Sunday, July 13, 2014
From the NTSB history of the flight (italics):
Pre selecting the missed approach altitude is common practice by B777 crews. However, setting an altitude above the aircraft without the flight guidance capturing and maintaining either an altitude or glide slope caused the autopilot to initiate a climb. The pilot naturally and appropriately disconnected the autopilot and manually flew the aircraft. Unfortunately, that unusual set of circumstances caused the auto throttle mode to remain in "HOLD" and not respond to the commanded speed as the crew expected.
Flight 214 was handed off to, but not acknowledged by, San Francisco Tower. In combination with the ATC imposed energy management complication, lack of electronic glide slope and flight guidance mode confusion, this was another significant distraction.
Sunday, April 6, 2014
On reports that possible “pings” from flight data recorders, Retired Air Chief Marshal Angus Houston, head of the Australian agency coordinating the search operation, briefed the press. "We are treating each of them seriously. We need to ensure before we leave any of those areas that this does not have any connection with MH370,"
It is very encouraging that there is some hard data to report in the search for Malaysian Flight 370. It’s only fitting that the Australians are assuming a leadership role in the hunt for the missing Boeing 777. It’s not just because of the proximity to the search location nor the vital role of the Australian vessel Ocean Shield or Air Chief Marshal Houston. It is because an Australian, Dr. David Warren, invented the flight data and cockpit voice recorders that have become the “holy grail” of this investigation.
Dr. David Warren was born in 1925 in the remote Northern Territories of Australia. To receive a better education he attended 12 years of boarding school in Sydney. His father’s last gift to him before an untimely death in a plane crash in 1934 was a crystal radio set. David hoped to pursue radio telephony and electronics, however, the war efforts were inconsistent with “radio hams” and he turned to his other hobby chemistry. Chemistry took his career path into the fuels industry, but he became famous for his contributions in electronics.David was involved in the accident investigations related to the mysterious crash of the world’s first jet-powered aircraft, the Comet, in 1953. He theorized that the cause of the accident would be obtained much easier if they knew what statements, if any, about the aircraft’s malfunctions the crew might have made in their last moments. He proposed a device to record cockpit conversations. Aviation had little interest for such a device at that time. However, Warren built a prototype based on a miniature wire recorder he had purchased. Voice and sound could be recorded on this pocket-sized device. He built two prototypes, one for voice and one for recording aircraft parameters such as speed, altitude, heading, etc.
There was little acceptance of the devices in Australia, however, a British company bought the manufacturing rights and began to produce cockpit voice and flight data recorders. Dr. Warren liked to share how his devices, which in fact are bright orange for better visibility, became known as the "Black Boxes". Warren says, “It was called a black box because in the records of my meeting in London when it was first demonstrated and they were so keen, one of the people in the discussion afterwards said, ‘This is a wonderful black box.’ And a black box back then was a gadget box. You didn't have to understand it but it did wonderful things.”
Coincidentally, the first government to make the flight and voice recorders mandatory was Australia. The step was taken after the investigation of a Fokker F27 crash in Queensland did not have enough information to reach a definite conclusion in the probable cause of the accident.
Dr. Warren’s “Black Boxes” and the information they've provided have contributed more to aviation safety than any other single device. They are the only way we will ever know the fate of Malaysian Flight 370.
Friday, March 28, 2014
The FAA is soon to implement “Climb Via” procedures and phraseology into SID (Standard Instrument Departures) clearances. On the surface it doesn’t seem like a big deal. “Descend Via” clearances have been around for some time. What has been learned, mostly through the non-punitive data collection efforts of the FAA, pilot unions, operators and LOSA (Line Operational Safety Audits) is that tactical reprogramming of the FMS (Flight Management System), particularly with respect to the vertical path, creates many threats. When real time adjustments are made to the FMS with LNAV (lateral navigation) and or VNAV (vertical navigation) engaged, the associated threats are increased many fold and their consequences are much greater. The vast majority of these threats involve communication. The remaining threats involve the pilot’s ability to effectively monitor the aircraft. There is a very critical communication process, especially in FMS equipped aircraft that must be precisely followed in order for an ATC clearance to be effectively consummated.
First and most important, the clearance must be clearly communicated. It must be understood and correctly read back by the pilots. The pilots must make the necessary inputs to the aircraft’s flight controls, either manually or through the auto flight systems. Those inputs must be crosschecked to ensure their compliance and accuracy. Finally, the crew must identify any inconsistencies between the acknowledged clearance and the aircraft’s current and anticipated speed, course and vertical path must monitor the aircraft. This communication process between ATC, pilots and aircraft is simple, but at the same time very complex. This is especially true of FMS equipped aircraft that, once programmed, have the “capability” to completely control speed, course and vertical path with no pilot input or supervision.
The final and most pernicious component of this communication process is time. During periods of time compression, i.e. when either the controller or pilots are rushed, are the most fertile territory for error. Generally this time compression is initiated by the controller’s need to make a tactical change to the SID or STAR (Standard Terminal Arrival Route). The dynamic environment air traffic controller must deal with drives the time critical changes. These tactical changes are usually communicated to the crew with minimal notice. Hence, the introduction of time compression into the communication paradigm between pilot crew, air traffic control and the aircraft. When this tactical change is received the crew is asked to rapidly understand it and transmit the changes to the aircraft. Most often this is done through the FMS and auto flight systems. This reprogramming of the FMS as well as time compression introduces many threats, i.e. potential for error. Time compression often causes the crew to abbreviate verification protocols. Just when extra scrutiny is needed most, crews short cut valuable error mitigation steps to try to expeditiously comply with the clearance.
When short cuts result in an error, a deviation from the clearance, it is often labeled as intentional non-compliance by the crew. That is a gross over simplification. More often than not the error comes from the crews attempt to respond the actual or perceived time compression introduced by ATC. Sometimes it feels like we’re at a “ho down” and the faster ATC fiddles the faster we need to dance. I have seen this time compression many times, often at Denver International Airport (KDEN). When a “Descend Via” clearance is modified the reprogramming of the flight guidance systems ranges from simply adjusting the altitude selector to reprogramming the entire arrival. This happens every day at KDEN when the crew is given a completely new arrival at, just prior to or even after the aircraft has begun its descent. This can be extremely challenging to do correctly and in a timely manner.
A solution to these threats includes a better understanding by air traffic control of the complexities of managing the sophisticated flight management systems on today’s modern aircraft. In September 2001 the predominant aircraft types were MD-80s, B-727s, DC-10s and older models of the B-737. There was also a number of FMS equipped aircraft, but not the large number of RNAV arrivals in use today. In over 12 years since 9/11 I have only had one air traffic controller ride in the flight deck. I know why, but that doesn’t eliminate the fact. My guess is that very few air traffic controllers working today that have ridden on the flight deck on modern airliners and observed crews manipulate the flight management systems in “real world” operations.
Another solution would be for ATC to use less off course vectoring for spacing arrivals. This would reduce the need to amend and reissue “Descend Via” clearances. RNAV arrivals are designed to minimize the amount of off course vectoring. London’s Heathrow airport (EGLL), one of the busiest in the world and equipped with only two runways, has a very efficient arrival without all the complexities of the typical RNAV arrival in the United States. The EGLL arrivals have only a couple of step down fixes and one speed limit point and ends at a holding fix adjacent to the airport. When the arrival rate exceeds capacity, the holding pattern acts as a buffer and eliminates the need for vectoring. Planes always leave the holding fix on a downwind heading. Speeds have been 220 knots on downwind, 180 knots on base and 160 knots on final since the days of the B-707. It’s very predictable and ATC issues very few amendments.
Another solution to communication problems between ATC and pilots would be for everyone to talk more slowly and clearly. The objective should not be the number of words spoken in the shortest amount of time, rather the amount of information effectively communicated. Pilots could do their part by using proper radio phraseology. Controllers need to speak clearly and deliberately. Talking fast and using jargon may sound cool, but is not the most effective way for controllers and pilots to communicate.
Sunday, March 23, 2014
Many relatives, close friends and trusted colleagues have asked me to weigh in on the Malaysia Airlines “circus”. I choose to call it a circus because that’s exactly what it is. It’s flamboyant, over-the-top and cheesy with the cast made up of some very talented, but often very bizarre performers doing and saying dumb and crazy things.
I don’t know what happened to the Boeing 777 and I am quite certain that no one else who is speaking publicly does either. The “Infotainment Industry” is going wild and getting all the attention they’re trying for. The coverage is sleazy and lucrative and let us not forget, like a circus, it’s a business. There are some very responsible, but mostly invisible, aviation writers out there who aren’t making wild and unsubstantiated speculations. They are studying, doing research and asking questions. They are trying to report responsibly and elevate the conversation. They know who they are (cn), but we don’t because they aren’t pontificating naive and ignorant theories.
I’ve heard these very unfortunate events, like the disappearance of MH370 where many lives are unaccounted for, referred to as “crack” for the media outlets. The longer it goes on the bigger their “high”. Unfortunately, for some media executives the 239 potential fatalities might just be seen as part of their business. Harsh, but that’s certainly what it looks like sometimes. Pretty soon everything is sacrificed for their “drug”. Our culture has deteriorated to the point where we are like the parents who were recently sued by their daughter. We have allowed things to get out of control little by little and then wonder how it ever got that way.
In the word’s of Harper Lee’s character, Mayella Ewell, “That’s all I’m gonna say and I ain’t gonna say no more.”
Monday, February 10, 2014
Jay Leno ended his 22 year run as the host of “The Tonight Show” last week. I was moved by the heartfelt goodbye his cracking voice delivered to the audience.
“Boy, this is the hard part. I want to thank you, the audience. You folks have been just incredibly loyal. This is tricky. Ah, we wouldn’t be on the air without you people. Secondly, this has been the greatest 22 years of my life.
I am the luckiest guy in the world. I got to meet presidents, astronauts, movie stars, it’s just been incredible. I got to work with lighting people who made me look better than I really am. I got to work with audio people who made me sound better than I really do. And I got to work with producers and writers and just all kinds of talented people who make me look a lot smarter than I really am.“
Jay Leno and I are, within a couple of weeks, exactly the same age. He grew up in the 50’s and 60’s on the east coast and I on the west. We graduated from college about the same time and perused careers that were only slightly related to our degrees. He majored in speech therapy and I in physical science.
Jay started doing stand up comedy and got his break when he moved to Los Angeles and started writing for television. I got my break when I joined the Air National Guard and went to Air Force pilot training. From there we honed our respective crafts and eventually moved into a leadership position. There were good times and not so good times both financially and in the relationship with our respective employers. All of that seems to be of very little importance now.
Billy Crystal, a long time friend and colleague of Jay’s, was his first guest when he took over “The Tonight Show” from Johnny Carson. It was only fitting that he asked Crystal to be his final guest. Billy brought with him his date planner from 40 years earlier. It had Jay’s address and phone number of the apartment where he, Jay and the other young comics they knew would hang out together. Their expressions gave away a flood of emotions. That was the same reaction when I recently ran across paperwork from when I was a Boeing 727 Captain in the late 80’s. In an instant all the memories came rushing back.
Next year when it’s my turn to hand over the controls, I will shamelessly plagiarize his words. I expect I will speak with a cracking voice.
Reflecting on the all the good things of a memorable career is the hard part. I want to thank the people who put their trust in me and in my crew to get them to their destination safety. You are the only reason I have had this wonderful job all these years. With the exception of the time I have spent with my family, my time at the airline has been the most rewarding of my life.
I also feel like the luckiest man in the world. I was able to travel to every corner of the globe and fly some of the most sophisticated and iconic airplanes every built. Besides the consummate professionals I flew with, I got to work with technicians that made the airplanes incredibly reliable. I got to work with Flight Attendants that made my job much easier than I deserved. Most of all, I was the recipient of all the thankless efforts of the many people working behind the scenes to make me look smarter and more capable than I would ever be on my own.
Jay, I get it.
Wednesday, January 29, 2014
I was a senior in college when I first thought seriously of making aviation a career. Like many before me, the first thing I did was to buy a copy of FLYING magazine. There were lots of advertisements for flying schools and stories about all different types of airplanes and their avionics. However, the article I enjoyed the most was, and still is, “I Learned About Flying From That”. I am not sure why I found it so interesting, but I couldn’t get enough of them. Before I had even taken my first flying lesson, I had read many of the articles that shared the stories of pilots who told the reader what they had learned from their “experience”.
I guess it is no surprise that after earning a private pilot’s license, flying in the military and over 35 years as an airline pilot, I am still fascinated by pilots telling their stories. I especially like hearing pilots’ self-critique of what they thought worked out well and what did not. I have used the information from those stories countless times in my career to keep me out of trouble or elevate my flying skill. I think many other pilots, private and professional alike; find the narratives have tremendous value.
I recently wondered when the first installment of “I Learned About Flying From That” appeared in FLYING. The magazine was originally entitled POPULAR AVIATION, and was first published in November 1927. However, “I Learned About Flying From That – No. 1” first appeared in the May 1939 issue. The publishers included a preface under the title of this first article. “This is the story of a pilot who had a harrowing experience that taught him a lesson. It is our hope that other airmen will profit by his mistake.” The first “I Leaned About Flying From That” was a story written about a rescue mission to Alaska in a Ford Tri Motor. The author, Garland Lincoln, relates the circumstances, including the weather and his decision making process, that allowed their flight to end with the Tri Motor upside down in the mucky tundra. Garland writes, “The lesson I learned? That, whether or not lives are at stake, taking chances is silly.”
The Aviation SafetyAction Program (ASAP) was initiated and authorized by the FAA for the same purpose. It was intended to be a venue “to enhance aviation safety through the prevention of accidents and incidents. Its focus is to encourage the voluntary reporting of safety issues that come to the attention of employees and certain certificate holders.”
It is unfortunate that ASAP has not been more successful sharing the actual experiences of airline pilots’ lessons learned in real life situations. Each one is another “I Learned About Flying From That”. Each one includes a narrative of the situation that initiated the report and then there is an opportunity for the pilot to self evaluate. How would this situation be handled differently if it were encountered again? What advice would be given to others to better prepare them for a similar situation? Professional pilots are always interested to hear advice from their peers that will keep them out of trouble.
Currently the data is collected and analyzed and then distributed through standardized recommendations or via new or amended standard operating procedure. I absolutely support the “just culture” that calls for immunity and anonymity unless there is reckless intent. However, ASAP data is not just for safety managers. Once these reports have been de-identified and any retraining has been accomplished, the raw information needs the widest distribution. It needs to be seen by line pilots as soon as possible. The narratives would be seen by line pilots as essential reading. Pilot associations as well should get behind the distribution of these reports not just protecting the anonymity of the data.
Saturday, January 25, 2014
In the most recent edition of Air Transport World magazine, Robert W. Moorman writes an excellent article reviewing the advances in technology that have improved flight safety. The article ends with quotations from (FSF) Flight Safety Foundation’s CEO Kevin Hiatt. Hiatt gives a statistic that most airline safety managers are aware of, but have not been able to change. He said, “What we’ve discovered is that 96% of the approaches in the system are flown correctly. But in the 4% that are not, we’re finding that the pilot is continuing to fly the approach, rather than initiate a go-around.” In fact, some airlines have been able to increase the percentage of stable approaches, but not the percentage of unstable approaches that result in a go-around.
This conundrum has no hardware solution. The statistics are solely dependent on decision-making. There is not a device that can prevent a pilot from making a poor or ineffective decision. Only training and experience can improve effective decision-making statistics. By experience, I mean the collective experience of all pilots. As the FSF has been doing for decades, data must be collected and shared among professional airmen for the purpose of collective knowledge. What is not being widely done, however, is using this body of data to help pilots learn decision-making skills.
Decision-making (DM) is not the same as standard operating procedure (SOP). In fact, it is just the opposite. Decision-making is, by definition, a choice. SOP does not rely on choice, rather strict obedience. Imagine a spectrum with DM at one extreme and SOP at the other. That spectrum defines the environment that pilots live in. Contemporary training and proficiency standards for commercial pilots are biased very heavily to the SOP end of the spectrum. Pilots are taught how to comply with SOP, but much less training is focused on how to remain within SOP or more importantly how to recover when a deviation from SOP has occurred. It’s easy to label this area as intentional non-compliance, but that would be far too simplistic.
Pilot performance outside SOP is exactly the territory the FSF data describes. When an unstable approach occurs, SOP is no longer controlling the outcome. If it were, the approach would not be unstable or a go around would always be accomplished. When outside SOP, decision-making will be the determining factor. However, the data shows that pilots can be very ineffective when making these decisions. The major approach and landing accidents from 2013 at SFO, LGA and BHM as well as two recent occurrences of landing at the wrong airport further support this position.
Decision-making is not simply a plot on a risk matrix. It is a proactive and deliberative process that evaluates and matches choices to the existing or expected conditions. The choice will most likely be dependent on the goal of the decision maker. If safety is perceived as the primary goal, landing will become subordinate. Conversely, if landing is the goal, it will drive the choice selection. In other words, “I am going to stay safe and land if it works out.” or “I am going to land and I think I can stay safe while I do that.”
Why have the hardware “safety enhancers” of airplanes been more successful than the pilots that fly them? I believe it is because the developers of hardware devices accept failure as a possibility, whereas writers of SOP do not accept the reality of non-compliance whether or not intentional. No component is ever installed on an aircraft without a tested and trained process in the event of it’s failure. What is the process for failure of SOP? Are we to expect that all pilots will follow all SOP all of the time? If not, then what is the process for human failure?
Airline pilots spend hours and hours in the classroom and simulators learning procedures for both normal and non-normal situations. They are carefully evaluated on their knowledge of what to do in the event of system failures. They practice and debrief realistic scenarios over and over to be prepared for extremely rare events. How much time is spent learning how to manage human failures? I bet it’s pretty close to 4%.