Showing posts with label accident investigation. Show all posts
Showing posts with label accident investigation. Show all posts

Wednesday, November 12, 2014

Hail. Well met, fair countryman!

Two nineteen year old German girls decided to obtain Gap Year visas allowing them to explore New Zealand. Unlike tourist visas, Gap Year visas allow a visitor to make money working at odd jobs so as to more fully explore the New Zealand culture for a longer period of time.

While many youths decide to explore nightlife and wineries, the two German trekers simply hiked large swaths of New Zealand. During one trip they met a fellow German, a middle aged man who was foreman of a milking crew at a New Zealand ranch.

During informal discussions of the two girls intended destinations the crew foreman revealed that he owned a sailboat and could sail the girls to their next destination. The trusting, youthful young ladies assented and soon set sail on an extremely hazardous voyage in what is considered to be the most dangerous body of water in New Zealand. Moreover the winds at the time they departed were clearly from the wrong direction. It is doubtful the Captain notified his two passengers of the inadequacies of his boat and its equipment. Likely undisclosed was the fact that although the Captain had owned the boat for over a year he had very little training or experience in sailing and that his sailing style was described as "uninfluenced by any advice he had been given".

ON EDIT: Anniversary.

Gee, its been my experience that young nineteen year old German girls wearing pleasantly revealing hiking outfits tend to very easily get their photographs into the newspaper, yet for some reason only the "missing" Captain, not either of his "missing" passengers appear in the papers. And if any wonders about that status of "missing" lets just say that the police seem to know just as well as the Coroner knows that their bread is buttered by the Travel Industry. So the travel statistics reflect a good deal of political correctness to them. Until the bodies are actually found, there will be no Coronal Inquiry therefore there can be no finding of criminally negligent homicide. Indeed, until a body turns up the police consider the pretty young girls to be merely "missing" and therefore not dead. Have to pretty up the statistics for the Tourist Industry.

Monday, May 16, 2011

AF447 FDR and CVR data readable.

The data from the Flight Data Recorder and Cockpit Voice Recorder is readable.

I'm sure that as the French finally get around to releasing transcripts more precise information will emerge and much of the speculation will have been proven to be baseless. A good deal of it, however, will have been shown to be quite sensible.

Its well known that the French investigation is focused on avoiding any allocation of blame. With all the inter-linkages between Airbus, AirFrance and the French government it is clear that the BEA is actually investigating the French government. The level of disclosure tolerated by the French is abysmally low in comparison to what the NTSB would be revealing.

The fact that controllers in Senegal and also Air France lost track of the flight entirely and that therefore Air France was woefully late in launching any search effort has absolutely nothing to do with the cause of any difficulties the plane suffered but it is a clear example of the differences in the type of investigation that is being conducted. The BEA will make no statement critical of Air France or commenting on the elapsed time prior to the initiation of search efforts.

I do so hope the French attitude changes and that the BEA will adopt a more open and informative orientation.

ADDENDUM: After the initial downloading and review of the FDR and CVR data, Airbus has sent a No Immediate Issuance of Any Service Bulletin telex to the aviation community. All the telex really means is that there is no immediately discernible indication of a design fault that would require immediate or extremely prompt servicing. Le Figaro appears to be encouraging the viewing of this Airbus action as some sort of determination that it was pilot error and nothing but pilot error. This is not the proper viewpoint. It will probably be next year before we learn a more complete sequence of events. The computerized flight control system detected a severe difference in pitot indications and dumped the pilots into Alternate Law. What the pilots did as far as attitude, throttle and angle of attack adjustments becomes critical. What the weather impact on the plane was will be critical. Probably the most important question is whether the CVR will reveal a reason for a lack of storm related course deviations. Also of interest will be any indications of whether the radar was operational. The important thing to remember at this point in the process is that the action recently taken by Airbus simply indicates no immediately discernible indication of a design fault that must be attended to immediately. It is not an accusation against the pilots and it is not a declaration that a design defect or deficiency may not later appear.

I remind everyone of the Gimli Glider incident in Canada. An airliner full of passengers suddenly became a glider. Most airline pilots today could not deal with that situation because they not only are not glider pilots they are button pushers who don't really have much "hands on" experience in flying an airliner. The don't know the "feel" of the controls in normal situations much less in emergency situations. The pilot of the flight that suddenly ran out of fuel in mid-air near Gimli happened to be glider pilot. He flew unpowered planes for fun. He suddenly found himself flying an unpowered airplane full of passengers. It was not fun, but he knew what to do and could do it. If Airbus dumps you into Alternate Law mode there no time to figure out what to do and get into Direct Law mode by pressing the overhead buttons. You know how to do it instinctively or you don't. Most pilots don't fly airplanes, they push buttons yet when it comes to the computer having given up and the pilots being forced to fly the plane out of a thunderstorm's downwash you can't call out "checklist", you can't grab for a manual and madly flip pages to find the directions, you can't break open the safe and find the secret code numbers to enter. You have to know what overhead buttons to press and where they are. You have to be able reach them in an unusual attitude with annoying alarms going off, you have to be able to fly the plane when you have to suddenly fly the plane. A simple act of leaving one altitude and climbing to another is done by pressing buttons because it saves fuel for a computer to make hundreds of extremely minute control inputs than to have some heavy-fisted human pilot actually try to level out precisely at a certain altitude. The problem is that when the pilots only have the experience of pressing the buttons and don't have any experience in flying the aircraft, they have no time to learn how to fly. When the computer gives up, they have to know how to get into direct law mode and fly the darn plane by feel even if its the dead of night and they suddenly find themselves in a super cell. The real problem is that any passenger selected at random probably has an much experience actually flying the plane as any of the pilots do. All the pilots have done is push buttons on a computer panel. The pilots do not really get any experience in flying the darn aircraft.

ADDENDUM: One item I've been considering for quite some time is the concept of latency of state. If ice accretion on the pitot tubes did send wildly disparate data to the computers and a program therefore cut out and dropped the pilots into Alternate Law, what happens if the fluctuations in the various readings have moments wherein the coincide within the accepted reference range. Is there a resumption of a Fly By Wire state wherein pilots are restrained from certain control inputs? Even in Alternate Law mode there are some systems working and a tendency to have a pronounced pitch-up. Its night, its stormy, the pitot condition may not have been noticed until there was the sudden cut-out and the computers that had been trying to deal with the speed signals suddenly realized the signals were spurious. Pitch and throttle settings had been changed to deal with the erroneous data during the time such erroneous data was well within the acceptable parameters, but once the data discrepancy exceeded the established parameters the pilots were in Alternate Law mode and in an unusual attitude with an unusual power setting.

Further ADDENDUM: A formal announcement is expected near the end of this week that will reflect a preliminary statement regarding the pilot's failure to react to a stall indication as automatic adjustments to pitch and thrust were made pursuant to erroneous pitot data prior to the computer declaring the pitot data to be unreliable and putting the plane in Alternate Law mode. Essentially its an instantaneous mental overload for the pilots who don't know that there has been a dangerous pitch up due to declining static pressure and the iced-up erroneous pitot readings. That reduced thrust and high angle of attack situation needs immediate attention and the pilots were probably so overwhelmed with a flurry of error messages and unreliable instruments that they just didn't have time to sort things out before they simply totally ran out of time and altitude. When you train people to push buttons on a computer rather than really flying the airplane its difficult for them to do what is right when that computer suddenly turns itself off. Increasing thrust with underslung engines and a somewhat aft center of gravity won't help the situation much. If they didn't realize what had happened immediately going into alternate sixty degree banks should have worked but it would take time. They had 35,000 feet to sort things out. It turned out not to be enough.

Thursday, May 5, 2011

AF447 Recovery of corpses from seabed.

It seems the families are divided as to attempts to recover corpses. It would be difficult but one has already been recovered so it is certainly not impossible. I doubt the corpses have much evidentiary value. The Brazilian mortuary was overwhelmed but would not permit the French doctors to perform autopsies. The Brazilian medical examiner made comments and drew conclusions well beyond his sphere of expertise even suggesting that the passengers had assumed crash positions prior to impact. Given the large number of passengers who were not belted-in and the fact that the galley had not been secured it was quite likely that there had been no instructions to even fasten seat belts much less an instruction concerning severe turbulence and certainly no instruction to assume crash positions.

The damage and injuries on the earlier recovered corpses all show major impact forces on the underside of an intact fuselage. Nothing reflects instructions to cabin crew or passengers regarding imminent impact.

There has been alot of discussion regarding overspeed conditions and underspeed conditions. At 35,000 feet that "coffin corner" is still a pretty wide window. And a stall could begin at six or seven degrees at that altitude. Presumably the iced-up pitot tubes would create a differential airspeed reading that was well beyond the computer's parameters. Error messages would be sent as the flight director computers cut out and placed the plane in Alternate Law mode. If speed either decayed too far or increased to far, a stall would take place but it seems crew awareness and crew actions should have been able to deal with it. Surely from 35,000 to 0 would have taken some time. Initially the French searchers felt they should estimate continued flight along intended course for some time beyond the Last Known Position. Although this may have taken place and then been followed by a course reversal that was either commanded or most likely uncommanded, it is quite possible that descent was rapid and largely devoid of forward motion. I can only envision direct flight into a powerful supercell as doing that.

I look forward to the CVR showing us why there were no WX related course changes to thread the plane around the intense storms. I look forward to the FDR analysis even more, but I don't see the corpse recovery as providing critical information.

Monday, May 2, 2011

AF447 FDR's Data Module recovered.

The Data Module that apparently was dislodged from the Flight Data Recorder upon impact was located and roboticly recovered. It appears to be intact based upon gross examination but it is likely to be two weeks before it is known if data can be recovered from it. It is likely to be considerably longer, however, before any recovered data is released to the aviation community or the public. Shear forces on the bolts of the data module and the ultrasonic pinger are unknown but separation of the data module from the chassis of the FDR has taken place in prior crashes involving impact with water. The BEA has not released definitive data on the pinger but it is believed that signals were recorded by the French submarine involved in the search but not detected at the time by sonar operators. Later data scrubbing is said to have provided a computerized detection of the pings.

There are so many questions as to why the plane went into an unusual attitude and most particularly as to why there was no recovery despite there being 35,000 feet in order for their to be recovery from a stall. It is possible that a pilot's attempt to re-establish computerized flight control created an additional upset since there is a difference between the plane's attitude and the computer systems processing of the attitude information. Essentially it would be a physical recovery from the stall followed by a systems induced control input that re-established the stalled condition as an unrecoverable deep stall.

There has been much ado about extreme turbulence and the plane's presumed entry into a supercell whose location was masked by a radar detection of a smaller but nearer cell. The trouble with all this turbulent weather assumptions is that other planes transited the area without incident and nothing in the wreckage or bodily injury data indicates that the plane ever encountered severe weather. Galley equipment was not secured and dogged-down as it would be had there been a severe turbulence warning nor was there any indication that all passengers had seat belts securely fastened.

The ACARS system indicates pitot icing problems causing a discrepancy in the speed data the flight computers were receiving. As the computer put the plane into Alternate Law mode and therefore no computer would override pilot input, there would have to have been prompt and proper action by the crew. I can not envision a pilot attempting to re-engage computer controlled flight until the plane itself was known to have recovered from any stalled situation. There was massive loss of data to the pilots and massive cognitive overload as whatever data that was available was unreliable.

As yet, there has been no word concerning the other "black box", the Cockpit Voice Recorder.

Tuesday, April 5, 2011

Undercarriage lowered on AF447?

Even though Phase 4 is still underway and the FDR and CVR have not been located, it seems the suspense is growing. A very small debris field, high vertical descent component suspected. Did the crew fixate on a problem and not realize they were in a gentle descent? Or did they attempt to increase drag by lowering the undercarriage? Why would they attempt such a thing? I just can't wait for the Flight Data Recorder to be recovered and analyzed, though I don't know how complete the information would be. Its possible that the data was changing so rapidly the recording of averages will be deceptive.

It just doesn't seem reasonable that the pilots would descend all the way from Level 35 to sea level without realizing they were descending, no matter how fixated on some other item they might have been. Also during any such gentle descent, the lateral travel from the LKP would be greater no matter what the direction of that travel was, even if they did a 180 whether it be intentionally or by happenstance. Being dumped into Alternate Law mode suddenly and losing so many instruments without warning may have overloaded the crews ability to cope with sensory input, but the plane would travel in some direction even if they lost engines.

I had thought a deep stall but this appears to be so very unlikely since it is not known how to put that plane into a deep stall and yet have it strike the water in a mainly downward direction consistent with a flat spin. So perhaps the answer is simply that there was no flat spin. Yet extending the undercarriage would indicate pilot attention and desperation. It would also indicate an over speed condition, not an under speed condition, though it is possible that a desperate crew could have extended the gear even if the airspeed was minimal simply as an attempt to lower the nose to re-stablish laminar flow over the wing and gain an attitude wherein an engine re-start might take place. However, I do think that only impact forces affected the main landing gear and the main landing gear doors. I doubt there was any inflight attempt to lower the landing gear.

Some are focusing on WX and pilot induced oscillations leading to a loss of longitudinal dynamic stability so that the plane was tail heavy and both engines had flamed out. No control surfaces effective, no way to restart, not much flight from LKP, high vertical component, low horizontal one. Not a good situation to be in at all and certainly not at night while inside a thunderstorm. Of course the problem is that other aircraft flew pretty much the same track not long before and not long after AF447 and had no problems at that flight level. So while its hard to imagine longitudinal stability problems its sort of harder to imagine anything else.

If the initial data from the iced pitot tube resulted in the throttles being retarded sufficiently to induce an underspeed stall and that stall progressed to a fully stalled situation with the nose down sixty degrees and neither the wings nor the horizontal stabilizer generating lift it is possible that leading edge vortexes impinged on the vertical stabilizer. Such vortexes when combined with commanded inputs from a desperate flight crew could result in a catastrophic failure at altitude but I would expect the fuselage to impact in a more vertical rather than horizontal attitude. So it seems that the vertical stabilizer did indeed remain attached until impact.

At impact the transmission would cease but the intermittent interruptions in the ACARS transmissions and unavailability of the signal is thought by some to have been caused by the antenna being occluded by an inverted fuselage but this is undetermined.