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	<title>Plastic Pilot &#187; Air Accidents</title>
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	<link>http://www.plasticpilot.net/blog</link>
	<description>General Aviation and Aviation In General</description>
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		<title>2 things we can learn today from the Tenerife disaster</title>
		<link>http://www.plasticpilot.net/blog/2010/04/21/2-things-we-can-learn-today-from-the-tenerife-disaster/</link>
		<comments>http://www.plasticpilot.net/blog/2010/04/21/2-things-we-can-learn-today-from-the-tenerife-disaster/#comments</comments>
		<pubDate>Wed, 21 Apr 2010 18:00:59 +0000</pubDate>
		<dc:creator>Vincent</dc:creator>
				<category><![CDATA[Air Accidents]]></category>
		<category><![CDATA[Guest Posts]]></category>
		<category><![CDATA[lessons learned]]></category>
		<category><![CDATA[Tenerife]]></category>

		<guid isPermaLink="false">http://www.plasticpilot.net/blog/?p=3393</guid>
		<description><![CDATA[This is a guest post from Jason Schappert, the blogger behing www.m0a.com, and my associate in the Flying Across America project. He comes back on aviation&#8217;s worst disaster, and what it teaches today. In 1977, one of the worst disasters in aviation history occurred in the Spanish island of Tenerife, in the Canary Island group. [...]]]></description>
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<p>This is a guest post from Jason Schappert, the blogger behing <a title="www.m0a.com" href="http://www.m0a.com">www.m0a.com</a>, and my associate in the Flying Across America project. He comes back on aviation&#8217;s worst disaster, and what it teaches today.</p>
<p>In 1977, one of the worst disasters in aviation history occurred in the Spanish island of Tenerife, in the Canary Island group. What makes this accident distinct is the fact that the mishap occurred on the ground, and involved two large-bodied aircraft.</p>
<p>The Tenerife disaster warrants a closer look as it was a perfect example of what happens when there is miscommunication coupled with poor weather conditions.</p>
<p>Upon close examination of the results of the investigation, it has been observed that the Tenerife tragedy had been caused by several mistakes from which lessons could be gleaned for the generations to follow.</p>
<p><strong>Poor Communication</strong></p>
<p>Miscommunication had ensued between the control tower, the Pan-American Flight Clipper 1736 and the KLM Flight 4805 during the last few moments leading to the collision. KLM’s crew misread the ATC message which specified a post-takeoff route as a clearance for takeoff. The control tower also misinterpreted the KLM Flight as stationary thus giving Pan Am time to taxi away from the runway, but what happens was when that message was broadcasted KLM was nearing the runway and ready to roll. While Pan Am was still turning into the taxiway slowly because of the apparent poor visibility.</p>
<p>If there’s any lesson clearly taught by Tenerife, it’s the fact that the controllers and flight crew need to double check with one another if for some reason you’re just not sure.</p>
<p><strong>There Should Be No Assumptions on Runway Status</strong></p>
<p>Another crucial factor in the final moments of each flight was the fact that some messages did not come across due to simultaneous transmission. Particularly, KLM 4805 did not receive Pan Am Clipper 1736’s transmission that they are still taxiing due to the double transmission. The tower could’ve relayed the message and not assumed that KLM received the message, which it did not. As mentioned earlier, the tower had thought that KLM 4805 was stationary and awaiting flight clearance. This was due to the fog, but the controller could’ve verified the status of KLM.</p>
<p>Although considered to be one of the worst aviation disasters in our history it’s vital that we learn from this even in our everyday general aviation flights.</p>
<p>To learn more about Jason and his flight training blog visit him at <a href="http://www.mzeroa.com/" target="_blank">www.MzeroA.com</a></p>
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		<title>Death on the 4th attempt</title>
		<link>http://www.plasticpilot.net/blog/2010/04/11/death-on-the-4th-attempt/</link>
		<comments>http://www.plasticpilot.net/blog/2010/04/11/death-on-the-4th-attempt/#comments</comments>
		<pubDate>Sun, 11 Apr 2010 18:00:29 +0000</pubDate>
		<dc:creator>Vincent</dc:creator>
				<category><![CDATA[Air Accidents]]></category>
		<category><![CDATA[crash]]></category>
		<category><![CDATA[Smolensk]]></category>

		<guid isPermaLink="false">http://www.plasticpilot.net/blog/?p=3358</guid>
		<description><![CDATA[On 10th of April 2010, a Tupolev 154 operated by the Polish Air Force crashed just north of Smolensk, Russia, killing all 96 on board, including many Polish officials and Polish President Lech Kaczyński. This accident occurred while the Smolensk airbase was covered with thick fog, and the aircraft was flying its fourth approach. This [...]]]></description>
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<p>On 10th of April 2010, a Tupolev 154 operated by the Polish Air Force crashed just north of Smolensk, Russia, killing all 96 on board, including many Polish officials and Polish President Lech Kaczyński. This accident occurred while the Smolensk airbase was covered with thick fog, and the aircraft was flying its fourth approach.</p>
<p>This is a national tragedy for Poland, and a personal tragedy for the relatives of the victims, and my first thoughts are for them.</p>
<p>Investigation is started, and will may be uncover unexpected facts, but there&#8217;s a very strong hint that the crew was under pressure. The crash occurred on the fourth approach. Not the first, not even the second. No, the fourth. There are millions of reasons for a pilot to decide to go-around and take a second chance on an approach when its not looking good. Check my &#8220;<a title="Going around is not a crime" href="http://www.plasticpilot.net/blog/2009/07/31/going-around-is-not-a-crime-and-even-less-a-threat/" target="_self">Going around is not a crime</a>&#8221; post to read more about this very standard maneuver.</p>
<p>But why four ? Fog can form and then vanish rapidly, particularly during the first hours of a day, but not that rapidly. The temptation of taking a second chance on an approach missed because of fog can be strong, but one should refrain from doing it. I don&#8217;t know what kind of approach was flown in this case (precise, non-precise, DME, timed, &#8230;) but if the aircraft did reach the minimums in good conditions on the first attempt, there is no reason to take a second one.</p>
<p>On a non-precision approach (without glide-slope), it is possible that the aircraft was above the minimum altitude when reaching the distance or time at which the go-around procedure must be started. This is the only case where a second approach in fog should be attempted. But four&#8230; I can&#8217;t imagine that pilots flying for a head of state were not able to fly an approach correctly three times in a row.</p>
<p>So what&#8217;s left ? Pressure on the crew ? Sounds likely. I never flown commercially, or for an head of state, but I can imagine the kind of pressure this crew had from the delegation on board. The president, his wife, many ministers and deputies, the head of Polish Olympic Committee, and many others. Landing there became such a &#8220;must&#8221; that the crew disregarded the possibility of flying to their alternate airport. I hope the cockpit voice recorder recordings will be released, to know what the crew discussed.</p>
<p>Was a diversion even discussed ? Did some officials intervene directly in the cockpit ? Was the cockpit really &#8220;clean&#8221; during the four approaches ? How was the fuel situation ? Flying four approaches consumes a lot of the fuel planned for a diversion. The flight took place early in the day, and was not very long (approx. 1h40) so crew fatigue should not be a factor. A second aircraft carrying journalists landed there before, and this probably added pressure to the crew. They did it before&#8230;</p>
<p>One is certainly much smarter after an accident than before, and criticizing from the comfort of my office is certainly easy, but I really feel like this will be a perfect case for human factor studies. Just like almost all recent aviation accidents.</p>
<p>Will we ever learn from our mistakes ?</p>
<p>For more details about the accident itself, the wikipedia page entitled &#8220;<a title="Wikipedia page on the accident in Smolensk" href="http://en.wikipedia.org/wiki/Smolensk_air_crash" target="_blank">2010 Polish Air Force Tu-154 crash</a>&#8221; is a good starting point.</p>
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		<title>What to expect from the Concorde trial ?</title>
		<link>http://www.plasticpilot.net/blog/2010/02/02/what-to-expect-from-the-concorde-trial/</link>
		<comments>http://www.plasticpilot.net/blog/2010/02/02/what-to-expect-from-the-concorde-trial/#comments</comments>
		<pubDate>Tue, 02 Feb 2010 18:00:13 +0000</pubDate>
		<dc:creator>Vincent</dc:creator>
				<category><![CDATA[Air Accidents]]></category>
		<category><![CDATA[Concorde]]></category>
		<category><![CDATA[trial]]></category>

		<guid isPermaLink="false">http://www.plasticpilot.net/blog/?p=3213</guid>
		<description><![CDATA[A French court starts the final phase of the Concorde trial today. The hearings are planned to last for four months, after eight years of investigation. The families of the victims will play a secondary role only, as most of them have been &#8220;compensated for their losses&#8221; by AirFrance. This wording is awful, isn&#8217;t it [...]]]></description>
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<p>A French court starts the final phase of the Concorde trial today. The hearings are planned to last for four months, after eight years of investigation. The families of the victims will play a secondary role only, as most of them have been &#8220;compensated for their losses&#8221; by AirFrance. This wording is awful, isn&#8217;t it ? Anyway, that&#8217;s not the point.</p>
<p>The favorite hypothesis is that a titanium blade fallen from a Continental aircraft which took-off before Concorde damaged a tire. A piece of rubber supposedly hit the wing, damaged a fuel tank, causing the fire which lead to the loss of the aircraft. Lawyers are still in action, and at least the French speaking media are full of speculations.</p>
<p>The AirFrance strategy seems to be to point towards Continental, using the &#8220;no blade &#8211; no crash&#8221; theory. One of Continental&#8217;s lawyer said that he intends to &#8220;use the hearings to demonstrate things that the experts did not understand so far&#8230;&#8221;. There are lots of eye-witnesses: airport firemen, other crews, passengers, and lots of non-aviation oriented persons. Some pretend that the fire started well before the aircraft rolled over supposed place of the titanium blade and other theories will certainly be discussed.</p>
<p>I&#8217;m not sure what to expect from this trial. The BEA (French equivalent of the NTSB) published its report years ago (check the <a title="Aviation Accidents" href="http://www.plasticpilot.net/blog/accidents/">Aviation Accidents page</a> for more details) and as all aviation investigation report, it aims at establishing facts, not responsibilities. This is the role of the court, and given the amount of money that such cases involve, the pressure quite high.</p>
<p>My crystal ball is undergoing maintenance, so I can&#8217;t say anything about the direction the court will follow, but I can imagine several scenarios:</p>
<ul>
<li>Bad hair day &#8211; Nobody&#8217;s guilty. As we say in French, &#8220;la faute à pas de chance&#8221;. Unpredictable circumstances, no faults, no sentence. Given the human price of this accident, this seems unlikely.</li>
<li>Scapegoat &#8211; Look away everybody! An obscure mechanic, preferably retired, will be blamed for the whole thing. The whole settlement will then depend upon the employer of that unfortunate person.</li>
<li>50 / 50 &#8211; Everybody&#8217;s happy. Shared responsibility between Continental and AirFrance, and may by Concorde&#8217;s manufacturer, and the tires manufacturer. When no one is innocent, no one is really guilty, isn&#8217;t it ?</li>
<li>La surprise du Chef &#8211; Chief&#8217;s surprise. Courts can make issue surprising rulings, and this case is complex enough to leave lot of room for a surprise, which I can&#8217;t anticipate, by definition&#8230;</li>
</ul>
<p>I&#8217;ll keep an eye on this trial and will surely post here again with news when they will break out. In the mean time&#8230; hypothesis anybody ?</p>
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		<title>Aviation accident updates &#8211; Osaka and Spanair</title>
		<link>http://www.plasticpilot.net/blog/2009/09/09/aviation-accident-updates-osaka-and-spanair/</link>
		<comments>http://www.plasticpilot.net/blog/2009/09/09/aviation-accident-updates-osaka-and-spanair/#comments</comments>
		<pubDate>Wed, 09 Sep 2009 18:00:48 +0000</pubDate>
		<dc:creator>Vincent</dc:creator>
				<category><![CDATA[Air Accidents]]></category>

		<guid isPermaLink="false">http://www.plasticpilot.net/blog/?p=2791</guid>
		<description><![CDATA[Aviation accidents are popular and attract lots of media attention. I both understand and regret this situation, but I can&#8217;t do a lot about it. The worst part is when rumors and speculation start &#8211; particularly when they are later confirmed as false. Investigation are always long and complex, and are all but attractive to [...]]]></description>
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<p><a title="PlasticPilot on aviation accidents" href="http://www.plasticpilot.net/blog/accidents/" target="_blank">Aviation accidents</a> are popular and attract lots of media attention. I both understand and regret this situation, but I can&#8217;t do a lot about it. The worst part is when rumors and speculation start &#8211; particularly when they are later confirmed as false. Investigation are always long and complex, and are all but attractive to mainstream media.</p>
<p>Updates were published recently about two accidents I posted about. The first one is the China Airlines Boeing 737 that burned after landing in Osaka. Click <a title="Boeing 737 catches fire after landing in Osaka" href="http://www.plasticpilot.net/blog/2007/08/20/china-airlines-boeing-737-catches-fire-in-japan-about-certification-standards/">here</a> and <a href="http://www.plasticpilot.net/blog/2007/08/29/airworthiness-directives-b737-burning-in-osaka/">here</a> to read more about this accident, during which the aircraft was destroyed by fire but no one was injured. Two years and eight days after the accident, the investigation authority published the final report. Not bad if you consider that the aircraft was completely destroyed by fire. Causal factors have been identified by the operator, the maintenance organization and the manufacturer. These factors include the way some maintenance documents were designed. <a title="aviation-safety.net about the China Airlines accident in Osaka" href="http://aviation-safety.net/news/newsitem.php?id=2179" target="_blank">Click here to read more about the final report about the China Airlines Boeing 737 that caught fire after landing in Osaka.</a></p>
<p>The investigation about the <a title="Reflections on the spanair accident in Madrid" href="http://www.plasticpilot.net/blog/2008/08/31/reflections-on-the-spanair-accident-in-madrid/">Spanair accident in Madrid</a> is not completed yet, but the <a title="Interim investigation report about the Spanair accident in Madrid" href="http://www.fomento.es/MFOM/LANG_CASTELLANO/DIRECCIONES_GENERALES/ORGANOS_COLEGIADOS/CIAIAC/INVESTIGACION/2008/SPANAIR/INTERINO_01_ENG.htm" target="_blank">investigation authority published an interim report</a>. Even if the investigation is still ongoing, the interim report contains one recommendation:</p>
<blockquote><p>&#8220;To promote the holding of an international conference, to be attended by every civil aviation representative organization, such as authorities, industry, academic and research institutions, professional associations and the like, for the purpose of drafting directives on good industry practices in the area of aviation operations as they apply to checklist design, personnel training and improved procedures and cockpit work methods so as to ensure that crews properly configure aircraft for takeoffs and landings.&#8221;</p></blockquote>
<p>This sounds a bit fuzzy&#8230; My understanding of it is that the relatively old cockpit of the MD-80 is more complex than modern ones. This is supported by the following sentence, extracted from the same report: &#8220;Current generation airplanes are equipped with computer-controlled instruments45 that are effective in helping crews avoid configuration errors.&#8221; Page 7 of the report contains three pictures illustrating the various controls and indicators related to the high-lift devices. Not exactly located centrally. I&#8217;m not saying that the MD-80 cockpit is unsafe, this airplane has a good safety record. But simpler, more integrated cockpits can help reduce crew&#8217;s workload.</p>
<p>I&#8217;m really looking forward to the final report and the causal factors. You can count on me to post about it again when the investigation will be completed.</p>
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		<title>About AirFrance flight 447</title>
		<link>http://www.plasticpilot.net/blog/2009/06/14/about-airfrance-flight-447/</link>
		<comments>http://www.plasticpilot.net/blog/2009/06/14/about-airfrance-flight-447/#comments</comments>
		<pubDate>Sun, 14 Jun 2009 18:00:04 +0000</pubDate>
		<dc:creator>Vincent</dc:creator>
				<category><![CDATA[Air Accidents]]></category>
		<category><![CDATA[AF447]]></category>
		<category><![CDATA[Airbus 330]]></category>
		<category><![CDATA[aircraft accident]]></category>
		<category><![CDATA[AirFrance]]></category>

		<guid isPermaLink="false">http://www.plasticpilot.net/blog/?p=2425</guid>
		<description><![CDATA[12 days ago, 228 lives were abruptly lost when the AirFrance flight 447 from Rio de Janeiro to Paris disappeared in the Atlantic Ocean. My thoughts go at first to the families and relatives of the victims. Now that the initial mediatic storm is over I want to comment on certain points. This post is [...]]]></description>
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<p>12 days ago, 228 lives were abruptly lost when the AirFrance flight 447 from Rio de Janeiro to Paris disappeared in the Atlantic Ocean. My thoughts go at first to the families and relatives of the victims.</p>
<p>Now that the initial mediatic storm is over I want to comment on certain points. This post is based on questions that friends of mine asked. Some are reactions to unclear or partial information heard in the media. This post is about thunderstorms, radar coverage, communication, automated messages, electronic flight instruments and flight controls, pitot tubes, and causality.</p>
<p><strong>Thunderstorms</strong><br />
Thunderstorms are powerful things. Can one destroy an aircraft ? Yes, indeed. Over the Read this older <a href="http://www.plasticpilot.net/blog/2007/06/16/what-planes-can-and-cant-do-thunderstorms-and-hail/">post about thunderstorms</a> for more details. Pilots avoid thunderstorms using the on board weather radar. No crew will ever fly in a thunderstorm without a working weather radar. Beyond lightning and hail, thunderstorms also contains massive quantity of water and icing.</p>
<p><strong>Radar coverage</strong><br />
The exact position of the accident was not known for a simple reason: there is no radar coverage over the ocean. A typical radar has a range of 150 to 200 nautical miles, which is much less than the distance flown over the Atlantic. Even if a radar was installed on each island, many holes would remain.</p>
<p>But what about GPS ? Yes, GPS is global. But remember, GPS is used by the aircraft to determine its position. The GPS system is &#8220;one-way&#8221;. The satellites are not informed about the position of the receivers.</p>
<p><strong>Communication</strong><br />
Over land and near the coasts, pilots and controllers communicate using VHF radio. This requires direct line of sight between the transmitter and the receiver. The range of such radio is limited because the Earth is not flat.</p>
<p>HF and satellite are working over the ocean but they are not reliable or easy to use. Typically, pilots receive two HF frequencies before crossing the ocean and have to use one or the others, depending the state of the ionosphere. Moreover, proximity with thunderstorms don&#8217;t facilitate communication because of electromagnetic perturbations.</p>
<p><strong>Automated messages</strong><br />
The aircraft sent a certain number of messages about failed systems. These messages are transmitted via the ACARS system to the airline&#8217;s maintenance unit. They are designed to inform the maintenance teams about the works to be done and help them prepare their intervention. Aircraft are complex systems and almost all flight sends at least one such message. Because of this limited purpose, these messages do not contain the position of the aircraft at the moment the failure occurs.</p>
<p><strong>Electronic flight instruments and flight controls</strong><br />
Airbus aircraft are equipped with computer screens that replace the classical, mechanical instruments and <a href="http://www.plasticpilot.net/blog/2009/06/08/fly-by-wire-explained-by-an-airbus-pilot/">fly by wire</a> systems which interpret pilot inputs and fly the aircraft accordingly. Is this high technology less reliable than &#8220;good old&#8221; electro-mechanical instruments and direct, hydraulically assisted controls ?</p>
<p>The safety record of Airbus is not bad at all. This A330 is indeed the third being lost within almost fifteen years. Remember that the certification standards are the same for all aircraft, whatever the technology they use. Are such modern aircraft too complex, are they &#8220;pieces of engineering&#8221; ? These are the classical things heard after each Airbus incident. Once again, the safety record seems to speak against that. Media never report about all the cases where the technology compensated for pilot errors. 80% of recent accidents find their roots in human (not always pilot) error.</p>
<p><strong>Pitot tubes</strong><br />
The pitot tubes are the sensors measuring the speed of the aircraft with respect to the surrounding air. They are tubes pointed in the direction of flight and provide air to a pressure sensor. The pressure generated by forward movement is measured and this is the base for speed measurement. If they get obstructed or damaged, the pilot and flight computers don&#8217;t get a correct speed reading anymore. The Airbus 330 is equipped with three pitot tubes.</p>
<p>Loosing all of them is not an enviable situation because the difference between stall speed and overspeed at high altitude is really small. However it the pitch attitude and power setting are maintainted there is no reason the aircarft would depart controlled flight.</p>
<p><strong>Causes and effects</strong><br />
In the present situation, we have very partial information only about what happened via the maintenance messages. A crutial part is missing: which of these messages are causes and which ones are effects. For example, the autopilot was disconnected. Was it because it failed or did the crew disconnect it for some reason ? The <a href="http://www.plasticpilot.net/blog/2007/08/17/the-black-box-is-orange/">black boxes</a> will tell a lot more, if they can be found. Until then, all what will be said will be speculation only.</p>
<p>I hope this post helped you to clarify your thoughts about this accident. Feel free to ask for more via comments.</p>
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		<title>The last 7 minutes of Colgan 3407</title>
		<link>http://www.plasticpilot.net/blog/2009/05/12/the-last-7-minutes-of-colgan-3407/</link>
		<comments>http://www.plasticpilot.net/blog/2009/05/12/the-last-7-minutes-of-colgan-3407/#comments</comments>
		<pubDate>Tue, 12 May 2009 18:00:21 +0000</pubDate>
		<dc:creator>Vincent</dc:creator>
				<category><![CDATA[Air Accidents]]></category>
		<category><![CDATA[Pilot Reports]]></category>
		<category><![CDATA[Colgan 3407]]></category>
		<category><![CDATA[CVR]]></category>
		<category><![CDATA[recodrings]]></category>

		<guid isPermaLink="false">http://www.plasticpilot.net/blog/?p=2245</guid>
		<description><![CDATA[This post is no judgement but expresses personal views about the CVR transcripts of Colgan flight 3407 which crashed near Buffalo. The investigation is not yet completed and the causes have not been established. There are however certain relevant points in these transcripts. This post focuses on the last seven minutes. 22:09:12: ATC clears Colgan [...]]]></description>
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<p>This post is no judgement but expresses personal views about the <a title="Transcripts of Colgan 3407 cockpit voice recorder" href="http://www.plasticpilot.net/blog/?file_id=60" target="_blank">CVR transcripts of Colgan flight 3407</a> which crashed near Buffalo. The investigation is not yet completed and the causes have not been established. There are however certain relevant points in these transcripts. This post focuses on the last seven minutes.</p>
<p><strong>22:09:12</strong>: ATC clears Colgan 3407 down to 4&#8217;000 feet. The approach procedure for ILS 23 is started and &#8220;sterile-cockpit&#8221; rules shall apply. This means focusing on the approach to the exclusion of any other topic. No private conversations, no disturbance of any kind.</p>
<p><strong>22:10:22</strong>: First mention of visible ice on the windshield.</p>
<p><strong>22:10.57:</strong> The crew discusses about career and training.</p>
<p><strong>22:11:39</strong>: The discussion goes on about experience.</p>
<p><strong>22:12:05:</strong> The co-pilot is talking about ice again: &#8220;<em>I&#8217;ve never seen icing conditions. I&#8217;ve never deiced. I&#8217;ve never seen any—  I&#8217;ve never experienced any of that. I don&#8217;t want to have to experience that and make those kinds of calls. you know I&#8217;dve freaked out. I&#8217;dve have like seen this much ice and thought oh my gosh we were going to crash</em>&#8221;</p>
<p>Reading from a transcript and hearing a person you work with is different and it&#8217;s hard to judge about the tone, but these remarks should have helped to re-focus the discussion on the present icing situation.</p>
<p><strong>22:12:37:</strong> The Captain continues the previous discussion: &#8220;<em>yeah uh I I spent the first three months in uh Charleston West Virginia and<br />
uh flew</em>&#8230;&#8221;</p>
<p>There is no further mention of ice, the conversation continues and the approach goes on normally. The transcript mentions &#8220;sounds similar to power increase&#8221; a couple of times. There is no mention of low speed or high pitch from the crew.</p>
<p><strong>22:16:21: </strong>The crew extends the landing gear.</p>
<p><strong>22:16:23:</strong> The Captain calls for flaps and before landing checklist. The approach seems to unfold in a perfectly normal way.</p>
<p><strong>22:16:27:</strong> The CVR records the sound of the stick shaker for 6.7 seconds. This is a safety mechanism which alerts the crew about a too low speed and risk of stall. Almost at the same time, the auto-pilot disconnect alert sound is recorded, which lasts until the end of the recording.</p>
<p><strong>22:16:35</strong>: The sound of the stick-shaker starts again, and is present until the end of the recording.</p>
<p><strong>22:16:46:</strong> The co-pilot suggests to retract the gear and the Captain requests it.</p>
<p><strong>22:16:53:</strong> End of recording.</p>
<p>The stick shaker is a quite aggressive mechanism, and it can hardly go unnoticed. This aircraft was also equipped with a second level of safety mechanism, known as stick pusher. If a stall occurs this mechanism pushes the control column to lower the aircraft&#8217;s nose and regain some speed. The transcripts makes no mention of it. Transcriptions of the flight data recorder (FDR) are not yet available but a lot of discussions are going on. It *seems* (read: not confirmed) that the Captain counter-acted the stick pusher, but this is both hard to do and to understand.</p>
<p>These transcripts raise many questions regarding the level of training and experience of the crew. I wrote questions and not that they were not up to the tasks. The particular environment in this cockpit could also be discussed but none of the crew survived and even CVRs can&#8217;t recreate the working atmosphere. I&#8217;m writing very carefully because I don&#8217;t have the competence to issue any judgment and I have only partial information. What I try to do here is to identify interesting points to be discussed, and to share the information I have. As always, any comment is welcome</p>
<p>On the same topic, <a href="http://fl250.blogspot.com/2009/05/canary-in-coal-mine.html" target="_blank">Sam from FL250</a> wrote an interesting post, already on the 10th of May. He also posted later on with <a title="Sam from Blogging at FL250 about Colgan 3407" href="http://fl250.blogspot.com/2009/05/thirty-seconds-of-silence.html">some details from the FDR</a>.</p>
<p>The present post has also been indirectly fed by Twitter discussions between <a title="TheGimliGlider on twitter" href="https://twitter.com/TheGimliGlider" target="_blank">@TheGimliGlider</a> (including a NASA video about<a title="NASA video on tailplane icing" href="http://bit.ly/v1EKS" target="_blank"> tailplane icing</a>, you can also check his <a href="http://thegimliglider.blogspot.com/" target="_blank">blog</a>) and <a title="mickyl on Twitter" href="https://twitter.com/mickyl" target="_blank">@mickyl,</a> who also <a href="http://comeletsflyaway.blogspot.com/2009/05/im-going-to-try-to-update-more-often.html">posted on the same topic on her blog</a> and also about <a title="Mickyl on Dash8, tailplane icing and more" href="http://comeletsflyaway.blogspot.com/2009/05/bit-of-discussion-on-tailplane-icing.html" target="_blank">Dash8, icing and autopilot</a>.</p>
<p>Once again, this post only aims at highlighting interesting points, not to charge or blame anyone. Many pilots and aviation enthusiasts discuss this accident. Such discussions (particularly when incorrectly relayed by mainstream media) may seem cold and disrespectful to the victims, but their sole goal is to learn from this accident and improve the system. As always, any comment is welcome&#8230; as long as it goes in this direction. This accident is before all a human catastrophe for the victims (incuding the crew), their families and their relatives. Any disrespectful comment will be deleted.</p>
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		<title>Nothing about Amsterdam &#8211; More about Accidents</title>
		<link>http://www.plasticpilot.net/blog/2009/02/28/nothing-about-amsterdam-more-about-accidents/</link>
		<comments>http://www.plasticpilot.net/blog/2009/02/28/nothing-about-amsterdam-more-about-accidents/#comments</comments>
		<pubDate>Sat, 28 Feb 2009 19:00:59 +0000</pubDate>
		<dc:creator>Vincent</dc:creator>
				<category><![CDATA[About this blog]]></category>
		<category><![CDATA[Air Accidents]]></category>
		<category><![CDATA[accident]]></category>
		<category><![CDATA[Amsterdam]]></category>
		<category><![CDATA[Boeing 737-800]]></category>
		<category><![CDATA[crash]]></category>
		<category><![CDATA[Schipol]]></category>
		<category><![CDATA[Turkish]]></category>

		<guid isPermaLink="false">http://www.plasticpilot.net/blog/?p=1639</guid>
		<description><![CDATA[A Boeing 737-800 operated by Turkish crashed shortly before landing at Amsterdam Schipol. The aircraft was broken in three parts but did not catch fire. Many passengers could leave the wreckage on their own, but some others were killed, including the captain and first-officer. Investigators are at work. These are facts &#8211; any information about [...]]]></description>
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<p>A Boeing 737-800 operated by Turkish crashed shortly before landing at Amsterdam Schipol. The aircraft was broken in three parts but did not catch fire. Many passengers could leave the wreckage on their own, but some others were killed, including the captain and first-officer. Investigators are at work. These are facts &#8211; any information about factors or (even worse) causes are speculation. My thoughts and sympathy go to the victims and their relatives. Loosing someone in such brutal and sudden circumstances is always a tragedy.</p>
<p>I don&#8217;t have additional information and do not want to speculate about this accident. If you want to read more about it, <a href="http://www.google.com" target="_blank">google</a>, <a href="http://www.cnn.com" target="_blank">CNN</a>, <a href="http://www.reuters.com" target="_blank">reuters</a>, <a href="http://www.bbc.co.uk" target="_blank">the BBC</a> and many other news sites are your friends. Instead of spending my daily blogging time by finding links that will become irrelevant in a couple of days, I decided to further develop the page dedicated to <a href="http://www.plasticpilot.net/blog/accidents/">Aviation Accidents</a>.</p>
<p>The <a href="http://www.plasticpilot.net/blog/accidents/" target="_self">Aviation Accidents</a> page went online almost six months ago and was the first of a series of theme-oriented pages which I continue to develop on this website. Check the &#8220;Read more about&#8230;&#8221; section in the navigation column to find more pages. Aviation accidents is the perfect example of topic that&#8217;s not time related and thus better addressed via a page than specific posts. This page naturally contains links to other posts about aviation accidents but also tips to get a better understanding of accidents, investigation and media reaction.</p>
<p>The list of links to accident reports that was published in the first version of this page is still present and will continue to evolve over time. It&#8217;s always fascinating to see how different the final report is from the initial media report and the first speculations.</p>
<p>So if you&#8217;re interested in this topic, click here to visit my <a href="http://www.plasticpilot.net/blog/accidents/" target="_self">Aviation Accidents</a> page, and if you like it don&#8217;t forget to link to it or send a link to your friends.</p>
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		<title>The Absence of Unacceptable Hazard</title>
		<link>http://www.plasticpilot.net/blog/2009/02/21/the-absence-of-unacceptable-hazard/</link>
		<comments>http://www.plasticpilot.net/blog/2009/02/21/the-absence-of-unacceptable-hazard/#comments</comments>
		<pubDate>Sat, 21 Feb 2009 19:00:22 +0000</pubDate>
		<dc:creator>Vincent</dc:creator>
				<category><![CDATA[Air Accidents]]></category>
		<category><![CDATA[On Airports and Airlines]]></category>
		<category><![CDATA[Speaker's Corner]]></category>
		<category><![CDATA[accident]]></category>
		<category><![CDATA[closure]]></category>
		<category><![CDATA[safety]]></category>
		<category><![CDATA[Samedan]]></category>
		<category><![CDATA[snow]]></category>
		<category><![CDATA[support]]></category>

		<guid isPermaLink="false">http://www.plasticpilot.net/blog/?p=1594</guid>
		<description><![CDATA[If you&#8217;re fit in safety management you already know that safety is defined as the absence of unacceptable hazard. This is a very formal way to say that as hazards are present in any system and must be mitigated to reach an acceptable level of safety. A typical approach is to classify hazards according to [...]]]></description>
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<p>If you&#8217;re fit in safety management you already know that safety is defined as the absence of unacceptable hazard. This is a very formal way to say that as hazards are present in any system and must be mitigated to reach an acceptable level of safety. A typical approach is to classify hazards according to their severity and probability of occurrence. This results in a visual hazards chart where the limits between what is acceptable or not must be defined. If a hazard is located in the &#8220;unacceptable&#8221; area, mitigation measures must be implemented to reduce its impact or probability of occurrence to bring it back in the &#8220;acceptable&#8221; area.</p>
<p>I know that this does not sound really &#8220;aviation-oriented&#8221; for the time being, but you&#8217;ll soon see what is the point&#8230; This classification principle sounds very systematic and almost scientific but it is only high-precision guesswork. The severity and probability of occurrence are not really easy to evaluate but this is nothing in comparison to the definition of the acceptable and unacceptable. Is a mid-air collision every 50 years acceptable ? How many runway incursions leading to a go-around are acceptable per year ? High-precision guesswork. Ask the same question to two professionals, you&#8217;ll get three different answers.</p>
<p>The definition of what is acceptable or not can also vary with time and events, and sometimes rather abruptly &#8211; as shown after an accident in Samedan (LSZS). Samedan is the highest airport in Europe, at 5&#8217;600 feet AMSL, in Eastern Switzerland, in the vicinity of Davos. The quantities of snow in the heart of the Alps in such a cold winter are quite impressive but the runway is properly de-snowed. Snow-walls along the runway are quite common and even a few meters away from the runway borders they can be well over a meter high. Because of its proximity with Davos the airport is used intensively during the World Economic Forum, but also throughout the whole ski season by rich skiers. Business jets operate there frequently.</p>
<p>On the 12th of February, a Falcon 100 skidded off the runway after landing, after what its wingip did hit a snow-wall. The preliminary description contained in the accident notification issued by the investigation body reads: &#8220;<em>Aircraft touched down left of centreline with the right wing first, then with right main gear. The aircraft drifted to the left and touched with the left wing a snow wall at the runway edge. The aircraft nose hit the snow wall frontally. The aircraft turned to the left and broke into two parts.</em>&#8221; The two crew members were fatally injured and the passenger severly injured. No finger-pointing here, just facts. Despite being unusual in comparison with other airports, the conditions that prevailed were not out of the norm for Samedan.</p>
<p>After the accident, the Federal Office for Civil Aviation (FOCA) decided to close the airport, because the height of the snow-walls is above what is prescribed in ICAO standards. Standards provide good guidance but can not always be applied by the letter. As long as they are well supported and accepted, deviations are acceptable. The deviations in Samedan were well known by the airport, by FOCA and by operators using the airport.</p>
<p>What does this all mean from the safety analysis point of view ? The presence of snow-walls was certainly identified as a hazard, which was possibly reduced via some mitigation measures to finally land in the &#8220;acceptable&#8221; area of the evaluation matrix. Because of various causes which will be determined by the investigation this hazard possibly contributed to an accident. Not to 0.0001% of an accident, but to an actual one. Does this accident have an impact on the previous classification of the hazard ? Is the snow more dangerous after an accident ? The answer is obviously no. If you hurt yourself with a knife, the knife is not more dangerous after the accident than before&#8230;</p>
<p>There is certainly something to learn from this accident &#8211; there&#8217;s something to learn from any accident &#8211; but closing the airport and requiring the application of standards that were previously not applied for good reasons looks to me like a bit of a panic-based reaction. The accident occured to a Falcon 100, right ? So why not ground the whole Faclcon fleet ? And the accident occured on a snowy airport. Close all of them ! After all, this &#8220;aviation&#8221;-thing is way to risky. This shall stop now ! Stop the whole aviation system, there was an accident !</p>
<p>There is however a positive side in this story. The airport resources being simply unsufficient to match the new requirements suddenly dictated by an almighty authority, it called for help. Many local construction companies sent trucks, snow-cleaners and bulldozers, and more than 300 simple citizens with gloves and shovels (well&#8230; some politicians as well) joinded the effort, voluntarily.  After one and a half day, the airport was matching the newly required standards and operations restarted. This was a splendid support demonstration from the local business and people to their airport. There is no airline activity in Samedan&#8230; people shown their attachement to a 100% General Aviation airport, and this makes me feel really good <img src='http://www.plasticpilot.net/blog/wp-includes/images/smilies/icon_smile.gif' alt=':-)' class='wp-smiley' /> </p>
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		<title>Icing</title>
		<link>http://www.plasticpilot.net/blog/2009/02/17/icing/</link>
		<comments>http://www.plasticpilot.net/blog/2009/02/17/icing/#comments</comments>
		<pubDate>Tue, 17 Feb 2009 19:00:40 +0000</pubDate>
		<dc:creator>Vincent</dc:creator>
				<category><![CDATA[Air Accidents]]></category>
		<category><![CDATA[On Airports and Airlines]]></category>
		<category><![CDATA[autopilot]]></category>
		<category><![CDATA[Buffalo]]></category>
		<category><![CDATA[icing]]></category>
		<category><![CDATA[Q400]]></category>

		<guid isPermaLink="false">http://www.plasticpilot.net/blog/?p=1562</guid>
		<description><![CDATA[The accident of a Continental Dash 8 Q400 in Buffalo raises some interesting questions about one of important weather hazards: icing. Note that I never said that icing is the cause of this accident &#8211; it is way too early to know about the causes &#8211; but it is a good opportunity to talk about [...]]]></description>
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<p>The accident of a Continental Dash 8 Q400 in Buffalo raises some interesting questions about one of important weather hazards: icing. Note that I never said that icing is the cause of this accident &#8211; it is way too early to know about the causes &#8211; but it is a good opportunity to talk about icing.</p>
<p>Icing occurs when an aircraft meets liquid water at temperatures below freezing. Liquid water at temperature below freezing ? Yes, this can happen. Cooling water below freezing is not sufficient to turn water into ice. The crystallization process also requires a solid support to start. Water droplets found in clouds are made of pure water and no impurity can serve to start the process. If the air is cold enough these droplets can reach temperature below freezing and become &#8220;supercooled&#8221;. But supercooled is not super-cool (sorry &#8211; I could not resist) because when an aircraft meets such droplets, it acts as a perfect starter for the crystallization process. When flying in clouds at temperatures between 0 and -15 degrees Celsius there is a risk of ice build-up on the airframe, propeller, and any exposed part of the aircraft: landing gear, rudder, elevator, &#8230; Below -15 °C, the air can&#8217;t usually contain enough water to create icing hazard.</p>
<p>Ice affects aircraft in many ways &#8211; none of them being positive:</p>
<ul>
<li>airfoils shape is altered making them less effective (wings but also elevator, rudder, ailerons and propeller blades)</li>
<li>weight increases</li>
<li>air-intakes &#8211; including pitot and static &#8211; can be obstructed by ice</li>
<li>in extreme cases control surfaces can be locked in position by ice accretion</li>
</ul>
<p>Different systems have been developped to fight against ice. Anti-ice system aim at preventing ice formation. On light aircraft they are based on fluids dripping out of micro holes on the leading edges or on electrical heating for propeller blades or windshield. De-icing systems are used to remove ice after if it form. On light aircraft and some turboprops this takes the form of pneumatic boots: rubber tubes on the protected surfaces (mostly leading edges) that inflate and break the ice accumulation. On jet aircraft both anti-ice and de-ice use hot air from the turbines (bleed air) which is directed on the surfaces to be de-iced.</p>
<p>The black-boxes of the Dash 8 Q400 destroyed in the Bufalo accident revealed that the anti-ice system was activated during most of the flight. The crew discussed about the observed ice accumulation on the windshield but never qualified it of &#8220;severe&#8221;. The flight data recorder shown that the aircraft&#8217;s pitched up to 31 degrees, then down to -45 and the bank angle increased over 100° before the end of the recording. The autopilot was engaged when the things started to get wrong.</p>
<p>I don&#8217;t know about the causes of the crash in Buffalo nor if what follows is applicable but it is worth discussing it in a general way. Icing is not affecting all parts of an aircraft the same way. As all turbulent phenomena the impact of icing is not easy to predict. It can impact wings and elevator differently, or make a prop become unbalanced. You probably remember from your basic aerodynamics courses that the horizontal tail plane&#8217;s role is also to maintain the airplane&#8217;s pitch controllable. If the tail airfoil is badly impacted by ice the airplane can become uncontrollable.</p>
<p>The use of autopilot in icing conditions is generallly not recommended, and sometimes formally forbidden. I don&#8217;t know about the autopilot used on the Dash 8 &#8211; once again, I don&#8217;t have any idea about the causes of this accident &#8211; but here is an extract of the DA42 aircraft flying manual supplement about the &#8220;Flight In Known Icing&#8221; conditions. By default the DA42 is not certified to fly in icing but with some extra equipment this can be allowed (more about this in a later post). This supplement contains the following remark about the autopilot:</p>
<blockquote>
<p style="text-align: left;">Use of the autopilot is prohibited when any ice is observed forming aft of the protected<br />
surfaces of the wing, or when unusual lateral trim requirements or autopilot trim warnings<br />
are encountered.</p>
<p style="text-align: left;">NOTE<br />
The autopilot may mask tactile cues that indicate adverse  changes in handling characteristics; therefore, the pilot should consider not using the autopilot when any ice is visible on the airplane.</p></blockquote>
<p>This is quite self-explanatory, but once again I don&#8217;t know if this applies to the Dash 8, this was a simple illustration how nasty icing can be. For light aviation icing is a very serious hazard and the only way to deal with it is to escape the icing area as soon as possible, even if this means turning around.</p>
<p>I&#8217;ll continue to read the information released by the NTSB about the accident in Buffalo. If you want to read more about it you can follow the following links:</p>
<p><a href="http://www.aero-news.net/index.cfm?contentBlockId=64af59cf-5209-46bb-8151-7ec76c45424f" target="_blank">Aero-news network about use of autopilot</a></p>
<p><a href="http://www.avweb.com/blogs/insider/AvWebInsider_Flight3407AndIcing_199779-1.html" target="_blank">AvWeb.com about icing</a></p>
<p><a href="http://www.avweb.com/avwebflash/news/Q400PitchedUp31DegreesBeforeCrash_199780-1.html?CMP=OTC-RSS" target="_blank">AvWeb.com about changes in attitude during the accident in Buffalo</a></p>
<p><a href="http://www.aero-news.net/index.cfm?contentBlockId=05fc105c-d443-42a4-ad20-a6ca49f39ef9" target="_blank">Aero-news network about FAA recommendations on icing</a></p>
<p>I posted here about my <a href="http://www.plasticpilot.net/blog/2007/09/01/geneva-biggin-hill/" target="_self">personal experience</a> and <a href="http://www.plasticpilot.net/blog/2008/03/31/light-aircrafts-and-icing/">opinion about icing and light aircraft</a>. Click <a href="http://aircrafticing.grc.nasa.gov/courses.html" target="_blank">here</a> if you want to <a href="http://aircrafticing.grc.nasa.gov/courses.html" target="_blank">learn more about icing from NASA</a>.</p>
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		<title>Dash 8 Q400 crashed in Buffalo</title>
		<link>http://www.plasticpilot.net/blog/2009/02/13/dash-8-q400-crashed-in-buffalo/</link>
		<comments>http://www.plasticpilot.net/blog/2009/02/13/dash-8-q400-crashed-in-buffalo/#comments</comments>
		<pubDate>Fri, 13 Feb 2009 19:00:01 +0000</pubDate>
		<dc:creator>Vincent</dc:creator>
				<category><![CDATA[Air Accidents]]></category>
		<category><![CDATA[3407]]></category>
		<category><![CDATA[accident]]></category>
		<category><![CDATA[Bombardier]]></category>
		<category><![CDATA[Buffalo]]></category>
		<category><![CDATA[Continental]]></category>
		<category><![CDATA[Dash 8]]></category>
		<category><![CDATA[Q400]]></category>

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		<description><![CDATA[A Bombardier Dash 8 Q400 operated as Continental Connection Flight 3407 was en route from Newark to Buffalo when it went down at around 10:20 p.m. ET, about seven miles from Buffalo Niagara Airport, killing all on board. If you landed on this blog because your favorite search engine directed you here, it is because [...]]]></description>
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<p>A Bombardier Dash 8 Q400 operated as Continental Connection Flight 3407 was en route from Newark to Buffalo when it went down at around 10:20 p.m. ET, about seven miles from Buffalo Niagara Airport, killing all on board. If you landed on this blog because your favorite search engine directed you here, it is because I posted about the Dash 8 Q400 by the end of 2007 and begin of 2008 when this aircraft type was affected by landing-gear issues (click <a href="http://www.plasticpilot.net/blog/2008/03/12/dash8-q400-incidents-secret-agreement-between-bombardier-and-sas/">here</a> to read more about that).</p>
<p>Back then, several Dash 8 Q400 had incidents were the landing gear collapsed on touchdown or shortly after. Even if it is way to early to talk about the causes of the Buffalo accident it seems quite obvious that it has nothing in common with a landing gear collapsing on landing. This sounds cautious but surprises are always possible and even saying that this accident has nothing to do with the landing gear is prematurate.</p>
<p>I don&#8217;t have any information about this accident apart from what has been published by medias like <a href="http://edition.cnn.com/2009/US/02/13/plane.crash.new.york/index.html" target="_self">CNN</a> and <a href="http://www.reuters.com/article/topNews/idUSTRE51C12T20090213" target="_blank">reuters</a>. Continental has already published several information bulletins (click <a href="http://www.continental.com/web/en-US/content/news/flight3407.aspx" target="_blank">here</a> to read them). Bombardier also published a <a href="http://www.bombardier.com/en/corporate/media-centre/press-releases/details?docID=0901260d800801ab" target="_blank">press-release</a> which is limited to the usual sympathies to the victims and confirmation taht they are supporting the investigation.</p>
<p>There is not much to say for the time being and if you read about &#8220;probable causes&#8221; or even &#8220;evidences&#8221; it can only be speculation. Investigating such an accident requires time and finding the exact causes are not always possible. If you want to read more about aviation accidents and investigation I suggest that you visit my &#8220;<a href="http://www.plasticpilot.net/blog/accidents/">Aviation Accidents</a>&#8221; page.</p>
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