Flight Safety Information June 6, 2011 - No. 114 In This Issue Air France Crash Suggests Inadequate Training Chile volcano ash cloud shifts direction The job: Aircraft repo man Santa Monica Suspends Fast Jet Fight Air India out of money, pilots warn passenger safety could suffer ERAU Graduate Survey Air France Crash Suggests Inadequate Training The focus of the investigation into why Air France Flight 447 crashed into the Atlantic a year ago is starting to change now that safety experts have begun evaluating information from the Airbus A330-200's flight recorders. Questions surrounding human factors are moving into the spotlight as the investigation further unfolds, with concerns of turbulent weather and pitot-tube icing shifting into the background. French accident investigation agency BEA released a three-page memo May 27 containing factual information excerpts that is likely to be followed by a more in-depth interim report within the next few weeks, possibly by the end of this month. The final report is not expected until 2012; it should also address concerns raised by some about technical problems with the A330. Initial analysis of the flight data and cockpit voice recorders is revealing more about what caused AF447 to crash on June 1, 2009: The aircraft stalled at 38,000 ft. and was never recovered. The sequence of events suggests that proper stall recovery procedures could have prevented the accident. Inflight loss-of-control accidents were the most frequent cause of fatal airliner crashes and by far the deadliest in 2000-09. Of the 89 fatal accidents recorded in the period, 20 were attributed to inflight loss of control; 16 were caused by controlled flight into terrain. Recent crashes linked to stalls include that of the Colgan Air Bombardier Q400 on approach to Buffalo, N.Y. (2009); Turkish Airlines Boeing 737-800 in short final for Amsterdam (2009); West Caribbean Airways MD-82 in Venezuela (2005); Thomsonfly Boeing 737-300 near Bournemouth, England (2007); and XL Airways Germany Airbus A320 off the coast of Perpignan, France (2009). "Most approach-to-stall incidents and accidents occur with sufficient altitude available for the recovery," Boeing Senior Safety Pilot Mike Coker told delegates at the Flight Safety Foundation's European Aviation Safety Seminar in Istanbul this year. "Incidents progress to accidents when the crew fails to make a positive recovery after the stall warning occurs." Flawed training is partly to blame, he asserts. Approach-to-stall training is typically conducted at simulated altitudes of 5,000-10,000 ft., but many stalls actually happen much higher. In the case of AF447, stalls occurred at 35,000 ft. and 38, 000 ft., respectively. That has important, negative implications, Coker concludes. "Recovery stresses an increase to maximum thrust and recovery with minimal altitude loss," he says. Therefore, "students try to minimize the nose-down pitch change while engines spool up." To make matters worse, engine margins at high altitude are much smaller than at lower flight levels, where pilots can count on a much greater response to power increases. Also, Coker says, "it is probable when pilots remain on a particular model for extended periods of time that their exposure to approach-to-stall indications and recovery occur as infrequently as once in a decade," when stall exercises should really be part of recurring training. He stresses that training should focus on correct procedures, reducing the angle of attack and appropriate energy awareness, and not so much on minimizing altitude loss. Airbus and Boeing have worked together to devise new procedures for stall recovery that emphasize angle of attack rather than preserving altitude. As far as AF447 crew coordination is concerned, there are at least two indications that there may have been problems. The pilot non-flying (PNF), a 37-year-old with 6,547 total hours and 4,479 hr. on type, tried several times to call back the captain, who was on an agreed break; at the time, the pilot flying (PF), the 32-year-old junior copilot with 2,936 flying hours and 807 hr. on type, continued to pull back his side-stick at Flight Level 380 with thrust set to takeoff/go around, the angle of attack increasing further and speed decreasing. The two pilots also made simultaneous control inputs (pitch up) at around 20,000 ft. and an estimated sink rate of more than 10,000 ft. per minute. Air France's training and crew coordination standards will therefore likely be another target for recommendations; the airline already has undertaken an outside audit, conducted by Delta Air Lines representatives, of its safety procedures. In spite of the new evidence, the airline states that "the crew, made up of three skilled pilots, demonstrated a totally professional attitude and were committed to carrying out their task to the very end." The sequence of events in the crash that killed all 228 people onboard the flight from Rio de Janeiro to Paris can be segmented into two distinct phases. In the first phase, the pilots were dealing with the failure of speed readings that are almost certain to be linked to iced-over pitot tubes. The second phase began when speed indications returned to normal and the aircraft was at the edge of its flight envelope but under control and not stalled. Phase two also coincided with the captain's return to the cockpit from an agreed-upon rest. The initial chain of events was kicked off by erroneous speed readings at 2:10:05 (UTC), when both the primary flight display and integrated standby instrument system (ISIS) showed a sharp fall from 275 kt. to just 60 kt. The autopilot and auto-thrust disengaged and the flight management system switched to alternate law. The aircraft rolled to the right and the PF reacted by making a nose-up and left input. The stall warning sounded twice. The nose-up inputs led the aircraft to climb fast, at a rate of up to 7,000 ft. per minute, but it almost leveled off at a slight climb of around 700 ft. per minute and Flight Level FL375. At 4 deg., the angle of attack was only slightly higher than in cruise flight (3 deg.). The return to normal of the primary speed indication after 40 sec., and after close to 1 min. on the ISIS, indicates the pitot tubes started to transmit valid data again and the icing issue appeared to have subsided. At this stage, the event could have been over, with the aircraft still in alternate law and manual control but stabilized. There appears to be no technical, aerodynamic or meteorological reason that would have kept it from returning to its previously assigned altitude (FL350) by simply applying nose-down stick-forward control inputs. But then things went terribly wrong. At 2:10:50, the PF continued to provide nose-up inputs, causing the trimmable horizontal stabilizer to go to 13 deg. nose-up from 3 deg. nose-up. The airspeed began decreasing, to 185 kt., and the angle of attack reached 16 deg. Gerhard Huettig, a professor of aeronautics at the Berlin Technical University, says the change in the horizontal stabilizer position was due to a software malfunction that could have been neither recognized nor corrected by the pilots and was a key factor as to why they were unable to fly out of the subsequent stall. He consequently asserts that the entire A330 fleet should be grounded until the software is corrected. However, industry officials point out that the automatic trim only became active after the crew pulled back on the stick and that it worked as expected. In this phase, the captain re-entered the cockpit. What role he played subsequently is not clear yet, because the full cockpit voice recorder content has not been published. According to one report, he immediately told his two copilots that they were in a stall and therefore should put the aircraft's nose down and reduce thrust. Others doubt that because there was hardly any nose-down control input in the remaining 3 min. of flight and from 38,000 ft. to sea level. In fact, forward speed declined so much that even stall warnings stopped, in spite of the fact that the aircraft remained in a stalled situation for the remainder of its flight. That only happens when measured speeds are below 60 kt. and angle-of-attack values are considered invalid. When speed drops below 30 kt., that is also registered by the flight management system as invalid-and that is what seems to have occurred 30 sec. later, as the PF stated, "I don't have any more indications" and the PNF replied, "We have no valid indications." That second instrument failure is thus most likely due to the slow speed and not linked to pitot-tube icing. Around 2.5 min. before impact, there was one short period in which the PF did the right thing by pushing the side-stick forward. The angle of attack decreased and speeds became valid again, with the stall warning returning and indicating an acceleration in horizontal speed. The stall warning may have caused the PF to pull back on the stick again, repeating his previous pattern; it was not corrected by either the PNF or the captain. "[The pilots] never made the inputs necessary to recover," says one official close to the investigation. "We will learn a lot from this accident," says William R. Voss, president and CEO of the Flight Safety Foundation, who believes that AF447 should have fundamental consequences for the content of pilot training globally. "We are still training [for] the engine fire at V1, but the complexity of automated systems has grown. We have to develop crews that can deal with incidents such as QF32," the Qantas Airbus A380 that suffered an uncontained engine failure after takeoff in Singapore on Nov. 4, 2010, and returned to the airport severely damaged. Voss argues that AF447 would not have crashed if the aircraft had been of an older generation. "Highly automated aircraft have saved many lives, but they fail differently than aircraft of 20 years ago," he says. He sees it as a "failure of the industry" that pilot training has not kept in step with the latest aircraft technologies. He also argues for improved upset recovery training, as "we are not explicitly training that" and the AF447 A330 "seems to have had pitch-and-roll authority all the way down to the water." The focus on the pilots is not likely to have an immediate impact on the legal landscape. Steve Marks, an attorney with Miami-based Podhurst Orseck, who represents 41 families of AF447 victims, notes that investigative reports like this "tend to focus on pilot conduct," adding that "in this case, there is no doubt the pilot confusion is linked directly to the failure of the pitot tubes." Marks is bringing a case against the companies involved in the A330 navigation system. On June 3, a San Francisco judge was due to hear arguments on whether the case could be brought in the U.S., or if the liability claims must be made in French court. If it is the latter, plaintiffs would have to wait until the judicial inquiry in France is complete, which, as in the case of the Concorde crash, could take years. The BEA report plays down two other issues that have been in the spotlight. One is speculation that the aircraft entered a severe storm; the BEA document suggests it was merely turbulence that is standard for that region. During a crew briefing 2 hr. into the flight, in which all three pilots participated, the PF said that "the little bit of turbulence that you just saw, . . . we should find the same ahead . . . . We're in the cloud layer. Unfortunately, we can't climb much for the moment because the temperature is falling more slowly than forecast." And 11 min. later, the PF told the captain that "in two minutes, we should enter an area where it'll move about a bit more than at the moment. You should watch out," adding that "I'll call you as soon as we're out of it." The PNF proposed 2 min. later that "you can maybe go a little to the left" and the aircraft turned left 12 deg. None of the actions suggest anything out of the ordinary. The second speculation surrounded pitot-tube icing. Although the pitot probes appear to have iced over, the speed discrepancy between the primary flight display and ISIS lasted around 45 sec., not atypical for the phenomenon. There remain some long-term questions related to the AF447 accident. Would better aural cues help focus pilot attention on recovering from a stall? One industry official doubts replacing the "stall" alert with a more specific instruction, such as "push stick," would make much of a difference. And should research be funded toward devising a better backup mechanism to pitot tubes or finding another way to determine true air space that is less susceptible to outside environmental factors? "It would be interesting to have another technology," the industry official says. http://www.aviationweek.com/ Back to Top Chile volcano ash cloud shifts direction LAGO RANCO, Chile (AFP) - A thick plume of ash from the erupting Puyehue volcano in the Andes shifted direction into Chile on Sunday after spewing volcanic dust over parts of Argentina. North-westerly winds pushed the giant column of ash from the Chilean volcano, located 870 kilometers (540 miles) south of the capital Santiago near the border with Argentina, into Chile's Lago Ranco area. The eruption forced some 3,500 people to be evacuated from 22 rural Chilean communities. "This change means that we will have ash falling in the area, with damage to the population and a threat to small farmers," Lago Ranco Mayor Santiago Rosas told AFP. The volcano, located in the Andes 2,240 meters (7,350 feet) above the sea level, appeared to have largely gone quiet on Sunday, though Chile's Office of National Emergencies (ONEMI) said it was experiencing a "moderate" level of erupting. The Puyehue rumbled to life on Saturday after showing no activity since 1960, when it was awoken following a magnitude 9.5 earthquake. "There are some people, especially heads of family, that have decided to stay home and take a risk. The government, for the time being, will not interfere in that individual decision," said the regional governor in Chile, Juan Andres Varas. The eruption forced the nearby Argentine resort town of Bariloche, population 50,000, to declare a state of emergency on Saturday and close down its airport. The eruption also forced a major border crossing point to close due to low visibility, an dropped ash on the upscale Argentine resort town of Villa La Angostura. Bariloche, located about 100 kilometers (62 miles) east of the volcano, had covered in a sooty blanket of several centimeters (inches) thick and remained under a state of emergency. The picturesque town, as well as others in the vicinity affected by the ash, welcomes thousands of foreign tourists each year to its lakes and mountain scenery, as well as ski slopes in the winter months. Chile has some 3,000 volcanoes, of which some 500 are geologically active and 60 have erupted in the past half century. In 2008 the eruption of the Chaiten volcano, also in southern Chile, spread a thick cloud of ash across a large swath of South America, grounding flights across the region. Ash from that eruption drifted east as far as the Argentine capital of Buenos Aires. ***** Argentine Airline Halts Patagonia Flights Due To Volcanic Ash BUENOS AIRES (Dow Jones)--Argentina's flagship carrier Aerolineas Argentinas (AR.YY) said Sunday that it has suspended flights to a broad swath of Argentina's Patagonia region due to volcanic ash from an eruption in Chile. Back to Top The job: Aircraft repo man The process starts with a call from a client saying that there's an aeroplane in trouble. This might occur when a bank has a mortgage on a plane which stipulates it has to be maintained to a certain standard; money gets tight and the owner starts cutting corners, triggering a default. The client gives us power of attorney, then we start to gather intelligence. We need to know where we're going to grab it, whether it is airworthy and plan our fuel stops. This is very time consuming as planes are mobile assets and can be tough to be find. We work for banks, leasing companies, multinationals, hedge funds, private trusts and government agencies; it could even be a maintenance facility that has a lien on the plane. Basically it's anyone who has an interest in the plane and wants it liquidated. If they're willing to cover the cost of getting the plane ($50,000-$100,000) we'll get it for them. We had a spike at the start of the financial crisis, but we do advise clients that it's better to work something out and avoid repossession. We've repossessed aircraft in more than 80 countries - everything from piston helicopters upwards - and we've repossessed from companies, individuals, military operations and heads of state. We usually fly into the airport and taxi up to the plane. Then we walk over and attach a public notice saying its being repossessed. Then we call the local police and file an incident. We do not have a court order and we do not breach the peace. If the owner appears and objects, we have to give the plane back. We try and work it out with them though. We explain that we'll get it at some point and that all our expenses will be billed to them. If that doesn't work out out we wait. We'll catch up with them somewhere. We then usually fly the plane to our home airport in Indiana and put it into storage. The owner will have a chance to redeem and pay their bills off. If they don't we file a notice of repossession. If the aircraft ends up in the ownership of the client, we might work with them to resell it. http://www.ft.com/cms/s/0/0ac9a660-8e28-11e0-bee5-00144feab49a.html Back to Top Santa Monica Suspends Fast Jet Fight The city council and Mayor Richard Bloom have announced they will not appeal a January ruling that prevents them from banning Category C and D jets at Santa Monica Municipal Airport, but 2015 may still bring a showdown. The city has argued that those larger, faster business jets at the airport present a safety hazard to nearby houses, some of which sit within 300 feet of the airport's one runway. But the airport had agreed when it previously accepted federal funds that it would operate without discrimination. That agreement expires in a few years, and there may be bigger battles ahead. Councilman Kevin McKeown on Friday told local paper, The Mar Vista Patch, that the city council has not given up the fight. "We also are engaging the entire community in planning for 2015, when our current obligations at the airport expire," McKeown said. He added that "we continue to value residents' safety over the somewhat different interests of the federal bureaucracy." The FAA has offered to help fund the installation of an emergency physical arresting system to act as a safeguard in the event of a runway overrun. The city has rejected those offers. http://www.avweb.com/ Back to Top Air India out of money, pilots warn passenger safety could suffer NEW DELHI: National carrier Air India has almost completely run out of money and its broke status now threatens to affect passenger safety. The pilots of erstwhile Indian Airlines have written to the safety regulator that with allowances (that form over 80% of total pay) not being paid since March 2011, they are "facing severe financial hardship". They have told the Directorate General of Civil Aviation that under such pressure any person is liable to make mistakes and that the management should be held responsible for any incident or accident. "We would like to apprise you of the grim and dangerous situation existing in AI today... in our field of work there is no scope for error, but any human being put under such extreme stress is liable to perform poorly. We (have) not been paid for three months... in case of any unfortunate incident/accident, the entire blame will be on the current chairman and managing director (Arvind Jadhav), the incompetent top management and nobody else," the pilots' union, Indian Commercial Pilots Association, wrote to the DGCA on Friday. Complaining of being "unfairly victimized by the CMD," the ICPA - which went on strike last month - has sought urgent intervention in the "interest of flight safety". http://articles.timesofindia.indiatimes.com/2011-06-05/india/29622674_1_passenger- safety-arvind-jadhav-allowances Back to Top ERAU Graduate Survey: My name is Francis Iniekpo, I am a graduate student seeking my Master's degree in Aerospace Management at Embry-Riddle Aeronautical University. The purpose of the enclosed survey is to gather information about the effect on air travel as a result of maintenance performed on US airlines aircraft by overseas maintenance facilities abroad. The survey will take 2 to 3 minutes to complete. All your responses will be kept confidential within reasonable limits. Only people directly involved with this project will have access to the surveys. Click on the link below to access my survey; http://www.surveymonkey.com/s/VPV8DK7 Completion and return of this survey indicate voluntary consent to participate in this study. Questions about this study can be directed to me at Embry-Riddle Aeronautical University, Randolph Air Force Base, San Antonio, TX. 78148. Thank you for taking the time to assist me in this research. Francis Iniekpo francis@femagroup.com Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC