Loss of Control
We haven’t had a FAAST presentation in our town for a couple of years and I was looking forward to attending the recent on on loss of control. Unfortunately, it turned out to be one of the worst presentations I’ve ever attended. The presenter was fairly well-spoken, but the entire presentation consisted of reading slides that had been prepared by the FAA. The slides themselves had tons of text on them—a big no-no if you want to hold your audiences attention. But what’s worse is that I think the first time he had ever seen the slides was when he was standing in front of the room reading them. There were a couple of interesting slides, but most of them were things that pilots don’t really care about. Here’s what I would have talked about…
Accident Statistics
They started off with a slide taken from the 2010 Nall Report—published by the AOPA Air Safety Foundation. Reports dating back to 1996 can be found on their website. The most recent 2011 Report below has similar statistics.
The take-away from these slides is that accidents happen to all pilots and the lethality is around 20%. In other words, about 20% of all accidents result in at least one fatality. The exception is student pilots, who—except for the long cross-country—are less likely to stray far from their home field, are presumably receiving closer scrutiny from their CFI, and hence are less likely to fly into adverse weather.
It’s hard to draw any other conclusions from this slide because it doesn’t show the number of pilots in each catagory or the number of hours flown. AOPA has the statistics on the number of pilots and private pilots make up 220,008 our of 627,588 or 35% of total pilots. The 51% of total accidents is much higher than the pilot population.
When we look at accident rates, some interesting information jumps out. There are 63 accidents per million hours for non-commercial operations (the chart reports it as 6.3 per 100,000 hours) and 2.97 per 100,000 hours for commercial operations. This is a significant difference.
The presentation mentioned three kinds of behavior that led to the accidents. First, doing the right thing poorly. Second, doing the wrong thing, and third, ignoring the FARs and common sense.
There are three Preliminary NTSB accident reports for recent high-profile accidents that are on point for Loss of Control that private pilots can learn from. The reports don’t contain much information but the NTSB member briefings have some interesting details.
The first is the Asiana 777 that landed short at KSFO. The second is the collapsed nose gear at KLGA, and the third is the UPS Airbus A300 that landed short in Birmingham (KBHM).
In the Asiana accident the NTSB found that (among a whole list of things) Adherence of Asiana pilots to standard operating procedures (SOP) regarding callouts. The flight crew did not consistently adhere to Asiana’s SOPs involving selections and callouts pertaining to the autoflight system’s mode control panel. This lack of adherence is likely the reason that the PF did not call out “flight level change” when he selected FLCH SPD. As a result, and because the PM’s attention was likely on changing the flap setting at that time, the PM did not notice that FLCH SPD was engaged.
In the LaGuardia accident, “The accident occurred at 5:45 p.m. after the twin-engine jet’s nose landing gear collapsed rearward and upward into the fuselage, damaging the electronics bay, which houses avionics and other equipment. The exterior of the airplane was also damaged from sliding 2,175 feet on its nose along Runway 4 before coming to rest, off to the right side of the runway.” There were no mechanical anomalies or malfunctions. “The weather in the New York area caused the accident flight to enter a holding pattern for about 15 minutes. The crew reported that they saw the airport from about 5-10 miles out and that the airplane was on speed, course and glideslope down to about 200-400 feet. The crew reported that below 1,000 feet, the tailwind was about 11 knots. They also reported that the wind on the runway was a headwind of about 11 knots. SWA 345 proceeded on the approach when at a point below 400 feet, there was an exchange of control of the airplane and the captain became the flying pilot and made the landing. The jetliner touched down on the runway nose first followed by the collapse of the nose gear; the airplane was substantially damaged.”
Collapsed nosegear accidents are fairly common as a quick search shows.
In the preliminary investigation of the Birmingham crash. The briefing by the NTSB member indicated that the control surfaces and and engines were working properly. The plane was on autopilot and auto-throttle up until the time data recording stopped. The PAPI was operational. The runway that they normally used was closed.
BHM 08/034 BHM RWY 6/24 CLSD WEF 1308140900-1308141000
The NTSB report indicated that communications between dispatch and the crew and among the crew were major factors in the crash.
Clear communications. This investigation identified several areas in which communication was lacking both before and during the flight, which played a role in the development of the accident scenario.
– Dispatcher and flight crew. Before departure, the dispatcher and the flight crew did not verbally communicate with each other even though dispatchers and pilots share equal responsibility for the safety of the flight.
Between flight crewmembers. During the flight, the captain did not rebrief the approach after he switched the autopilot from the profile to the vertical speed mode. Therefore, the first officer was initially unaware of the change and had to seek out information on the type of approach being flown.
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s continuation of an unstabilized approach and their failure to monitor the aircraft’s altitude during the approach, which led to an inadvertent descent below the minimum approach altitude and subsequently into terrain.