Transcript 27th International Aircraft Cabin Safety Symposium Orlando, Florida, USA 27-29 April 2010 Recent Major Accidents & the Capacity of Training To Avoid Them World.

27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
Recent Major Accidents & the Capacity of
Training To Avoid Them
World Aviation Training Conference
Orlando, Florida
April 2010
Robert Matthews, Ph.D.
Senior Safety Analyst
Office of Accident Investigation, FAA
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
Training is a good thing; it reduces the risk of accidents.
Start with the premise that training is part of a 3-legged stool:
Establish good standard operating procedures (SOPs);
Train repeatedly to those good procedures; and
Enforce those good procedures.
This presentation reviews 19 recent hull-losses involving 3
common accident categories to illustrate training’s capacity, as
part of this 3-legged stool, to reduce risk.
Bottom Line: training can reduce the likelihood of many serious
accidents, though its capacity to do so has practical limits.
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
Six Take-Off Accidents
From 2006 through 2008
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
27 August 2006; Comair CRJ2 at Lexington (49 fatal)
 Early morning flight in night VMC.
 Flight crew planned to take off on
22 but lined up on a much shorter
runway 26 & began takeoff roll
 Ran off the runway end and struck
the airport perimeter fence, trees,
and terrain
Causes, Factors & Issues:
 Non-pertinent conversation on taxi & loss of positional awareness.
 Failed to cross-check & verify they were on the correct runway.
 Crew failed to use available cues & aids to identify location during taxi.
 Add airport configuration (short, single taxiway to 2 near-by runway ends) &
possible fatigue for Captain.
 Crew issues are basic in training programs, including private pilot training.
 Score for More Training: Low. Limited to the capacity to instill discipline &
adherence to SOPs on every flight.
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
25 Jan 2007, Regional Air, Fokker 100, at Pau-Uzein
Airport (No injuries to 54 onboard; 1 ground fatal)
Photo: BEA
Causes: Limited awareness by crew &
company of effects of ice on the ground;
•No tactile verification of wing condition;
•Wing design’s sensitivity to icing.
•Rapid rotation & lack of “crew vigilance.”
Training Score: Moderate; high if good
SOPs were in place; they were not.
•T/O after 50-minutes on ground. WX:
snow, broken 1,100, Temp/dew 0/-1C.
•Rotated “abruptly” at 128 knots when
the crew saw flocks of birds.
•A/C immediately banked 35 degrees
left, 67 right, then 59 left.
•Reached 107 feet, sank, right gear
struck runway & A/C bounced.
•PIC (PF) aborted at 160 knots.
•Touched down right of runway end,
crossed a road & hit a truck, killing its
driver, then rolled out into a field.
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
25 May 2008, Kalitta Air B742 at Brussels (Minor injuries to 5 onboard)
•BRU uses 25 for T/O but 20 on Sunday for
noise 9,573 feet (1,950 shorter).
•Began T/O at taxiway 800 feet down runway;
had computed T/O parameters for full runway.
•Bird strike & compressor stall at V-1 & ATC
noted flames on right side.
Aviation safety.net
•Captain continued several seconds, then
decided he could not T/O safely & aborted 12
knots above V-1.
Causes: RTO 12 knots past V-1;
•All 4 engines were brought to idle and did not
deploy thrust reversers.
Miscalculated takeoff parameters.
Failed to use thrust reversers.
Situational awareness.
•Overran 1,000 feet down embankment &
came to rest with nose overhanging second
embankment next to busy rail line.
Training Score: Moderate - - Event complicated by bird strike & compressor stall exactly at V1. Training still may have helped to emphasize SOPs, including check of computed T/O
parameters & use of thrust reversers
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
7/708, Kalitta Air B742, Bogota (3 ground fatal; 2 of 8 onbd serious)
•Night T/O (02:50); ceiling 1,700; calm.
•Engine #4 failed on rotation.
•Climbed out & began circular engine-out
return in Bogota Bowl.
•#1 failed 55 seconds after rotation 8.5 miles
out at ¼ through circling return.
•Seconds later, #2 engine entered
compressor stalls.
•Made emergency landing in dark field 6
miles NW of airport & struck a farm house; 3
fatal on the ground.
Cause: No report yet.
Broader Issues still not clear: investigation
has become costly JT9D science project.
Training Score: Zero. Crew performed well
under conditions; 3 engines failed in a
mountainous black hole
El Tiempo & Reuters
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
8 Aug 2008, Spanair MD-82 at Madrid (154 fatal & 18 serious)
Reuters
Issues: No final report yet but issues
appear to include maintenance SOPs
(Tagging) & checklist discipline (flaps) &
risk from small disruptions.
Bottom line: Moderate. Like LEX, must
assume capacity to ensure adherence to
SOPs every time, but a better chance
here: if either flight crew or maintenance
had followed procedures, no accident.
•Awaiting T/O, A/C returned to gate for
faulty Ram Air Temperature probe.
•Maintenance pulled 2 CBs for ground
control relay switch but tagged just 1.
• Flight crew later reset tagged CB but
not the other CB.
•Crew ran all check- lists, yet failed to
set flaps (FO simply replied “check” for
flaps, but did not set them).
•Result: no-flap T/O & configuration
warning system was disabled.
•Rotated at 154 knots, reached 40 feet
AGL, then sank & rolled.
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
20 Dec. 2008, Continental B737-500 at Denver (5 serious, 115 onboard)
Rocky Mountain News
Under investigation but likely to include:
Demonstrated crosswind with winglets.
Crew performance & response to drift.
•B737 with winglets began T/O on
34R; wind 290 at 24, gusting 32.
•A/C weather-vaned & drifted left as
engines were nearly spooled up.
•Ran off left 40 seconds into T/O roll.
•A/C continued accelerating several
seconds, then speed brake handle was
deployed & A/C began decelerating.
•Rolled across turf & down slope, with
engines starting to burn.
•Successful evacuation
Training Score: Low. Training for crosswinds & use of tiller may have had some
effect, but, crew was experienced in make-model. On net, more targeted pilot
training probably had only limited hope of avoiding this accident.
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
Findings for 6 recent Take-off Accidents
3 cases illustrate the value of training to & following good SOPs
(BRU, Madrid & PAU-Uzein), while Pau-Uzein also illustrates the
need to have appropriate SOPs & guidance in place to start.
Madrid also illustrates the same lessons in maintenance.
But, training had limited hope of directly influencing or averting
LEX, DEN or Bogota.
Bottom line for training is mixed:
•3 low scores & “only’ 3 moderate scores, but somewhat higher
with good SOPs in place.
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
Four Runway Overruns on Landing
From 2007 & 2008
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
18 Feb 2007: Shuttle America as Continental Connection
ERJ-170 at Cleveland (No Injuries to 4 Crew & 70 Pax)
Photo: NTSB
Causes, Factors & Issues:
•Lost visual cues & failed to go around.
•Descent to ILS DH instead of localizer MDA
(glideslope out).
•Landed long on contaminated runway
•No max reverse thrust or max brakes.
•Captain’s fatigue & fear of reprisal.
Training: Moderate on net. Winter ops
training & go-around gates score high, but
offset by fatigue & violation of several SOPs.
•FO flying in first pairing of this crew. Contradicted
SOP but PIC was fatigued.
•Cleared to runway 28 (6,017 ft).
•RVR reported at 6,000 & braking action fair, but
glideslope unusable due to deep snow.
•Passed FAF & ATC reported RVR at 2,000.
•PIC (PNF) reported approach lights in sight &
runway in sight at 50 feet AGL.
•FO then turned off the A/P to land.
•At 30 feet AGL, PIC briefly lost sight of the
runway, then regained it, & continued.
• In strong gusty winds, high sink rate developed in
flare & “likely stalled.” Landed long & hard; gear
trunnion fractured.
•Reverse thrust peaked at 70% for 2 seconds, then
slowly to reverse idle.
•Applied 20% max brakes for 8 seconds, then 75%,
then 90% when PIC applied his brakes.
•Ran off into snow-Ccovered grass & penetrated a
fence 150 feet past runway end.
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
17 July 2007, TAM A320-200 at Congonhas, Sao Paolo
(All 181 pax & 6 crew fatal; 12 Fatal & 11 severe on ground)
•6,365-foot runway was repaved but not
yet grooved; no overrun area.
Causes: Runway characteristics; construction;
inadequate crew training; Airbus’ lack of
warning for braking system failure.
•T/O Porto Alegre with #2 thrust reverser
deactivated before flight.
•ATC advised crew of light rain & wet
runway (35L); wind 330 at 8.
•Landed at normal spot but software
requires both reversers at or near idle for
spoilers to deploy.
•#1 engine went to reverse, #2 to “climb.”
•Overran left at high speed, over adjacent,
low highway; into TAM Express building &
gas station.
•Training Score: Moderate – conceptually high for crew knowledge of software; risk
assessment; recognition of single-engine reverse thrust.
•But offset by MEL & dispatch procedures (A320 to short, wet runway without T/R) & by
airport operations (un-grooved, short runway).
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
12/16/07: Air Wisconsin as US Airways Express,
CRJ-200 at Providence (No Injuries to 3 Crew & 31 Pax)
• FO (PF) recently completed IOE in CRJ2; this
was his second flight on this route (PHL-PVD)
• ILS approach to runway 5 (7,000 feet, snowcovered in rain & mist, in darkness).
• Winds aloft at initial descent from 220 at 100
knots (large tailwind component).
Causes, Factors & Issues:
• Unstable approach, high sink rate, stall, &
hard landing.
• FO’s poor execution of ILS approach
• Poor communication in cockpit.
• Inadequate FO training & experience.
Training Score High: time in A/C; Go-around
gates; CRM; winter ops.
• 2 miles out at 700 AGL, FO disconnected the
A/P & FD to “get the feel of the airplane.”
• A/C drifted left & above glidepath.
• Broke out at 300 & saw approach lights at 2
o’clock. PIC took control.
• FO thought PIC had called for power to idle &
FO reduced power without PIC’s knowledge.
• A/C reached max 22-degree bank below 100
AGL & descent rate of 2,000 FPM.
• “Porpoised” in the flare & landed 1,200 feet
long in 9-degree bank; main gear collapsed.
• Ran off 3,700 feet on snow-covered grass.
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
30 May 2008, TACA A320-200 at Tegucigalpa
Of 135 onboard, 3 fatal, 60 serious; 2 fatal on ground
Training Score: Moderate. LOFT, risk
assessment & go-around gates score
high. Offset by national airport policies,
dispatch & crew’s failure to monitor.
•Landed near max weight (63.5 versus max 64.5t)
on short, wet runway in light drizzle & 12-knot
tailwind from nearby tropical storm “Alma.
•Runway: 5,410 feet available landing distance at
3,300 MSL; 1% downslope & ungrooved).
•A/C was configured for landing in Speed Mode –
(above Vref); landed at 139 IAS.
•Immediately selected MAX REV. Nose touched
down 7 seconds after mains.
•Applied manual braking 4 seconds later & max
pedal braking 10 seconds later.
•Selected IDLE REV at 70 knots & 625 feet
remaining.
•Overran at 54 knots & dropped down 65-foot
embankment onto street.
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
Findings from 4 Runway Excursions on Landing
(CLE, PVD, TEG, SPO)
Training scores range from moderate at TEG & CLE to high at Sao
Paulo & PVD.
Some high scores:
More time learning the airplane;
Stable approach & go-around gates (all 4 accidents);
Risk Assessment (all 4 accidents)
LOFT & winter operations (CLE & PVD).
Offset in some cases by:
Airport configurations;
Crew fatigue & violation of established SOPs;
Carrier policies & guidelines (unclear or inappropriate).
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
Nine Undershoot Accidents,
2008 & 2009
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
17 January 2008, British Airways 777 at Heathrow (1 serious among 152)
•Normal approach until 600 feet AGL & 2
miles out, when auto throttle demanded an
increase in thrust.
•Both engines failed to respond.
•Crew moved levers manually & again no
response.
•A/C lost speed & landed short.
Ice deposits of water & fuel (soft & mobile)
accumulated in fuel lines.
Cause: No final report yet.
Issue: Rarely identified fuel-heating issue
unique to one system.
AAIB recommends all CAA’s require the use
of anti-icing fuel additives, such as FSII,
used in military and high-end business jets.
•Restricted flow in fuel/oil heat exchanger
(FOHE) in Trent-800.
•This led to thrust rollback in flare.
Training Score: zero.
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
21 Feb. 2008, Santa Barbara Airlines ATR42 at Merida, VZ (All 46 fatal)
•Airport closes at sundown. Accident A/C
last scheduled T/O for day.
•Clearance delayed for inbound aircraft.
•On taxi, FO (PF) notes gyros had failed.
•PIC says equipment is “crap” & says he
has had to operate w/o gyros before.
•Crew: “Go visual” & “try to reset it in flight.”
Cause: No report yet.
Broad Issues:
SOPs; Maintenance; Corporate culture
Decision making; Situation Awareness
CAA (Carrier’s AOC later revoked).
Training Score: zero. Lots of conceptual
opportunities, but plausibility is overwhelmed by more basic issues.
•Start T/O roll; no brief of visual departure.
•On climbout, PIC tells FO “a hair more to
the right.”
•Then confusion: FO & PIC read different
headings, then “PULL UP.”
•PIC takes control but confusion continues
about heading, with more “PULL UP.”
•PIC starts right turn early & strikes 80degree rock face.
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
6 July 2008, USAJET (Cargo) DC-9-15 at Saltillo, MX (1 of 2 pilots fatal)
Reuters
Cause: No report yet.
Possible Issues: Go-around gates,
current weather information, SOPs.
•Crashed ILS approach at night.
•Airport at 4,646 MSL & surrounded
by mountains.
•Visibility 1 mile in fog.
•Crew never checked in with tower &
did not have current weather.
•Video shows A/C flying low, wings
rocking, then wing dropped (stalled).
•Crashed onto loop road next to
major highway.
Training Score: High, depending on
strength of SOPs.
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
14 Sep. 2008, Aeroflot-Nord B737-500
at Perm, RU; (All 82 pax & 6 crew fatal)
Causes:
Spatial disorientation (ADI)
Pilot workload (independent throttles)
Pilot’s BAC, fatigue & lack of CRM
Maintenance - - carrying faulty throttle.
Carrier’s transition training to 737 fleet.
Carrier’s operation of 737 fleet.
•Late night approach in rain & fog; A/P & A/T off
due to long-recurring A/T problem.
•Crew recently transitioned from T-134 & AN-2
(Reversed ADI); both low-time M/M
•On final, ATC tells crew they are right of course.
•Corrected but climbed from 600m to 900m
instead of descending to 300M to land.
•ATC advised crew of climb: “Affirmative; we’re
descending, then climbed to 1,200m.
•ATC instructed right turn for go-around.
•Acknowledged but turned left & rapid descent.
Impacted industrial area & rail line.
Training Score: Despite extreme corporate issues, crew pairing issues & maintenance practices,
net training score is high because a single item (ADI transition) comes close to a knock-out.
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
27 Jan 2009, Empire at Lubbock;
1 of 2 crew serious)
Cause: Still under investigation.
Broad Issues:
•Possible flap damage from past
events (Engine/wing fire & bird strike).
•Asymmetric flaps?
•Monitoring airspeed
•Crashed short of 17R on ILS in night
IMC. (Wind 350 at 10), visibility 2, light
freezing drizzle, mist, 500 overcast.
•On descent from FL100 to FL80, ATC
advised crew of wind shift.
•PIC acknowledged & noted 8-degree
drop in outside air temp.
•At 0434, cleared to land 17R.
•Set flaps 15 but got asymmetric flaps.
•Shedding speed on final.
•Landed short, struck approach lights,
& skidded off right, into grass.
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
12 Feb. 2009, Colgan Air DHC-8-400 at Buffalo (All 49 & 1 fatal on ground)
•FO arrived EWR on red-eye from West
Coast via MEM at 0623. PIC with significant
sleep deficit.
•Accident flight delayed; T/O EWR at 2120.
•Newly upgraded PIC (110 hours in M/M);
FO had 700 hours in type.
•Steady chatter throughout flight.
BBC & AP
Causes & Factors: PIC’s incorrect
response to stick shaker & then stall;
failure to monitor airspeed & low-speed
cue; sterile cockpit; PIC failed to manage
the flight; & inadequate procedures for
airspeed selection in icing conditions.
•Cleared to descend & maintain 2,300. Had
been bleeding off airspeed & 20 knots slow.
•Failed to note low-speed cues.
•A/P disengages; A/C stalled in turn & struck
home in dense area, 45 degrees wing low,
30 degrees nose low, & little forward speed.
Training Score: Lots of conceptual opportunities (transition to DHC-8-Q400, stall
recognition, CRM & flight monitoring-SOPs). But effectiveness reduced by constant chatter,
lack of professionalism & especially by fatigue. Yet, net score still earns a “moderate.”
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
25 Feb. 2009, THY B737-800 at Amsterdam
(9 fatal & 28 serious, 134 onboard)
•Crashed 1km short of Rwy 18 in day-time
mist & low ceiling, wind 200 at 10.
Reuters
Broad Issues: (No report yet.) Faulty altimeter;
•Knowledge of A/C (A/P reads #1 altimeter);
•Flight monitoring & SOPs
Training Score: Moderate to high for software
& recognizing that A/C reads left altimeter, &
that A/C assumed landing logic; offset by
maintenance issues.
•At 1,950 feet on coupled approach, left
altimeter suddenly read 8 feet.
•Crew noted faulty altimeter but did not
consider it a problem.
•Faulty altimeter reading caused A/C to
assume landing logic, so throttles went to
retard & A/C lost altitude.
•When crew selected 144 knots airspeed
but with thrust levers at idle.
•A/C commanded more pitch.
•Crew did not notice loss of altitude until
stall warning at 150 AGL.
•Added power & pulled up but impacted
before spool-up.
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
22 March 2009, Fedex MD11 at Narita (Both Pilots Fatal)
Cause: No report yet.
Broad issues:
•Familiarity with MD-11 (tendency to pitch
up after ground spoiler deployment & crew
tendency to over-control).
•(Newark & Air China accidents).
•Flared late & touched down flat.
•Bounced nose high & PIC pushed
the nose over.
•Second touchdown landed sharply
on nose gear, at 30 degrees nosedown in moderate left roll.
•Left wing failed & instant fire ball.
•Right wing continued flying; A/C
rolled inverted.
Training Score: Moderate. Crew
experienced in MD-11; had the
appropriate training many times.
27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
23 Dec. 2009: American 737-800 at Kingston, Jamaica
(4 pax serious, minor-no injury to 144 pax, 4 FA & 2 pilots)
Under Investigation
Possible Issues:
•Unstable approach, SOPs.
•Risk assessment; go-around gates;
approach briefing; CRM.
•Overran shortly after midnight in “fierce rain.’”
•Paxs said turbulence forced crew to halt cabin
service 3 times, then terminated service.
•Before descent, pilot warned of more turbulence
but said it likely would not be much worse.
•Crew requested Runway 12 with 14-knot tailwind
from 310 degrees. ATC offered Runway 30 but
crew repeated request for 12.
•Cleared to 12; ATC added that runway was wet.
• After descent through clouds, crew made visual
contact with runway at @ 800 AGL.
•Landed 4,000 feet long on 9,900-foot runway at
162 knots. Overran at 73 mph, through perimeter
fence, crossed road & came to rest 175ft past
runway end, 12 meters from water line.
Training Score: High – if good SOP
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
Findings from 9 Undershoots
On balance, high scores.
Zero to little chance in 2 cases (LHR & Santa Barbara).
Moderate or moderate-high at BUF, Saltillo & Narita)
High at Perm, Amsterdam & Kingston
Training issues focus on aircraft characteristics, SOPs, risk assessment
& go-around gates. Offset by absence of good SOPs & more basic
corporate short-comings in some cases
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27th International Aircraft Cabin Safety Symposium
Orlando, Florida, USA 27-29 April 2010
Conclusions from 19 Recent Accidents
Though training is not a key issue in every accident, recent major
accidents illustrates that training can significantly reduce risk in the large
majority of cases.
Training is most effective as an intervention when:
(1) we establish good standard operating procedures ;
(2) we train repeatedly to those good procedures;
(3) we enforce those good procedures; and
(4) we train to the aircraft characteristics.
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