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Wednesday, September 30, 2009

We don't need no stinkin' Rules!

TEB Challenger Crash Photo

Maybe you’ve thought about it.  What will this aircraft actually do?  Unless your primary training included aerobatics, most of your flying to this point has been directed at keeping the coffee in the cup.  Although your instructor may have chided you about obeying the “rules” or staying within the flight envelope, the accident record shows that willful non-compliance is continuing to occur.  Why do pilots behave badly?  According to situational control theory (as described by Dave Huntzinger—former senior principal safety scientist for Boeing) three things are correlated with intentional rule breaking: a reward, a probability of success, and peer acceptance. 

    

     In 2005 a Challenger business jet failed to rotate during the takeoff roll at Teterboro (TEB).  The investigation revealed that the company, along with the pilot, had been concealing the fact that the plane was routinely operated over weight and outside the center of gravity limits. Why? They preferred to buy cheaper fuel (the reward) whenever possible and “tanker it” to avoid higher fuel costs elsewhere.  They had gotten away with it in the past (probability of success), and no one objected to the practice (peer acceptance).  The jet was unable to liftoff prior to reaching the end of the runway, crossed a highway, and embedded itself it a building.  Although no fatalities resulted, the aircraft was destroyed and several people were injured.

 

     Pinnacle3701.jpgThe crew of a Regional Jet was not so lucky in 2004.  During a reposition flight (without passengers or a flight attendant) the pilots decided to push the performance to the maximum.  While attempting to reach the service ceiling of 41,000 feet the crew willfully violated some fundamental rules.  They allowed their aircraft to slow below the published limit—while fully aware of it—and began to encounter the aerodynamic mush associated with a stall.  As the speed decayed, one engine flamed out. The other engine followed.  During the confusion, the internal engine parts stopped rotating and rapidly cooled as a result of the low temperatures at the high altitude.  The rapid contraction of the metals “fused” the engines, making a restart impossible.  With no operating engines, the aircraft descended from 41,000 feet and impacted houses just short of the Jefferson City, Missouri airport.  Both pilots were killed.  What was the perceived reward? It was admission to an “underground club” of company pilots that had accomplished reaching service ceiling in this particular type of jet.  Essentially, bragging rights. I’ve flown this jet and I’ve got to tell you it was a slow climbing brick above 35,000 feet.

 

     The next time you think about pushing the rules just a little—going below minimums, foregoing that required maintenance, flying a GPS approach with an expired database, or another transgression, pause for a minute.  There may be a reward associated with it and a probability of success, but what would your primary instructor say?  SJF.

11:34 am cdt          Comments

Tuesday, September 29, 2009

Glass Cockpit Errors from the ASRS

g1000.jpgAlthough glass cockpits can provide increased situational awareness, the automation induces a unique set of challenges.  The latest version of CALLBACK--the monthly newsletter of NASA's Aviation Safety Reporting System (ASRS)--describes typical difficulties associated with glass cockpit operations. Humans have a tendency to try to use automation to extract the aircraft from an undesired state.  Sometimes the best course of action is to reduce or eliminate the automation until the situation is fully understood.  Actual events as reported by the persons involved can be read here: ASRS 356. SJF.

7:57 am cdt          Comments


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