Tag Archives: NTSB

AIR FRANCE FLIGHT 447 PILOTS WERE “DEAD TIRED”

Airbus 330

ANOTHER TOO-SHORT LAY-OVER

ANOTHER TOO-SHORT LAY-OVER

On June 1, 2009 Air France Flight # 447, en route from Rio de Janeiro to Paris in airspace located approximately 400 miles north of the northwest corner of Brazil, inexplicably crashed in the ocean. It was somewhat inexplicable at the time, but eventually the cockpit voice recorder and the flight data recorder were recovered from the floor of the ocean. These two devices, when reviewed, analyzed, and evaluated presented a despicably ugly picture. It revealed a scenario that was very similar to the highly publicized and equally ugly Continental (Colgan Air) flight 3407 crash on approach into Buffalo, New York, killing all 49 people on board and one person on the ground
The commonalities in these two aircraft crashes are uncannily similar. The pilots of Continental Flight 3407 were extremely tired and in a state of advanced sleep deprivation. They were also relatively inexperienced and poorly trained. These factors resulted in a breaking of the chain of elements that result in a successful flight. The pilots of Air France flight 447 were equally handicapped. The initial information released by the BAE (A European aviation investigation organization) and Air France indicated a very minor abnormality on the flight deck that related to an iced pitot tube resulting in erroneous airspeed. Unfortunately, as is the case in all too many aviation accidents, this was a recurring problem that had been identified by both Airbus manufacturing the aircraft and Air France, the operator of aircraft. It had, however, not been given the priority that it shouldn’t been given.
The NTSB, after sifting through the ashes of Continental #3407, determined that improper manipulation of the flight controls, along with a counterproductive retraction of the flaps by the copilot, was the cause of this accident. They also cited poor or inadequate training. Flight crew experience, particularly in this new aircraft, the Bombardier Dash 8-Q400 also played a small role. Neither pilot of this aircraft had had adequate rest in the previous 30 hours. While this was, subjectively, but unquantifiable, the primary precursor, it was only mentioned as a contributing factor. A significant sidebar to this accident is the fact that the last six fatal domestic accidents with the US domestic air carriers involved regional carriers, or, as they are more commonly referred to, “commuters.” Four of these six accidents occurred when tired pilots in the cockpit were entrapped in an excessively long duty period.
Nearly five years after the Air France Flight 447 accident, it was just recently revealed that the pilots assigned to this flight were also extremely tired. The captain had stated that he had only one hour of sleep during the previous rest period and his relatively inexperienced copilots—this was an augmented crew with one extra pilot—also were extremely tired when they began their projected long duty period (13 hours). As was the case with Continental # 3407, the Air France pilots were relatively inexperienced, but more importantly, they had no experience flying the Airbus 330 at high-altitude. The two pilots on the flight deck severely over controlled the aircraft and it entered into a deep stall. The airplane plummeted tail first, with the nose high pitch attitude of 35°, and engines at full power. It plummeted 38,000 feet to the ocean surface in three minutes and 30 seconds. The aircraft splattered into the water and 216 passengers and 12 flight crew members were killed instantly. A sadder chapter is that the pilots, and most likely all of the passengers and cabin attendants, were fully aware that the airplane was out of control and would soon be crashing. That awareness that your life will be soon coming to a very abrupt end, will most certainly create an unparalleled state of horror and emotional turmoil.
These two accidents when evaluated by the NTSB, the FAA, and the BAE in the many pilots who have read and reviewed the accident information leave those aviation oriented folks in a state of disgust. Why had the Air France pilots never been trained to fly their aircraft and cruise altitude? Like Capt. Marvin Renslow of Colgan air infamy, the two pilots on the flight deck of AF 447 flew the airplane into a deep stall and maintained that catastrophe-inducing pitch attitude. In the AF 447 flight the captain arose from his designated nap, rushed to the cockpit—actually there was a significant delay—and stood on the flight deck repeating the mantra from the two seated copilots, “What’s going on here; what’s happening.” Continental # 3407 had two tired, poorly trained, inexperienced pilots in the cockpit. AF # 447 had three pilots in the cockpit. They were somewhat more experienced and perhaps better trained, but they all experienced the common thread of diminished performance capability as a result of sleep deprivation.
For additional information relating to the problem of tired pilots in the cockpit, you can listen to my recent interview at http://webtalkradio.net/ by clicking on HOST and Ace Abbott’s Aviation Affair. The book, Dead Tired: Pilot Fatigue- Aviation’s Insidious Killer is available at http://www.deadtiredpilots.com/
This blog is prepared by Allen Morris, a.k.a. Ace Abbott, author of The Rogue Aviator: In the Back Alleys of Aviation (http://www.therogueaviator.com/) and the above mentioned “Dead Tired”

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TIRED PILOTS: A WORLDWIDE AVIATION PROBLEM

Sweden

ANOTHER TOO-SHORT LAY-OVER

ANOTHER TOO-SHORT LAY-OVER

The ongoing problem of tired pilots in the cockpits of airplanes continues to undermine the safety of commercial aviation. In the United States, the FAA has finally stepped forward and made an effort to mitigate the problem of pilot fatigue. The changes were well thought out and based on significant analysis and study of sleep deprivation research. They will be very effective in reducing the number of accidents and incidents that result from pilot error in which sleep deprivation was a precursor. Unfortunately, there are two small caveats relating to this legislation: 1.The revised rules do not go into effect until January 14, 2014; Caveat number two: they do not apply to commercial pilots who fly cargo. This malfeasance was precipitated by allowing the profit factor to trump the safety factor. The lobbyists once again kneed the pilot force in the groin for the financial enhancement of their masters.
The highly publicized Continental flight 3407 accident in Buffalo, New York on February 12, 2009 was a great wake-up call that forced the FAA, after nearly 50 years of inaction, to finally act proactively regarding the problem. Amazingly enough, the pilots who fly for Canadian airlines and any of the EASA (European Aviation Safety Agency) airlines are now dealing with overzealous controlling agencies that want to increase the workload of commercial pilots. A recent survey amongst pilots from Austria, Sweden, Germany and Denmark revealed that fatigue is “common, dangerous and underreported.” The EASA is calling for regulations that will allow for 22 hour duty days for flight crews. This might be somewhat of an improvement, since 50% of surveyed pilots have reported being on duty after having been awake for 23 hours or more.
The Continental Flight 3407 (Operated by Colgan Air) that crashed in Buffalo on February 12 2009, provided the impetus to totally revise the FAA’s rules regarding flight and duty times. The two pilots in the cockpit of this airplane were severely fatigued and the NTSB did indicate that their state of fatigue was a precursor to the accident. After several years of in-depth studies of sleep deprivation and pilot fatigue instances and incidents, the FAA produced a science-based, airline safety enhancing set of revised regulations that will be finally implemented on January 14, 2014. The previous mentioned caveat: cargo pilots are exempt from the new more restrictive ruling has resulted in a lot of justifiable backlash from the pilot community.
ALPA to the rescue! An ALPA study has revealed that the FAA study relating to the projected cost savings of allowing the cargo pilots to utilize the antiquated and less restrictive limitations was an error. The FAA “cooked the books,” to indicate that pilot fatigue played a small role in cargo airline accidents. In actuality, during the last 20 years cargo airline accidents have been infinitely more prevalent than passenger operations. Captain Lee Moak and his ALPA colleagues have recently been making a very strong stance in Washington DC, regarding this issue. Hopefully, the ALPA lobbying will overcome the efforts of the spokesman for the cargo airline management operatives who do not want to have to hire additional pilots to fly their airplanes. There have already been too many “dead-tired” cargo pilots who have bought the farm.
For more information relating to pilot fatigue, consider reading Ace Abbott’s book, Dead Tired: Pilot Fatigue- Aviation’s Insidious Killer. (www.deadtiredpilots.com)
This blog is prepared by retired commercial pilot and aviation author Ace Abbott; (www.therogueaviator.com

BOEING 787–DREAMLINER OR NIGHTMARE AIR MACHINE?

The Boeing 787 Dreamliner has been plagued with recent turbulence. The airplane that was supposed to be the best thing since retractable landing gear appears to be a big black eye for the Boeing engineers. While it is true that most new high-tech devices will have preliminary bugs, it seems that the Dreamliner is burdened with a plethora of them. The ongoing growing pains that frequently erupt are usually related to the lithium ion batteries. They are a relatively recently developed type of battery that appears to have not been given the appropriate quality control evaluation.
While United Airlines has had a few recent Boeing 787 Dreamliner incidents, Japan Airlines (JAL) has had numerous incidents, including a recent fire in the cargo compartment, likely caused by the lithium ion batteries. Luckily the airplane was on the ramp at Boston’s Logan Airport. Another aircraft operated by JAL had a windshield shatter. Most of the recent rash of problems has been related to electrical smoke and fire caused by the lithium-ion batteries.
The most recent incident involved the All Nippon Airways (ANA) flight that departed Western Japan and had to make an emergency landing in Takamatsu airport where the passengers disembarked, utilizing the emergency escape slide system. There were, as always, a few injuries during this evacuation procedure. ANA and JAL operate one half (24) of the 787 Dreamliner aircraft that are currently operational. Both airlines have elected to ground all of their 787 Dreamliners until the Boeing tech reps and engineers can provide a solution. An interesting and ironic side note is that the Boeing engineers union (SPEEA) is threatening to go on strike.
United Airlines is the only US carrier operating the 787 aircraft and both Ray LaHood, the director of the NTSB, and Michael Huerta, the FAA administrator stated they would not hesitate to ride on the aircraft. {{ “Should travelers be worried? No, says Charles “Les” Westbrooks, Associate Professor of Aeronautical Science at Embry-Riddle Aeronautical University in Daytona Beach, Fla. “In aviation we have learned that accidents are caused by a series of events rather than any one catastrophic event. Because of this we have ‘safety stand downs’ when events are happening in succession so as to break the chain of events which could lead to an accident.”}} (Extracted from Forbes Lifestyle by Andrew Bender/ 1:37 pm EDT, Jan 16, 2012
This blog is prepared by aviation author, Allen Morris/a.k.a. Ace Abbott, (www.therogueaviator.com) and (www.deadtiredpilots.com).

LEARJET CRASH WITH JENNI RIVERA–TIRED PILOTS?

sleeping-pilot1

 

Last Sunday morning’s crash of a Learjet with renowned singer Jenni Rivera aboard recently jumped into the forefront of the news cycle. The aircraft departed Monterrey, Mexico at 3:15 AM en route to Toluca, Mexico. It was reported the aircraft was it 35,000 feet and made a rapid descent to 9,000 feet, during which time air traffic control communication was lost. At 3:30 AM the aircraft slammed into the high terrain South of Monterrey. All seven people aboard were killed, including the two pilots. The Learjet was chartered from a Las Vegas based company.

The media have not yet discussed or even mentioned the likelihood of tired pilots in the cockpit. It will be very interesting to read the final NTSB report that will hopefully have a report of the two pilots most recent rest period prior to the flight. Based on my experience of eight years flying chartered Learjets I would be near certain that pilot fatigue played a major role in this accident. The world of on-demand jet charter lends itself to frequent scenarios that result in severely fatigued pilots flying high profile wealthy people. A 3:15 AM departure would require the pilots to have been awake since no later than 1:30 AM. It is likely and almost certain that they were prepared for departure several hours prior to the actual departure. On-demand jet charter is fraught with significant delays. It is not likely that anyone would schedule a flight departure for 3:15 AM.

Also relating to pilot fatigue, the FAA has just determined that the lawsuit filed by UPS cargo pilot union, IPA has no merit. This lawsuit was in reference to the revised crew rest, flight time and duty limitations that are to be implemented on January 15, 2014. These new rules were mandated to enhance aviation safety after the crash of Continental flight 3407 (operated by Colgan air) in Buffalo on January 12 2009. These revised rules for commercial pilots operating in the FAR 121 airline environments were mandated by Congress. As a result of lobbying and special interest groups influence all cargo airline operations were exempt from these new rules— effectively an exemption from operating at a much higher level of safety. As I stated in my book, The Rogue Aviator, “I’m from the government and I’m here to help you— unless you are a pilot who might want to get a little sleep.”

The media has barely scratched the surface of this onerous failure to reduce the pilot fatigue factor in cargo airline aircraft. My book, Dead Tired: Pilot Fatigue- Aviation’s Insidious Killer, elaborates on the subject as it points out the obvious; if allowed, corporate profits will always trump any element of safety that might be implemented. Unbeknownst to most laymen, the power of airline unions has been a significant contributor to aviation safety. A review of aircraft accidents operated by nonunion pilots will validate this. The exemption of cargo pilots from reasonable work rules that result in minimizing pilot fatigue in the cockpit will reveal a continuation of aircraft crashes and incidents that were piloted by very tired pilots.

This blog is prepared by Allen Morris, a.k.a. Ace Abbott (pen name), author of The Rogue Aviator: in the back alleys of aviation, (www.therogueaviator.com or http://goo.gl/Y2LhX, and Dead Tired: Pilot Fatigue Aviation’s Insidious Killer (www.deadtiredpilots.com or http://goo.gl/Gzucw.

SUMMER THUNDERSTORMS—KEEP SEAT BELT FASTENED

A “PRETTY-PUFFY” ABOUT TO BE A NASTY THUNDERSTORM

EXCERPT FROM THE ROGUE AVIATOR; FASTEN SEAT BELT SNUGLY!

(Ace had the opportunity, later that summer, to experience the frightening exhilaration of flight into a severe thunderstorm at 37,000 feet. The entire Midwest and Northeast United States was engulfed in an August heat wave that was accompanied by severe embedded thunderstorms. An inoperative radar during night flight resulted in an inadvertent adventure into a very intense mature thunderstorm. The severe turbulence was such that maintaining the aircraft in a controlled flight situation required Ace’s maximum effort. The loud noise of the heavy hail pelting the aircraft on the windshield along with the thunder and lightning was tweaking on the edge of being terrifying. During this nightmarish flight experience Ace had made a silent vow that if he survived this experience he would retire from aviation and sell insurance. This vow was soon broken when he very briefly considered the nature of real work. With today’s very effective and very reliable aircraft airborne radar systems, along with the air traffic control’s improved weather detection radar, it would be very unlikely that one would encounter this situation. A pilot’s healthy fear of entering a mature cell thunderstorm is an attitude that that will greatly enhance pilot and passenger longevity.)

As we get into thunderstorm season it is also time to discuss a few of the many considerations of these phenomena as it relates to both airline passengers and all pilots. The destructive power of the thunderstorms will get most peoples’ adrenalin flowing. The thought of being airborne in a turbulent thunderstorm will induce serious stress and anxiety—particularly for us pilots that have incurred the wrath of a level 5 TRW while penetrating it’s core. It is fear that breeches upon that same level felt by men in combat who are fighting for their lives.

As an airline passenger you want to be sure that your pilot has a healthy fear of thunderstorms. Unfortunately, there is no method available to determine such. If the pilot is a “gray-beard” it is likely that he has been at least severely nicked by a mature thunderstorm. Younger baby-faced pilots might not have outgrown the common affliction that often results in a mistaken self-perception of being immortal. It is also more likely that the less-experienced pilot had not yet had the pulse-racing experience of being in the middle of one of those “Level 5” TRWs. An additional note as a defense against exposure to that terrifying TRW; you can simply plan your trips so as to fly in the morning hours when the likelihood of thunderstorms is minimal.  If there are TRWs in the area, that suggestion to keep your seat belt “loosely fastened,” should be changed to snuggly fastened.

The airline pilot is prohibited to fly in an area of thunderstorms or to a destination with TRW’s forecast anywhere along the route of flight. FAR 121.0 (governs airlines) is very clear and empathic—operational radar is a must. The CONUS ATC is quite helpful in providing  vectors around areas of threatening weather but the functional radar installed in the aircraft provide the best insurance against banging into one of these “hard spots” in an airplane. A venture into a mature thunderstorm by U.S. air carriers is quite remote but if you on a third world airline the chance of getting whacked greatly increase. Avoid third world airlines— the safety quotient plummets.

For the general aviation pilots without onboard radar the pilot can get weather info on his IPAD or Garmin, but keep in mind that this weather can be more than 20 minutes old and the antiquated information could be counterproductive in its false presentation. The NTSB has just issued a warning that some firms that provide “real time” data to cockpit displays can be obsolete. They also mention that accident investigations have revealed that at least 2 fatal accidents were possibly caused by this delayed weather information. The common and best course of action is utilized by most pilots is to wait for the weather to improve, even it means waiting until the next day.

A ‘PRETTY-PUFFY’ ABOUT TO BE A NASTY THUNDERSTORM

Also, keep in mind that the microburst that often occurs many miles from the actual storm can be devastating with gusts that might exceed 60 knots. The rapid change in wind direction, commonly referred to as wind shear can bring a large jet down as it did in DFW on August 2, 1985. Delta Flight 191, a Lockheed L-1011 was slammed into the terra-firma by a microburst that created a net loss of more than 40 knots airspeed. The often-unseen but unforgiving microburst is responsible for many fatal aircraft crashes. Aviation has become much safer in recent years but eternal vigilance regarding thunderstorms remains critical to maintain that high level of safety.

The severe weather that wreaked havoc across much of the Midwest and Northeast last week was caused by a very unique phenomena called derecho. An AOPA blog, with the following web address,  http://blog.aopa.org/blog/?p=3729, can provide a well-written description of what created this rare weather event.

This blog is prepared by Ace Abbott, author of The Rogue Aviator (www.therogueaviator.com)

CARGO PILOTS NEED REST- FAA DISAGREES!

After a few decades of delay, and despite strong urging from the NTSB, the National Safety Council, pilot unions , and any other group or agency that is concerned about aviation, the FAA has capitalized on three years of study and decades of sleep-deprivation research and have reached the following conclusion: Pilots that fly passengers for hire under the stringent rules of FAR 121 which governs all  of the operating parameters for airlines along with the commuter airlines, must have their flight and duty times decreased in order to enhance aviation safety and reduce the increased probability of a tired pilot crashing an airplane. We all remember the Continental flight 3407 (operated by Colgan Air) that crashed in Buffalo, New York with two “dead-tired” pilots at the controls.

There is, however, an interesting caveat relating to this new aviation safety-enhancing legislation, and that is, very simply: cargo-carrying airlines, (such as Fed-Ex or UPS) are exempt from the new rules. The next immediate question is: Do cargo pilots require less sleep than passenger pilots? Of course not, but money and politics have once again trumped aviation safety. We all remember the 1970s Harvard Business School mantra of “maximum utilization of human resources.” This is one more example of that axiom being employed at the expense of aviation safety. An interesting addition to this travesty is that a little research into aviation accident investigations will reveal that far more cargo airplanes are involved in accidents and incidents than passenger carrying airplanes. The cargo “freight-dog” pilots who often operate on the “back-side” of the clock and have their fatigue factor intensified by circadian rhythm dysfunction.

As one might expect, the cargo pilots and their unions have very wisely jumped into this fray and are now filing lawsuits to eliminate this severely mis-guided shortsightedness by the FAA. In December, 2011 The Independent Pilots Association (IPA) that represent 2,700 pilots who fly for UPS, filed a petition asking the federal appeals court to review the rules.

The FAA very recently decided to review the rules after stating that it made “errors” in cost calculations used to justify the exemption. That is a glaring example of a confession of a decision that was made regarding aviation safety that once again placed corporate profits ahead of the possible consequences of a Boeing 747 filled with cargo, (perhaps hazardous material) flown by tired pilots that crashes into the hospital. If there was ever high-level government officials left with “egg-on-their-face” this is a high-level glaring example. 

This blog was prepared by Ace Abbott, author of The Rogue Aviator (www.therogueaviator.com)  

           

Tired Pilots Get Reprieve

This is the result of an extended duty time for an Air Force nuclear alert pilot. Now, on the serious side. Today is a great day for all pilots (except cargo pilots) since the FAA is finally implementing the long-overdue changes to flight and duty time limitations for commercial pilots. Twenty years ago the NTSB had informed the FAA that there was a need to revise these regulations for the sake of aviation safety. After the highly publicized Continental 3407 (Colgan Air) crash in Buffalo on February 12, 2009, the congressional sub-committee on aviation gathered up Sully Sullenberger and several other high-level aviation Kahunas and demanded that FAR rules relating to pilot fatigue be revised. Nearly three years later, it was finally effectuated. Yes, better late than never!

However, there is a fly in the ointment since the pilots that fly cargo are exempt from the new rules. Do cargo pilots require less sleep? No, on the contrary, they may require more because they are more likely to be working on “the back side of the clock” when the circadian rhythm monster is nipping at their heels. This exclusion for cargo pilots is an unjustifiable mistake. Perhaps with enough outrage from the folks with the megaphones, we will put, the all to often and unfairly demeaned “freight dogs” on an equal footing with the passenger carrying pilots. It should also be pointed out that airplanes operated by very tired cargo pilots have a much worse safety record and nearly all of the accidents have occurred with pilots at the helm were in an advanced state of sleep deprivation.

“I’m from FAA and I am here to help you.”( unless you might be a very tired but experienced, competent, and well-trained cargo pilot). In 1995 a Kalitta Air DC-8 on approach into GITMO (Guantanamo Bay) crashed on approach and either killed or seiously injured the flight crew aboard the aircraft. A review of their duty day revealed that they had been on duty for 19 hours. And here is the “kicker.” After off-loading cargo at GITMO they were scheduled to fly their airplane to Atlanta. I elaborate on the “tired pilot”syndrome in my book, The Rogue Aviator, and there are numerous passages relating several 20 hour plus duty periods. The problem of tired pilots in the cockpit is only partialy solved. At GITMO there were no apartment building or schools on the approach path. There are many airports where hundreds, if not thousands of people on the ground could be killed or seriously injured in the event of a large (747 for instance) splattering itself into the terra firma someplace other than a runway.