrast, although just as desperate, the last words recorded on the CVR transcript of Air France 447 were, “But what’s happening....?”

I have spent many hours thinking about these unfortunate airmen and what are they trying to say to us. What do they want us to learn? What lesson are they trying to teach? This is what I think the lesson is. When distracted, stressed or confused all humans can act in very inconsistent and unpredictable ways. Effective training will only help us deal with our humanity, but cannot remove us from it.

This is why, “We are them.”

Below are links to the referenced accident reports.

Northwest 6231

Air France 447
 

We Hold These Truths ...........

Today is the 4th of July, the day we celebrate the birth of our nation as documented by the signing of the Declaration of Independence.  The genius of our Founders has allowed the United States of America to provide more freedom, liberty and wealth to more people than by any other government in history.  When we hold to the principles outlined in the Declaration America is at its best.  We we lose focus on those ideals our country and its citizens are diminished.

"We hold these Truths to be self-evident, that all Men are created equal, that they are endowed by their CREATOR with certain unalienable Rights, that among these are Life, Liberty and the Pursuit of Happiness. — That to secure these Rights, Governments are instituted among Men, deriving their just Powers from the Consent of the Governed,……"

The latest Real Clear Politics average poll results show that less than 18% of the population approve of Congress performance. That would not meet anyone's definition of "consent of the governed".  I believe that at least part of that disapproval is a result of the loss of focus on the Founders instructions.  Personal freedom, and that includes the responsibility for our choices, is the essence of American exceptionalism.

Although not as well known and quoted as the Declaration of Independence, one of the fathers of aviation, Wilbur Wright, had some things to say about the fundamentals of operating his new machine.

“What is chiefly needed is skill rather than machinery.”- Wilbur Wright

“It is possible to fly without motors, but not without knowledge and skill.”- Wilbur Wright

“Do not let yourself be forced into doing anything before you are ready.”- Wilbur Wright

The inventors of the airplane understood from the beginning that the machine was an extension of the human. The pilot and his choices were responsible for the outcome of the flight.  The Wright Brothers had just invented a tool that would change the world like no other since the wheel, yet Wilbur knew that the human was the master of the tool and not the reverse.  

When humans, whether in the role of pilot or citizen, abdicates their responsibility of control, the outcome diminishes.  In either role we need to be knowledgeable, informed, and engaged.  If we aren't careful, we could end up in San Francisco instead of Philadelphia.

Just as the words of our Founders are true today, so are the words of Wilbur Wright.  

Happy 4th of July.

The Road To Hell Is Paved With Good Intentions

While the news media has been busy lately looking for disgruntled ex wives and off shore accounts, there has been some other news more relevant to the aviation industry.  Yesterday I was reading about the late Rube Goldberg, whose cartoons became well known for depicting complex devices that performed simple tasks in indirect, inefficient, creative and convoluted ways.  I couldn’t help but think about recent events in Europe in the pursuit of environmental nirvana. Their new carbon tax system, ETS, the harbinger of a cap and trade system in the United States, went into effect January 1, 2012.  It has been in effect less than a month it is already having a profound effect on airlines that fly within and without Europe.

IATA, the International Air Transport Assn., has estimated that the ETS will cost the airline industry overall $1.16 billion this year, up to $3.63 billion in 2020.  Passing on the costs to consumers alone will not work, according to a 2007 study commissioned by the aviation industry. It found that airlines would themselves have to absorb a large proportion of the additional costs, estimating that complying with the ETS would cost carriers more than $60 billion between 2011 and 2022.

The ersatz logic of the European carbon tax (i.e. cap and trade) was explained in a World Bank draft report on "Mobilizing Climate Finance.  "…..a modest carbon tax — at around $25 per ton — would be a straightforward way to cut aviation emissions. The tax would raise ticket prices 2 to 4 percent, the World Bank estimates, while emissions would fall by 5 to 10 percent. Slightly fewer people would fly, but most of the gains would come from airlines finding more efficient routes and sending their older, dirtier aircraft into early retirement."  Aviation generates about 3% of the world’s CO2 emissions.  It has been estimated that US carriers are responsible for about half of that percentage. 

Biofuels have been touted as a major part of the plan to reduce CO2 emissions from jet aircraft.  Unfortunately, biofuels are not currently a viable option for the airline industry.  They are not widely available.  They are very expensive, about 9 times the cost per gallon of traditional jet fuel.  The kicker is that for all their negatives, biofuels still emit from 50% to 75% as much CO2 per mega joule of energy as traditional jet fuel.

If understood correctly, it means the airlines will be expected to reduce their emissions by flying fewer passengers on less route, on newly purchased aircraft with a limited supply of expensive fuel.  In pursuit of lower CO2, the already overregulated European Union is going to further burden and further regulate one of the few positive segments of the world’s economy, air transportation.  The U. S. State Department argues that ICAO, the aviation arm of the United Nations is the venue for this issue.  It tried unsuccessfully to get the carbon tax postponed or excluded until ICAO decided the issue. The European Court of Justice dismissed the State Department’s suit in December.  In the mean time travelers can expect to pay US$ 3.00 – 6.00 surcharge to the European Union for their trip across the Atlantic.

Some countries have said they may not pay the tax.  The United States, Russia and China among other countries have threatened retaliatory measures if the carbon tax is not rescinded.  Recently the Chinese news agency, Xinhua, editorialized in The Financial Times: “This is a trade barrier in the name of environmental protection, and it constitutes an attack on the interests of travelers and the international aviation industry. It will be difficult to avoid a trade war focused on a 'carbon tax' for airlines.”  The European Commission then responded, “Airlines failing to follow a new European law requiring them to account for their emissions of greenhouse gases could face a ban from European airports.”

The European carbon tax, ETS, may be successful at generating significant additional expense for the airline industry, but it will do almost nothing to change CO2 emissions.  This is an absurd scheme, not because airline companies are environmentally insensitive, but there is no viable alternative at the present time.  Rube Goldberg, however, would be extremely proud of the plan.

"I'm Here To Help You"

The Transportation Security Administration is the poster child for the incompetence of the federal government.  It's not that they don't do anything, it's that they do it poorly, inefficiently, expensively and insensitively.  We need to demand better of our government.  Protecting its citizens is the fundamental responsibility of the federal government.  It is not that the TSA is not properly funded or staffed.  Screeners are paid very well as unskilled workers.  Requirement for a TSA Screener starting position is the same as a Wal Mart associate.   Screeners generally start at about twice the hourly rate of an employee at Wal Mart and a full benefits package verses the lack of any benefits for the Wal Mart associate.  It's hard to understand why most Wal Mart associates are friendly while most TSA employees do not display a helpful attitude.  When I go through a security checkpoint at the larger airports there never seems to be a lack of TSA employees.  TSA Managers can earn well in excess of $100,000 annually.

In spite of very competitive wages and benefits as well as adequate staffing, there continues to be incidents of screener misconduct and incompetence.  After first denying the allegations of Lenore Zimmerman, 85, of Long Beach, N.Y., and 88-year-old Ruth Sherman, of Sunrise, Fla., the TSA finally admitted this week to improperly screening the ladies medical devices.  In November 2011 these ladies were asked to remove clothing, in an unapproved manner, to conduct secondary security screening.  Ms. Sherman was required to undergo the humiliation of displaying her colostomy bag.  The TSA's justification for these de facto strip searches is to ensure that no weapons get aboard airliners.

On January 18th of this year Judith Kenney, a 65 year old Addison, Texas attorney boarded an American Airlines flight from Dallas to Houston one and a half hours after going through a TSA security checkpoint with a loaded .38 caliber revolver left mistakenly in her briefcase.  There was no intent by Ms. Kenney to carry the weapon aboard.  After an extensive search of Terminal D and considerable disruption to passenger, Ms. Kenney was located on one of the many flight that had been held on the tarmac.  Ms. Kenney apologized to the pilots and passengers as she was taken into custody.  The Ft. Worth Star Telegram quoted Bruce Schneier, an author and aviation security expert about the incident.  "They really made her day miserable, and if she was a terrorist, they would have caught her," Schneier said. "Which means the whole gun system is working great, even if there is a failure."  Mr. Schneier added, "Guns in carry-on bags are spotted 9 times out of 10, so terrorists are unlikely to bring guns into airports given the high chance of being caught." 

I might disagree with applauding a 90% success rate of finding weapons given the lengths some of the screeners use.  The real threat, I believe, is the person not the weapon.  Focus the resources on those individuals that can be reasonably identified as a threat.  If there is something in a person's background or behavior that arouses suspicion, I am all for enhanced screening no matter how old or in firmed they are.  I have always wondered why more canines have not been deployed to airports.  Until the latest technology was deployed post 9/11 dogs were more accurate than machines in identifying explosives.  Today, in all but a few airports in the US, crew members must still be screened at the same checkpoints as the customers.  Over a decade after 9/11 we are just now implementing a system that acknowledges the identity of flight crew members. 

If the TSA is going to base their security strategy on finding the weapons vis a vis identifying the terrorists they need to come up with a system that is more sensitive to the customers and better at locating contraband at the checkpoint.  Unfortunately, the federal government has decided to address aviation security the same way it does everything else, with lots of money, bureaucracy and political correctness, but very little common sense.

One Flight At A Time

The results are in.  2011 was the safest year ever for the airlines.  The safest form of travel is even safer.  As it has been for decades, the most dangerous part of an airline journey is the automobile journey to the airport.  You are still more likely to die by lightning than from an airline accident.  Where do we go from here?

There were still fatalities in 2011, just not very many.  For those fatally injured in airline accidents and their loved ones that fact is not much comfort.  Can we drive the number of fatalities to zero? I believe we can.  We do not need to accept that airline fatalities will always be a reality.  Even when airborne mechanical failures degrade the aircraft’s airworthiness, fatalities are not inevitable.

The strategy to achieve this goal is simple.  One flight at a time is how we do it.  This is not as ambitious as it might seem.  If we were to do a forensic analysis of the fatal accidents of 2011 we would see that there was a point in each flight where the safe outcome was no longer assured.  Circumstance and human factors allowed the potential for disaster to evolve from possible to probable to inevitable.

Terrain does not rise up and strike the aircraft, rather just the opposite.  The runway does not posses the ability to control the aircraft.  The control of the aircraft and the associated decisions are the sole responsibility of the crew.  Crews can relegate most of the functions of flying the modern aircraft except decision-making and aircraft control.  ICAO data shows that the most likely causes for an accident are CFIT, loss of control and runway safety issues.

It is absolutely possibly to report zero fatalities next year.   

For us in North America, we don’t have that far to go.  In some other areas of the world, it might take a more dramatic effort, but I believe the worldwide brother and sisterhood of airline professionals are up to the challenge.  It won’t be the managers or the dispatchers.  It will be the same as it always has been.  Passengers will be putting their lives in the hands of their pilots.  It is an honor to have that responsibility.