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Kaleva was a Junkers Ju-52/3m with registration OH-ALL operated by Aero OY.
The Junkers Ju-52 is a German tri-motor transport aircraft. It was originally designed with a single engine and was known for its corrugated aluminium alloy (duralumin) skin, making for an uncommonly strong structure. It had a double wing, as the flap ran along the entire trailing edge of each wing panel.
The initial prototypes showed that the single-engined Ju-52 was hopelessly underpowered. The fix? Add more engines. The Ju-52/3m was a modified Ju-52 with two wing-mounted engines to support the the engine at the nose. In the 1930s and 40s, the aircraft saw both civilian and military service and was popular with political figures of the time. Hitler used a Deusche Lufthansa Ju-52 for his campaign travel in the 1932 German election and Chiang Kai-sheik used one for his personal transport.
Aero OY was a Finnish airline founded in 1923 by Bruno Lucander, who had previously run the Finnish operations of the Estonian airline Aeronautics. The first flight was from Helsinki to Tallinn in 1924. Lucander made a deal with Junkers Flugzeugwerke AG that they would provide the aircraft and technical support needed in exchange for 50% ownership of Aero-OY.
Aero OY received its first Junkers Ju-52/3m in 1932. The 14-seater passenger plane was used to provide a regular service around Europe…as long as there was water nearby. The aircraft was on floats and only flew in the summer months. Soon, however, it was fitted with wheels in order to offer a service between Helsinki and Stockholm. Over the next ten years, Aero-OY took on a further four Ju-52/3M aircraft.
However, air raids on Helsinki made operations difficult during World War II and half the fleet was requisitioned by the Finnish Air Force. In 1939, the Soviet Union invaded Finland. During the Winter War of 1939 and 1940, 50% of the airline's passengers were children who were being evacuated to Sweden.
In March 1940, the Finns negotiated an armistice with the Soviet Union by agreeing to cede 11% of its border territories. A few weeks later, Aero OY resumed flights accross the Gulf of Finland to Tallinn.
Soviet troops had been based in Estonia for around eight months, since the signing of the Molotov–Ribbentrop Pact.
The Nazi–Soviet Pact was a commitment that neither government would ally itself or aid an enemy of the other party. The treaty included a secret protocol which divided the territories of Poland, Lithuania, Latvia, Estonia, Finland and Romania into German and Soviet "sphere's of influence". (The Soviet government denied this secret protocol until 1989, when it was finally acknowledged and denounced. Since then, however, Putin has defended the pact as necessary, blaming Britain and France for allowing Hitler's expansion into Europe.)
Meanwhile, in 1940 the Soviet military had received instructions to isolate Estonia in an unofficial blockade, so that Estonian ships and aircraft could not leave the country, including preventing aircraft departing over the Gulf of Finland to Finland – the standard route from Tallinn. The Soviet Navy's Baltic Fleet moved into position on the 11th of June.
On the 14th of June, the Junkers 52/3m known as Kaleva flew from Helsinki to Tallinn.
In Tallinn, the aircraft picked up seven passengers bound for Helsinki: a Finnish-born Estonian woman, two German businessmen, two French embassy couriers, one Swede and an American foreign service courier who had flown in from Helsinki that day and was returning with three diplomatic pouches. The aircraft carried over 120 kilograms of diplomatic mail – it's been said that the Estonian woman was the only "real" passenger on the flight.
The aircraft departed at 14:54. The flight crew spoke to Tallinn and then at 15:05 contacted Helsinki, who acknowledged them on frequency.
At 15:06, Helsinki attempted to contact the aircraft again but received no response.
A group of three Estonian fishing boats saw the aircraft in the sky, along with two Soviet aircraft. They were Ilyushin DB-3, a twin-engine, low-wing, long-range Soviet bomber. The DB stands for Dalniy Bombardirovschik.
Ilyushin developed the DB-3 to compete against Tupolev's DB-2 to create the best long-range bomber. The bomber needed to be capable of delivering a 1,000 kg (2,200 lb) payload of bombs to a range of 3,000 kilometres (1,900 miles) at a maximum speed of no less than 350 km/h (220 mph).
Ilyushin_DB-3 on Wikipedia
The DB-3 was not a simple or easy aircraft to manufacture as Ilyushin had pushed the limits of the available construction technology to make it as light as possible. For example, the spar in each wing panel had four parts which had to be riveted together and there were numerous welds that each had to be inspected by an X-ray machine, with many failures. In addition the internal riveting of small-diameter tubing was also a difficult and time-consuming process.
As the Estonian fishermen watched, the two Soviet bombers opened fire on Kaleva with their machine guns.
The passenger plane faltered and then flamed up before crashing into the water a few kilometres northeast of Keri Lighthouse.
A more dramatic version of the story is on the Historic Wings website, although I'm not sure what their source is; the detail isn't mentioned in the Soviet reports.
The Kaleva Shootdown
The two Ilyushin DB-3T bombers, even if they were not proper pursuit planes, were fast and well-armed. Machine guns bristled from the nose and sides. The Soviet crews proceeded with deadly efficiency. Once alongside the Kaleva, they opened fire and raked the plane with extensive fire. Just two or three kilometers northeast of the Keri lighthouse, the Kaleva exploded and crashed into the water at 2:05 pm on June 14, 1940. Everyone on board was killed.
The fishermen rushed to the scene and found flotsom and at least one of the diplomatic pouches floating at the oil slick but no sign of any survivors.
A submarine surfaced next to the wreckage. This was Shch-301, a Soviet submarine in the Baltic Fleet.
The Shchuka-class submarines were medium-sized Soviet submarines built in large numbers and used during World War II. The 300-series Shchuka submarines belonged to the Baltic Fleet, the Soviet Navy's presence in the Baltic Sea (now the Russian Federation Navy). The Baltic Fleet is headquartered in Kaliningrad, which is now a small Russian exclave between Poland and Lithuania. Shch-301 was lost on 28 August 1941. The last of the Shchuka submarines were decomissioned in the mid-1950s.
This is the 14th of June 1940 and the submarine was active. The commander of the Shch-301 wrote a report, which was released from the Russian State Naval Archives in the 1980s. They saw a Finnish aircraft en route from Tallinn towards Helsinki, which was being chased by two Soviet high-speed bombers. He reported that the aircraft caught fire and fell into the sea at a location about 9 km (5 miles) from the submarine. The submarine changed course to the crash site, arriving 40 minutes later. They discovered the Estonian fishing boats already on the scene. The fishermen were searched and the submarine crew confiscated all valuables found on the fisherman and in the sea.
Meanwhile, Helsinki had never had a response from Kaleva and alerted the military. A Finnish fighter plane was sent to the approximate location where the aircraft had been. It reported that about six km north of Keri Lighthouse, there was an oil slick and a submarine. The Finnish fighter circled the site three times and then returned to Helsinki.
The submarine remained on the site for a further ten minutes, recovering about 100 kg of diplomatic mail and quite a bit of hard currency of various nationalities. They rendevoused with the patrol boat Sneg who took the recovered items to Kronstadt, Saint Petersburg's main seaport.
At the same time, some 3,000 km (1,900 miles) to the southwest, Germany had occupied Paris.
Both the Estonians and the Finns launched investigations, which ground to a halt two days later.
On the 16th of June the Soviets, accusing Estonia of military collaboration against the Soviet Union, made their move. With the country blockaded and 25,000 Soviet soldiers in the country, they invaded Estonia. Lithuania had been taken the day before and Latvia was taken that same day. The so-called Baltic countries were now occupied by the Soviets.
It seems likely shooting down Kaleva was related to the preparations for the invasion and occupation of Estonia. However, it's not clear whether the Soviets intentionally took out the aircraft in order to prevent the diplomatic mail from leaving Estonia or that the bombers became over-excited and shot down the civilian craft without direct orders. Based on later actions by the Soviet military, it could also have been a simple show of force, looking to provoke a reaction directly before the occupation of Estonia.
Under the circumstances, they were never held to task.
On the 17th of June, the day after the Soviets occupied Estonia, the Finnish commission investigating the crash released a report on the loss of Kaleva. The report stated simply that "the explosion was caused by an external factor". The wreckage and the bodies of the victims were never recovered.
Aero OY painted the Junkers Ju-52m/3 remaining in service in neutral markings with FINNLAND in large letters over its fuselage and Finnish national flags on her wings, in the hopes that Soviet and German aircraft would recognise it as a civilian aircraft.
Estonia regained its independence on the 20th of August 1991.]]>
At the same time, British Airways flight BAW17, a Boeing 777-200, was travelling on route P862 on its way from London Heathrow Airport to Inchon International Airport in Korea. The Boeing was cruising at FL350 (35,000 feet). At 14:59, the flight crew contacted Tallinn Area Control Centre as they crossed into their zone.
The two routes, L729 and P862, cross over the north end of Kihnu island. Thus, at this stage the aircraft were both travelling towards that intersection, with the Italian Dassault climbing to FL340 and the British Airways Boeing steady at FL350.
At 15:00, there was a scheduled staff change at Tallinn Area Control Centre. The controller coming on duty was briefed about the "situation" with the two aircraft, although the report does not get into any detail as to what the controllers saw the situation as being. The two aircraft were expected to cross paths with a vertical separation of 1,000 feet, which is sufficient.
The controller contacted the Italian Dassault.
|Tallinn Area Control Centre
|Italian Air Force, maintain FL340 when reaching, expect further climb in 1.5 minutes.
|Italian Air Force IAM3116
|Copied, maintain 340 and we advise you that we don't need anymore climb, so 340 will be good final.
|Tallinn Area Control Centre
|Italian Air Force, roger, 340.
Now, I'm not quite sure how it was that the aircraft separation reduced below safe minima but at 15:05, various safety net systems triggered. These systems are specifically in place to warn that standard methods of safe separation may fail or have failed.
On the ground, the Short-Term Conflict Alert triggered, showing the distance between the two aircraft in red, to alert air traffic controllers of a potential or actual infringement of the minimum separation required. The two aircraft flashed on the controller's radar display.
At the same time, the Traffic Collision Awareness System triggered in both the Dassault and the Boeing.
All modern commercial transport aircraft has a Traffic Collision Avoidance System (TCAS) installed. In this case, both aircraft were equipped with TCAS II version 7.0.
The TCAS interrogates the transponders of all nearby aircraft, receiving their altitude and distance. If it discovers aircraft nearby, it offers a traffic advisory (TA) to alert the flight crew of the nearby aircraft. When the flight crew receives a traffic advisory, they are not expected to perform avoidance manoeuvres, simply to be aware that there is the possibility of a conflict. It gives the flight crew a chance to locate the other aircraft visually and prepare for the next instruction if the risk of conflict continues.
If the TCAS determines that there is a real risk of collision, and if the other aircraft is also TCAS-equipped, the TCAS will send a coordination signal to the other aircraft in order to resolve the encounter. This is called a resolution advisory (RA) and should always be followed by the pilots, even if it contravenes air traffic control instructions.
TCAS coordinates the evasive manoeuvres ensuring that the two aircraft increase separation as quickly as possible: most commonly, one TCAS system will select an "upward sense RA" (instructing the pilot to climb) and the coordination signal to the second TCAS means that the second system will select a "downward sense RA" (instructing the pilot to descend), thus resolving the conflict immediately.
At 15:05, both aircraft received a TCAS traffic advisory, alerting them to potential conflicting traffic.
The flight crew in the Italian Dassault identified the British Airways Boeing at their 2 o'clock position and the British Airways Boeing identified the Italian Dassault at their 11 o'clock.
The flight crew in the Italian Dassault then began to reduce their vertical speed in order to level off at FL340. Two seconds before the aircraft reached FL340, they received a resolution advisory.
The Dassault descended about 80 feet and then resumed climbing, reaching FL343 (flight level 34,300 feet), leaving just 700 feet between the two aircraft.
The Area Control Centre's radar displayed both flights in red, to indicate that the separation between the two aircraft was unsafe.
The Italian Dassault contacted the controller.
|Italian Air Force IAM3116
|Control, IAM3116, we had a TCAS climb, now TCAS completely is ended, we continue descent FL340
|Tallinn Area Control Centre
|IAM3116, flight level was 340.
|Italian Air Force IAM3116
|Yes, but we had a TCAS conflict that commanded us to climb.
|Tallinn Area Control Centre
|Traffic was at FL350…above you.
|Italian Air Force IAM3116
|It was maybe a problem of the wrong indication of the TCAS, but my rules say that I have to follow.
|Tallinn Area Control Centre
Now the controller's confusion here is plain. It made no sense for the TCAS to advise the Italian aircraft, which was the lower aircraft, to climb. The two aircraft had 1,000 feet separation but because the Italian Dassault then climbed above its cleared level, that separation reduced to 700 feet. The British Airway's Boeing did not receive a resolution advisory and continued at FL350. The two aircraft, which had appeared to be crossing paths safely had suddenly become dangerously close to each other. It seems incredible that the TCAS resolution advisory could have been CLIMB, CLIMB, directing the aircraft towards the other aircraft.
And in fact, it wasn't. At the time of the resolution advisory, the Dassault was still climbing, as it was just below its assigned flight level of 340. As a result, the RA received was not so straight forward.
The TCAS issued a resolution advisory which I have to admit, I have never heard before: ADJUST VERTICAL SPEED, ADJUST.
This advisory always means a reduction of vertical speed, never an increase, although in the heat of the moment that might not be clear. The point of the advisory, I think, was that the aircraft would be fine at FL340 but needed to stop climbing in order to be sure not to infringe on the minimum separation. There's no aural advisory for "stop climbing and maintain your current altitude", so the only option is to adjust the vertical speed (in this case, to zero). This would also explain why the British Airways Boeing did not receive a resolution advisory: all it needed to do was keep doing what it was doing, continuing on at FL350.
So the flight crew, by continuing the climb past their assigned level, generated a more dangerous situation, although clearly the captain believed that they had correctly responded to the TCAS resolution advisory.
I'm slightly unhappy with the conclusion of the report in this instance.
Causal Factors
This incident is attributable of the fact that the crew of IAM3116 misinterpreted TCAS RA "Adjust vertical speed, adjust", by increasing the rate of climb instead of levelling off.
Contributory factors
The aural warning wordings of TCAS II Version 7.0 RA can be misleading. This might have contributed to the incorrect pilot response
Now, I agree with the causal factor but at no point does the report actually investigate the inciting incident: the triggering of the TCAS in the two aircraft and the Short-Term Conflict Alert on the ground. In fact, the only discussion on the air traffic control aspects is that the Short-Term Conflict Alert provided little little help to the controller to avoid this conflict. It seems to be that understanding how the situation arose is deserving of a little more analysis than that and it's hard not to feel like the accident report gave a pass to the Estonian traffic controllers, without investigating their understanding of the situation and their reactions to it. I've complained about this in regards to both French and German reports before, so this is by no means specific to the ESIB. But even if they concluded that the Air Traffic Controllers did everything correctly, the investigation should spend some time on how the inciting incident could have been avoided.
Meanwhile, the safety recommendation for this case is a bit of a soapbox, in my opinion. The underlined emphasis is from the original.
EU 1332/2011 is mandating TCAS version 7.1 to be used in European airspace on civil aircraft. State aircraft are subject to National jurisdiction and no mandatory action can be enforced at EU level. Since the State transport aircraft may operate in the same airspace as civil aircraft, the adoption of TCAS version 7.1 on transport-type State aircraft may not be seen as mandatory in regulatory terms, but it is strongly recommended to all ICAO and EASA member states, that for safety reasons, all State aircraft should be upgraded to version 7.1 as soon as possible, including when forward-fit opportunities arise.
Taking in account that "The Convention of International Civil Aviation" Article 3 and EC 216/2008 Article I exclude State aircraft, ICAO and EASA cannot mandate the implementation of TCAS version 7.1 on State aircraft, which decision at the moment is on the separate member states. It is therefore recommended to ICAO, EASA and European Commission to consider promoting member statesto take further actions in enforcing the adoption of TCAS version 7.1 on State aircraft, when operating in common airspace to mitigate the risks of loss of separation between civil and State aircraft.
In other words, TCAS version 7.1 should be required by state aircraft (for example military aircraft) the way it is for civil aircraft, because the two are sharing the same airspace.
The thing is, both aircraft were using TCAS II Version 7.0, so it's not like the Italian Air Force Dassault was operating a different traffic collision system from the British Airways Boeing, the civil aircraft.
Also, there's no justifying argument within the report. There is a total of 9 aural warnings on TCAS II v7.0 (including the climb/descend as pairs). Clearly, this one was not easily understood, although that should have been dealt with through training. But there's no information at all as to what the aural warnings are on TCAS II v7.1 or what the Dassault flight crew would have heard in the same situation if they were using that version.
You can read the full report here: Serious incident, loss of separation between Boeing 777-200 and Dassault Falcon 900 near Kihnu Island on 17.10.2013.
The investigation and report took over a year to complete. It seems to me that the Estonian Safety Investigation Bureau could have been a lot more thorough in investigating the case and justifying their conclusions.]]>
The aircraft was a BAe Jetstream 3200 (J32), a low-wing twin turboprop aircraft popular for small passenger services. The J32 seats up to 19 passengers.
The J32 was operated by AS Avies, an Estonian airline offering both cargo and commercial passenger flights. AS Avies worked as a sub-contractor to a Swedish operator who held the contract to run services between Torsby and Stockholm.
AS Avies held a valid operating licence and AOC issued by Lennuamet, the Estonian Civil Aviation Authority.
That day, the schedule was to fly from Stockholm to Torsby in Värmland. Then, after refuelling, the aircraft would continue to the operator's base in Tallinn, Estonia.
However, Stockholm was suffering from heavy snowfall. After the aircraft was de-iced, it was held for a further half an hour on the taxiway while waiting for the runway to be cleared of snow.
The flight from Stockholm, with two crew and fifteen passengers on board, finally departed an hour after its scheduled departure time. However, the weather at Torsby was no better and the crew received warnings of severe icing along their route.
Icing conditions are when water freezes on impact with the external structure of the aircraft during flight. Atmospheric water exists in liquid form well below freezing. This supercooled water forms droplets which can strike the surface of the aircraft. When an airframe collects ice, the aircraft performance is reduced. The icing can lead to a change in the control ability of the aircraft, as the structure has been changed, as well as a loss of lift, causing a stall and loss of control of the aircraft. In addition, ice can form along the air inlet path of the engines. If the engine inlet path becomes blocked, the engine will fail.
The captain was not concerned by the warnings of severe icing on his route, conditions under which many flights are cancelled, as he understood that the BAe Jetstream 32 was approved for flight in all ice conditions, thus he felt there was no issue with severe icing.
He planned the flight with two alternate airports in case it was not possible to land in Torsby. The fuel on board was the minimum permitted fuel quantity for the flight. This allows for reaching the alternate airport after two missed approaches and then a further thirty minutes reserve.
The captain knew that the aircraft's propeller de-icing system for the right engine was not working, although this defect was not noted in the aircraft logbook.
The flight proceeded normally. Although other flights in the area reported moderate to severe icing, the Jetstream appears to have only collected light icing during the flight.
As they approached Torsby, the visibility was 2,000 metres and the snow was still falling.
Here's the view from the Torsby airport webcam today. You can click on the image to see the webcam with live updates.
Runway 16 at Torsby Airport is 1,590 metres (5,200 feet) of asphalt. The snow was falling continuously leading to what is called a "contaminated runway". The airport staff check the runway condition by sending a vehicle to collect samples from the runway, so that they can measure the friction coefficients.
Friction coefficients is a way of calculating how slippery a surface is. The friction coefficient is directly proportional to the braking action that an aircraft can achieve when braking after landing.
This measurement basically gives a value to the friction between the aircraft tyres and the runway's surface. A lower coefficient means that the aircraft will have a reduced braking ability. This means that the aircraft will require a longer distance to come to a halt.
The runway samples gave measured coefficients of 0.25, 0.25 and 0.23, which is marked as a rating of 1 out of 5 and correlates to 'poor braking action' in standard phraseology. The airport staff sent snow clearing vehicles to clear the runway in an attempt to improve conditions.
Nineteen minutes before the flight was due to land, the airport took new samples from the runway. This time, the coefficient results were 0.30, 0.31 and 0.33, rating a 3 out of 5 and corresponding to "medium braking action". This information was passed to the aircraft which was still over 15 minutes away. The snow continued to fall.
There are regulations regarding operations on wet vs dry surfaces: the landing distance under conditions with a wet runway must be at least 115% of the required landing distance of the aircraft in dry conditions. However, there is no such rule specifying calculations for contaminated surfaces; it is up to the operator to determine the additional landing distance required if the aircraft is expected to operate on runways with contaminated surfaces. It must, however, be at least 115% of the required landing distance of the aircraft.
The snow-clearing vehicle cleared the runway as the aircraft turned for its approach, seven minutes before touchdown.
The flight crew acknowledged the information about the friction coefficients but did not change their planned approach. They had no information about the performance data of their aircraft on contaminated runways and they did not believe that there was anything they should do differently in reported conditions of "medium braking action". So they did nothing.
The first officer was the Pilot Flying as the aircraft came in to Torsby. The runway lights were clearly visible as he flew in for a manual landing. The captain did not see any visible icing on the aircraft and so did not see a necessity to increase the VREF speed (the speed when passing over the runway threshold) by 10 knots as prescribed by the flight manual if there is ice on the aircraft.
In the final stage of the approach, the captain pointed out to his first officer that his speed was high: he was coming in too fast. He also noticed that the PAPI lights indicated that the aircraft was coming in low.
The first officer couldn't remember if the wings were checked for ice during the approach; he was focused on flying the aircraft, which did not have an autopilot. He said he decided to maintain a somewhat higher speed during the approach although they'd not agreed a faster landing speed. Later, investigators found that the airspeed indicator on the first officers side showed a speed about 5 knots lower than the airspeed indicator on the captain's side, causing a further discrepancy between the agreed VREF and the actual speed of the aircraft.
The first officer raised the nose to correct the pitch angle. At this late stage of the approach, the aircraft was travelling faster and lower than expected. The first officer's last minute adjustment to the pitch was too abrupt: the overcorrection led the aircraft to come in over the runway threshold too high.
This is exactly why a go-around is executed if the approach is not stabilised. Most accidents of landing planes are preceded by an unstablised approach. If the speed and glide path angle are not as expected, the approach should be broken off and the aircraft should go around and try again.
It is the job of the Pilot Not Flying to declare whether the approach is stabilised. The captain considered the approach to be stabilised and that it was safe to continue.
The aircraft touched down on runway 16 at high speed. The first officer retarded the throttles to idle and initiated thrust reversal. They had 800 metres (2,625 feet) remaining runway length ahead of them. It didn't look like it was going to be enough.
The captain took over the controls and started braking. He set the engine controls to full thrust reversal.
The aircraft continued to speed across the runway. The captain said that the surface was "very slippery". They were not going to stop in time. The captain had to choose between running off the extension of the runway or attempt a high speed turn onto the taxiway.
The captain realised they were not going to stop in time and he attempted to turn right onto the taxiway. However, the aircraft was travelling too fast for the manoeuvre and he lost control during the turn. The aircraft veered off of the runway, running into the snow between the runway and the taxiway. It plowed into a snowdrift and came to a halt a few metres away from the taxiway.
The crew informed tower of the situation, shut off the engines and evacuated the passengers.
On the face of it, this was a minor incident. The aircraft came to a safe stop no one was injured and there was no damage to the aircraft. The Swedish investigation only had to answer one question: Why had the aircraft not been able to stop in time?
It soon became clear to the investigators that the answer was complicated. Not all was right with this flight.
First, there was the issue of the right-side propeller's de-icing system not working. The decision to carry on into severe icing conditions despite this was not just foolhardy, it meant that the flight crew was not complying with the Minimum Equipment List, which defines the conditions under which an aircraft can still be operable when there are equipment failures.
The captain was aware that the de-icing systems were not working and he also knew that this was not noted in the log book, as required. However, he was equally adamant that there were no deviations from operational routines or regulations. Not on that flight and not at any other.
He considered the situation in Torsby to be normal winter weather and that the flight that day had no operational problems or limitations. He said that the BAe Jetstream 3200 had been designed to cope with a lot of ice and he had only had good experiences of flight under severe icing conditions.
Now, the J32 is a lovely little aircraft. It is designed and certified to be able to meet the requirements for operations in icing conditions, and the truth is, there's no detail as to which icing conditions are appropriate. But generally speaking, even certified aircraft avoid severe icing conditions and in fact in the J32 Aircraft Flight Manual, there are clear warnings and instructions for crew in the case of encountering severe icing. Instructions that the captain knew nothing about.
More importantly, the Minimum Equipment List makes it clear that the aircraft can be flown without a serviceable propeller de-icing system but only if it is not operating in known or forecast icing conditions.
In the Swedish winter conditions, the aircraft should have been grounded as soon as that defect was clear.
The first officer also said that they did not experience anything out of the ordinary and believed that they only experienced light icing during the flight. He was not aware that the right-side propeller de-icing system was not working.
He couldn't recall if the expression "stabilised approach" had been used to confirm that he should continue. In fact, he said that the concept of a stabilised approach was not one that they used in daily flying or in training.
He was sure, however, that there was no discussion regarding the landing conditions or the friction coefficients that had been reported. He said that they didn't discuss this as there are no procedures to correct for contaminated surfaces, for example a runway covered in snow.
This is particularly disturbing as the airline's routes in Sweden and Estonia meant that the airline crew must regularly encounter snow on the runway and icing conditions, yet they were not given even the most basic information for dealing with this.
The first officer was also right in that the airline didn't have any definition for a stabilised approach, which should be used for flight crew to determine whether to continue the approach or break off and try again, especially in adverse weather conditions.
The investigation looked at the calculations regarding landing on Runway 16 under the conditions of the flight that day. The calculations were done with a friction co-efficient of 0.275, as the snow had continued to fall for 17 minutes after the previous measurement of just above 0.30.
So: the wind was variable at 3 knots, the aircraft was 7,059 kg (max 7,080), at a VREF speed of 125 knots (115 knots + 10 for icing, as per the aircraft flight manual) and a friction coefficient of 0.275.
On the basis of those values, the landing length required for the aircraft was 1,473 metres. As runway 16 is 1,590 metres, this would leave additional margin of 117 metres (380 feet).
However, the aircraft didn't land on the numbers. From the point where it actually touched down, there were only 800 metres of runway remaining; no where near enough to stop the aircraft in time.
The investigators recovered the Cockpit Voice Recorder and the Flight Data Recorder from the aircraft.
The Cockpit Voice Recorder holds 30 minutes recorded conversation from the cockpit. In this instance, it consisted of telephone conversations between the captain and the operator's technical department, which took place some time after the incident. When an aircraft is involved in a serious accident, for example, veering off the runway at high speed and plowing into a snow drift, the flight crew should cut the power supply to the cockpit voice recorder, in order to avoid overwriting the recording with new information. However, the crew didn't do this and thus the recordings of the approach and the incident were lost.
The Flight Data Recorder holds 25 hours of data, recording the flight parameters using a microprocessor that converts, digitises and formats the data for later retrieval. When reading data from the FDR, the data values are relative. They are decoded into engineering units (for example knots or degrees) using a system specific to the installation in an individual aircraft. That is, you can't just drag the FDR out of any old plane and plug it in and get the data. You need to know the details of how it was installed in order to convert the data into something useful.
The Flight Data Recorder held all the data from the flight in question but the operator didn't have the documentation in order to convert the data. This means that the recorded parameters from the FDR weren't reliable and attempts to read the data using generic conversation document led to parameters which were not representative. As a result, the data from the Flight Data Recorder cannnot be treated as definitive.
The worst of it was, both of these issues, the overwriting of the Cockpit Voice Recorder and the lack of documentation for the Flight Data Recorder, had come up in a previous incident in Sweden. The investigation had highlighted this at the time and the airline had been informed that these were regulatory issues that they must comply with. This wasn't a one-off problem but a systemic failure to abide by regulations.
The airline had also previously had issues with aircraft faults not being logged in the technical log. The airline explained that they had their own system for this and did not use the technical log. Note: this is not something that an aviation operator can choose not to do. It is required.
But they didn't do it. I would hate for you to think I am exaggerating for effect so here is the exact quote from the previous accident where this came up.
The operator has stated that the system works well in general and that there have only been a few instances of misunderstandings. The reason for the pilots being instructed not to write the technical remarks in the logbook is, according to the operator, that this entails a greater risk that the aircraft will be grounded.
Yes, that's right. The pilots are not to report defects with the aircraft because it might mean that the aircraft is not deemed fit to fly.
This is exactly the bloody point.
The Swedish Accident Investigation Authority contacted the Estonian and Swedish aviation regulators during the investigation to highlight the compliance issues they were finding. The Estonian authority, as the issuer of the operator's Air Operators Certificate, has the responsibility for the company. The Swedish Transport Authority cannot regulate the airline but can initiate safety inspections to verify the operator's safety and quality for flights within Sweden.
The Swedish Transport Agency began conducting inspections of the airline, specifically focused on the flight crews' performance calculations. They reported that the crew continued not to have any performance data for dealing with contaminated runways. They forwarded the report to Lennuamet, the Estonian Civil Aviation Authority, for immediate response to ensure that AS AVies used the correct data for performance calculations and if they did not, the Swedish authorities advised Lennuamet that they should limit or revoke the airline's Air Operators Certificate.
Lennuamet responded to say that AS Avies had demonstrated the relevant performance calculations were being used by the airline for safe operations on contaminated take-off and landing runways.
The airline hired a consultant to draft a manual with performance data for the BAe Jetstream 31/32 including tables and correction data. The performance data manual was submitted to Lennuamet on 24 October 2014. It was approved the same day and distributed to the pilots for use.
However, the manual was hardly much of an improvement. Usually, such a manual will contain data on all of the airports that the operator flies to. In this case, only general calculation bases were produced, which meant that pilots had to manually enter in all the conditions for operations at an airport: runway lengths, slopes, height above sea level, etc, every time they wished to calculate the aircraft's performance in winter conditions.
On the 6th of March 2015, the Swedish Transport Administration terminated the contract with AS Avies and opted not to sign agreements for another two routes which had been under discussion. The reasons given included the fact that the operator had by now already suffered four serious incidents in Sweden.
The cause analysis by the Swedish Accident Investigation Authority is extremely well written and worth quoting directly.
In this case, the direct cause of the aircraft running off the runway is simple to establish:
The touchdown took place too far into the runway and at too high speed.
However, this conclusion is inadequate as a thorough explanation of the incident and, even more so, as a basis for effective safety recommendations.
SHK has chose to to give a picture of the incident that occurred by means of the following description of cause.
In the final report, the Swedish Accident Investigation queried directly as to why Lennuamet aviation had not discovered the operator was routinely deviating from regulations. The failure to comply with the technical log system regulations was specifically highlighted.
[The deviation] has instead had the stated purpose of reducing the risk that aircraft will be grounded (the operator does not have technicians stationed at all the places where the aircraft have night stops and where technical service could consequently be carried out), i.e. a purely economic purpose. This is, from a safety perspective, remarkable.
The technical log system, the failure to protect the data on the CVR and the inability to convert data from the FDR had all been highlighted by the Swedish Accident Investigation Authority previously, without seemingly any action by the operator or Lennuamet, whose responsibility it was to regulate the operator.
Further non-compliance was the decision to take off from Stockholm into severe icing conditions with the right-of side propeller de-icing system unserviceable.
For an aircraft in winter conditions, the ability to understand the landing characteristics of a contaminated runway is critical. The complete lack of performance data for the aircraft meant that the flight crew had no means of working with the friction coefficients given to them, and in fact believed that the information did not apply to them.
And finally, the fact that the first officer was unaware of the requirement for a stabilised approach and that the captain believed the too-fast approach with last minute pitch change bringing the aircraft from too low to too high could be considered a stabilised approach speaks to a clear training issue at the company.
These deviations all show systemic safety and training issues at the airline. More importantly, it is the regulator, in this case the Estonian Civil Aviation Authority, who was allowing the airline to continue to operate despite its continued disregard of regulations.
The final report ends with a single safety recommendation.
Considering the fact that the Swedish Transport Administration has terminated the contract with the operator in question, SHK has limited the report's recommendations to only cover the Estonian civil aviation regulator, Lennuamet, which is recommended to:
* Tighten its supervision of the operator, AS Avies, in order to ensure that operations are conducted in accordance with applicable flight safety requirements, in particular with respect to such deficiencies as identified in section 2.5 of this report.
Although Lennuamet initially expressed confidence that AS Avies was responding to the safety concerns and complying with regulation, on the 1st of April in 2016, Lennuamet suspended the air operator's certificate of the airline for not meeting the requirements laid down in regulation. The suspension was set for six months or until the airline restructures to improve its activities and addresses the identified shortcomings.
The story does have a happy ending. As far as I can see, the airline has not resumed operations.]]>
Currently, more and more applications for drone technology are being discovered every day. People that are passionate about aeronautical technology have likely already realised some of the possibilities of drone technology and have been forced to wait for the world to catch up with their ideas. Well, it seems that the world might be catching up with the future a lot faster than we had expected.
While everyone is highly aware of drones being used for surveillance purposes, the extent of surveillance will more than likely be expanded in the future. For example, the University of Missouri started training journalism students how to pilot drones to gather information from events that may be difficult to film with a hand held camera. Surveillance drones are also being used to document wildlife and explore archaeological excavation sites. The development of a waterproof drone capable of remaining submerged in briny water for months at a time without being damaged could even indicate a near-at-hand revolution of the methods of the marine science community.
In regards to gathering information, chances are that the technology of surveillance drones is going to continue to be improved. We expect drones will get smaller and quieter for discreet documentation.
Drones have already shown incredible potential when it comes to providing aid and supporting the emergency services. In warzones they have been used to deliver food and medical supplies, they've been used to combat fires trials are being conducted to see how they might fair when used to catch criminals. It can be proposed that drones will become a vital component of the emergency services. With the use of such technologies as heat sensitive cameras there's also a lot of potential for drones to be used at disaster sites to locate survivors quickly.
In terms of the development of military and defence drones, the improvement is not necessarily in the application of drone technology, but rather the quality. Drones are stronger, faster, quieter and capable of carrying devastating weaponry. While it is still uncertain as to what the next step is in regards to enhancing drone power there is some speculation that Trump might take charge over drone warfare after Trump made a particularly disturbing comment about the treatment of terrorists and their families during the election. Now that the technology is in his hands we might see more deadly military applications being developed. But, this is still only a theory and so far Trump has not shown much intention of creating airborne Terminators. So, if you need a distraction from the political bleakness, you can play Trump's Whitehouse Game and imagine for yourself what Trump's Whitehouse would look like.
This is the industry filled with independent innovators, focusing on experimenting more than they are developing. New creative ways of utilising drones are being introduced all the time, including Singapore restaurants using drones as waiters and delivery services using them to deliver goods to their customers.
Intel's experiments with controlling hundreds of drones as one unit were shown at its best in the exciting Super Bowl display in Houston last weekend.
But it's not all just spectacle. Young film makers and media enthusiasts are using drones to enhance their cinematography on a budget. Combining camera stabilisers and gimbals with their drones that can capture incredible longshots that might have taken a professional studio thousands of dollars to create.
There's also cases of people using as 'battle bots', with fans from all over the world organising drone racing and fighting tournaments in which the winner can win thousands of dollars in prize money if they win.
Hopefully, in the future, we'll see a lot more of this creativity. We expect that artists are going to start thinking about the possibilities of drones our daily lives will be a little bit easier and cheerier.
Over the past year, Tallinn has worked to expand its single asphalt-concrete runway to 3,070 metres but at the time, in 2010, runway 08 had a length of 2,800 metres (9,186 feet).
The take-off distance of the Antonov An-26 is around 1,250 metres (4,000 feet), less than half of the available runway at Tallinn at that time.
And still, somehow, it wasn't enough.
Flight 3788 was a scheduled cargo flight operated by Exin Co. Ltd., a Polish charter airline. Exin was established in 1991 and currently operates two aircraft, both An-26s.
This is a photograph of SP-FDP taken by Mikko Mertanen in Helsinki just three months before the incident.
SP-FDP was an Antonov An-26B, a twin-engine transport plane with two turboprop engines and one auxiliary turbojet engine. The An-26 was designed and produced in the Soviet Union from 1969 to 1985 and was very popular as a cargo aircraft because of the retractable cargo ramp. The An-26B is the civilian cargo version of the aircraft equipped with roller gangs which can be swung up against the cabin walls when not in use. The two turbo-prop power plants deliver higher thrust than the standard model and an additional small turbojet adds thrust to act as a climb rate/high altitude cruise booster.
On the 25th of August 2010, the aircraft was scheduled for a cargo flight from Tallinn to Helsinki.
There were four crew on the flight deck: the captain, the first officer, the navigator and the engineer. The crew had been put together five days earlier. The flight engineer was new to the company and, before joining it, he'd had a three month gap in his flight activities.
All crew had passed the Crew Resource Management training given by the company in May-June 2010; that is, all of them had covered CRM training within six months of the accident.
The crew was based in Helsinki, where Exin had a guest house. Rest and duty time rules were observed. None of the crew members showed any signs of alcohol or medical issues which might have inhibited their ability to act as crew.
There's one oddity though. The flight engineer said that, despite a restless night at the guest house, he slept about three hours in Tallinn before the flight and he felt fresh. The report also quotes him as saying that for no specific reason, he felt thoughtful during the accident flight and could not concentrate. That doesn't sound like "fresh" to me.
That evening at Tallinn Airport, the first officer was the Pilot Flying.
After uneventful flight preparations, the flight crew taxied to runway 08, entering at the west end of the runway. They lined up for take-off. At 16:47:22 UTC, the aircraft began its take-off roll.
In aviation, we use V-speeds to refer to specific speeds that are critical to flight. These speeds vary from aircraft to aircraft and even flight to flight, so it is important to know what the monitoring flight crew member is referring to when calling out the speed reached on the ground or in the sky. There are two V-speeds relevant to this incident.
V1 is the speed beyond which the take-off should no longer be aborted.
VR is the rotation speed: the speed at which the pilot gently pitches the aircraft up, which causes it to lift off from the runway.
So on a normal take-off, the monitoring flight crew member, in this case the navigator, would call out when the aircraft reached V1 which means that the speed at which they can safely abort the take-off has been exceeded. On this flight, V1 was 182 kilometres per hour (98 knots, 113 mph).
Then the navigator would call out that the aircraft has reached VR, which is when the Pilot Flying should initiate rotation because the aircraft is now going fast enough to take off. The Pilot Flying should not attempt to lift off before this speed is reached. On this flight, VR was 201 kilometres per hour (108 knots, 125 mph).
So where were we? At 16:47:22, the aircraft began its take-off roll.
Ten seconds later, the Pilot Flying initiated rotation. He pulled back on the elevator controls to lift the nose-wheel off the ground, so that the aircraft would lift up from the runway and take off (rotation). The elevator, which controls the pitch, was positioned to 17º and then released to 9.2º. The aircraft pitch angle increased to 4.6º.
That's when the navigator made the V1 call.
So this is already a mess. The Pilot Flying started rotation long before the aircraft had reached the right speed. But even worse, the V1 call was early. At that point, the aircraft had reached a speed of 160.5 kilometres per hour (86 knots, 100 mph) which means the take-off could still safely be aborted. The calculated V1 was quite a bit faster: 182 kilometres per hour (98 knots, 113 mph).
When interviewed later, the Pilot Flying couldn't remember if he'd heard the VR callout before rotation. He said that he rotated the aircraft "at VR or maybe a bit earlier". Analysis of the Flight Data Recorder showed that the Pilot Flying started rotation at 144.5 km/h. Just to refresh your memory, the VR speed was 201 km/h. They weren't even close.
It was at this point that the flight engineer called out Retracting! in Polish and selected the lever to bring the gear up.
The landing gear control is located in the cockpit central console. The landing gear on the An-26B should not be retracted until the aircraft has at least fifty metres (164 feet) in altitude and an indicated airspeed of 230 kilometres per hour.
It's operated by the flight engineer who retracts the landing gear by turning the switch counter-clockwise from the neutral position. The flight engineer does this when commanded to do so by the Pilot Flying.
The flight engineer later said that he saw the Pilot Flying rotating the aircraft and clearly heard him command "Gear Up!"
None of the other crew members heard the command. There is no record of the command on the cockpit voice recorder. The Pilot Flying was clear that there had been no call-out for "Positive Climb", which would have preceded his command to raise the gear. On the other hand, neither had there been any V-speed call-outs which should have preceded his attempt to take off.
Under normal circumstances, flight crew are prevented from retracting the landing gear on the ground.
When the landing gear is supporting the weight of the aircraft, the landing gear can't retract: a Weight-on-Wheels switch blocks the electrical current so that the electro-hydraulic retraction system cannot operate. However, the lift on the wings during the end of the take-off roll can sometimes be enough to allow the landing gear to be retracted.
Although the aircraft was moving slowly and at this stage was not actually airborne, when the Pilot Flying pitched up, he would have increased the lift on the wings. It seems that this extended the landing gear struts to the point where the current was passed to the retraction system.
The wheels retracted.
The control is not within the pilots' field of view. Presuming both the captain and the first officer were focused on looking forward and scanning the instruments, they would not have seen the flight engineer's action.
To be honest, by this point so much had gone wrong, I just can't really imagine what they could have done to save the situation even if they had known.
Let's look at all the calls that didn't happen.
V1, the speed at which it is no longer safe to abort the take-off, was called out by the navigator, but the call was made after the aircraft had rotated. The call was wrong however, as the aircraft had not reached that speed.
VR, the correct speed at which to rotate the aircraft, was never reached and never called.
Positive climb! (or in the US Positive rate!) is called when the aircraft is climbing away from the airfield at a safe velocity. Only after this call would the command to bring the gear up to be given.
Gear up! is called by the Pilot Flying as an instruction to retract the landing gear. Changes in configuration of the aircraft are generally never made without a direct instruction by the Pilot Flying.
Only one call-out relevant to the take-off was made, which was that the speed at which the aircraft take-off run could safely been aborted had been exceeded. And sadly, even that call was wrong.
As a sideline, there was a great thread on Airliners.net which asked what the opposite call was to Positive climb!. What would the call be if, after rotation, there isn't a positive rate of climb. The following are my favourite answers:
Those words get the famous [expletive] on the accident report when they transcribe the CVR
Technically, the opposite would be 'negative descent, gear down'. Which would be odd because two negatives make a positive, so the plane is climbing but with its gear down.
The point is clear: if you have rotated correctly, then a positive rate of climb can be assumed; so much so that, in simulator training, flight crew being tested on their monitoring are caught out calling positive climb without actually checking first. Only after the positive climb call should the gear up call be made. And I can't believe I'm even having to say this, but only after the gear up call has been made should the gear be brought up.
The accident report makes a similar seemingly banal statement on this.
Rotating at the correct VR will result in aircraft being able to take off and retraction of the gear will not result in runway contact.
Well, that's the idea anyway…
So the aircraft was travelling along the runway, not having quite hit V1 but still travelling at a fair speed, when the wheels disappeared out from under it.
The aircraft obviously then slammed onto the ground to skid along its belly, although the report charmingly refers to it as "contacted the runway", as if it were an old Facebook friend.
The blades of the right-hand propeller scraped along the runway. A few metres down, the left-hand propeller left similar marks on its side of the runway. The aircraft slid for 1,228 metres (4,000 feet) before coming to a rest.
The aircraft's belly was scraped and abrased. The tips of the propeller blades were bent backwards. The left bay door had bent to the left and partly broken off.
As crash landings go for a plane that hadn't taken off yet, it was a pretty good one.
The core issue here is that the crew did not appear to be working together in any sensible way. The Pilot Flying initiated rotation without waiting for the call from the navigator. The navigator made the initial call early, which meant that he'd stated that the aircraft was travelling too fast for the take-off run to be aborted, whereas it was not too late. Based on the accident report, the captain appears to have done nothing at all. And the flight engineer, presumably triggered by seeing the Pilot Flying pull back on the controls, retracted the landing gear while the aircraft was still (barely) on the ground.
The crew had only worked together for nineteen hours, so they hadn't had the time to become a team. The Pilot Flying had less than 500 hours experience on type and had trained on a different aircraft type. The flight engineer had only just joined the crew and had not flown for three months before taking the position. Although the records show that all of the crew had gone through CRM training within the past few months, clearly it wasn't enough.
The accident report cites the flight engineer as the cause of the accident. There's no question that it was his action which directly caused the aircraft to "contact" the runway. However, the instigating action was the Pilot Flying who initiated rotation without waiting for the VR call. The report also correctly calls out the CRM of the crew and the switch that allowed the gear retraction to be activated in the contributing factors.
The report concludes with a recommendation that the operator "set up and implement procedure with clear verbal exchange between pilot flying and flight engineer confirming the gear operations". I find this odd, because this procedure already exists and the statements by the crew make it clear that they were aware of the call-out/response sequence, they just didn't follow it. The second recommendation is more sensible, in that the operator should monitor and supervise their crew better to ensure that they are following procedures. And finally, they recommend that the operator look into the operation of the Weight-on-Wheels switch.
The full accident report can be read in English here: ACCIDENT INVESTIGATION FINAL REPORT AN-26B, SP-FDP Tallinn, Estonia 25. August 2010
I am enjoying an extended stay in Tallinn and it occurred to me that I'd never written about an Estonian aircraft incident…or even read an Estonian accident report. So while I am here, I'd like to make up for this omission and share a collection of accidents and incidents with you. I hope you find the collection as interesting as I do.]]>
This was originally posted in September 2009. I can vouch for the fact that the Killer Cattle Protection System works: I have not trespassed on CAA land since.
I shouldn't have hopped the fence.
It was shut with a big padlock and surrounded by barbed wire so I can't exactly claim that I hadn't noticed it.
But I'd walked such a long way – 5 miles! – just to take some photographs for my blog, it seemed such a shame to give up at the last hurdle. There was no one else there so it wasn't like I was getting in anyone's way. And it wasn't like there was anyone to tell me off – just me and some cows off in the distance.
I didn't know that they were guard cattle.
But let me start at the beginning…
Brookmans Park is a small village in Hertfordshire, population 3,475. There isn't much exciting to say about the place: the locals are friendly, the Indian restaurant is divine, the village green is pleasant in nice weather.
However, pilots who fly around southeast England will recognise the name as home to the Brookmans Park VOR (BPK) which is used by commercial aircraft flying in and out of the London area. In addition, the airspace over London is structured such that a lot of VFR traffic passes over BPK. When I was flying in and out of High Wycombe, I regularly routed via BPK.
When I found out that I was going to be
trapped visiting family in Brookmans Park for a few days, I immediately thought of BPK and wondered if I could actually visit a VOR and find out what they look like.
A VOR (VHF Omni-directional Radio) beacon is a navigational aid which broadcasts on a specific radio frequency in such a way that a pilot can get a bearing from the VOR to her aircraft.
Patrick Flannigan has a better explanation of this on Aviation Chatter: How VORs Really Work and you can even test it out yourself on this VOR / ADF Navigation Simulator by Tim Carlson.
If you want to know the detail, the Wikipedia article on VORs is probably the best single reference:VHF omnidirectional range
It turned out that the Brookmans Park VOR is not actually located in the village but a few miles east, near Epping Green. The weather was glorious and I
needed an excuse to get out of the house thought a walk would do me good, so I made my way there, walking along the country roads and enjoying the mild weather.
I used a hand-held GPS and reached the location after about 2 hours gentle strolling.
That's when I discovered that the VOR was in a field, surrounded by a fence with two padlocked gates.
It seemed so sad. I could see the field and the VOR and a herd of cattle grazing in the distance. I considered my situation for a few moments and then convinced myself that the fence was merely to keep the cattle in, surely not to keep me out. Besides, I wasn't going to do any harm. I just wanted a closer look at the VOR.
So I clambered over the fence with my camera in hand.
The ground was firm beneath my feet and the sun warmed my shoulders. A light breeze carried the scent of freshly-cut grass to me. The bird song was only interrupted by the roar of the engines overhead. If I had any chance of forgetting my purpose in coming to this lovely location, the air traffic would make sure I was reminded.
I was taught to avoid routing directly overhead popular VORs and VRPs when flying VFR as it is simply concentrating the traffic into a single place but I haven't thought about in a long time. This was the first time I had a visual.
There was never any question of danger, the separation was more than enough but it did feel a bit like Grand Central Station above my head as various low planes from all directions flew straight towards the VOR.
Despite the traffic, it was a pastoral scene: the golden colours of September all around me, the cattle lowing and a blackbird singing in the distance. I walked closer to the VOR.
It was much bigger than I expected. I stepped around the cow pats and peered up at the phased array antenna. BPK looked both old-fashioned and futuristic, like something I might see in a 1950s sci-fi film.
I walked up to the fencing surrounding the structure and began talking close-up photographs when I realised that the lowing of the cows was getting louder.
The two clumps of cattle I'd seen off in the distance had joined forces and come to deal with the intruder.
Of course, I didn't realise this immediately. I simply thought that they happened to be wandering my way. I took a few more photographs, thinking the juxaposition of the cattle and the VOR would make for an interesting contrast.
The cows kept on coming.
Now. in my defence, I'm very much a city girl. I grew up in Los Angeles where there is not a lot of wildlife to be found, unless you count pigeons. Maybe the occasional lizard.
So I still did not realise that there was an issue. I thought the cows were interesting and I was pleased for the great opportunity for some nature shots. I looked for a clean bit of grass and knelt down, taking a few more photographs before I realised …
… they were coming for me.
I smiled nervously and gave the cows a little wave. This had no effect at all. I realised that perhaps I had outstayed my welcome. I assured them that I was on my way and that I hoped they had a pleasant afternoon.
I turned my back. Mistake. Never turn your back on a herd of guard cows.
I heard the thunder of running cattle behind me.
I spun around and they screeched to a halt, a few yards behind me, rumbling in a melancholy way, pretending that they weren't after me.
I turned to continue walking to the gate. I heard the hooves thud against the grass. I whirled towards them and they stopped again, blinking innocently.
I began walking backwards, keeping an eye on what I now knew were killer attack cattle, ready to defend the VOR against all intruders.
They stumbled forward, slowly closing the gap between us. I was almost surrounded When I felt the cool touch of shade of the trees, I knew I was close to the gate. I turned around and made a run for it.
I had no idea I was capable of hopping a fence in a single bound but I'm glad for it.
The cows clustered at the fence and stared at me. They didn't make a sound but the message was clear:
I assured the guard cattle that I had every intention of respecting fences in the future. Then I edged my way backwards until I was safe on the main road. I made my way back to civilisation, relieved that I had survived my encounter. Only later did I think to check for NATS id badges. I hadn't noticed whether they were attacking with a 30° intercept angle. I wasn't even sure if they were instrument rated!
So that's the story of my afternoon walk in a quiet English village. And people tell me General Aviation is dangerous!]]>
The Boeing 777-300ER, registration 9V-SWH, was operated by Singapore Airlines for scheduled passenger flights.
That day, the Singapore Airlines crew prepared their Boeing 777 for their international flight from Houston, Texas to Moscow. They had arrived from Moscow two days previous. The flight crew consisted of two captains and a senior first officer. One of the captains took the role of Pilot Flying and the senior first officer took the role of Pilot Monitoring.
The flight was departing from Houston's runway 15 left. As they prepared for the flight, they planned their route on the expectation that they would receive ATC clearance for the Standard Instrument Departure route (SID) known as the INDIE ONE RNAV departure.
A Standard Instrument Departure is a procedure used at many busy airports to simplify giving clearances to crew. A SID should offer the flight crew a straight-forward departure via a number of waypoints or fixes which is documented in the airline charts. The SID should be easy to understand and, if possible, limited to one page. ATC will issue a specific SID based on a combination of the destination, the first waypoint in the flight plan and the take-off runway in use.
In the United States, the name of a SID refers to some notable characteristic of the procedure, often a waypoint, along with a single digit which signifies the version of the procedure. There is a waypoint called INDIE near the airport and this particular SID routed the aircraft north-north-east away from the airport via this waypoint. It was the first revision of that route (ONE) and the flight-crew would follow the beacons using area navigation (RNAV). If you were to fly out of Houston today following the SID, you would be given INDIE FOUR as there have now been three revisions to the INDIE SID.
A SID must have a textual description. In the Jeppesen charts, which were the charts that the crew was using, there was a route description followed by a pictorial version of the SID showing tracks and distances.
The text read as follows:
|Climb heading 087° to 600′, EXPECT RADAR vectors to RENNK.
|Climb heading 149° to 600′, EXPECT RADAR vectors to RENNK
|Climb heading 267° to 600′, EXPECT RADAR vectors to RENNK.
|Climb heading 329° to 600′, EXPECT RADAR vectors to RENNK
|From RENNK on track 016° to COLET, then on track 025° to SUSHI, then on track 026° to INDIE, then on transition. MAINTAIN 4000′ or as assigned by ATC. EXPECT filed altitude 10 minutes after departure.
If you are wondering about that waypoint called SUSHI, well, Houston has a number of interestingly named waypoints, which are only restricted in that they must be five letters, easy to pronounce and not similarly named to any other waypoints in the general area. Houston waypoints include SSLAM and DUUNK, as well as TQELA, WORUM, CRVZA, CARNE and QUESO. I have to admit, I'm not sure that CRVZA fits the bill of being easy to say if you can't guess the inspiration!
Looking at INDIE ONE RNAV, the flight crew needs to travel via the following waypoints: RENNK, COLET, SUSHI and INDIE. At INDIE, they would be cleared to follow their filed flight plan navigation.
In any event, the instructions are clear: if you are departing from 15L, you climb heading 149° to 600 feet, and you should expect ATC to offer you radar vectors to the waypoint called RENNK. At RENNK you should turn north to 016° until COLET, then 025° to SUSHI, then 026° to INDIE. You must maintain 4,000 feet or the altitude assigned to you by ATC with the clearance. ATC should clear you for your cruising altitude around ten minutes after departure. On this day, the flight crew's initial cruising altitude was Flight Level 310 (31,000 feet).
The captain, as pilot flying, conducted a departure briefing with the Pilot Monitoring. The second captain followed the briefing. Each pilot had an Electronic Flight Bag (EFB), a tablet holding flight management information, and each EFB included a copy of the Jeppesen charts.
This was the first time that any of the crew had flown the INDIE ONE RNAV departure. The captain read the first line of the "Routing" section and then scrolled to the picture at the right of the chart. He zoomed in to check the track and distances. He ended his briefing without zooming back out or scrolling back to the routing section.
The Mode Control Panel (MCP) controls the advanced autopilot systems and related systems. It has many different modes (hence the name) to allow the flight crew to select which parts of the flight should be controlled automatically. Depending on the mode and settings, the MCP will instruct the autopilot to hold a specific altitude or to change altitudes at a specific rate. The flight crew use it to establish altitudes, speeds and climb/descent profiles.
As the captain concluded his briefing, he stated that there was no altitude restrictions.
The flight crew expected that Air Traffic Control would give them some intermediate altitude to level off at before they were cleared to FL310. The captain said later that as he didn't see any intermediate altitude on the SID chart, he thought that ATC would give him one later. If ATC did not give him an intermediate altitude, he planned to ask them. However, he never mentioned his plan to ask ATC to the Pilot Monitoring, who later might have reminded him to ask.
The Flight Deck Preparation – Before Start checklist calls for the assigned altitude or SID limit altitude to be set in the altitude window on the Mode Control Panel.
The captain set the altitude window on the Mode Control Panel to FL310 (31,000 feet), the initial cruising altitude, which he described as the "next best thing as there was no other altitude to set".
The Pilot Monitoring received an ATC departure clearance to Moscow, "via INDIE ONE RNAV departure, TPAKK transition, climb via SID."
As they departed on runway 15L, the Pilot Monitoring contacted ATC. "Singapore 61. Take up heading of 020 passing 2,500 feet." This means that the aircraft was at that moment climbing through 2,500 feet. Generally, the call is accompanied by a statement of the altitude that the aircraft was climbing to, for example "passing 2,500 feet to FL310". In fact, the Singapore Airlines Flight Crew Training Manual is clear that pilots should state both the passing altitude and the assigned altitude in their initial contact with a radar departure frequency. In this case, the Pilot Monitoring did not ask what altitude they were cleared to for the departure and he did not include the set altitude of FL310 in his call.
As they were climbing through 5,600 feet, an alert sounded in the cockpit: TRAFFIC, TRAFFIC!
A Traffic Collision Avoidance System (TCAS) is installed into all modern commercial aircraft. TCAS interrogates the transponders of all nearby aircraft, receiving their altitude and distance. It uses this information to alert the flight crew of nearby aircraft. In the first instance, it will alert with a traffic advisory (TA). The flight crew are not (yet) expected to perform avoidance manoeuvres in response to a TA. The purpose of the TA is to make the flight crew aware that there is the possibility of a conflict, which gives the flight crew a chance to locate the other aircraft visually and prepare for an evasive manoeuvre if needed.
The Traffic Alert and Collision Avoidance System had generated a traffic advisory (TA).
An air traffic controller contacted the flight crew at the same time and urgently instructed them to descend to 5,000 feet. A conflicting aircraft had been cleared to descend to 6,000 feet and the two aircraft no longer had the 1,000 feet of vertical separation required.
The captain disconnected the autopilot and manually initiated a descent.
If the TCAS determines that there is a real risk of collision and, if the other aircraft is also TCAS-equipped, the TCAS will send a coordination signal to the other aircraft in order to resolve the encounter and then broadcast a resolution advisory (RA) in the cockpit.
In this way, the evasive manoeuvres are coordinated: one TCAS system will select an "upward sense RA" (instructing the pilot to climb) and the coordination signal to the second TCAS means that the second system will select a "downward sense RA" (instructing the pilot to descend).
Generally, the RA per aircraft is chosen that the aircraft with the higher altitude is advised to climb and the aircraft at the lower altitude is advised to descend, thus immediately increasing the vertical separation between them. However, in rare instances, the best way to separate the aircraft includes the two aircraft crossing altitude. In this instance, the higher aircraft was already descending fast and the Singapore Airlines 777 had been climbing. So the TCAS resolution was for the Singapore Airlines 777 to continue to climb, although it meant that they would cross altitudes.
The RA in the cockpit reflected this so that the flight crew would be aware: CLIMB, CROSSING, CLIMB! CLIMB, CROSSING, CLIMB!
Under FAA rules, the flight crew are expected to follow the resolution advisory "unless doing so would jeopardize the safe operation of the flight or the flightcrew can ensure separation with the help of definitive visual acquisition of the aircraft causing the RA". The worst case scenario is when one aircraft follows the advisory and the other aircraft disregards it and does the opposite, which means that the aircraft, already at risk of collision, are heading towards each other.
That's what happened in this instance. The conflicting aircraft received the resolution advisory DESCEND, CROSSING, DESCEND! so it continued its descent, expecting the other aircraft to climb. The Singapore Airlines Captain, however, continued his descent as well.
They were lucky. A second resolution advisory came in, instructing the flight crew to level off. The aircraft was still descending. Eight seconds later, the TCAS sounded that the conflict had been avoided with the message Clear of conflict. The aircraft started to level off. The resolution advisory episode lasted 27 seconds and standard vertical separation of 1,000 feet was restored in less than ten seconds.
The flight crew reported to ATC that they were clear of conflict. The captain reconnected the autopilot at which point the aircraft resumed its ascent. ATC immediately contacted the crew to ask why they were climbing, as the flight's last instruction had been to descend to 5,000 feet.
The crew had forgotten that the MCP altitude window was set to FL310. The first officer, not doing very well in his role as Pilot Monitoring, changed the setting to 5,000 feet. The aircraft descended again and then maintained the assigned altitude of 5,000 feet.
The second captain in the cockpit spoke up, asking if ATC had assigned an altitude when they gave the flight its departure clearance. The first officer remembered, correctly, that no specific altitude had been assigned. The controller had cleared them to "climb via SID".
If a Standard Instrument Departure contains a published altitude restriction or top altitude, then ATC will clear a flight to "climb via SID", which means to comply with the published procedure. This is new phraseology in the US but Singapore Airlines had informed their crews about the procedures and done training on Standard Instrument Departures as a part of their simulator sessions.
The second captain pulled up his copy of the Jeppesen chart. He read it aloud to the captain and the first officer: "MAINTAIN 4,000 FT or as assigned by ATC." All three of them had missed the altitude restriction during the departure briefing.
The captain had scrolled and zoomed in to a specific part of the chart without ever taking the time to read the Routing section, which included the altitude restriction. The first officer should have been monitoring the briefing but he didn't notice the altitude restriction either, nor did the second captain. This is a clear failure of crew resource management (CRM) in the cockpit.
The flight crew did notice that there was no intermediate altitude to level off before being cleared to the final cruising altitude. However, they never discussed this. No one commented when the captain set FL310 on the MCP altitude window. The pilot monitoring never asked the question when speaking to the controller and he didn't specify the altitude they were climbing to when he made the initial call. If he'd followed standard operating procedure, the controller would have stopped the climb at 4,000 feet, keeping the aircraft out of the way of the descending traffic.
When the controller saw the conflict and instructed the crew to descend to 5,000 feet, no one in the cockpit set the new altitude in the MCP. None of the flight crew noticed that it was still set to FL310 and once they had dealt with the conflicting traffic, they all simply left the aircraft to begin another unauthorised climb. It wasn't until ATC directly asked the flight crew why they were climbing that anyone in the cockpit paid any attention to the problem at all.
Finally, there's the issue that the flight crew did not comply with the TCAS resolution advisory. In interviews after the incident, the flight crew all confirmed that they understood that resolution advisories must be complied with even if they are in conflict with ATC instructions. The captain said that he had experienced resolution advisories before but had never heard the CLIMB, CROSSING, CLIMB advisory. Both the first officer and the second captain said they'd never heard a resolution advisory in actual flight before. The lack of familiarity might be why the captain continued his descent and the other two did not argue. In response to this incident, Singapore Airlines has incorporated more demanding TCAS resolution advisory scenarios in their simulator recurrent training programme, including scenarios where there are conflicting instructions from ATC to the RA commands and specific scenarios where the Pilot Flying is not following standard operating procedures and the Pilot Monitoring is expected to challenge the Pilot Flying or even take over the controls. The airline also issued circulars to remind flight crews to be aware of altitude restrictions as indicated on the SID charts and to check with ATC if there is any doubt as to what the intermediate altitude should be.
The US Federal Aviation Authority has also responded to this incident. The RNAV SIDs, including the INDIE procedure (which is now currently revision four and had the altitude restriction raised to 16,000 feet) have been amended to always show the top altitude in a box at the top centre of the chart.
As a result of these actions by the airline operator and the aviation authority, the AAIB of Singapore ended their report with no safety recommendations. Everything was already in progress.
I'm impressed that they took the time to put together an incident report simply for the learning experience that it provides.]]>
That morning, the pilot arrived at the airport at around 07:30 local time. He was well-rested and had no medical issues that might have affected his operation of the aircraft. His medical certificate had expired but when he was examined a few weeks later, there was no issue with a renewal.
He wore polarised sunglasses, unaware that both the Australian and US aviation authorities do not recommend polarised lenses when flying. Although they reduce reflected glare from horizontal surfaces, they can also mask the "sparkle" of light reflecting off shiny surfaces.
His aircraft was a Maule M-5, popularly known as the Lunar Rocket. It's an American four-seater high-wing tail-wheel monoplane with a 235-horsepower engine. The pilot flew the M-5 several times a month.
The aircraft was hangared at Casino Airport in New South Wales, Australia. The pilot completed his pre-flight inspection: all was well with the plane. He then flew to Lismore airport to refuel.
The pilot planned to fly to Bonshaw, about 175 kilometres west of Casino, to visit a family member. He had arranged to pick up a work colleague at Murwillumbah who would accompany him for the flight to Bonshaw. At the last minute, they arranged for the colleague's 11-year-old daughter to join them on the pleasure flight.
They departed Murwillumbah with the pilot sat in the front-left seat, his colleague in the front-right seat and the daughter in the rear passenger seat. The pilot helped her to adjust and fasten her seat belt through the rear cabin door, which is on the right of the aircraft. The pilot and front passenger seat each had a three-point seat belt with lap and shoulder restraints. The rear seats were two-point seat belts providing lap restraint only. At the time when the Maule M-5 was manufactured, shoulder restrains were not required for rear passenger seats.
The colleague has no recollection of the pilot briefing them about the use of seat belts but he understood that they were expected to keep the seat belts fastened throughout the flight.
The three of them departed Murwillumbah to the southwest shortly after 09:00. Initially, the pilot planned to fly to Bonshaw via Tenterfield. Once en-route, however, he changed his mind as they encountered strong headwinds and a lowering cloud base over the mountains. They landed at Tenterfield Aerodrome and the pilot discussed the issue with his passengers. He decided to track back east towards Ballina and take them to look at the Clarence River along the way.
The weather improved. As they arrived at the Clarence River, the pilot descended to 800-1,000 feet above the ground. He tracked south towards a section of the river that he was familiar with, an area that he thought was called "The Cascades". He scanned for power lines as he flew, spotting one which had been marked with high visibility markers.
They were just north of Baryulgil when he recognised the area he was looking for. He turned north and descended to tree-top height to follow the river back the way they had come. By now, there were only broken clouds in the sky and visibility was good. The pilot said that there was only a slight ripple on the water from the wind and the flying conditions were generally smooth. believes that he was flying along the river at about 100 knots (185 km/h).
An eyewitness who was about 5 kilometres north of the Cascades on the western bank of the river saw the aircraft. It was some time between 10:30 and 11:00. The witness noticed that the aircraft appeared to be flying at "normal speed" but very low. This would have been noticeable as an aircraft in normal flight must keep to a minimum specified height unless there are unavoidable reasons to fly lower or if the aircraft and pilot are approved for specific low-flying operations (for example search and rescue).
From the ATSB report:
Specialised training and endorsements are required to conduct approved low-flying operations. This training includes the relevant operating techniques and procedures to safely operate in a low-level environment, the procedures to follow prior to descending to commence low-flying operations, and identifying the types of ground-based infrastructure frequently associated with hazards such as powerlines. This includes power poles and the cleared easement that often exists in the immediate vicinity of a powerline.
In fact, the ATSB have collected data on the numerous low-flying accidents which they have investigated, of which a significant number both involved wirestrikes and proved fatal to the pilot and/or passengers. Of these, many were the result of unauthorised and unnecessary low-flying, where there was no operational reason for the pilot to be flying so close to the ground. They released what I'm sure is a riveting publication entitled Avoidable Accidents No. 1 – Low-level flying in 2010, which discusses seven accidents, of which only one had survivors. The second in the series, Avoidable Accidents No. 2 — Wirestrikes involving known wires: a manageable aerial agricultural hazard deals specifically with strategies developed to help agricultural pilots manage the ongoing risk of wirestrikes during spraying operations. And I know you'll be thrilled to hear that there's another half dozen in the series, although the rest don't deal with low flying. My favourite title is Starved and exhausted: Fuel management aviation accidents.
The pilot was almost certainly aware of the restrictions. In Australia, the aircraft must be 1,000 feet above any city or populous area and 500 feet over the terrain or obstacles on that terrain in any other area.The pilot did not hold a low-flying approval and he had not received any low flying training. In this case, he should have been flying at least 500 feet above the trees, not at "tree-top height".
They continued to track the river heading north.
They encountered a sharp westerly bend and the pilot pulled up, climbing to about 400-500 feet above the ground. Then he made a spur-of-the-moment decision to descend back down to tree-top height and fly further north along the river, although this included a section of the river that he was less familiar with. After the bend in the river, the west bank of the river was slightly higher than the eastern bank.
As he descended back to tree-top height, still banking left to follow the bend in the river, the pilot saw wires immediately ahead.
There were two power poles, one on each side of the river, holding two galvanized steel cables, each containing three wound strands of 2.75mm diameter wire, spanning the 665 metres across the river. They carried 11kV of electricity.
There was no aerodrome in the area and no expectation of low flying. The Australian standard only recommends the permanent marking for overhead cables that exceed a height of 90 metres (295 feet ).
But these cables were only 16 metres (53 feet) above the waterline on the eastern bank and 25 metres (82 feet) on the western bank. They did not require permanent marking. They were only about 6mm (¼") in diameter and had become weathered and dull grey.
By the time the pilot saw them, it was much too late.
The left wing of the Maule M-5 struck the wires at two different points. The cables cut through the structure of the wing's outboard leading edge, the mid-section leading edge and the wing support strut.
The cables did not break, although the power poles were damaged and a significant amount of cable was dislodged from the poles. A high-voltage protection device about three kilometres away detected a fault at 11:02 and isolated the power.
The pilot lost control of the aircraft and it crashed into the river. The windscreen shattered. The right wing folded rearwards, blocking the cabin door.
The aircraft came to rest upside-down, a short distance from the powerlines. The cockpit was inverted, fully submerged and flooded.
As the first cable struck the left wing, the nose yawed violently, so that the second cable struck the leading edge inboard of the first strike. As the aircraft impacted the water upside-down, the water flooded the cabin. Still reeling from the impact, the occupants needed to escape
The occupants must have been terribly disoriented
The pilot was bruised across his left shoulder and both hips, consistent with the three-point seat belt. The passenger suffered serious injuries in the initial impact and both had bad chemical burns from the aviation fuel. The pilot was able to release his seatbelt and escaped through the forward-left cockpit door. The front-seat passenger also escaped the flooded cockpit, exiting through the forward-right cockpit door. The rear-seat passenger was still in the submerged cabin.
The pilot could not open the rear cabin door to get the rear passenger out, eventually managing to drag her out through a cockpit door.
The pilot and her father were unable to resuscitate her. She had died in the impact, breaking her neck.
The pilot trekked to a nearby property to find help although it took hours for emergency services to get through. The front-seat passenger was winched to an ambulance helicopter and flown to Lismore Base Hospital. The pilot was taken by ambulance.
The Northern Star wrote about the incident:
"After a painstaking operation lasting all day, the plane was finally dragged from its resting place and towed upstream to a waiting truck at about 5pm. The job started about 10am from Yates Crossing – a shallow causeway about 3 km upstream – where a flat-bottomed SES boat borrowed from Lismore was launched into the Clarence to venture downstream to the crash site.
If he had been trained in low-level flying, the pilot might have noticed the powerline easement through the nearby scrub, or the the power poles close to each river bank.
The ATSB concludes with the following:
From the evidence available, the following findings are made in relation to the wirestrike involving a Maule M-5 aircraft, registered VH-HOG, which occurred 50 km west south west of Casino, New South Wales on 12 April 2014. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
- Contributing factors
- The pilot made a spur of the moment decision to fly along an unfamiliar section of a river at very low level and collided with a powerline, which resulted in a loss of aircraft control and uncontrolled ditching.
- Other factors that increased risk
- The pilot did not hold any approval to conduct low flying, nor had they received training to identify hazards or in the operating techniques for flight close to the ground.
- Other findings
- The powerline was not fitted with visual warning markers, nor was there a requirement for such markers in accordance with the relevant Australian Standard.
The final report was released on the 12th of April, 2014. The pilot of the aircraft was charged with manslaughter, recklessly inflicting grievous bodily harm and endangering the life of another flying below 500-feet. In April 2016, he was sentenced to 15-months suspended jail sentence for reckless flying, having been acquitted of manslaughter. The front-seat passenger, the girl's father, said in court that he wished that he had died with her that day.
A tragedy in every way.]]>
The question was whether to land downwind on a foggy runway in icing conditions or whether to circle to land. The circle to land could have meant that the crew would not have time to have a meal. The captain and the flight engineer make their priorities clear and when the co-pilot expresses concern about the approach, the flight engineer puts him in his place. "What's the difference between a duck and a co-pilot? The duck can fly."
|First Officer
|Want me to fly today?
|No Response
|First Officer
|What's the glide slope there John?
|Well, we know where we are … we'll be alright
|Flight Engineer
|Don't you worry, the fox is gonna have it wired.
|First Officer
|I hope so.
|No problem.
|First Officer
|This a little faster than you normally fly this, John?
|Oh yeah, but it's nice and smooth. We're gonna get in right on time, maybe a little ahead of time. We got it made.
|First Officer
|Sure hope so.
|Flight Engineer
|You know John, what's the difference between a duck and a co-pilot?
|What is that?
|Flight Engineer
|A duck can fly.
|Well said.
|First Officer
|Seems like there's a bit of tail wind up here, John.
|Yeah, we're savin gas …help us get in a couple of minutes early too.
|First Officer
|John, you're just a little below the MDA (maximum descent altitude) here.
|Yeah, we'll take care of it here.
|First Officer
|This is a little too high.
|Yeah, gear down.
|First Officer
|You really look awfully high.
|15 degree flaps … 25 on the flaps.
|First Officer
|John, you're really high …you're gonna need 40 on the flaps here to get this thing down. I don't think you're gonna make it John, if you don't get this sucker on the ground.
|Flight Engineer
|Get it down, John.
|First Officer
|I don't think you're gonna make it. I don't think you're gonna make it.
|We're going around. Oh darn.
|Flight Engineer
|130, 140 knots.
|First Officer
|It isn't gonna stop John. We're not gonna make it John. Great John. I told you. …Geez…
Then there is the sound of impact on voice recorder.
The unprofessional "banter" in the cockpit and the utter disregard with which the captain treats his first officer's concerns really show the importance of good Cockpit Resource Management (CRM). This is something we know a lot more about now but in 1976, the focus on CRM was just beginning.
The following is directly from the December 1976 NTSB accident report
The Safety Board believes that all flight crew members, and most particularly the second-in-command, should be more outspoken in advising the pilot-in-command when they believe that the flight is being conducted in a non-standard, careless or dangerous manner. Such constructive advice could prompt the pilot-in-command to reassess his procedures. Similarly, pilots-in-command should foster an atmosphere in the cockpit which permits constructive advice and positive recommendations for change where safety may be involved.
The safety board has previously recognized the need for improved guidelines regarding the circumstances and manner in which a flight crew member should take affirmative action and has urged that copilots strengthen their sense of responsibility in adhering to prescribed procedures and safe practicies. The Board again urges airline management and pilots' organizations to reexamine the relationship between the captain and the flight crew members with a view towards formulating an effective enunciation of responsibilities in circumstances where the aircraft is being operated unsafely.
The reenactment shows how terrible CRM was forty years ago, with the Captain cutting the first officer off and then the flight engineer putting him down. The first officer clearly recognised that the approach wasn't stabilised and said so repeatedly but the captain was not interested in his help. I have to say, from a modern perspective, I'm a bit miffed that the investigation report complains that the second-in-command (the first officer) should be more outspoken.
These days, of course, he'd be fully correct in taking control from the captain, nevermind "constructive advice"!
The captain's faulty judgement in initiating a go-around after he was committed to a full stop landing following an excessively long and fast touchdown from an unstabilized approach.
Contributing to the accident was the pilot's unprofessional decision to abandon the precision approach.
This Christmas Card from the Aviator Website made me smile, so please consider it my Just-In-Time Christmas card to you!
I won't be around next week either, so I'll see you in the New Year!
I'm expecting 2017 to be fantastic.]]>


text:
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I see these nearly everyday from my back yard, photo of which I just pointed and shot. I am not a photographer
keith kimbaross melbourne ross sunset
Beautiful shot. very colorful. I think you are becoming a photographer.
Wow this is stunning…make a great painting.,…lucky you to see this that often…cheers
Turned out great!
I like your position! If I saw this every day….!
Really gorgeous image – I love your composition!
Something different from you KBR… And the artist is still shining through… A beautifully composed work
looks so pretty
What a beautiful sight to see everyday! Well captured. Thanks for your comment too.
Stunning photograph!
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subset: commoncrawl