A Fairly Bad Week (Part 1 of 2)

Last week began and ended with flights that I will not cherish as warm and glowing memories of my aviation experience. And the first is going to be rather painful to discuss here.

Monday began with a disarmingly uneventful flight from the DC area up to Sikorsky Memorial Airport (KBDR) in Connecticut. The weather was clear and dry at about 0915 local time, when N631S and I landed on Runway 29 and were cleared to taxi to parking via taxiways Hotel and Alpha.

Approaching the tie-down area I took note that a rather large aircraft, a Piper Navajo, was parked in the last space of the row behind my assigned spot. That space is usually occupied by an Archer and so I thought that as I maneuvered N631S into its tie-down I'd have to be very careful to avoid the big Piper's wing.

Well, I succeeded after a fashion. As I turned 45 degrees to the right exiting the taxiway I carefully monitored the position of my wingtip relative to the Piper. Once sure that it was clear, I started to swing the nose to the left to align with the tie-down centerline. That's when I heard the sound of aluminum striking aluminum and felt '31S decelerate (from 3 or 4 mph) and yaw a bit to the right.

What I saw when I looked to the right was dismaying. I had completely disregarded the Piper's high, wide-span tailplane and my wingtip had struck and damaged the larger plane's elevator. Sick at heart, I shut down and got out to examine the extent of the damage. Pretty quickly, I had company.

Tony came out from Three Wing's maintenance hangar, looked up at the sad sight, and called the folks that own the Navajo. Meanwhile, I was calling Dan Schrager, of The Aviation Insurance Agency. He asked the basic questions and said he'd get back to me soon.

It appeared that N631S had come through the incident in pretty good shape. I couldn't see any significant damage to the wing. The Piper had been less lucky. The right elevator was clearly toast, and worse, the outer third of the horizontal stabilizer was bent down at a significant angle. It looked like I'd made a rather costly mistake.

Tony said they'd wait for the Piper's owners before separating the aircraft so I went to my office, having said I'd return if and when I was needed. That happened about two hours later when I received a call saying that the FAA was headed to the airport and had asked that I be there. So I hustled back.

The Piper Navajo that I'd damaged was in Part 135 service for an air charter operator, 'Fly the Whale'. As a "for hire" operator, they had to report the incident to the FAA and the FAA had to do an investigation. If the Piper had been a Part 91 aircraft like N631S, no FAA involvement would have been required.

While waiting, I met Andy, the CEO of 'Fly the Whale'. I apologized for the inconvenience I'd caused and he was extremely understanding and a perfect gentleman about it. He was the first, but not nearly the last, to tell me that, "Hey, things happen in life, nobody got hurt, it's OK." (No...it is not OK.)

The FAA inspector arrived, surveyed the scene, and asked if we could talk. A brief, cordial and professional interview ensued. I told him exactly what had happened. He asked a few relevant questions. I gave him my contact information for follow up and he joined the growing group saying to me, "Hey, things happen in life, nobody got hurt, it's OK." (No...it is not OK.)

And, yes, I've filed my NASA ASRS form.

I also heard from the insurance company, USAIG. Rob, the adjuster on the case, had been informed of the incident by Dan, my agent. Rob said he'd e-mail me a 'Report of Hull Loss' form to get the claim started and asked me for contact information for the shop and the other involved parties. Starting then and throughout, the service provided by Rob and USAIG has been impeccable!

The next day I returned to Three Wing, where both aircraft had been moved into the maintenance hangar. The news was better than I'd expected. N631S's right wingtip had been removed and the interior of the wing structure inspected. The shallow dimple in the leading edge was nicely between ribs and purely cosmetic. The remedy would be an application of aerodynamic filler, i.e., "Bond-O" at the next annual. N631S was, meanwhile, airworthy.

The right elevator of the Navajo would, as expected, need to be replaced along with the plastic tip of the stabilizer. But the apparent bend in the outer portion of the stabilizer that had worried us proved to be entirely elastic in nature. When the load imposed by N631S was removed the stabilizer "unsprung" back into its normal configuration. A thorough inspection revealed no consequential damage. The repairs would still be rather costly (elevators for big twins aren't cheap) but not nearly as bad as had been feared. And the time out of service for the airplane would be fairly brief.

So I felt much better. Not good...but better. You see, I had hoped to get to the time when I hang up my headset for the last time without having bent an airplane. I can no longer achieve that goal. I can't dismiss the loss of situational awareness that I had on Monday – which led to the incident – as one of those "hey, stuff happens" things. I've been committing aviation for 18 years now and have logged 1,500+ hours as Pilot-in-Command...and now I have a clear understanding of an area where I need to get better.

At least N631S was good to go for Friday. The forecast was telling me that a large ridge of warm air would be arriving in the East on Friday bringing rain but no risk of icing. I could plan for a wet IFR trip home to the DC area. Which was how I got to the second part of my Fairly Bad Week (to be covered in the next post).

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This is Why We Walk Around the Airplane

A while ago I posted a discussion of how to change the oil in a Cessna 182. On the list of items to be gathered in preparation for changing the oil I included "a helper." The helper becomes very useful when it's time to wrangle the lower cowl.

About a week ago it was time, indeed past time, to change the oil in N631S. I'd accumulated about 56 hours since the last change and it was getting to be important to get to the job. But my usual helper was out of town on travel, and my backup helper was not feeling well. So I decided to see if I could change the oil "solo" – and in the event, it did not prove terribly difficult.

I removed the upper cowl and loosened the quarter-turn Cleco fasteners on the right side of the lower cowl. Then I disconnected the cowl flap control cable from the right cowl flap. This gave me access through the cowl flap opening to the quick-drain fitting on the bottom of the crankcase. Without too much difficulty I was able to slip a 1" vinyl hose over the quick drain and open it to allow the used oil to drain. (The resulting lash-up appears at left.) And while the oil drained, I replaced the filter and safety wire in the normal way.

I don't expect to make this my standard procedure for oil changes, because it doesn't provide an opportunity to give the lower parts of the powerplant a thorough inspection. But in the circumstances (no helper) it worked well.

Feeling rather satisfied with myself, I re-secured the lower cowl and replaced the upper cowl. The latter needed the usual amount of persuasion but after a few minutes it dropped into place and I finished up, closed the hangar, and went home.

About 0600 the following Monday morning I arrived back at the airport, for my weekly trip to Connecticut. I stowed my bag and briefcase and began to do my pre-flight inspection. Of course I use a checklist, but I also like to take a step back and just look at the airplane. And when I looked at the right side of the upper cowl, this is what I saw:

As you can see, the whole row of Cleco fasteners that fasten the right side of the upper cowl to the lower were not secured. As I finished the oil change, I'd gotten the right side of the upper cowl seated, walked around to wrestle the left side into place, secured the Clecos on that side and then declared myself finished.

And that is why you always walk around the airplane. If I'd not bothered with a good pre-flight walk-around, would the upper cowl have come adrift during the takeoff roll? I don't know and have absolutely no interest in finding out. This highlights a second reason to do the oil-change with a helper if one can be had – a second pair of eyes greatly increases the probability of trapping boneheaded errors.

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Lift is Temporary; Gravity is Permanent

Yesterday about 2020Z, Cessna 631 Sierra and I were motoring along on a 270 heading at 8,000 feet MSL somewhere north of White Plains (KHPN) and east of the Hudson River. We were talking to New York Approach on 120.8 MHz. That's about when I heard an exchange involving an eastbound Bonanza – 1 Sierra Mike – at 7,000 feet (N.B. – all quotes from memory, some paraphrasing inevitable):

1SM: "Approach, Bonanza 1 Sierra Mike, we're going to need a vector to the nearest airport."

NY Approach: "What was that? 1 Sierra Mike, you need to go to an airport?"

1SM: "Yes, we're having some engine problems and we're going to need to land."

NY Approach: "OK, that'll be White Plains. 1 Sierra Mike, turn right to a heading of 240 and descend and maintain 3,000 feet. You can expect the visual to Runway 16 at White Plains."

1SM: "OK, right turn to 240, descend to 3,000, 1 Sierra Mike."

Am I the only one that has a couple of problems with that? Hold the thought while I continue here.

After a couple of minutes...

1SM: "New York, 1 Sierra Mike, can you tell me where the airport is?"

NY Approach: "The airport is about 9 miles at your 10 o'clock now."

1SM: "OK, we don't see it; I guess we want to try to stay a little higher here..."(sic)

NY Approach: "1 Sierra Mike, altitude your discretion, the airport is about 8 miles now at your 9 o'clock. Turn left to 180."

1 SM: "We're having trouble holding altitude here. I'm not sure we're going to make the field."

Here, courtesy of FlightAware.com is the ground track of 1 Sierra Mike, beginning with departure from Teterboro (KTEB):

My inference is that the controller had 1 Sierra Mike on a left base for Runway 16 at KHPN and planned to turn him onto the localizer somewhere around the usual intercept gate for IFR approaches. (As usual, click to enlarge. Bonanza 1SM is the blue track.) Unfortunately, 1 Sierra Mike was running out of altitude before that plan could be accomplished. Meanwhile, the riveting exchange continued on the frequency...

NY Approach: 1 Sierra Mike, say souls on board and, er..., fuel."

1SM: "It's the two of us on board and we've got one full tank and the other side is about half."

1SM: "Approach, 1 Sierra Mike is definitely not going to make the field. We're going to put it down out here. There's a field and a road over to the right."

NY Approach: "1 Sierra Mike, radar contact lost."

A minute or so later, an Emergency Location Transmitter (ELT) signal began on 121.5 MHz, the emergency frequency. 1 Sierra Mike was presumably on the ground, and had decelerated abruptly enough to trigger the ELT.

Again courtesy of FlightAware.com, here are the altitude and speed profiles for 1 Sierra Mike.

Quite soon thereafter N631S and I were handed off to the next sector, but I tuned the number two radio to 120.8 and kept monitoring. Soon, several aircraft, carefully separated by altitude, were looking for 1 Sierra Mike's location. One searcher posed a question:

Search Aircraft: "New York, what's the type aircraft and color?"

NY Approach: "It's a BE36...I guess we don't know the color."

After perhaps another five minutes, the controller said to one of the search aircraft, "Thanks for your help, you can continue. Somebody found them over there."

When I arrived at home in the DC area I quickly looked for news of the incident on-line and was rewarded with a brief article that referred to a "forced landing" and, more importantly, did not mention injuries or worse.

This, to me, is a beautiful picture. They may not get to use that airplane again, but it shows a controlled touchdown and a survivable event. The pilot, who had sounded very calm throughout, clearly kept his composure, chose a viable emergency field, and executed a good off-airport wheels-up landing.

This morning, I learned from updates to the news item, that the two on board were transported to the hospital with injuries judged to be not life-threatening. So the outcome, basically, was good. And that leaves open a question: Why am I troubled by this incident?

Let's start with a disclaimer: I'm not a qualified accident investigator. I am typically appalled by speculation in the aftermath of accidents. I guess I'm about to do that which usually annoys me. Well, here goes...

• First, the pilot – who really did a great job throughout this incident – erred, in my view, by not using the E-word on the first call to approach after the engine went bad. His phraseology was ambivalent and the seriousness of the situation was not at all clear. It costs NOTHING! to say, "Bonanza 1 Sierra Mike is declaring an emergency due to loss of power." Doing so removes all doubt from the minds of the ATC people.
  
• Second, the controller treated the situation like a normal approach into KHPN. He issued a descent to 3,000 feet (to get below KLGA arrivals?) and pointed the airplane toward the 16 localizer. The pilot didn't declare an emergency, and the controller didn't treat it as one. If the initial vector had been directly to the numbers at KHPN Runway 16, would 1 Sierra Mike have made it?
  
• Third, the controller issued a descent to three thousand and the pilot knew his engine was in trouble. The best one word response would have been, "Unable!" Instead, he started down. With the engine questionable (or worse), altitude is your bank account. You don't give it up without a really good reason. It seems that the pilot ceded command authority to ATC...never a good idea.
  
• Fourth, even as it became clear that an emergency had developed, the controller asked for "souls on board" (good!) and "fuel" (why?). In the moment, it would admittedly be hard to do the logical thing – ask for the color of the airplane that is about to be on the ground – but that just emphasizes the rote nature of the responses. Perhaps ATC needs a better training module for dealing with emergencies.
  

I would ask a favor from all who read this. Please don't think that I'm condemning the pilot or the controller in this incident. They both did well given the circumstances, and the people on the airplane will, it appears, be OK. But I believe there are lessons here. I've taken them aboard and I hope others will, as well.

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Send in the Drones? (cont'd)

I guess we have to talk about this. A post appeared on this blog 20 months ago, saying in part:

..we are being prepared for the day, not very far off, when we will be sharing the skies with Unmanned Aircraft Systems (UAS), also known as drones or remotely piloted vehicles (RPV's)...

As of Valentine's Day, when the President signed the recently passed FAA Reauthorization Act (Public Law 112-95), that day is upon us. There are some who are evincing surprise at the developments in this arena. I can only surmise that they have of late been asleep.

Section 332 et seq. of P.L. 112-95 has quite a lot to say on the topic of Unmanned Aircraft Systems. To begin with, the Law requires that on or before the 14th of May of this year the Secretary of Transportation must enter into agreements with "appropriate governmental agencies" that streamline the issuance of waivers or authorizations to operate "public unmanned aircraft systems" in the National Airspace System [P.L. 112-95 Sec. 334 (c)(1)].

The contemplated agreements must provide for expedited review, approval action within 60 business days, and expedited appeal in the event of disapproval. These agreements will, further, permit one-time approval of "similar operations carried out during a fixed period", and allow a "government public safety agency" to operate UAS's weighing up to 2 kg. within the operator's line of sight, up to 400 feet AGL during daylight conditions in uncontrolled airspace outside of 5 statute miles from any airport, heliport, etc.

One suspects that after about mid-August, anyone that flies low in uncontrolled airspace (agricultural applicators? pipeline patrols? balloonists? transiting helicopters?) is going to need to keep a sharp lookout for little 4 pound camera carriers buzzing around to help the constables search for marijuana patches, meth labs and undocumented immigrants. Will it be the responsibility of the operators of these devices to "see-and-avoid" other traffic? That would seem to be a rule-making matter,but the expedited schedule allows little time for orderly rule-making.

Once that little piece of business is under control, P.L. 112-95 gives the Administrator of the FAA until the 12th of August to set up a program of, at most, five years duration, that will establish six "test ranges" for the integration of UAS's into the National Airspace System (NAS) [P.L. 112-95 Sec. 332 (c)(1) et seq.]. In selecting locations for the test ranges, the Administrator is required to consider "geographic and climatic diversity", "ground infrastructure and research needs", the views of NASA and DoD, and no doubt (though not explicitly required), the location of the districts represented by the relevant congressional committee chairs.

The program's goals are fairly ambitious:

• To "safely designate airspace" for integrated manned and UAS operations;
  
• To "develop certification standards and air traffic requirements" for UAS's;
  
• To "coordinate and leverage" NASA and Dod resources;
  
• To "address both civil and public" UAS's;
  
• To coordinate with NextGen;
  
• To verify the safety of UAS's and related navigation procedures before integration into the NAS.
  

With these pilot projects established, no doubt to the financial pleasure of the usual suspects among DoT contractors, the cognizant managers will need to hustle to comply with the next requirement of P.L. 112-95. The act gives the Secretary until November 10th of this year to develop a "comprehensive plan to safely accelerate the integration of civil [UAS's] into the [NAS]." This plan is to be formulated "in consultation with representatives of the aviation industry, Federal agencies that employ [UAS] technology in the [NAS], and the [UAS] industry." [P.L. 112-95 Sec. 332 (a)(1) et seq.] (One wonders whether the GA community will have a seat at that table.)

The Act is fairly explicit on what it expects this "comprehensive plan" to comprehend, among other things (emphasis added):

• The anticipated rulemaking that will (i) define operating and certification standards for civil UAS's, (ii) ensure that UAS's incorporate "sense-and-avoid" capability, (iii) establish standards (including registration and licensing) for operators and pilots of UAS's;
  
• To project methods to enhance the technologies needed to achieve safe and routine operation of UAS's in the NAS;
  
• To recommend a phased-in approach to the integration of civil UAS's in the NAS;
  
• To project a timeline for this phased-in approach;
  

The plan is required to provide for the "safe integration" of UAS's into the NAS "as soon as practicable, but not later than September 30th, 2015."

The Act requires that the integration plan be forwarded to congress within a year (i.e., by February 14th, 2013), and that also by that date "the Secretary shall approve and make available in print and on the Administration’s Internet Web site a 5-year roadmap for the introduction of civil unmanned aircraft systems into the national airspace system...," said roadmap to be updated annually.

And, finally, the Act requires [P.L. 112-95 Sec. 332 (b)] that:

• "not later than 18 months after the date on which the (integration) plan...is submitted (i.e., at latest, by August, 2014)...the Secretary shall publish...a final rule on small (i.e., 25 kg or less) unmanned aircraft systems that will allow for civil operation of such systems in the national airspace system...",and;
  
• "a notice of proposed rulemaking to implement the recommendations of the (implementation) plan (presumably to encompass UAS's other than "small")...with the final rule to be published not later than 16 months after the date of publication of the notice (i.e., not later than December, 2015)."
  

So let us summarize the timeline:

• May, 2012: Agreements with government agencies on waiver procedures for operating public UAS's (of max. wt. 2 kg) in the NAS;
  
• August, 2012: Likely first operations of public UAS's in the NAS under waivers;
  
• August, 2012: Establish "test ranges" for development of UAS technologies and methods needed for integration;
  
• February, 2013: UAS Integration Plan due to Congress; Roadmap published in print and on-line;
  
• August, 2014: Deadline for final rule for civil operation of "small" (i.e., 25 kg.) UAS's in the NAS.
  
• December, 2015: Deadline for final rule for civil operation of all UAS's in the NAS.
  

The planning and rulemaking processes set in motion by the recent act of Congress deserve close watching, particularly as each key milestone is reached. It's going to get busy up there over the next few years!

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"It's the Third Approach that Kills You"

One of the "Ancient Pelicans" hanging around KBDR shared the wisdom in this post's title with me soon after I got my Instrument Rating. His theory was that if you were shooting an instrument approach for the third time you were tired, and frustrated, and maybe getting a little thin on fuel...and thus perfectly set up to push things a bit too far. And your funeral would be held on a sunny day.

So, he advised, go ahead and take it around for a second try. But if the second approach is a miss...go somewhere else where conditions are better. I thought that was pretty good advice.

That advice came back to me this afternoon, after the folks at FlightAware.com sent me an e-mail notification about a friend's flight. I have the "N" numbers of several friends' airplanes set up for the service and one of them had departed Lancaster (KLNS) for a flight to Manassas (KHEF). I clicked on the link to see where he was.

He'd departed KLNS shortly before 2:00 PM, launching into some fairly significant weather. By the time I brought up the web site (just about 3:00 PM) I expected he'd be close to his destination. But I found him 20 miles north of Manassas, on the ILS approach to Runway 17 at Leesburg (KJYO). Given the weather depicted on the screen, this would likely be an interesting approach. I pulled up the METAR:

 
KJYO 221955Z AUTO 00000KT 4SM RA BKN002 OVC017 10/10 A3009

That was not at all a sure thing! Ceiling reported at 200 feet, and the Decision Height for the approach at 250 feet AGL. I refreshed the screen a couple more times, watching the airplane icon near the airport location, and the altitude readout roll down. Then, it started to roll up, the speed readout increased and the icon turned away. Missed approach.

My friend flies a Cirrus SR-22, and is a fine instrument pilot. But this was no-kidding-around weather – the Real Deal. I had to hang around to watch the story unfold.

The airplane icon moved off to the north, then turned back toward KJYO. Vectors for a second approach. Back to the final approach course, speed reduced, altitude decreasing...and then increasing. A second missed approach! And the advice of the Ancient Pelican, gone West years ago, arose in my mind. Get out of there, my friend. You don't have to be in Leesburg today.

At left, the track as shown on FlightAware.com to this point. (Click to enlarge.) You can see the first approach, the turn outbound and then back in for the second ILS. And finally, the airplane icon outbound again to the Northwest. "Say intentions."

I will admit to a sigh of relief when he turned to the northeast and left KJYO well behind. Having decided that two tries at that ILS were quite enough he was headed somewhere else. I watched to see where he'd go.

The track bent to the east and then around to the southwest. He was lining up for the Runway 23 ILS approach at Frederick (KFDK). As the icon representing my friend's airplane approached KFDK I pulled up the METAR that was on offer there:

 
KFDK 222051Z AUTO 36005KT 7SM +RA SCT004 BKN009 OVC023 08/08 A3009 RMK AO2 P0002

Despite the heavy rain (+RA) this looked better. Good visibility and a broken ceiling at 900 feet. I watched, refreshing the display periodically, as the tiny blue airplane moved over the airport symbol...and stopped. Safe on the ground. (Below, the rest of the track courtesy of FlightAware.com)

Of course, the outcome was never seriously in doubt. My friend is a capable aviator, well qualified to deal with these conditions. But I'm sure he had some adrenalin flowing and he probably sat in the airplane for a minute after shutting down, while some tension dissipated.

As for me, I applauded the good judgement he exercised in avoiding a third approach to KJYO. Perhaps somewhere my other friend, the Ancient Pelican, is smiling.

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Children of the Magenta Line

The video embedded below was posted on the AvSig online forum by a friend. It's a presentation by a senior American Airlines training Captain on the subject of automation dependency (a subject I've commented on before). For my friends out there who fly aircraft that are able to let the GPS navigator drive the autopilot – well, you really ought to invest the 25 minutes in watching this; every time he says "FMC", substitute "GPS".

Automation Dependency from Bruce on Vimeo.

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Into the Darkness

Hindsight being consistently 20-20, I now find myself looking back on last Friday's flight from Bridgeport (KBDR) to Potomac Airfield (KVKX) with acute interest. The interesting bits came in three distinct parcels; I'll describe them in turn.

Part I

The previous post reviewed my planning for the flight, and included an off-hand comment that it's the time of year when one needs to think "less about, 'Will there be convection issues?' and more about 'Will there be ice?'" Famous last words.

As N631S and I were taxiing for departure, the controller advised that ATC was not providing IFR releases for aircraft headed west or south "due to weather." I said I'd park and wait it out. On the way back to the tie-down I took the screen shot at left, showing the weather that was causing the problem.

I was aware that there was significant weather in that area, but I had felt I could depart and work with ATC to find a route through the line or at worst, turn around and return to KBDR. But that scheme didn't work for ATC! In the busy New York Approach airspace, I guess that there isn't time to work individual aircraft through a line of convection. They just shut the routes down until the weather improves.

So, N631S and I sat on the ramp, checking in with the tower every 15 minutes for an update. After an hour and a half, the answer came back as, "Things are improved over by Sparta...you'd better get taxiing." Which we did!

The screen shot at left was taken soon after departure and shows the break in the line that we were aiming for. With just a few vectors for spacing, we were on our way westward. There were some cloud buildups to go through that looked a little intimidating, but the NEXRAD radar display showed little precipitation and there was no indication of lightning. And in the event, the clouds contained nothing worse than light turbulence.

At left, the view at 8,000 feet, coming out of the far side of that line of weather near the Sparta VOR (SAX). You can see the glow of sunset, a result of the delay in departure from KBDR. I hadn't expected to be logging night time on this trip but it was working out that way.

Part II

In looking at the weather forecast for this flight, it was clear that there might be some flirtation with ice. And near Allentown at 8,000 feet N631S and I found ourselves in the cloud layer with the outside air temperature (OAT) coming down. I wanted to stay at 8,000 as long as possible because the winds were more favorable there than at 6,000. Despite a true airspeed of about 140 knots, speed over the ground was only about 110 knots. Lower, the wind would be more directly "on the nose" and the headwind component stronger. I watched the declining OAT until it reached 34°F, and then asked Allentown Approach for a descent to 6,000. And as expected, about 7 knots of ground speed went away. But that altitude was below the clouds and significantly warmer.

Except for needing to be vectored around an isolated patch of convective weather just north of Lancaster, the balance of the en route portion of the flight was uneventful.

Part III

As had been forecast, the surface winds in the DC area were strong and gusty. And, as expected, the winds at KVKX were moderated by the field's location in a valley. Still, there was enough wind (reported as 7 knots from 260°) to make Runway 24 the clear choice. My final controller from Potomac Approach asked if I had the weather at KVKX and I replied, "Yes, I've picked that up; looks like it'll be Runway 24 tonight."

That elicited an offer that I couldn't refuse. Andrews AFB, which lies about 5 miles northeast of KVKX, was more or less between my position and the approach end of runway 24. I could get a turn toward the airport passing just south of Andrews, provided that I agreed to timely cancellation of IFR (since I'd wind up below Approach's Minimum Vectoring Altitude). Visibility was good, so I said, "Sure, we can do that." To which the controller said, "Proceed direct to VKX while I talk to Andrews."

A few minutes later I was at 1,500 feet, essentially crossing east to west over the approach lights of Andrews' Runways 1R and 1L. I was set up on a left base for 24 at VKX. Having cancelled IFR when I had the beacon in sight, I reported the runway in view and was released by the controller. N631S rolled out on about a 3 mile final.

It was a bit after 8 PM local time, and completely dark. Approaching KVKX from the northeast – something I'd never before done at night – offers only the most sparse ground lighting. The runway lights are clearly visible and welcoming, but the intervening terrain is something of a "black hole". The area is basically flat and featureless and I was down at about 1,300 feet to stay well below the floor of the Class B Airspace.

We've all read the training materials on visual illusions. We've been told about the dangers of the "black hole approach." (Avoiding Black Holes by Dale Wilson gives a good overview.) But now I was about to have the experience.

The visual approach aid for Runway 24 is a two-light VASI (Visual Approach Slope Indicator). Red beside red means you're low. White beside white, you're high. Red with white is just right. As I looked out into the dark night, the VASI was stubbornly red with red. Yet everything else about the sight picture had my ground-dwelling brain screaming at me, "Too high! You're too high! Get down!" I had to consciously remind myself, "It's an illusion. Do not descend. Trust the VASI." I was applying that first rule of IFR flight – trust your instruments! And soon, one of the red lights turned white and I started a descent toward the runway.

The landing itself was uneventful, and I was left reflecting on how a VFR-only pilot, trained to trust his eyes, could so easily be trapped by what I'd just experienced. It's a sobering thought.

Coda

Two nights later. Sunday, about 8 PM, N438CP – a Cirris SR-22 – was on a visual approach to Runway 26 at Danbury (CT) Municipal Airport (KDXR). The weather was good. I've flown into Danbury on occasion and can state that the terrain surrounding the airport is interesting at the best times.

The approach to 26 is over a residential neighborhood, presumably fairly dark. About a half mile short of the runway, at a point approximately 160 feet above the threshold elevation, the Cirrus flew into the terrain (reportedly where the red dot appears at left). The pilot, sole occupant of the aircraft, was fatally injured. And now I wonder...was he a victim of the siren call to fly lower that I was fortunate enough to be able to ignore?

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Reflecting on Reno

It's been difficult for me to sort out a number of conflicting impulses in the aftermath of the crash of Galloping Ghost at the National Championship Air Races in Reno, NV. My initial reflexive reaction was to recoil from the pointless tragedy. So much death and destruction for so little purpose! In the wake of the mishap, I would not have protested a decision to end these events forever. And yet...

In another context, these words have appeared in this venue:

"...it is very good for the character to engage in sports which put your life in danger from time to time. It breeds a saneness in dealing with day-to-day trivialities which probably cannot be got in any other way, and a habit of quick decisions."

This was written by Nevil Shute Norway in his autobiography, Slide Rule. And he did engage in such sporting activities: offshore yachting, motor racing, and aerial exhibitions. Air racing fits neatly into this context and has, in fact, a long heritage in aeronautical development.

Not long ago, I acquired a copy of The Conquering Wing by Grover C. Loening. This author was a giant figure in the early decades of American aviation. He managed the Wright Aircraft factory for Orville Wright, founded his own aircraft manufacturing firm, and made important contributions to aeronautical design. But in this book, published in 1970, he chose to write a work of fiction to convey what aviation was like in the U.S. prior to the First World War. Air racing is central to Loening's plot as it was central to pushing the bounds of technology before the imperatives of combat took over that role. And Grover Loening was there!

The names of the great air race trophies resonate with us. The Thompson Trophy, the Bendix Trophy, the Schneider Trophy. In pursuit of these prizes, the great pilots and engineers advanced the state of the art. Who can say what ships "the Few" would have had to launch against the onslaught of the Luftwaffe if Spitfire designer Reg Mitchell hadn't the opportunity to design the Supermarine S.6B (and its immediate progenitors) for the Schneider Cup?

The National Championship Air Races in Reno have carried on this rich tradition – but they have not fulfilled the role. Aeronautical engineering has passed by the air race. It no longer can serve as a technology driver. The only role left to it is commemoration of the glory of a bygone era. Who can say that isn't enough, for the zealous participants who willingly assume the obvious mortal risks?

But there must be a corollary to Shute's endorsement of danger-laced sport, stipulating that the dangers must not, beyond irreducible minima, devolve upon non-participants. In many cases – mountaineering, spelunking, white-water kayaking, as examples – all of the risk is assumed by the participant. But in some cases the risk to life and limb flows outward to others. For example, there has been controversy in the offshore yacht racing community over races that were started in awful weather, with a foreseeable likelihood that air-sea rescue teams would be called on to risk their lives to recover crews in distress. And now, there is controversy in the air race community, and in the wider community surrounding the races, about the risks assumed by spectators. This issue has been confronted by other motor sports and by the related air show community. Now the air race world will have to adapt.

The argument that spectators at high-risk events have somehow "volunteered" to accept the risk by choosing to be present does not hold water. It is the obligation of the participants and the event organizers to so arrange things that the dangers to which spectators are exposed are mitigated to the greatest degree possible. No "hold harmless" printed on the back of a ticket can change this.

Motor racing and the air-shows have implemented serious risk-mitigation efforts, triggered in each case by horrific mass-casualty mishaps. Motor racing changed forever after the 1955 LeMans Gran Prix accident. Thereafter, improved barriers, track reconfiguration and performance limits (e.g., restrictor plates) led to a profound reduction in spectator risk.

For the airshow world, the triggering event was the disastrous accident at the 1988 Ramstein Airshow in Germany. Three aircraft of the Italian Frecce Tricolori demonstration team crashed into the crowd causing 67 fatalities and hundreds of injuries on the ground. This led to regulations requiring designated buffers (of sizes that depend on aircraft performance) and a ban on aerobatic maneuvers that direct kinetic energy toward the spectators. In the U.S., each airshow functions under an FAA waiver that codifies these requirements.

An air race is a somewhat different animal. Because of the oval course configuration, the notion of "no energy directed toward the spectators" has been regarded as impractical for air races. (At Reno, the Grandstand is located in the apron area across the runway at the "bottom" of the oval course (left).) Thus, the tragedy at Reno was made possible.

It has been suggested that the spectators could be relocated inside the oval course. This notion has several drawbacks: (1) The cost of relocating the race's infrastructure could be prohibitively high; (2) much of the action would take place behind the spectators; and (3) the dimensions of the oval courses for the smaller, slower classes are confining.

There may be another alternative; one that would require the abandonment of two-dimensional thinking.

Keep the Grandstand and the Start/Finish line where they are. Run a "lap" that begins with a straight course from left to right across the front of the crowd (with an appropriate buffer distance ) at an altitude no lower than 1,200 feet AGL, After passing the crowd, there would be a tear-drop course reversal beginning with a turn away from the crowd and incorporating a descent to an altitude no higher than 1,000 feet AGL and then a second opposite direction straight pass in front of the stands. At the end of the second straight, a course reversal in the vertical plane (an "Immelman") to re-establish the aircraft on the initial straight.

This would give the spectators a good show, require a bit more of the pilots than "fly low, go fast and turn left", and enhance safety by ensuring that no kinetic energy is directed toward the crowd.

I can claim no qualification to justify my making suggestions to the air racing community at this sad time. But perhaps this sort of "out of the horizontal plane" thinking can help to bring about practical changes that will allow the Air Race tradition to continue and make the loss of Jimmy Leeward and ten others the impetus for a new era of reduced risk at Reno.

Jimmy Leeward – Gone West, 16 September 2011

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IFE

The second most intense event in aviation, short of having an emergency develop on your own aircraft, may be to hear another pilot on the frequency dealing with an emergency of his or her own. It certainly concentrates one's attention.

This morning, not very long after departing KVKX and climbing to 7,000 feet MSL, we (that's me and N631S) were crossing Delaware and doing business with Dover Approach.

As is common, I listened as the Dover controller cleared a departing flight - REACH 7045 - to climb on course. He called the departure as traffic for a northbound Beech Baron, saying, "Traffic is a C-5, Heavy, climbing to 11,000." Soon thereafter, Dover Approach transmitted, "REACH 7045, contact Washington Center on..." and gave them a frequency. The big Lockheed transport was gone on its way.

About ten minutes later, an unexpected call: "Dover Approach, REACH 7045, at 5,000, we need a straight-in visual to Runway 32." I took note - wasn't that the call sign of the C-5 that just departed?

The controller responded calmly, saying, "REACH 7045, I understand you have an IFE. You are cleared for the visual, Runway 32."

IFE? In Flight Emergency? The C-5 must have reported an emergency to Washington Center and turned back to Dover. Center had undoubtedly called Dover Approach with a "heads up."

The C-5 Galaxy responded with, "Understand cleared visual Runway 32. We'll be on the ground in ten minutes. We'd like a truck standing by."

From Approach, "REACH 7045, are you declaring an emergency? If we need to roll the equipment, that's the only way they'll respond."

"OK, yes, we are declaring an emergency," said the Galaxy pilot, and Approach asked, "What is the nature of your emergency."

"We have smoke and fumes in the aircraft."

Approach asked, as they must, "Say souls on board and fuel on board in time," which elicited "10...no, 11 souls on board and three hours of fuel."

OK, deep breath. Remember Swissair 111. Remember the recent UPS crash in the Middle East. This is as serious as a heart attack. This can turn completely to...well, you know...in a matter of minutes. At this point, I'm rooting for the C-5 crew. The guy handling the radios sounds cool and calm. They have many more options than the crew of the UPS flight that augured in recently; they have access to the cargo deck and they have troops ("11 souls on board") that can try to attack the problem. Still...get it on the ground!

"REACH 7045, contact tower on 126.35."

"Tower on 26.35...REACH 7045." I reached toward my Number 2 Comm radio to dial in the Tower frequency but heard on Comm #1, "Skylane 31 Sierra, contact Atlantic City Approach on 126.4." Damn! "31 Sierra, A.C. Approach 26.4, thanks and so long," and a quick switch. "Good morning, Atlantic City Approach, Skylane 631 Sierra level 7,000." As I waited for Atlantic City to respond to my check-in I dialed up Dover Tower on #2.

"Skylane 631 Sierra, good morning, Atlantic City altimeter is 30.22." I no sooner said, "30.22 for 31 Sierra" when I heard over the Dover frequency, "Tower, REACH 7045 will clear the runway and then stop to meet the trucks." They had to be getting close. From Tower, "REACH 7045, will you clear at Charlie or at Golf?" Good for the Tower controller! He's getting the information he needs to direct the emergency equipment to the correct taxiway. These guys are well trained! "We'll clear at Charlie," was the answer.

Perhaps a minute later, "REACH 7045 is clear of the runway." From Tower, "REACH 7045, the equipment is with you, contact ground on 118.87."

And that was that! An Air Force crew had a really interesting morning, and I got to listen in. Everyone involved sounded sharp and in control. And luck was with them today. This was a live, in-the-moment reminder that there is only one acceptable response to smoke in the aircraft - land, NOW! We fly and we learn.

Mid-Air Over the Hudson - Probable Cause

The National Transportation Safety Board (NTSB) met a couple of days ago in Washington to approve the final report on the "Hudson River Mid-Air." Just over a year ago (9 Aug 2009) a transient Piper Lance and a sight-seeing helicopter collided over the river. The mishap was fatal for all nine occupants of the two aircraft.

The Board has made a synopsis of the final report available on its web site. (The report itself is in final editing and won't be posted for a couple of weeks.) The synopsis contains recommendations, conclusions and a statement of Probable Cause:

"The National Transportation Safety Board determines that the probable cause of this accident was (1) the inherent limitations of the see-and-avoid concept, which made it difficult for the airplane pilot to see the helicopter until the final seconds before the collision, and (2) the Teterboro Airport local controller’s nonpertinent telephone conversation, which distracted him from his air traffic control duties, including correcting the airplane pilot’s read back of the Newark Liberty International Airport (EWR) tower frequency and the timely transfer of communications for the accident airplane to the EWR tower. Contributing to this accident were (1) both pilots’ ineffective use of available information from their aircraft’s electronic traffic advisory system to maintain awareness of nearby aircraft, (2) inadequate Federal Aviation Administration (FAA) procedures for transfer of communication among air traffic control facilities near the Hudson River class B exclusion area; and (3) FAA regulations that did not provide adequate vertical separation for aircraft operating in the Hudson River class B exclusion area." (emphasis added)

Several of the Board's conclusions, as contained in the synopsis, relate to the inadequacy of "see-and-avoid" as a strategy for avoiding mishaps like this one (in each case, emphasis added):

• "The airplane pilot may have believed that no other potential traffic conflicts existed because he had not received additional traffic advisories, but the pilot was still responsible for seeing and avoiding other traffic."
• "The helicopter would not have been obscured from the airplane pilot’s view but would likely have been difficult for him to detect until the final seconds before the collision because, before that time, the helicopter would have appeared as a relatively small and stationary object against a complex background of buildings."
• "The airplane would likely have been in the helicopter pilot’s field of view until 32 seconds before the collision, after which time the airplane was above and behind the helicopter and was outside the pilot’s field of view."
• "The guidance in Advisory Circular (AC) 90-48C, “Pilots’ Role in Collision Avoidance,” could better assist pilots’ efforts to establish effective see-and-avoid skills if the AC were to recognize current challenges that pilots encounter in managing their see-and-avoid responsibilities, including complex, high-density airspace and the increasing presence of technology in the cockpit."

So, in sum, the airplane pilot was responsible for seeing and avoiding conflicting traffic; it was difficult (maybe impossible) for him to detect the conflicting aircraft before it was too late to avoid a collision; the helicopter pilot was completely unable to see the fixed-wing aircraft; and the FAA's existing guidance on "see-and-avoid" (AC 90-48C), is obsolete (having been issued on 18 March 1983) and not comprehensive.

None of this comes as news. I've written about this event and its aftermath in six previous posts ( 1 - 2 - 3 - 4 - 5 - 6 ). In the first of these posts, written about a week after the mishap, I linked to a 1991 report published by the Australian Transport Safety Bureau (ATSB) titled Limitations of the See and Avoid Principle. This very well written report effectively demolishes the notion that unalerted "see-and-avoid" can be an effective strategy for collision avoidance.

In that post a year ago, I wondered if "...a technological aid like the TIS system shown above, could be required for commercial operators and strongly urged for non-commercial users of the Hudson airspace." I claim no prescience, but in its recommendations, the NTSB has netted out to the same place. Here (among other recommendations) is what they are proposing (again, emphasis added):

• "Update Advisory Circular 90-48C to reflect current-day operations, including (1) a description of the current National Airspace System and airspace classifications, (2) references to air tour operational areas as high-volume traffic environments, and (3) guidance on the use of electronic traffic advisory systems for pilots operating under the see-and-avoid concept."
• "Develop standards for helicopter cockpit electronic traffic advisory systems that (1) address, among other flight characteristics, the capability of helicopters to hover and to fly near other aircraft at lower altitudes, slower airspeeds, and different attitudes than fixed-wing airplanes; (2) reduce nuisance alerts when nearby aircraft enter the systems’ alerting envelope; and (3) consider the different types of operations conducted by helicopters, including those in congested airspace."
• "Once standards for helicopter electronic traffic advisory systems are developed, as requested in Safety Recommendation [4], require electronic news gathering operators, air tour operators, and other operators of helicopters used for passenger revenue flight to install this equipment on their aircraft."

"See-and-avoid" has been a cherished part of the freedom to fly as it's practiced in the US. And it can continue to be so, but the time has come to acknowledge that for high traffic areas "see-and-avoid" must be augmented with effective alerting technology.

In her opening statement for the meeting, NTSB Chairman Deborah Hersman made these observations (emphasis added):

"What I find so striking about this accident is that the airplane pilot was simply following his directions. And although the helicopter’s conspicuity was improved by anticollison lights and a high-visibility paint scheme on the blades – these enhancements didn’t help. Both aircraft were equipped with radios and traffic information systems, yet they didn’t hear or see each other, and the technology did not prevent the accident, and the air traffic system neither separated them nor alerted them that they were about to collide.

...

I might add that the ability to avoid future accidents like this one is dependent on a fully implemented ADS-B (automatic dependence surveillance-broadcast) program. The FAA has taken the initial steps to move towards an ADS-B-based ATC environment, but that is an expensive proposition. If we are serious about changing the paradigm and moving forward, then it’s critical that ADS-B, both in and out, be a part of this next phase of safety for collision avoidance."

The last part of this statement is quite controversial, as ADS-B (especially the "in" part) has no shortage of detractors. But some enhancing technology is needed and ADS-B is on the program.

There's a lot more that's of interest in the Board's synopsis (including some fairly severe criticism of ATC's involvement in the mishap). I urge you to read it, along with the final report when it issues.

On the Art of Crashing

"If you're faced with a forced landing, fly the thing as far into the crash as possible."
-- R.A. "Bob" Hoover

As recently discussed in this post, my friend Steve Cavallo had occasion in late June to deposit his Cessna 210D behind the boardwalk in Robert Moses State Park on Long Island after a total engine failure. Here is a news photograph of the result:

N3973Y - Photo (c) and courtesy of Fred Miller

To me, that picture speaks volumes about airmanship of the highest order. The airplane is resting in a confined space, at the very end of the available run, gear wisely left up and with a minimum of bent metal. In one of the press reports of the incident, the helicopter-borne reporter takes breathless note of how close the airplane came to the boardwalk and parking lot. This amused me as I was thinking, "Ol' Steve put that bird just exactly where he wanted it."

The quote below is from Steve's contribution to NASA's Oral History Project:

"[NACA Langley] also had [circa 1943] a rocket testing facility at Wallops Island, Virginia that required transportation service. To get to Wallops, we needed to fly a Grumman Goose Amphibian into a creek. The creek was a body of water about 50 meters wide and 2500 meters long which ran parallel to the ocean and was about 150 meters from it. The sand strip between was where the testing facility was located.

I was checked out to fly into the creek and it became pretty much my specialty. I got very proficient at landing and taking off into that small area, in all kinds of wind and current conditions."

The whole interview makes for compelling reading. But for now, I think it's fascinating to note that while Steve was slipping that Grumman amphib into confined waters over 65 years ago, and putting it just exactly where he wanted it, he was building up the experience and airmanship that allowed him to survive a close call and walk away just two months ago.

On the Ethics of Crashing

Just yesterday, it came to my attention that my friend Steve Cavallo had an engine failure and a forced landing late in June. He had departed Easton, MD (KESN) and was headed toward Gabreski Field (KFOK) in Westhampton, NY when the engine in his Cessna 210D quit over the waters off the south shore of Long Island.

Steve nursed the crippled Centurion to the shoreline and, in a remarkable display of airmanship, bellied it into a sandy lot behind the boardwalk at Robert Moses State Park. He was a little banged up but basically fine and no one on the ground had so much as a scratch.

Press articles describing the event can be found here, and here, and here. (The first story linked is the best.)

Steve Cavallo in a P-51 Mustang

I've written about Steve before. He is, in my view, a giant of aviation still flying with us. He flew as a test pilot for NACA during World War II and made incredibly valuable contributions to the war effort and to aviation progress. But today, I want to emphasize one quote from Steve, taken from one of the news accounts. He said this to a reporter:

“The main thing I was trying to do was not hurt anybody,” he said. “I would have opted to land on the beach—that would have been a cinch—but the beaches were full. The only thing that was open was this strip. If I didn’t go there, I think I would have been in a lot of trouble.”

That, I submit, is in the first place unsurprising given the experience and character of the man, and, in the second place, a humbling and vital lesson for the rest of us. As that silent powerless Cessna approached zero feet AGL Steve Cavallo was not preoccupied with his own safety and survival. He was determined to get the thing down without hurting people on the ground. Those folks never signed up to be Cessna-catchers!

I hope if any of us find ourselves in a similar situation we can work through the event with Steve's words in the back of our mind.

And...Steve, if you read this: Thanks for the lesson, you Great and Ancient Pelican. I'm happy that you're safe.

Don't Blame It on the Weather!

James Fallows is a National Correspondent for The Atlantic whose work I enjoy greatly and respect immensely. He also happens to be a capable instrument-rated private pilot (I believe he owns a Cirrus SR-22). Mr. Fallows maintains a blog wherein he comments on matters political, cultural and occasionally aeronautical, and yesterday he offered observations on the Airbus mishap in Islamabad.

The information in the post is helpful and cogently presented...but there are a couple of paragraphs, tangential to the main thrust of the piece, that I feel require a counterpoint. He has this to say:

"Bad weather is ultimately responsible for most of what goes wrong in aviation.(*) Fog or clouds that keep pilots from seeing the runway (the Polish airline tragedy), strong or gusty winds that complicate the process of touching down, icing in below-freezing clouds (Colgan in Buffalo), severe turbulence from thunderstorms (probably the Air France flight over the Atlantic), etc. ..."

The asterisk points to this footnote:

"(*) For another time: the different genesis of commercial-airline versus private-pilot accidents, with flat-out pilot error playing a far larger part in the latter case. But there too weather makes a huge difference."

With all due respect, I disagree. Bad weather is not "ultimately responsible" for anything. Bad weather simply is!

The fog in Smolensk wasn't responsible for the accident that killed the Polish president; blame lies with poor decisions made (for whatever reason) by the flight crew. The cold, wet weather in Buffalo wasn't responsible for the Colgan Air crash; at issue was the inability of the Captain to respond correctly to the situation. We don't know what brought down Air France 447 (and may never know) but other aircraft passed through that area before and after the fatal flight without incident.

The quoted footnote seems to imply that "private-pilot accidents" differ in kind from air-carrier accidents. Certainly they differ in frequency (air-carrier accidents being far more rare). But in the vast majority of cases, across all segments of aviation, the sudden meeting of aluminum and unyielding earth is the result of carelessness, incapacity or neglect on the part of the flight crew. We, ourselves, are the greatest source of risk.

Don't blame it on the weather.

The Fallacy of Safety

Let me begin by affirming that I am a great admirer of Ms. Deborah A.P. Hersman, the Chairman of the National Transportation Safety Board (NTSB). It seems to me that she well understands the power of moral suasion at her agency's disposal, and she makes good use of the bully pulpit that her office provides.

Given my admiration of her, I was taken aback and disappointed when, in her opening remarks for the Board's recent forum on Professionalism in Aviation, Ms. Hersman said this:

"[T]he American people rightly demand not 99-plus percent safety, they demand 100% safety."

Of late, we are daily reminded that we engage as a society in high-risk endeavors. Whether we are speaking of an aviation mishap or a major casualty in some other technology-intensive field, we understand that some combination of carelessness, incapacity and neglect tipped the balance from "ops normal" to catastrophe. The systematic defenses that had been designed to save the day were overwhelmed. And people died.

Predictably, the cries for safety ring out across the land. Managements and regulators are faulted because they failed to ensure that the operations were safe. We must be able to assure the public that they will be safe! Tell me, please, what does "safe" mean?

The dictionary teaches that "safe" means "secure from liability to harm, injury, danger, or risk." So, to render an activity safe, must we reduce the "liability to harm, injury, danger, or risk" to essentially zero? Is that to be our goal?

"A ship in harbor is safe, but that is not what ships are built for."

-- John A. Shedd, educator, Salt from My Attic, 1928

If, in our economic activities, we are to venture out of the harbor and onto the stormy seas of real life, we have to realize that there will be risk, there will be danger, that we shall go in harm's way. We cannot be safe.

Let me repeat that: We cannot be safe! Ever! To live, is to live with risk. To "demand 100% safety" (in Chairman Hersman's words) is to be at best naive and at worst a fool.

"Insisting on perfect safety is for people who don't have the balls to live in the real world."

-- Mary Shafer, NASA Dryden Flight Research Center

If we will wrap our minds around this simple, somewhat discomforting truth, perhaps we can abandon the fallacy of safety and start to think seriously about risk mitigation. To live in the real world, we need to understand the sources and magnitudes of our risks. We need to think through ways to avoid or to counteract them. And we need to so order our lives that adequate countermeasures will be at hand whenever danger looms.

Risk mitigation is always purchased. We must decide how much of it we wish to pay for. The calculus, whether explicit or instinctive, involves evaluation of the likelihood of mishap and the cost of consequences.

When the potential cost of failure is very high (say, a nuclear plant core melt-down) there is almost no limit to the risk-reduction budget. When the cost of failure is less extreme (as with aviation systems, where at worst a few hundred people are at risk) then we will spend a lot to reduce risk, but not an unlimited amount. We just can't afford to reduce risk in aviation to the level where it must be in nuclear systems.

Once the calculus of risk mitigation is completed and appropriate safeguards are in place, it's essential to avoid deviations that introduce unmanaged risk factors. There are always pressures, economic and political, to allow a risk in "just this once". And then if no mishap occurs, well, it must be all right to accept that risk routinely. That's called "the normalization of deviance," and we lost two space shuttles that way in spite of supposedly nuclear-quality risk management systems.

When the public asks of us, "Is aviation safe?" we can't honestly say, "Absolutely!" We have to answer: "We understand all of the risks and we take measures to deal with them. And we work every day on doing it better." And it has to be the truth.

---

Further reading: Prof. Sharon Beder, 'The Fallible Engineer', New Scientist, 2nd November 1991

Mid-Air Over the Hudson - Remedial Action

You'll all remember the accident that occurred last August 8th, when a Piper Saratoga and an air-tour helicopter collided in the Hudson River VFR corridor, fatally injuring all nine souls on board the two aircraft. I posted about it HERE, HERE and HERE.

The last of those posts discussed the FAA's proposed remedial actions to improve the safety of aircraft transiting or operating in the corridor. Now, I hold in my hand the recently issued 78th Edition of the New York VFR Terminal Area Chart (TAC). Published by the National Aeronautical Charting Office, it enters into effect at 0901Z tomorrow, 19 November, and it embodies the remedial actions previously discussed. Here's a clip of the affected portion:

A Regulatory Notice on the back of the chart sets out the rules in force in the Special Flight Rules Area. It begins by defining the Hudson River and East River Exclusions (i.e., excluded from the Class B airspace).

Alpine Tower

For the Hudson, it's essentially that airspace from the surface to 1,300 feet MSL between the banks of the river from the Alpine Tower in the north to the Verrazano Narrows Bridge in the south. (The East River Exclusion is mainly of interest to local helicopter and seaplane operators.)

The notice then sets out communication requirements. While operating in the exclusion, pilots must monitor the Common Traffic Advisory Frequency and announce aircraft type, position, direction and altitude at (as a minimum) these prominent points:

Goldman Sachs

• Alpine Tower
  
• George Washington Bridge
  
• USS Intrepid
  
• Goldman Sachs Tower
  
• Statue of Liberty
  
• Verrazano Narrows Bridge
  

The notice goes on to specify requirements for aircraft operation. It imposes a maximum speed of 140 KIAS and mandates use of anti-collision lights and position/navigation lights (illumination of landing lights is recommended). Pilots must have the current New York TAC on board and be familiar with its contents.

Aircraft are required to follow the eastern bank of the river when northbound and the western bank when southbound. (Keep Right!) And, aircraft that are not landing or departing the Manhattan heliports or conducting other local operations are required to transit the exclusion at altitudes from 1,000 feet MSL to the Class B floor (i.e., 1,300 feet MSL). The transient VFR pilot thus has a 300 foot altitude band to work with. Interestingly, local operators seem not to be constrained to operate below 1,000 feet MSL.

Adjacent to the Regulatory Notice on the back of the chart is a description of the new VFR Transition Route (referred to as "the Skyline Route"). This route is a VFR "tunnel" through the Class B airspace, not an Exclusion therefrom - so the usual Class B operating rules (14 CFR 91.131) and transponder requirements (14 CFR 215) apply.

The Skyline Route overlies the Hudson River Exclusion from Alpine Tower to the Verrazano Narrows Bridge, at altitudes from 1,300 feet to 2,000 feet MSL. The description advises northbound aircraft to contact Newark (EWR) Tower and expect to fly the east bank of the river, and southbound aircraft to contact LaGuardia (LGA) Tower and expect the west bank. The specific transition altitude will be assigned by ATC, and all are advised to "remain clear of the New York Class B until receiving specific ATC approval to enter".

I confess to some surprise that the towers are the primary contacts for the Skyline Route; I'd have expected Approach Control to assume that role. If an approaching aircraft is receiving Flight Following service from New York Approach, will they be handed off to the applicable tower for the Skyline Route transition?

I look forward to giving the Skyline Route a try, probably on one of my Monday morning trips from the DC area up to Bridgeport. I expect that I'll request the route from the first New York Approach sector and then see what develops.

The more interesting experiment will be to take the Skyline Route southbound and then pick up an IFR clearance in the air over New Jersey to facilitate later entry into the Washington Special Flight Rules Area (SFRA) and Flight Restricted Zone (FRZ), where I live. If that works, it may resolve my ongoing frustration with the "preferred" routing that usually takes me over eastern Pennsylvania.

This will be interesting.

Automation-Induced Complacency

Image shamelessly stolen from NASA ASRS Callback #315

It would seem that you can't conduct an aviation-related blog without commenting on the saga of the peripatetic Northwest Flight 188. You know - the one where the flight crew reportedly went "Heads-Down-and-Locked" over their personal laptops while 'George' flew the airplane past the intended destination (KMSP) at FL370 and on for another 150 miles into the wilds of darkest Wisconsin. It was the Mother of all LOSA (Loss of Situational Awareness) incidents.

Now it's reported that the FAA has issued an emergency revocation order for the certificates of the Captain and First Officer involved. They can appeal the order to the NTSB but based on the circumstances reported in the press their prospects of continued employment as professional aviators appear bleak. Perhaps that's as it should be. It is certainly easy to imagine ways in which their inattention to duty could have led to catastrophe. But at the same time, I'd suggest that to a degree they were set up.

Based on what's been revealed to date, it looks like this flight crew fell victim to Automation-Induced Complacency. And this is not in any way a new problem. Consider the following quote:

"Another problem concerns the new automatic systems which are coming into service with newer aircraft and being added to older aircraft. Flightcrews become more reliant upon the functioning of sophisticated avionics systems, and their associated automation, to fly the airplane. This is increasingly so as the reliability of such equipment improves. Basic control of the aircraft and supervision of the flight's progress by instrument indications diminish as other more pressing tasks in the cockpit attract attention because of the overreliance on such automatic equipment.

Pilot's testimony indicated that dependence on the reliability and capability of the autopilot is actually greater than anticipated in its early design and its certification. This is particularly true in the cruise phase of flight....

In any event, good pilot practices and company training dictate that one pilot will monitor the progress of the aircraft at all times and under all circumstances."[emphasis added]

Those words come from an NTSB report dated 14 June 1973. The subject is the crash, on the preceding 29 December, of Eastern Airlines Flight 401 in the Florida Everglades. That was the L-1011 aboard which the entire crew was busy troubleshooting an indicator light problem while the airplane - with the autopilot inadvertantly disengaged - spiralled slowly down into the swamp.

And here we are, 36 years later, with another crew allowing themselves to be distracted to the point where no one was flying the airplane! Fortunately, this time nobody died.

"During the long ages between dawn and sunrise, I'm thankful we didn't make the Spirit of St. Louis a stable plane. The very instability which makes it difficult to fly blind or hold an accurate course at night now guards me against excessive errors. It's again a case of the plane and me compensating for each other."
-- Charles A. Lindbergh, "The Spirit of St. Louis"

Flying in the Lone Eagle's day was the polar opposite of today. The problems revolved around task saturation, i.e., there was too much to do. But aviators like Lindbergh and Doolittle and Rickenbacker nonetheless excelled. It was an environment where human beings could, with training, do well. Yet, as aviation matured, new capabilities of pilot and aircraft were needed. Necessity brought forth the autopilot.

"I pay those guys to fly, so let them fly. I'll be damned if I'll pay them to just sit there."
-- reportedly, Eddie Rickenbacker, CEO Eastern Airlines. Eastern aircraft were some of the last to be equipped with autopilots, his pilots saying if it wasn't in Captain Eddie's SPAD he won't buy it. Quoted in 'Human Factors in Multi-Crew Flight Operations' by Orlady & Orlady.

In spite of Capt. Eddie's resistance, flight systems automation has become ubiquitous and now it looks like problems are arising from crews having not enough to do. The terms in current vogue for the flight crew are PF and PM - that's Pilot Flying and Pilot Monitoring. But for long stretches in cruise there is precious little flying for the PF to do, and the PM is probably, like all humans, rather poor at monitoring.

In a 2002 paper entitled Enhancing Flight-crew Monitoring Skills Can Increase Flight Safety, Capts. Robert Sumwalt & Ronald Thomas and NASA's Dr. Key Dismukes point out that:

"...although monitoring may seem intuitive and easy, in reality, continuous and effective monitoring is not natural. In fact, it is most natural to do things as you think of them, instead of delaying them until later. However...an effective monitoring strategy involves sometimes delaying some tasks until less vulnerable periods. It is also not natural to stop doing something in the middle of the task to scan instruments (monitor). Instead, people prefer to complete the task before stopping. However, effective monitoring requires a more-or-less constant scan of instruments."

And, quoting an earlier Air Transport Assn. Automation Sub-Committee paper:

"...serious errors do not occur frequently which can lead to boredom and complacency. 'A low probability, high-criticality error is exactly the one that must be caught and corrected.'" [emphasis added]

And so we have this highly experienced flight crew on NWA188 whiling away the hours from KSAN to KMSP with 'George' doing all the work. Ostensibly, of course, they are "monitoring systems" but you can only devote so much attention to static displays and creeping moving maps. So, being human and fallible, they turn their attention to "more pressing matters" -- like the arcane new pilot scheduling software. And the share of their attention devoted to "monitoring" their progress through the night sky falls to...zero. It's just unlikely enough to be the truth.

I think of the times I've been humming along over eastern Pennsylvania with 'George' in control of N631S and the GPS in control of 'George' and me, both the PF and the PM, with no flying to do and not a lot to monitor. If there were a distraction available, I might be vulnerable. So, while I can't excuse the guys up front on NWA188, I can see how they got in trouble.

The airlines may want to look into ways to keep the flight crew engaged with the airplane during extended low-workload periods. There is, for example, the concept of Adaptive Automation which uses novel approaches to task allocation and task partitioning to be responsive to changes in workload and operator behavior. The system could deliberately cede tasks to the pilots during low-workload periods simply to maintain a minimum level of operator involvement.

For my part, I think I'll just continue to keep Rule 1 in mind: Always fly the airplane!

Stupid Pilot Trick

A video clip that showed up recently on YouTube has been generating quite a bit of commentary on the aviation internet forums I frequent. Recorded by a passenger, it shows an unintended encounter with IMC and a resulting really close encounter with the local trees and bushes - to the point where the aircraft sustains impact damage but manages to return safely to the airport. The consensus of the pilot community seems to be that this pilot displays monumentally poor judgment. If you haven't yet seen this, here it is. Have a look (about 3 minutes running time).


I don't take issue with the position that the behavior shown here is about as bad as it can get. It is astounding that the flight shown didn't terminate with a smoking hole on the side of the mountain. What does give me pause is an underlying current in the commentary implying, "Hey, I'd never do that." Not smugness, just a feeling of disbelief that the observer could at any time even approach that level of stupidity.

To anyone who just can't conceive of ever being the central player in such a misadventure, I have a book I'd like to commend to you.

In Darker Shades of Blue: The Rogue Pilot Tony Kern explores the phenomenon of the aviator who inexplicably throws caution to the winds and behaves in ways that seem to invite fatal mishap. He explores many case studies and delves into the root causes of the FAA's familiar five Hazardous Attitudes (found in AC60-22 on Aeronautical Decision Making, available at: Link 1 and Link2). I won't try to summarize Dr. Kern's work here (please find and read the book). But at the end he concludes that, on any given day and for any given flight, every one of us harbors the potential to become that rogue pilot who abandons discipline with catastrophic results. Awareness of this potential is our sharpest tool in avoiding the terrible consequences of such behavior.

So I return to the Bonanza pilot seen in the linked video, not to condone him (he surely will - and should - face consequences for his actions, but for now they won't be fatal to anyone), but to acknowledge that there, but for the exercise of constant vigilance, go even the best of us.