Showing posts with label safety. Show all posts
Showing posts with label safety. Show all posts

Sunday, May 12, 2019

737 MAX Update




https://creativecommons.org/licenses/by/2.0/deed.en


I haven't written about the saga of the MAX lately because there hasn't been much change in the situation concerning the grounded airliner. Progress is being made in fixing the MCAS system implicated in the two 737 MAX crashes, and estimates for the ungrounding of the aircraft range into the July-August timeframe.

The FAA recently convened a multi-agency Technical Advisory Board to review Boeing's proposed software fix for the MCAS system. The results of that review will be needed prior to FAA approval of the design changes.

That said, there have been a number of stories brought to light as to how the MCAS system came to be designed, and some more disturbing revelations about Boeing failing to disclose an inoperative warning feature to its customer airlines.

MCAS: What It Is and What It Is Not


The Maneuvering Characteristics Augmentation System (MCAS) has been routinely described in popular media stories as a stall prevention or mitigation device. It is really neither, but rather is a system designed to make the MAX "handle" just like the older Boeing NG series aircraft it replaces.

During flight testing of the MAX, test pilots and engineers noticed that in a very small corner of the flight envelope: lightweight, aft center of gravity (CG) and approaching a stall, the forces on the stick varied from the NG version of the aircraft. MCAS was introduced in order to counter this divergence in longitudinal stability between the two models to make them "feel" the same. The genesis for the difference in handling is due to the MAX having larger, heavier engines which are set further forward on the wing for ground clearance.

The need for identical handling between the two aircraft was to maintain a common "type rating" on both aircraft thereby allowing pilots qualified on earlier versions of the 737 to fly the new aircraft without extensive training. Airline pilots, unlike, say, flight attendants, cannot fly separate types of aircraft but are generally only qualified on one "type" of aircraft (at a time).

The word "type" has a very specific technical definition in that the FAA designates which aircraft fall under the specific "type rating". For instance, being "type rated" in the 737 allows pilots to operate all the various sub-models of that series (-200, -300, -400, etc) without an extensive course of study for each sub-model. The Boeing 757 and 767 were also given a shared type rating as those aircraft were considered similar enough that pilots could fly both of them under a single "type rating". These ratings are annotated on all pilots' licenses. The same is true for the Airbus A320 series of aircraft.

As we now know, the MCAS system was flawed in its design due to being able to be triggered by a single angle of attack (AOA) indicator, and also by the ability of the system to reset itself and re-engage multiple times without limit. The question of how and why this design flaw happened is the subject of multiple investigations into the certification process.

Inoperative Angle of Attack Warnings


The WSJ has done some excellent investigative reporting on the MAX story and revealed recently that not only did the MAX aircraft not have a specific AOA warning indication which had been included on the earlier NG, models but that Boeing engineers were unaware that the warning on the MAX was inoperative. Furthermore, Boeing delayed notifying their customer airlines of the situation for nearly a year.

Angle of attack cockpit indicators are not known as what are "primary flight instruments" such as airspeed, altitude, and attitude. Pilots use primary flight instruments to directly fly the aircraft. An angle of attack indicator, however, is not required to safely operate most aircraft and is usually not included in cockpit displays. 

An analogy might be to a tachometer in your car. Nice to have but not needed. Much outrage has been vented over Boeing's not including this cockpit indicator as standard equipment, but I don't see it that way. AOA cockpit indicators are simply not needed for safe flight.

Angle of attack sensors, small vanes on the exterior of the aircraft, are traditionally used to send AOA information to an airliner's flight control computers and are used to provide "stick shaker" stall warnings. There are two installed on the 737 and the cockpit warning "AOA Disagree" would display should the two indicators return different readings, indicating a malfunction in one or both.

It was this "AOA Disagree" warning which was inadvertently deactivated on the MAX aircraft. Had the AOA only served its previous function of activating stall warning, this would be no big deal. But because the MCAS system was triggered by a single AOA sensor, not having this warning quickly became a very big deal. 

A single malfunctioning AOA indicator has been implicated as a possible cause for the inadvertent activation of the MCAS system on both the Lion and Ethiopian crashes. Having this alert enabled might have aided the pilots of those aircraft to figure out what was going wrong.

Pinto, Tylenol, MAX?


It is becoming apparent that the MAX will be back flying at some point, but the question now arises as to how well Boeing will weather the ongoing tsunami of negative PR. Even President Trump weighed in on this question recommending that Boeing rebrand the aircraft.

If you recall, the Ford Pinto never rose above safety concerns after several accident caused fires and the model was eventually terminated. The response to the Tylenol poisonings, however, is now considered a textbook example of how to manage a public relations crisis. One thing learned is that transparency and being forthcoming in light of a tragedy is essential. Boeing has only made matters worse by their perceived lack of candor.

My guess is that once the MAX is back in the air, the crisis will be quickly forgotten. My reasoning is that the public has a notoriously short memory for these sorts of things. Other aircraft have had spotty beginnings and went on to become successful. The MAX, which is still a 737 at heart, has a long and enviable safety record. As the parable states, the dogs may bark, but the caravan moves on.


Sunday, March 31, 2019

Flight Data Results from Ethiopia 302 and the MCAS System - Smoking Gun or False Lead?



737 MAX throttle quadrant showing trim wheel and stab trim cutout switches (lower right).



The Wall Street Journal is reporting that, after preliminary analysis of flight data from the downed Ethiopian 737 (ET302), investigators now believe the controversial Maneuvering Characteristics Augmentation System (MCAS) activated and may have played a part in the accident.  This finding is significant because the MCAS system has now been implicated in both this crash and the Lion Air crash which occurred last year.

MCAS - What is It?


To recap, the MCAS system was installed on the 737 Max aircraft to mitigate some unique handling characteristics of the new model which differed from older 737s. Boeing originally chose not to document this new system in the aircraft flight manual, but has since briefed all Max operators on the existence and function of the system in the aftermath of the Lion Air crash.

Among the reasons Boeing engineers may have had for not including the system in the flight manual are that the system was only supposed to ever activate during aerodynamic stall conditions in manually controlled flight, which in normal operations would never be seen. Entire careers are flown without ever seeing an actual stall, so this rationale might have been thought sound.

The problem for the MCAS system wasn't necessarily its intended operation, which was to be rarely if ever seen, but rather any potential failure modes. Unintended activation of the system due to a mechanical fault has now been suggested as a factor in both Max crashes. Flight data from the Lion Air crash show the pilots repeatedly fighting the inputs from a misfiring MCAS system, and according to latest reports, the MCAS system also activated on the mishap Ethiopian airliner.

Adding to the controversy of the existence of an undocumented system is the revelation that the system can be activated by a single angle of attack (AOA) sensor. Angle of attack sensors measure the angle of the relative wind over the wings. Too great of an angle between the wing and the airflow over it will result in an aerodynamic stall wherein the wing stops producing lift.

The questions being asked involve the engineering decision to use the input of a single AOA sensor to trigger the MCAS system to operate. There are two (or more) AOA sensors installed on all airliners which among other things are used to provide "stick shaker" stall warning to pilots if they get too slow or approach a stall. Again, a stall is something that most airline pilots will never see outside of a training simulator where stall recovery is practiced routinely.

What Did the ET302 Pilots Know about the MCAS System?


Lion Air JT-610 crashed on October 29, 2018. The investigation of that crash first brought the MCAS system and a malfunctioning AOA sensor to light. On November 7th, Boeing released an Operations Manual Bulletin (OMB) to all 737 Max operators. This bulletin mentioned that erroneous AOA signals can cause the trim to run uncommanded by the pilot. The directed remedy is to apply the runaway stabilizer trim checklist which directs the use of the center pedestal mounted stabilizer trim cutout switches. The text of the bulletin is as follows:

The Indonesian National Transportation Safety Committee has indicated that Lion Air flight 610 experienced erroneous AOA data. Boeing would like to call attention to an AOA failure condition that can occur during manual flight only.

This bulletin directs flight crews to existing procedures to address this condition. In the event of erroneous AOA data, the pitch trim system can trim the stabilizer nose down in increments lasting up to 10 seconds. The nose down stabilizer trim movement can be stopped and reversed with the use of the electric stabilizer trim switches but may restart 5 seconds after the electric stabilizer trim switches are released. Repetitive cycles of uncommanded nose down stabilizer continue to occur unless the stabilizer trim system is deactivated through use of both STAB TRIM CUTOUT switches in accordance with the existing procedures in the Runaway Stabilizer NNC. It is possible for the stabilizer to reach the nose down limit unless the system inputs are counteracted completely by pilot trim inputs and both STAB TRIM CUTOUT switches are moved to CUTOUT.
Additionally, pilots are reminded that an erroneous AOA can cause some or all of the following indications and effects:

- Continuous or intermittent stick shaker on the affected side only.
- Minimum speed bar (red and black) on the affected side only.
- Increasing nose down control forces.
- Inability to engage autopilot.
- Automatic disengagement of autopilot.
- IAS DISAGREE alert.
- ALT DISAGREE alert.
- AOA DISAGREE alert (if the AOA indicator option is installed)
- FEEL DIFF PRESS light.

In the event an uncommanded nose down stabilizer trim is experienced on the 737 - 8 / - 9, in conjunction with one or more of the above indications or effects, do the Runaway Stabilizer NNC ensuring that the STAB TRIM CUTOUT switches are set to CUTOUT and stay in the CUTOUT position for the remainder of the flight.

A subsequent Emergency Airworthiness Directive (EAD) directed this information to be included in the flight manual of all Max aircraft within three days.

In my view, it is reasonable to assume that the ET302 pilots were well aware of the MCAS system, its possible failure mode due to an erroneous AOA sensor, and the steps to be taken to remedy the malfunction.

Why Didn't They Just Turn it Off?


The investigation of the Lion Air crash has revealed that on the flight immediately preceding the mishap flight, an off-duty 737 qualified pilot was occupying the jumpseat. That aircraft also suffered the same malfunction of the AOA sensor resulting in uncommanded nose down trim. On that flight, however, the guest pilot recommended that the operating pilots use the stabilizer trim cutout switches, which they did. That flight landed uneventfully.

The pilots on the subsequent Lion Air flight fought against the nose down trim commands continually, but never did deactivate the electric stabilizer trim with the cutout switches. The errant automated trim commands eventually trimmed the aircraft into an unflyable condition.

It would seem easy to Monday morning QB the actions of the Lion Air mishap pilots, but it must be remembered that there were many other things happening at the same time. One important thing to note is that the stick shaker activated right at liftoff and continued for the entire flight. The stick shaker is a device that literally vibrates the control yoke when an aircraft approaches an actual stall. It is loud and disconcerting when activated. The pilots were no doubt startled and distracted.

Another point to note is that the MCAS inputs would not "present" like a traditional runaway trim situation. Typically, a runaway trim malfunction in a simulator would simulate a stuck switch where the trim wheel would run continuously in one direction. During the mishap Lion flight, the flight data recorder showed the pilot actively trimming back against the MCAS inputs followed by a few seconds delay when the MCAS system would reactivate and start trimming forward again.

Another system called "speed trim" installed on earlier and subsequent 737 models can also run the electric trim with the autopilot disengaged, so it is not completely unusual to see the trim wheel spinning by itself with the autopilot off. This "negative training" may have contributed to the pilots not focusing on the uncommanded movement of the trim wheel even though speed trim only functions with flaps extended while the MCAS system only functions with the flaps retracted.

What Happened Then on ET302?


The flight data recorder and cockpit voice recorders from ET302 have been recovered and sent to France where they were downloaded and decoded by the BEA, the French equivalent of the NTSB. The data from the recorders have not been released to the public, however investigators have an "emerging consensus" that the MCAS system activated and contributed to the accident. The story also noted that this preliminary finding is subject to revision.

The pilots of ET302, however, had something that the Lion pilots did not, and that is a detailed description and knowledge of the MCAS system and the procedure to disable it by throwing two easily reached switches. Without more information from the accident investigation, it is simply too early to reach any definitive conclusions about the fate of that airliner.



Tuesday, December 04, 2018

The Lion Air Crash: What You Need to Know



PK-REN from Jakarta, Indonesia [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons
Lion Air B737 MAX 8 (Wikimedia Commons)



On October 29 of this year, Lion Air Flight 610 crashed into the Java Sea 11 minutes after departing Jakarta for Pangkal Pinang with the loss of all 189 souls on board. What first called special attention to this accident was that the mishap aircraft was a brand new MAX 8 version of the venerable Boeing 737, and had been delivered to the airline less than a year earlier.


Also of note has been the revelation in the wake of the ongoing accident investigation that a new safety system designed to prevent stalls had been installed on the aircraft, but had not been publicized nor documented in the flight manuals used by flight crews. The flight data recorder (FDR) from the mishap aircraft has been recovered and data from that recorder shows that an errant sensor on the aircraft may have provided bad data to this new system possibly implicating it in the accident. 

The investigation is ongoing and it is inappropriate to assign blame to any system or persons until the completion of the accident review, but as there is much misunderstanding concerning what information is already known, we can take a closer look at the circumstances surrounding this tragedy.

An Undocumented System


The new safety system installed on the MAX version of the 737 known as the Maneuvering Characteristics Augmentation System or MCAS, was designed to provide a nose-down trim input during manual flight as the aircraft approached a stall. What this means in simple terms is that if a pilot is flying the aircraft without the autopilot, and is for whatever reason flying the aircraft well below a safe speed, the aircraft will automatically run the stabilizer trim forward which will have the effect of making the controls heavier to hold.

In addition, once full power is eventually applied to recover from the stall, the forward trim assists the pilot in keeping the more powerful engines on the MAX from overpowering the recovery by exceeding elevator authority. The nose tends to want to rise during a stall recovery and forward trim lessens that effect.

Here is an excerpt from the multi-user message sent by Boeing on November 10 to all 737 MAX operators:

A pitch augmentation system function called 'Maneuvering Characteristics Augmentation System’ (MCAS) is implemented on the 737-8, -9 (MAX) to enhance pitch characteristics with flaps UP and at elevated angles of attack. The MCAS function commands nose down stabilizer to enhance pitch characteristics during steep turns with elevated load factors and during flaps up flight at airspeeds approaching stall. MCAS is activated without pilot input and only operates in manual, flaps up flight. The system is designed to allow the flight crew to use column trim switch or stabilizer aisle stand cutout switches to override MCAS input. The function is commanded by the Flight Control computer using Input data from sensors and other airplane systems.

It is also important to note that any pilot finding him or herself in this position has real problems and has already disregarded the "stick shaker" stall warning system which vibrates the control column well before reaching stall speed. The reason the system was installed on the newest MAX 8 versions of the 737 and not earlier models is apparently the discovery during flight testing of some unfavorable stall characteristics on the new aircraft that did not exist on earlier models.

Angle of Attack


Ok, so far so good. A new safety system was installed. Who can argue with a safety system? The problem that the Lion Air flight encountered, however, was some sort of malfunction in information coming from a sensor being fed to the new system. This sensor is known as the "angle of attack" or AOA sensor. The angle of attack of a wing is the angle between the chord line of a wing and the relative wind moving across that wing. A chord line is an imaginary line which runs from the leading edge to the trailing edge of a cross section of a wing. 

A wing which exceeds the critical angle of attack stalls, which is where boundary layer separation occurs and the wing stops producing lift. If you've ever stuck your hand out the window of a moving car and made a wing with it, you've experienced how changing the angle of attack changes lift. For more on AOA, see here.

The angle of attack sensor is essentially a very small wing on a hinge mounted on the fuselage which measures direction of the relative wind passing the aircraft. You can see them installed near the pitot tubes on most airliners and there are usually at least two installed for redundancy. AOA data is used by a number of systems on an airliner, but happened to be one of the primary inputs to the MCAS system on the MAX 8 aircraft. It is here where problems occurred.

Faulty Input Means Faulty Output (GIGO)


Analysis of the flight data recorder from the Lion Air flight revealed that the data from the two AOA sensors installed on the aircraft did not match. The left AOA sensor was recorded as giving erroneous information during the entire flight. An erroneous AOA information feed or some other malfunction is suspected to have caused the activation of the MCAS system resulting in the system trimming the aircraft in a nose down direction. During the entire flight the pilots trimmed in a nose up direction to keep the aircraft flyable, but at some point stopped trimming and allowed the MCAS system to trim the aircraft nose down to an unflyable condition.

The reason for this is unknown and may be determined when the cockpit voice recorder (CVR) is recovered. Also unknown is why the pilots never used the two stabilizer cutout switches located on the center stand just behind the throttles. These switches remove all electric power from the stabilizer trim motor and would thereby deactivate the MCAS trim inputs.

In fact, on the previous flight of the mishap aircraft, a failure of a similar nature also resulted in uncommanded nose down trim inputs and required the pilots of that flight to use the cutout switches to deactivate the electric trim system. The 737 has a large manual trim control wheel mounted on the center stand that can be turned to adjust the stabilizer trim. It is normally not touched but spins as the electric trim motor is engaged. The pilots on that previous flight used the manual trim wheel to adjust the trim to safely land.

The aircraft did have maintenance performed on various airspeed, AOA and other systems in the days leading up to the mishap flight in response to several defects being written up on previous flights. The exact nature of the malfunctions and degraded systems on the mishap aircraft has yet to be determined as the investigation proceeds, but an AOA sensor had been replaced in response to writeups on the previous flight. A closer look at the flight data from both the mishap flight and the previous flight can be found here.

Protecting Pilots From Themselves


There is an ongoing debate in the aviation community about the benefits and liabilities of cockpit automation. This debate has centered on the effect that highly automated cockpits have tended to make pilots rusty in their "stick and rudder" or basic flying skills. Make no mistake, automation has been a boon to both aviation economics and safety, but it is now being realized that it is not an unmitigated benefit.

At question is the design philosophy incorporated into automation. Years ago, the two main commercial airframe manufacturers, Boeing and Airbus, diverged in their approach to flight control automation. While Boeing aircraft have always incorporated the ability to disconnect all automation, Airbus on the other hand was a pioneer in designing "fly by wire" flight controls into their aircraft. This meant that pilot inputs were sent to a computer and the computer controlled the aircraft. There was no ability to completely bypass the computer and control the aircraft directly.

The revelation that a safety system designed to prevent an inattentive pilot from stalling the aircraft was surreptitiously installed will raise questions as to whether Boeing has decided to follow Airbus down the road of incorporating behind the scenes automation to prevent pilots from doing stupid things. Remember, the original anti-stall device was always the pilot. Warning systems could signal that the airplane was getting slow, but the pilot was always the backstop. Given that the MCAS system can be disabled by the trim cutout switches makes the above scenario less likely.

The alternate explanation to the installation of the MCAS system is that it is simply designed for the mitigation of unfavorable stall characteristics as mentioned above. This raises the question, though, of why the system would not be documented in the aircraft flight manual. Surely pilots would want to know of these unfavorable characteristics and also of the existence a system designed to compensate for those effects. Since the system was undocumented, the pilots of the mishap flight likely had no idea why their trim kept running forward nor were they expecting such behavior.

What's It Doing Now?


It is imperative, then, that pilots are well versed in not only the normal operation of their aircraft, but also in any possible failure mode and are ready and able to assume complete command at any time that the automation is not performing as expected.

Several high profile accidents such as Air France 447 and Asiana 214 serve to highlight the potential pitfalls of flying highly automated aircraft. Part of the problem confronting pilots of these aircraft is the danger of becoming confused about what the aircraft automation is doing. Known as "mode confusion", pilots can make the mistake of assuming that the automation will perform in a certain manner and become confused if it doesn't.

This was one of the findings in the accident review of Asiana 214 which crashed into the seawall at San Francisco. The pilots realized too late that the mode that had been selected would not do what they were expecting. They were then unable to prevent the aircraft from crashing short of the runway.

Now extrapolate mode confusion to a malfunctioning system which the pilots were unaware was even installed, and you can see the difficult situation they faced.

In Conclusion


The cause(s) for the crash of Lion Air 610 are currently unknown and will remain so until the investigation is complete. In the interim, new knowledge of the existence of an undocumented safety system installed on the 737 MAX should serve to further the debate on the appropriate role of cockpit automation.




Thursday, March 08, 2018

Do I Talk Too Much? A Primer on Airline PA Announcements






The chapter in Tom Wolfe's novel, The Right Stuff, which introduces us to Chuck Yeager, starts with this vignette:

Anyone who travels very much on airlines in the United States soon gets to know the voice of the airline pilot—coming over the intercom with a particular drawl, a particular folksiness, a particular down-home calmness that is so exaggerated it begins to parody itself (nevertheless!-it's reassuring) the voice that tells you, as the airliner is caught in thunderheads and goes bolting up and down a thousand feet at a single gulp, to check your seat belts because "it might get a little choppy"...

Wolfe went on to describe how that drawl, which characterizes the "pilot voice", had its genesis in Chuck Yeager's West Virginia cool-as-a-cucumber mein and delivery.

That southern drawl style of voice can still occasionally be heard over an airline PA, but it seems to have been eclipsed in recent years by the nondescript mid-Atlantic patois of most television news anchors. And that is too bad. A certain cachet has been lost in my opinion, but then again, a fake accent is probably worse than no accent.

My real problem with airline PA announcements, however, has nothing to do with the delivery, but rather the content and timeliness. We actually do talk too much when we should probably shut up and not enough when something needs to be said. Let me explain:

Mandatory versus Optional


Pilot PA announcements are prescribed in our manuals as either customer service announcements, which are mostly optional, or required safety announcements, which are mandatory. There is little that can be done about the mandatory safety announcements such as those required when the seat belt sign is cycled on or off, but it is the customer service announcements which can probably use the most improvement.

We are encouraged to give an opening PA to introduce ourselves and to give some information about the flight. My problem starts right away when pilots introduce themselves using first names only such as  "Bob and Tom". Perhaps I'm just old school, but when I hear that, I can't help but think I've tapped into the Wiggles channel, or perhaps wandered into a birthday party at a Chuck E. Cheese joint. Our informality infection has progressed just a bit far. Professionals should try to look and sound the part.

After the introduction comes a several minute soliloquy about the length of the flight, the filed altitude, the expected ride enroute, the destination weather, and those super gals and guys serving you in the back. Perhaps there was a time in years past when this information was not publicly available to anyone who cared to know, but that time has long since passed. Nearly all that information is now easily available on the iPad that every passenger will now have to put down while Captain America, er, Bob, rambles on for interminable minutes.

Opening PAs should be short, to the point, and only offer information that is not already available through the internet or the airplane's entertainment center. If the destination weather must be given, "partly cloudy and breezy" will suffice rather than well, folks, there's a scattered layer at 3000 ft and a broken layer at 12,000 ft with 8 miles of visibility and the winds at 320 degrees at 8 gust 15 knots. Passengers' heads often cock when hearing such details much in the same way as your dog's head does when you try to explain the theory of relativity. Passengers aren't trained in pilot jargon.

Silence is Not Always Golden


Now if things are going to be out of the ordinary, such as being so turbulent that the flight attendants won't be getting out of their seats, or there's an ATC departure delay, then that is worth passing along. This brings us to the times when something needs to be said and yet only golden silence prevails. If the push time is 0900 and it's, say, 0905 and we haven't pushed, a PA should be made to inform the customers that, yes, we know that we're now late, and here's the reason, and here, also, is when we expect to be moving. Not announcing those things makes it seem like the pilots are hoping that no one notices. They do.

This is especially important during lengthy ATC or maintenance delays. If we're stuck at the gate for an extended period of time, I personally like to give an update every 10 to 15 minutes. This won't be a long announcement but rather something along the lines of yes, the mechanics are still working the problem, but we expect that we will eventually be under way in so many minutes.

Honesty is (Usually) the Best Policy


Many pilots prefer to use euphemisms when describing things like turbulence or maintenance issues. I personally prefer an honest but not too detailed description of weather and mechanical issues. If we're expecting moderate turbulence, I'll use that term instead of "really bumpy". If there is a line of thunderstorms ahead, I'll say that. If those terms scramble someone's eggs, perhaps they should not be flying. 

Likewise, if we have a mechanical issue, I'll mention the system that is affected without going into unnecessary detail. "Folks, we have an electrical problem" is probably better understood rather than the number 2 transformer/rectifier is showing zero amperage (usually followed by a detailed discussion of what a T/R even is).

One thing to be careful about concerning maintenance announcements is the subject of deferrals. Most people expect that their airplane is perfectly functional all the time and will likely not understand the concept of redundant systems and deferred maintenance. In those cases, I'll usually announce that the mechanic has the problem squared away and we'll be departing soon.

Apologies


Is there anything more annoying than modern day customer care speak? Endless apologies followed by assurances that your experience and well being are of the highest concern have become a ubiquitous soundtrack to life in our deracinated corporate infused existence. A bit of real talk is a great antidote and is usually well appreciated by people trapped in an aluminum tube for extended periods of time. 

If we (the airline) screwed something up, I like to say so, but if that's not the case, I'll say that as well such as "our good friends at the FAA have instituted a flow control program".  Another annoying tic that I hear occasionally on the PA is the airing of dirty internal laundry such as "well, folks, we're ready to go but the ground ops folks are dragging their feet getting the plane serviced." When speaking to customers, you are the voice of the corporation. They don't know or care about internecine tribal spats.

Flight Attendant Announcements


Admittedly, most of the announcements you hear on an airliner come from the flight attendants. Cut them some slack because most of what they say is mandated by either the corporation or the FAA. And I wholly approve of pre-recorded safety videos that are now becoming common. I'd much rather watch a professionally produced safety video than listen to a harried flight attendant rush through a safety demo for the fourth time that day.  Other announcements such as the mandatory seatbelt sign notification are also being automated on newer aircraft.

Humor of course always has its place in airline PAs, but like wearing Spandex, only certain people can pull it off. Unfortunately, most of those that do, probably shouldn't. Perhaps there should be an audition where aspiring comedians can go through their schtick and get feedback before inflicting their routine on a captive public.

 In Conclusion


Airline PAs should convey valuable and timely information to customers who have no other means of gaining that information. Redundant, rambling, or lengthy announcements merely add insult to the injury of modern air travel. And of course, don't forget to bring your noise cancelling headset.







Tuesday, May 23, 2017

Decision Making in Real Time: Are Your Priorities in Line?



Steer clear of this


I recently operated a flight from Las Vegas to New Orleans which, while having an unremarkable outcome...we landed safely at our destination...presented my first officer and I with some interesting challenges. In short, a solid line of thunderstorms had formed stretching from southwest Texas up to Wisconsin. While the line was mostly unbroken, there were a few gaps that an airliner might have safely passed through. The rest of it was bad news and several serious tornadoes were spawned by this storm.

The questions confronting us were: Could we get around the line? Did we have enough fuel to deviate around the line and continue to our destination? Should we deviate to the south to go around the line or to the north and try to shoot through a gap? Should we turn around and return to Vegas? Or should we simply divert to a closer airport to wait out the storm?

We of course knew that there was a forecast for convective activity and were carrying extra fuel for that reason, but the exact shape and location of storm formation cannot be forecast with any accuracy. We deal with a world of probabilities.

First, though, I should describe the nature of thunderstorms for any aviation laypersons who might be reading. Thunderstorms, otherwise known as "convective activity" or "extreme precipitation" are not to be trifled with. There are essentially no aircraft, including military aircraft, which can safely penetrate a large thunderstorm. Even the military "hurricane hunter" C-130 aircraft must avoid embedded storm cells, and while a fighter aircraft might not be torn apart by a storm, it's engines can be easily extinguished by the sheer amount of water that they would ingest or the canopy might shatter due to hail.

Airliners, of course are soft targets when it comes to large thunderstorms. Though built to take a lot of pounding, intentionally penetrating a thunderstorm in an airliner would be a supremely foolish and dangerous act. It just isn't done, and much care is taken to avoid tangling with these monsters.

Operational Priorities are at the Heart of Good Decisions


Having been made aware of the unbroken nature of this line several hundred miles prior, we had to make a decision and implement it with not much time before we were upon the storm. Decision making is never done in a vacuum, but must include the consideration of current conditions, collaborative input from other resources such as my copilot, air traffic control, and our dispatcher, and finally and perhaps most importantly, our operational priorities.

My airline, along I suspect with most others, has published a list of operational priorities to which we must adhere in all our operations. Those priorities in order are 1) Safety, 2) Service, and 3) Being efficiently on time. I must confess that having such a simplified and straightforward list of priorities really makes my job a lot easier. I can also see that losing sight of these priorities is an easy way to get into trouble.

So keeping these priorities in mind, we had to decide the best way to either navigate around the storm or to turn around and to wait it out. Revisiting our decision tree with these priorities in mind, we determined that the storms were too high and dangerous to go over, and while the gap up north might have worked, there was no guarantee that it would stay open until we got through it. Turning around and returning to Las Vegas would have been safe, but would also have caused an unnecessary delay and burned a lot of fuel for no reason, violating priorities two and three.

We were left with choosing between a divert to a nearby city to wait out the storm or to deviate to the south to go around the line. As we had fuel for the extra distance, we elected to fly several hundred miles to the south to go around the line while enjoying a truly awesome lightning display. Had we decided, however, that the extra flying took more fuel than the extra fuel that we had, a divert to a nearby city would have been the next best choice.

What are Your Priorities?


I have it much easier than you. My company has given me a short and cogent list of priorities, and any decision I make will be weighed with those in mind. You, however, may not have a list or it may be a long and constantly changing one. Or perhaps it is vague to the point of uselessness. Your challenge, in whatever business you may happen to be in, is to ferret out what those priorities are and to apply them correctly in your business decisions.

When you do make a decision, be sure to make a note of the priorities that were under consideration at the time. Monday morning quarterbacking is easy to do (which is why it gets done so often) so it is always best to be able to explain your thought process. A bad decision is much easier to defend if it was made in good faith with pre established guidelines.

So that's it. We lived to fight again another day by keeping our priorities straight, and you will too. Now if we can only get through Atlanta one more time with our sanity intact.




Thursday, January 05, 2017

I Feel Ok, But I Still Called in Sick



Flight doctors keep pilots flying
A visit to the flight doc might prevent this 


To be fair, I really do have a bit of a cold. It started the day before my trip with some sneezing and a headache. It's really nothing most workers would consider staying home for. A daytime Theraflu has got me feeling almost fine, but I still didn't go to work. Instead, I called scheduling to get myself pulled off my trip and replaced. Now I've got some extra time to write a blog post. Am I lazy or is this a good call?

You Don't Want Me Flying Your Plane


Though it may sound like I'm milking the system, trust me when I say that you do not want me anywhere near your airplane for a number of reasons. The first, obviously, is that I'm not 100%. Flying places enough physiological stress on a body as it is. Disrupted circadian rhythms, fatigue, dodgy airport food, and dehydration from hours in dry airplane air can all contribute to a degradation of the alertness which is needed to operate an airliner.

Throw in additional stressors such as congestion, or a headache and effectiveness in the cockpit can drop precipitously. My experience has been that no matter how you feel while sitting in your kitchen, you will always feel worse on an airplane, medically speaking. A bit of an itchy nose is guaranteed to become a non-stop sneezing fit on the airplane. So if I'm feeling a bit off at home, I don't go in. 

Almost as important as the underlying illness, the drugs taken to combat the symptoms of a cold or flu are themselves disqualifying for operating a commercial airliner. The FAA does not publish a list of medicines which pilots are allowed to take while operating an airliner, but would rather have each individual pilot with a medical complaint be evaluated by a doctor. Then a determination should be made as to whether the pilot should be flying with that medication. Some common ones are approved, while others are not.

For simple ailments such as a cold or the flu, pilots are expected to remove themselves from flying until they feel fit to fly. As far as the over the counter drugs for a cold are concerned, the FAA recommends a wait of five times the recommended dosing interval. This means that if the directions suggest a certain dose of say every six hours, a pilot should wait five times that, or 30 hours before operating an aircraft.

Pilots and Doctors: An Uneasy Relationship


All pilots, whether civilian or military, need the approval of a doctor to be able to fly. But because doctors can ground pilots, this means that pilots are never too comfortable around doctors. Airline copilots or first officers in the US are required to get an annual FAA Class II medical exam. Captains and international pilots need to have an FAA Class I medical exam every six months. All airline pilots require a Class I medical after age 60 and an electrocardiogram is required annually after age 40. 

The idea here is to catch any sort of medical problem before it manifests itself while the pilot is behind the controls. If something should be found that is disqualifying, such as say complete color blindness, there isn't much that a pilot can do. For many other ailments, however, a pilot can appeal their case to the FAA's Office of Aerospace Medicine for the issuance of a waiver, otherwise known as a Special Issuance.

In this case, a pilot would be able to continue to fly using a "Statement of Demonstrated Ability" which means that whatever ailment they have is considered to be static or non progressive. In plain speak this means it is not getting worse nor affecting the ability to fly.

The unease which pilots have around doctors stems from the perception of misaligned incentives. If something during a flight physical is found to be in a grey area, the pilot will naturally want to keep flying, while the doctor would rather err on the side of keeping the pilot grounded. There is good reason for this as the doctor could be held responsible for missing something which causes trouble later. Here's the text from the FAA's guide for aviation medical examiners (AMEs):

The consequences of a negligent or wrongful certification, which would permit an unqualified person to take the controls of an aircraft, can be serious for the public, for the Government, and for the Examiner. If the examination is cursory and the Examiner fails to find a disqualifying defect that should have been discovered in the course of a thorough and careful examination, a safety hazard may be created and the Examiner may bear the responsibility for the results of such action.

So of course this makes pilots naturally wary about reporting every little ache and pain during their flight physical. They don't want to lose their livelihood for what they might perceive as overreach on the part of an overly cautious doctor. Pilots also tend toward stoicism as a general rule, so keeping quite about a random ache, especially when it might ground them, suits them just fine.

A Flight Doc and a Real Doc


Most aviation medical examiners, or flight docs, do not work for the FAA. They are usually physicians in private practice who have volunteered and are designated and trained by the FAA to perform flight physicals. It seems to be a somewhat lucrative practice as the physical itself usually takes about a half hour with about ten minutes of that time actually being spent with the doctor. The cost is around $150 cash as many AMEs do not take insurance. I even know of some AMEs who have shut their general medicine practices and now perform only FAA physicals.

Of course it is now generally recognized that avoiding the doctor is not really a good long term health care strategy. Pilots (begrudgingly) accept this as well, but rather than confessing all their health issues to their AME, they engage another or "real" doctor to check things that aren't included in the FAA medical exam. This might include things like a prostate exam or perhaps a closer look at a discolored mole. 

Truth be told, the AMEs I've seen over the years have never seemed too thrilled to have these sorts of ancillary medical issues raised in an FAA examination. The idea is to check the things on the FAA list, collect their fee, and usher in the next pilot. They get it. Should a complaint which is ancillary to the flight physical be investigated and found to be nothing by the non-FAA doc, all the paperwork of having to deal with the FAA bureaucracy is also conveniently avoided. In fact, in the competition between AMEs, the word quickly gets out on the street about which docs just check the essentials and which ones are "tougher".

So do I mean to suggest that pilots or flight docs are somehow "cheating" the system? Absolutely not. Should a serious issue be found by a non-FAA doc, pilots are legally obligated to inform their AMEs of all medical care other than routine physicals, so even the FAA recognizes that their own exams are not all encompassing. It is the false alarms and paperwork that are being bypassed.

Went Peacefully


There's an old aviation joke that goes: "When it's my turn to go, I want to go out peacefully in my sleep like ol' Joe...not screaming in terror like his passengers".

Yes, macabre, but there have been a number of times that a pilot has died at the controls. The latest incident happened just over a year ago when the 57 year old captain of an American A-320 died while enroute from Phoenix to Boston. The pilot had had bypass surgery years earlier and likely suffered a heart attack even though he had been flying for years after the surgery. The first officer landed the plane without incident.

Keep 'em Flying


So even though there exists some measure of disaffection between pilots and doctors, I believe the system functions well to ensure that only healthy pilots are at the controls. For those pilots who end up with serious health issues such as heart problems, or cancer, the bureaucratic wheels at the FAA can turn slowly, but they do eventually turn and many pilots who have suffered these types of problems can get back into the cockpit once their problems have resolved. 

Flying airplanes demands complete attention from alert and healthy pilots. With all the negative physiological stresses on members of this profession, having someone keep an eye on the pilot's health while he or she keeps an eye on your airplane maintains the high integrity and safety of today's aviation system.


Monday, January 02, 2017

Don't Depend on the Kicker to Win the Game



LaMia 2933
If it routinely comes down to the kicker to win, the team has failed.


Last month I wrote about the crash of LaMia 2933 which resulted from fuel starvation. Post crash investigation revealed that the flight was planned beyond the range limits for the aircraft and no provisions were made for required reserve fuel. Thus, after encountering a slight delay for another aircraft, the LaMia airliner ran out of fuel and crashed killing 71 of the 77 passengers and crew aboard the aircraft.

Much opprobrium has (rightly) been placed upon the heads of the pilots who planned the trip to exceed the capabilities of the aircraft they were flying, but I'd like to take a closer look at the circumstances of the situation to try to understand why the pilots would make such a foolish mistake. It certainly wasn't made in a vacuum.

Cinderella Story


The trip was a charter flight for the staff and players of the Brazilian Chapecoense futbol squad along with some journalists to the Copa Sudamericana Finals in Medellín. They were scheduled to play against Atlético Nacional the day after their arrival in Medellin.

Chapecoense was the first Brazilian football team to make it to the final of the Copa Sudamericana finals in three years. Representing a city of about 200,000 in the state of Santa Catarina, Chapecoense had bested more highly favored teams to represent Brazil in the finals match. Thus, there was intense interest in the match including a significant amount of national pride.

Chapecoense had wished to charter LaMia to transport the team directly from Sao Paolo to Medellin but were prevented from doing so by international regulations. Any charter aircraft flying between Brazil and Colombia would have to be registered in one of those countries. LaMia, however was a Bolivian registered operator, so provisions were made to fly the team on a Bolivian commercial airline to Santa Cruz in Bolivia before transferring to LaMia for the leg to Medellin.

A delayed departure from Santa Cruz meant that a planned refueling stop in the Bolivian city of Cobija was not available as that airport closed at sunset due to lack of runway lighting. The LaMia pilot then filed a flight plan showing a refueling stop in Bogota, but did not make that stop as Bogota is just slightly closer than Medellin. A stop there for fuel would have raised awkward questions about inadequate fuel planning. Another possible refueling stop was available in Iquitos, Peru, but would involve a two hour notification for customs and prior permission to enter Peruvian airspace from the DGAC (Bolivia's Civil Aviation Authority).

A Roll of the Dice


We must remember that the captain of that doomed airliner did not get up that morning with any idea that his actions would end up killing himself and his passengers. His essential error was that of what safety experts call "expectation bias". Simply put, the human brain has an expectation that things will work out in the future as they have in the past. The result of succumbing to expectation bias is that it effectively masks the underlying risk of one's actions.

In the back of our minds all pilots "know" that the risk of screwing up badly is an untimely meeting with the grim reaper. Pilots are famous for making macabre jokes about death even as aviation has grown safer. But with such sentiments being always present throughout a career in aviation, it becomes ever easier to believe that bad stuff only happens to the other guy who got unlucky. The fact that any particular pilot is around to reflect on the demise of compatriots can actually reinforce the belief that he or she is doing it right.

Now contrast that omnipresent but dull sense of risk of a crash with the very clear and present fear of the consequences had these pilots not gotten the beloved Chapecoense football team to their championship match. The pilots likely thought that cancelling the flight was not an option as the match was scheduled for the next day. The captain, and the airline of which he was part owner, would have suffered tremendous enmity and a loss of future business when it was learned that they were the cause for the team to miss their game or to arrive without the needed rest to play the next day.

There is little doubt that the captain knew that fuel was going to be tight, but he conflated the risk of running out of fuel with the risk of not getting the team to the game. He rolled the dice without understanding how many chips were on the table.

The question is, how does one person get put into the position of making a decision between an uncomfortable outcome that is certain to happen (if the flight cancels) and a deadly outcome that might or might not happen (if the plane runs out of fuel)? Had the plane not run out of fuel 10 miles from the airport, no one would have been any the wiser.

Depending on the Kicker


Any organization depends on cooperation between individual team members to be successful. Success or failure should not, however, be dependent on the actions of one person. Like any complex machine, an organization must have redundancies for critical functions. Too much stress on a critical link in any chain guarantees eventual failure. If winning the game always depends on the kicker, the team has failed.

The captain of LaMia 2933 should not have been in the position to be able to trade safety for financial gain. This crash was due not only to a bad decision made by the captain, but also to the organization which allowed one actor to be pressured to make such a decision. So how should an organization insulate itself from this type of single point failure?

Culture of Safety


First, in any industrial setting, cultivating a "culture of safety" is paramount to a successful operation. What this means is that safety of the operation is first and foremost. This culture must be internalized by everyone from senior management to entry level and temporary employees.

Successfully installing such a culture is hard work and will not be accomplished through mere platitudes or safety posters hung in the workplace. There will need to be honest organizational support for safety initiatives and a reassurance from the C-Suite on down that the goals for a safe operation are embraced. This will include a robust safety reporting system and employees who are empowered to implement correctives for identified deficiencies.

Secondly, individual employees should not be put in a position of having to choose between a competing set of values. In the case of airline operations, the people in charge of financial results are probably the wrong people to be making operational decisions that impinge on safety. The bottom line must obviously be watched, but if an operation cannot be done safely, then it probably shouldn't be done at all. Management tools such as pay protection for line employees when operations are cancelled can help in the effort to make sure the correct decisions get made.

The Choice is Yours


Whether you find yourself as a manager or operator, you must understand that humans respond to incentives. Wrongly aligned incentives will eventually manifest themselves by coming back to bite the unwary. Is your organization optimized to be as safe as it can be? How will you know if it isn't?



Thursday, December 22, 2016

The Crash That Made Your Airplane Safer


Terrain is now displayed on primary flight displays
Enhanced GPWS display showing terrain (in green)


Any airplane crash is a tragedy, but in the investigation following a crash, it is always hoped that something can be learned which will aid in the prevention of a future crash. Commercial aviation is now one of the safest modes of transportation available, but it has only become this way through dogged investigation of aircraft accidents and the application of lessons learned. Such was the case of American 965.

On December 20, 1995, American 965, a 757-200, crashed in the mountains of Colombia while enroute to Cali. 151 passengers and eight crew were killed while five passengers survived the impact. The investigation into the crash concluded that the primary cause was a navigational error made by the flight crew resulting in terrain impact.

There were, however, some unique aspects of this accident which highlighted contributing factors. One of these was found to be several errors in the aircraft's navigational computer database which led the crew astray.  Also unique to this accident investigation was the method in which investigators were able to reconstruct the events which led to the crash. As it happened, one of the 757's flight navigation computers was found in the wreckage with its internal battery and volatile memory still intact. 

This allowed investigators to reconstruct electronically what the aircrew saw as they were descending through the mountainous terrain that night in Colombia. This finding revealed the true cause of the errors that were made by the flight crew which had until then eluded investigators. And this, in turn, directed investigators to the errors in the onboard database.

Increasing reliance on automation meant that aircrews were becoming more dependent on onboard electronic systems used for navigation rather than on the printed paper charts and radio beacons which had been the mainstay of airborne navigation since the dawn of aviation. Uncritical trust in this system, however, turned out to be deadly.

The aftermath of this crash resulted in new safety systems that are now installed on virtually all commercial airliners to aid in terrain avoidance as well as new procedures to be used with automated aircraft navigation systems.

Let's take a closer look at the causes of this accident and some of the changes resulting from the investigation.


Where is it Taking Us?



Alfonso Bonilla Aragón International Airport, which serves Cali, lies in a valley with mountainous terrain rising to over 12,000 ft on either side of the north-south running Cauca Valley. The arrival path of AA965 had the aircraft descending through this valley to pass over the airport and then reverse course to land to the north.

At some point though, the controller, who had no operable radar due to terrorist activity, offered the crew a straight-in approach to land to the south on the north-south runway. The crew accepted this clearance but were now high on profile without the turn around to lose the excess altitude. Thus they were expediting their descent with the aircraft's speed brakes being extended.

There was also some confusion in the instructions given to the crew by air traffic control with the aircrew finally asking to proceed directly to a radio beacon near the airport. This beacon, really just a radio transmitter, was named "Rozo NDB". It is here where a database error and a lack of situational awareness caused problems.

The paper charts which the crew was using listed the Rozo beacon by its identifier as the letter "R". That meant that typing that identifier into the computer should have caused the aircraft to fly to the Rozo beacon straight down the valley. The database installed in the aircraft, however, had an error and differed from the paper charts the crew was using, The identifier of the Rozo beacon in the electronic database was "ROZO" and not the letter "R" as the crew believed.

Thus when the crew typed in "R", the aircraft turned left towards another beacon located 130 miles to the east in Bogota named "Romeo". This beacon actually did have its identifier listed as "R" in the electronic database. This turn to the east took the aircraft directly into the mountains on the east side of the Cauca Valley.

Maintain Situational Awareness


If the above description is confusing for you to read, imagine what was going through the minds of those pilots as they tried to sort out where they were and why their airplane was mysteriously turning when it should've been going straight south to the runway. It took the crew about a minute to sort out that the airplane shouldn't be turning and another minute to start a turn back to safety. But even though they eventually got terrain warnings and had started an emergency climb, they had descended too far into the mountains and hit a ridge at an elevation of about 8900 ft.

One of the prime directives of aviation, drilled into all pilots from the beginning of their careers, is to maintain situational awareness. This means knowing what is going on around you at all times. It is a fundamental skill in aviation. This crew was set up by a database error, but should have had an idea that any turn off their course down the valley was ill advised. They should also have known that they had descended below the altitude of the mountains bordering the valley.

One of the luxuries that US based airlines enjoy is a first rate air traffic control system which is unparalleled in not only maintaining traffic separation, which is their main objective, but also in providing terrain avoidance. They're so good at it in fact, that it is easy for pilots to become complacent about the need to always be vigilant about terrain if for no other reason than they (and their passengers) will suffer the consequences of any such complacency.

The same, unfortunately, cannot be said for many countries without the superb infrastructure found in most first world countries. While most controllers are excellent at what they do, the Colombian controller had no radar with which to warn American 965 that they were in danger. It is the pilot's sole responsibility to maintain awareness of any terrain clearance problems.

Not in Vain


The story does not end here. The fallout from this accident was wide ranging. The database error which led the pilots to make a wrong turn into the mountains prompted a thorough review of the navigational databases which are used by commercial aircraft, including safeguards to ensure that the information printed on charts matches that in navigational databases. Flight crew procedures were also changed to ensure that a "common sense" check of any computer commands were made before those commands were executed in the navigation computers.

It also became apparent that faster and more capable computers coupled with GPS receivers would be able to provide a whole new level of protection against controlled flight into terrain (CFIT). Ever since the crash of Eastern Airlines 401 into the Florida everglades in 1972, commercial aircraft have had a system installed that is known as the Ground Proximity Warning System (GPWS). Pronounced "jip whiz", this system warns pilots of approaching terrain through a downward looking radio altimeter. 

GPWS is the source of the electronically generated "PULL UP" command you may have heard in movies or when the system is tested at the gate. The limitation of this system is that there is no way to reliably warn pilots of very rapidly rising terrain as the system can only look straight down at what is directly below the airplane. In fact, the GPWS system on American 965 did warn the pilots of danger but not until it was too late.

Enhanced GPWS


A new system called Enhanced GPWS has since been designed to use a database of all the terrain an aircraft is expected to encounter either regionally or globally. When coupled with GPS location, this system can give pilots enough warning to avoid any possible terrain conflicts well in advance of encountering any high terrain. It generates a terrain map on the primary flight display. This display looks somewhat like an old fashioned topographic map but terrain is displayed in green, yellow, or red depending on the height of the terrain in relation to aircraft altitude.

The system is proactive and will also generate cautions and warnings based on the current aircraft trajectory and any terrain that may be a danger. Pilots are warned well in advance of any projected terrain encounters. The system finally gives pilots real time feedback on exactly where they are in relation to high terrain, a problem which has always plagued aviation.

Aviation is safer now than at any time in history but this is no accident. Many accidents are caused by carelessness or complacency on the part of crews or maintainers, but occasionally something is learned that materially affects the safety of the entire industry. American Airlines 965 was a tragedy for everyone aboard that fated airliner as well as for their friends and families, but at least in this one case, real changes were made which will make a recurrence of this accident much less likely.

The next airplane trip you take will also be safer because of lessons learned from the crash of American 965.


Addendum: Counterfeit Parts and Aircraft Design



Two other issues were brought to light in the aftermath of American 965. One that was highlighted was the existence of an international network of counterfeit aircraft parts as some of the parts from the wreckage began to show up on the black market. Aircraft parts are built to exacting and expensive standards, so an incentive exists for unscrupulous actors to sell counterfeit and stolen parts. Parts with serial numbers from AA 965 did make their way into this network.

A second issue was that of cockpit design. When the pilots realized that they were near the terrain, they initiated an emergency climb, but neglected to retract the speedbrakes which they had been using to descend. Because the aircraft hit the ridge only a few hundred feet below the summit, speculation was made as to whether the speed brakes should automatically retract when the throttles are pushed up and whether doing so would have saved the aircraft. Some aircraft have this feature while others do not, but highlighting the issue should make pilots aware of the potential problem.

Wednesday, May 25, 2016

Does Falling Asleep at the Controls Make You a Bad Pilot?



A Delta 767 gets intercepted by Greek F-16s after comm loss.
Delta 767 and Greek F-16s in formation.

Not necessarily, though it might very well make you a dead pilot if you were in a single pilot aircraft such as an F-16 or Cessna. But as far as airliners go, if the pilots take a snooze at altitude with the autopilot flying, the airplane stays on course and airspeed. Falling asleep is a physiological incident which can be due to many different reasons, but one thing it is not, is a moral failing. Let me explain.

In a recent event over Greek airspace, a Delta Airlines 767 flying a charter for the US military entered Greek airspace and did not check in with air traffic control. The Greeks then launched two F-16s which intercepted the airliner about 40 minutes after it entered into Greek airspace. Shortly after the intercept, the aircraft reestablished communications with air traffic control and proceded onto its destination of Kuwait.

There have been some unsubstantiated reports in Greek media that the fighter pilots saw the airline pilots unresponsive in their seats. The reports also claim that it was calls from the flight attendants who noticed the intercept which alerted the pilots to the situation.

Delta, for its part, reported that the aircraft couldn't make contact with Greek controllers after their handoff from a previous sector. That's plausible, though losing communications in an extremely busy part of the world for 40 minutes does seem unlikely. Maybe 5 or 10, but 40 is more difficult to swallow.

They Want You to Lose Communication


A little known fact is that many jurisdictions around the world actually love it when an airliner from a wealthy nation flies into their airspace without making contact. They then get to launch an intercept or search and rescue (SAR) forces and then send the bill to whoever has the deepest pockets. That would be Delta and the US government in this case.

Notice that it only took 18 minutes from the time the airliner entered Greek airspace to the launch of the fighters. There are rumors around that Greece itself is in some financial straits. They're smelling a payday. Sure there are legitimate reasons to intercept a comm-out airliner in today's crazy terrorist besotted world, but money also makes a good motivator as well. Win-win I suppose.

At any rate, any pilots worth their salt flying in this part of the world must know that going comm-out while crossing a flight identification region (FIR) boundary while bound for the Middle East will not be good.

So what other reason might there be?

They Were Snoozing (Maybe)


The nature of this job is many days and time zones away from home, back side of the clock flying, lousy diet, and hotel beds which only get the straw changed every other year. I jest about the straw beds, but I often feel like I've slept on one as my back will let me know when trying to roll out of bed. 

My point is that getting a reasonable amount of sleep on the road is a serious challenge, and that is if everything goes right. A noisy or inop air conditioner, maids knocking on the door early in the morning after a late night arrival or my personal favorite, hammer drills in a nearby room from construction crews can make a good night of sleep nearly impossible.

Even though most airlines have good fatigue policies which allow pilots to decline a flight with no sanction, there is no guarantee that halfway through a flight which you felt fine to start that you won't simply find it impossible to keep your eyes open. This can be in the middle of the day, perhaps right after lunch while sitting on the sunny side of the jet.

Do you do what you can to prevent this? Sure. Get up and stretch, get a cup of coffee, or take a restroom break. Even after all that you might still be droopy. So it is by far from implausible that this happened to both of the guys or gals up front.

Are They in Trouble?


No, they are not. As I mentioned above, falling asleep is a physiological incident and not a moral failing. There will be no scene from 12 O'clock High with Gregory Peck chewing out a guard who has fallen asleep at his post. What will happen is the crew will fill out various safety and fatigue reports (if that indeed is what happened) and life will go on. And if it was merely a case of lost comm, mostly the same thing will happen.

Their reports will go into a safety database where de-identified safety data will hopefully guide any policy changes which need to be made. Yea, that may be somewhat idealistic, but the point is the crew will live to fly another day.

And as I always brief to my copilots, I never want to wake up and find them sleeping! (Just kidding!)

Sunday, May 01, 2016

How to Fly with a Jerk





Yea, they're out there. The perfectionists, the disgruntled, the narcissists and especially the ones who are going to teach you the "proper" way to fly. Spend enough time in the front of an airliner and sooner or later you will be paired to fly with a jerk. Short of calling in sick, you will have to spend the next several days locked in a closet sized space for hours on end with the south side of a northbound horse.

So how will you cope? Remember that you have an important job to do and to do it well, you have to work with the other pilot. There was a time when the standard method of dealing with a jerk was to simply not deal with him or her. This could've meant each pilot scanning the 10 or 2 o'clock positions permanently while never interacting save for required checklist callouts.

That strategy clearly has drawbacks and can seriously degrade safety. There's a reason that airliners still have two pilots (for now). You're a professional even if the other guy or gal is less so, and the folks in back are counting on both pilots up front to conduct themselves as such. With all that in mind, here's the Captain's guide to surviving a pairing with a jerk! (Me included.)

Don't Keep It to Yourself


I think that most people are generally conflict averse. I know I am. Most of us don't go around looking for a fight or trying to cause trouble, especially on the job. We want to get through our day, finish with zero airspeed at the correct gate and go to the hotel. So when a situation crops up that causes us some consternation, a first reaction may be to just keep it to ourselves. After all we place a high value on good cockpit relations and rationalize that some internal discomfort is not too high a price to maintain a cordial cockpit atmosphere.

Don't fall for this rationalization. It is built on a fallacy. For starters, if the other guy is doing something that bothers you, he may not even realize it. Secondly, your discomfort won't go away. It will only fester and get worse. Trust me on this. And if you keep your feelings to yourself for any length of time, it can get really awkward when you finally do speak up. It is always best to get things off of your chest as early as possible.

Don't Ever Accept Non-Standard Operation


Again, there may have been a time in the distant past where the Captain was omnipotent and not to be questioned no matter what he did, even if it fell outside of standard operating procedures (SOP). Those times are absolutely long gone. You have a legal and moral duty to make sure that the aircraft is always operated by the book. Does this mean that you must become a pecksniff and point out every deviation no matter how minor? No it does not; there is a middle ground between being a bag of sand in the seat and what we sometimes refer to as a "check F/O".

Getting back to the professionalism part, when the aircraft is operated in a non-standard fashion and something bad happens, claiming that the other guy was flying is of course no defense. My advice is to predetermine your own personal boundaries and then stick to them. You'll sleep better at night. If push comes to shove, which it hopefully never will, take the airplane if you must, and after landing grab your gear and get off the airplane. This will of course involve scheduling and chief pilots but your career is worth it.

And I want to add a note here about bringing in third parties to a dispute. I believe in handling conflict personally whenever possible. The outside resources available to you are your union's professional standards people and your chief pilot. The first thing either of these people will ask is whether you discussed the matter with the other person. If you reply in the negative, your credibility drops. Nobody will care about your issue more than you, so start there. 

The pro standards folks and (most) chiefs are great, but my thoughts are that if the guy you're flying with is that big of a jerk, the pro standards folks are probably already well acquainted with him. Taking an issue to a chief pilot should be an absolute last resort. You don't want to be known as the guy who runs to management with a personality conflict. Gross or continued non-standard flying? Maybe. Just be ready to defend your actions.

Sometimes You Have to Just Suck it Up


I personally like to let my F/Os fly the airplane any way they'd like as long as it is within SOP, but that's just me. Some cappies like to dictate how the plane should be flown or how a system should be operated. According to most airlines' procedures and FARs, they are within their rights to have it done the way they want it done, again as long as it is within SOP.

As an F/O, you learn to become a chameleon and do it the way the boss likes it to be done. For instance, in the age old argument of whether or not to run the packs on high on a hot day in a 737, everyone has an opinion. But if the guy in the left seat has a preference, his vote is the one that counts. Hopefully he will be willing to listen to your reasons. If not, there's not much that can be done until you upgrade yourself.

My airline has a "bid avoidance" feature that can be used by F/Os to avoid people with whom they really don't want to fly, but it comes with the price of subrogating their own seniority. This feature didn't exist when I was in the right seat so the "suck it up" or "talk it out" methods were all that were available. It did, though, in some measure force people to get along to some degree.

Take a Look in the Mirror


If you find that you seem to end up having more than a few tiffs in the cockpit, then perhaps the problem doesn't lie with the other guy. If it seems to you that everyone you fly with is a pig-headed jerk, then that may become a clue for you. I think this advice is especially useful for captains. F/Os are naturally inclined to become chameleons, so if you find that your cockpit has a tense atmosphere or you spend a lot of time eating alone in the hotel, perhaps some introspection is merited.

Captains, on the other hand, really get very little feedback. Some are conscientious enough to ask how they're doing, but many are not. Most people with a blind spot are unaware that they have one, which is why my above advice to not keep things to yourself may be more useful than first thought.

Do I have war stories about conflict in the cockpit? Yes I do. I think conflict of some sort with another pilot is inevitable given enough time. My personal technique is to try to not bring up topics which might be touchy such as union issues or politics. I'll talk about that stuff all day long if it comes up, but it is much easier to "kick someone's anthill over" when discussing those things as opposed to Da Bears. And I'm not a huge sports fan, but being at least somewhat conversant in sports can be helpful.

In Conclusion


Unlike many other workplace environments, a cockpit is an especially bad place for conflict. Both pilots must make an effort to recognize and to quarantine conflict. Getting things on the table early and using techniques such as humor can go a long way to defuse the bad feels. Pilots aren't necessarily known for being great "people people" but getting along up front should be considered as essential a skill as maintaining airspeed on final.

 Of course, I always get to fly with my favorite jerk.





Sunday, April 03, 2016

Another Drunk Pilot?



Pilots are routinely tested for drugs and alcohol
All airline pilots are randomly tested for both drugs and alcohol.



Last week another pilot was pulled out of his cockpit and arrested for being under the influence. So what's up with these guys? It seems like you can hardly turn on the news without hearing about another drunk pilot, right? They're even making movies about them. Why is this even a thing?

Well it's easy to explain why the furor over alcohol abuse by pilots is a "thing". And by that I mean something which garners immediate headlines and watercooler talk. This is because short of nuclear power station operators or cruise ship captains, few other professions leave so many lives in the direct immediate control of another human as does aviation. And for all the oft-stated reasons that riding in an aluminum tube at 30,000 ft is already nerve wracking enough, the thought of having a tipsy pilot up front is something that no one needs or wants. And that is completely reasonable.

If your lawyer is sloshed on the job, maybe it'll cost you some money if you lose a suit. And perhaps after a few martinis your doctor might prescribe a Tylenol when what you needed was an Advil. Even if a hammered surgeon nicks an artery and the patient bleeds out on the table, it's just one person. But a pilot can kill hundreds, which is especially bad if you happen to be one of the ones riding along.

As an aside, I admit to being amused by passengers who will say something like: "Well, you know, pilots really only fly the plane for an average of 30 seconds during any given flight. It's the computers which really fly the plane." And then quickly follow it with "Did you hear about that drunk pilot? He could've killed everybody!"

Alcohol Abuse Among Pilots is Actually Rare


So is there actually an alcohol abuse problem among pilots or is this something which just tends to make the headlines? In actuality, airline pilots are nowhere near the top of the list of professions with high degrees of alcoholism. Ironically, doctors and lawyers are high up on the list. But a study conducted by NIH found a total of 13 alcohol related incidents involving airline pilots over a 16 year period between 1990 and 2006 which would indicate that this "problem" is actually quite rare.

Additionally, there has never been an aviation accident attributed to substance abuse by airline pilots. Government data suggest that about 12 pilots annually are found in violation of FAA standards for blood alcohol content out of over 11,000 tested. But overall, the incidence of alcoholism among airline pilots is below that of the general population.

Where There are Humans, There are Human Frailties


Because the "Drunk Airline Pilot" headline makes such excellent clickbait and draws so many eyeballs (see the title I chose), there's little incentive to tone down the story to something like "Airline Pilot Only Half as Drunk as You Driving Home". That's because the legal limit imposed by the FAA is a BAC of .04% whereas a DUI in most states is defined as a BAC of .08%. Furthermore, a test result of .02 to .04% will result in a pilot being removed from duty though it doesn't carry a criminal penalty.

Now this guy may have really tied one on and was actually blotto, I don't know. But most of the cases I'm familiar with resulted from one too many drinks the night before followed by too short of an overnight for the alcohol to wear off. If this was the case, our hero was probably not ripped but rather just across the line of .04%. Obviously he was displaying some signs of inebriation or perhaps odor as he was identified at the security checkpoint.

Please don't get me wrong. I am not defending this guy's actions. He screwed up big time and betrayed the trust placed in him. He will also pay an extremely heavy price. My point is that this guy was most likely not as stumble drunk as the headlines usually suggest, but he certainly was impaired.

So What Happens to Him Now?


To use a technical term, this guy is royally screwed...and he has nobody to blame but himself. The use of alcohol by airline pilots is governed by federal aviation regulation (FAR) 91.17 and stipulates:


(b) Committing an act prohibited by §91.17(a) or §91.19(a) of this chapter
is grounds for: 
(1) Denial of an application for a certificate, rating, or authorization
issued under this part for a period of up to 1 year after the date of that
act; or 
(2) Suspension or revocation of any certificate, rating, or authorization
issued under this part.

The mechanism that the FAA uses to get problem pilots out of the cockpit is through the denial of a medical certificate, which is needed to fly. Furthermore, the FAA defines a history of alcohol abuse as a disqualifying medical condition. Using a bit of circular logic, being cited for attempting to operate an aircraft while having a BAC in excess of the limit can be considered as evidence of a history alcohol abuse and therefore disqualifying for holding a medical certificate.

Getting past all the legalese, this means the guy is quite possibly grounded for good. But that's just the Feds. Most airlines have very severe sanctions for alcohol use by employees in safety sensitive functions which includes pilots. If this guy tested at more than .04% BAC, he will most likely be canned. And that likely means termination with prejudice as it is unlikely that he'll find another flying job.

There is a pathway back to the cockpit, but it is long and expensive often taking years to regain ratings and certifications from scratch. In the meantime he'll be busy selling his house, finding new schools for his kids and explaining to friends and family why he's no longer an airline pilot.

But I Thought Alcoholism was a Disease


Alcohol abuse has always carried the stigma of being a moral failing but that perception has faded over the years. The American Psychiatric Association describes the conditions which define both alcohol abuse and alcohol dependence in the Diagnostic & Statistical Manual (DSM). The recently published DSM-5 is moving away from treating both abuse and dependency as separate conditions though the criteria used by the FAA in defining alcohol abuse is significantly different than that described in the DSM.

It is generally recognized though, that a problem with alcohol should not be faced alone. To that end, the Human Intervention and Motivation Study (HIMS), a program funded by the National Institute for Mental Health (NIMH) has resulted in resources being made available for pilots who have alcohol problems. The idea here is that a program which concentrates on the rehabilitation and return of pilots to the cockpit would encourage others to come forward for treatment.

The caveat of this program is that it does not protect pilots who operate or attempt to operate an aircraft under the influence from sanction. So what should this guy have done? How could he have avoided all this bother?

Well, short of not drinking so much the previous evening, he should have called in sick and not gotten on the aircraft. In fact any time up until a predetermined point a pilot can refuse to operate the aircraft and not be in violation. At my airline that point is the threshold of the aircraft door though it may be different for other carriers. That is the point of no return when determining intent.

Are You Drunk?


One of the more enervating aspects of being an airline pilot most likely not enjoyed by other professionals is having complete strangers come up to you and ask if you're drunk. This just happened a few weeks ago to me as I was in the gate area waiting to board a deadhead flight. The guy came up and asked, "Hey, you look sober. Are you our pilot?" I told him I was not (his pilot) but must confess to being a bit annoyed. 

He should ask his doctor that question on his next visit. The odds are statistically higher that the answer is yes.

But I get it. People getting on an airplane are nervous and see a guy in uniform so they open their mouth and something stupid comes out. One reply which I always long to make (but never would) is "not as far as you know."

So rest assured, nervous flyer, your pilot is not drunk. But you might want to ask yourself who would you honestly rather have flying your plane given the choice: The alcohol and drug abusing pilot played by Denzel Washington in Flight who saved everyone's life, or the stone cold sober Asiana pilots who crashed their 777 into a seawall in San Francisco on a clear day? Take your time answering. I'll wait.