Lessons from Dubai

The 3 August Emirates Boeing 777 crash at Dubai may have happened a while ago, but the man/machine interface implications are so complex it still has human factors experts’ heads spinning.

Following an uneventful final approach to runway 12L the aircraft hit the runway with its gear in the retraction cycle, slid to a halt on its belly and burst into flames. All on board got out alive before the fire destroyed the fuselage, but a firefighter was killed by a fuel tank explosion.

That’s a surprising outcome for a serviceable aeroplane carrying out a normal landing at its home base.

So what happened?

Flight EK521 was inbound from Thiruvananthapuram, India carrying 282 passengers and 18 crew. The ambient temperature was high, nearly 50degC, and there was a windshear warning on all runways, but this did not cite high winds or powerful gusts. Probably the wind was swinging around under the influence of vertical air currents generated by intense surface heating combined with the coastal effect.

When the 777 had about 5nm to go on approach to 12L ATC cleared it to land and told the crew the surface wind was 340deg/11kt. That’s a touchdown-zone tailwind.

As the aircraft descended through 1,100ft on final approach the aircraft was also registering an airborne tailwind. It persisted almost all the way down.

But apart from the tailwind on the aircraft’s approach, the descent was uneventful until just before touchdown. At that point the tailwind switched to a headwind, adding about 20kt to the 777’s airspeed.

Around 5sec after the flare the right gear touched down about 1,100m beyond the threshold, and 3sec after that both main gear touchdown switches were made and the RAAS (runway awareness advisory system) voiced the alert “long landing, long landing”.

Questions still remain about exactly what happened next on the flightdeck. Who did what, and why?

The United Arab Emirates General Civil Aviation Authority has released some factual information about weather and aircraft performance, but the investigators are expected to take another three months or so to ready their final report.

Meanwhile from what the GCAA has released, we know that the captain was the pilot flying. He disconnected the autopilot at about 900ft on approach but left the autothrottle in. When he began the flare at 35ft AGL the throttles retarded to idle, and within about 10sec both touchdown switches had been made.

What happened next, or at least why it happened, is difficult to work out.

Witnesses say the aircraft “bounced” from the first touchdown. But the crew was attempting a go-around – possibly prompted by the “long landing” alert mentioned earlier – so the “bounce” may have been the result of the crew pulling the nose up for a go-around.

Some 4sec after the warning the aircraft was airborne again, the crew reduced the flap setting to 20deg, and 2sec later selected the gear up, both acts part of a go-around drill.

But the throttle levers remained at idle.

About 5sec after the aircraft had become airborne the tower, noticing the apparent intention,  cleared the aircraft straight ahead to 4,000ft, and the crew read that back. Then the first officer called “check speed”, the throttle levers were moved from idle to fully forward, and the autothrust transitioned from idle mode to thrust mode.

Unfortunately the increasing engine power arrived too late to prevent the aircraft sinking back onto the runway with its gear almost fully up. It slid on its belly for 800m before coming to rest with the right engine detached and a fire under that wing.

The GCAA interim report doesn’t mention whether or not the crew attempted to trigger go-around power by selecting the TO/GA (take-off/go-around) switches at the time of the go-around decision, but it appends a page from the flight crew operating manual about autothrust modes.  It contains this sentence: “The TO/GA switches are inhibited when on the ground and enabled again when in the air for a go around or touch and go.”

This situation raises questions galore. In a go-around situation the drill is to select power first, then set the appropriate flap, then register a positive rate of climb and pull the gear up. Maybe the crew thought activating TO/GA was enough, but they didn’t monitor engine power, throttle lever movement or rate of climb before retracting the gear.

This is basic stuff, so what’s going on here?

Are we witnessing the actions of a crew rendered insensitive by automation, or de-skilled by the same thing? Or is this an event involving mode-confusion because of the complexity of modern aircraft and their smart control systems?

The industry is going through a crisis of confidence in pilot training. The doubt arises from increasing numbers of accidents that began with a non-critical fault or distraction and result in the pilots becoming startled and not acting as they had been trained to do.

Behind it all is the fact that today’s aircraft and their systems are impressive and reliable, but ultra-complex. Meanwhile the basic approach to pilot training is the much the same at was in the pre-digital era.

Emirates is in the vanguard of modern attitudes toward evidence-based training, but maybe the fundamentals are set before pilots reach the line.

Finally, pilots are never really trained to operate the digital systems they use all the time at work. They just learn that on the job.

Let’s go back a bit to the quote from the Emirates 777 FCOM: “The TO/GA switches are inhibited when on the ground and enabled again when in the air for a go around or touch and go.”

I bet the pilots never tried that in the simulator.

Modern aeroplanes now are rather like personal computers in the relationship pilots have with them: most people are skillful users of tablets or laptops for routine tasks, but never have a chance to try out their full capabilities, most of which would rarely be needed. But if things go wrong or something unusual happens, the user is often out of his depth.

The Royal Aeronautical Society is hosting its two-day International Flight Crew Training Conference in London next week. This is one of the subjects that will be examined there.

MH370 search extended into August

The Australian Transport Safety Bureau, coordinating the multinational search for flight MH370, the missing Malaysia Airlines Boeing 777, had planned to complete the mission this month.

But winter weather has slowed down the sea-bed search for the main aircraft wreckage.

The ATSB says: “It is now anticipated it may take until around August to complete the 120,000 square kilometres, but this will be influenced by weather conditions over the coming months, which may worsen. More than 105,000 square kilometres of the seafloor have been searched so far. In the event the aircraft is found and accessible, Australia, Malaysia and the People’s Republic of China have agreed to plans for recovery activities, including securing all the evidence necessary for the accident investigation.”

The ATSB statement continues: “Consistent with the undertaking given by the Governments of Australia, Malaysia and the PRC in April last year, 120,000 square kilometres will be thoroughly searched. In the absence of credible new information that leads to the identification of a specific location of the aircraft, Governments have agreed that there will be no further expansion of the search area.”

The investigators have now examined half a dozen pieces of floating wreckage that washed up on beaches, mostly on the shores of islands in the western Indian Ocean or off south-eastern Africa. The have all been determined either to be definitely or almost certainly from the missing Malaysia 777. They include a flaperon, a wing flap section a flap track fairing, a part from a horizontal stabiliser, a piece of engine cowling, and a section of laminate material from the cabin trim of the aircraft.

So the aircraft is in the Indian Ocean, but if it is not found in the area where the sparse data the authorities have at their disposal suggest it should be, they have decided that the search will stop there.

MH370: the search nears its end

If the multinational team searching for missing Malaysia Airlines Boeing 777 flight MH370 does not find the wreck by mid-2016, the search will stop and the loss of the flight will remain a mystery.

Termination at that point, when the designated remaining search area has been covered, has been agreed by the Malaysian, Chinese and Australian partners in the search effort.

The search has suffered numerous snags recently, but the Australian Transport Safety Bureau and its Chinese and Malaysian partners have emphasised their commitment to search another 35,000 square kilometres of the ocean floor before they abandon the attempt. The team, says the ATSB, is also committed to MH370’s recovery, if found.

Ironically, one of the snags that has delayed the latest stage of the search process has proven once again that the technology the team is using will definitely identify the MH370 wreck if they look in the right place. When one of the deep-tow sonar vehicles recently hit a sea-bed mountain and was severed from its mother-ship Fugro Discovery, deployment of a remotely operated vehicle quickly found it, relayed a clear picture of it to the crew, and established the connections that enabled its recovery.

lost-towfish-on-ocean-floor

The area already searched amounts to 85,000 sq km, the entire search pattern based on the “7th arc”, the linear location indicated by the last satellite signal received from the missing aircraft.

Fugro search latest

The extended 35,000 sq km search continues to use the 7th arc as the prime indicator of where the aircraft could be, but further to the south-west around the arc.

If the Joint Agency Coordination Centre search assumptions, which tally with several independent calculations of where MH370 could be, are indeed correct, the wreck will be found within approximately the next six months.

If not, MH370 will become one of the great travel mysteries of all time.

Latest phase of MH370 search gets interesting

On 3 November the Australian Transport Safety Bureau resumed the deep sea search for the lost Malaysia Airlines flight MH370 [but see update at end of story].

Refuelled, replenished and ready to go, the ATSB’s survey ship Fugro Discovery has arrived on station once more in the southern Indian Ocean (see footnote for an update).

For those seeking a reason to be optimistic following a discouraging 20 months of searching the ocean without a result, there is definite cause for renewed hope this time.

Since it began the search the ATSB has been scrupulously methodical, scanning the ocean floor within a long, slender curved rectangle that encompassed what became known as the “7th arc”. This is a long line on the earth’s surface established by vestigial radio responses from the fatal aircraft to Inmarsat satellites just as it was running out of fuel.

Theoretically the Boeing 777 could have come down anywhere close to it, but working with the aircraft’s last radar position the ATSB identified the arc sector where the aircraft could realistically have come down, and has searched almost all of the identified curve and its close vicinity.

Since it has now trawled almost all the 7th arc’s viable sector and not found the wreckage of MH370, there is not much more to search. Logic says they must be getting close.

But not only logic.

For those who doubted MH370 came down in the sea at all, the fact it did so was established in July when one of its flaperons was washed up on a beach on the Indian Ocean island of La Reunion. This fact was forensically confirmed more recently by the French air accident investigation agency BEA.

But there’s another reason for optimism: on 22 December last year Flightglobal published a mathematical/geometric calculation by Boeing 777 captain Simon Hardy, also a mathematician, which indicates precisely where, according to his calculations, MH370 came down.

The search sector that Fugro Discovery has just begun to trawl encompasses Hardy’s predicted position for MH370. His recent refinements to the aircraft’s final descent profile put it at S39 22′ 46″ E087 06′ 20″. He adds, however, that depending on how long the aircraft floated, the main wreck could have drifted some time before sinking, and even during the descent could have travelled laterally. At this location he would expect to see mainly “some moveable aerodynamic surfaces, like the missing part of the flaperon that we already have, and parts of slats and flaps and maybe even the RAT [ram air turbine].”

This could be said to be the last chance for the search under present estimated criteria, because 777 performance dictates that the aircraft could not have flown further than this extreme southern end of the 7th-arc-defined potential ditching area.

Anyone who has published material on the web knows that it may receive praise, but it will certainly receive criticism. The impressive fact about Hardy’s mathematics is that, despite hundreds of thousands of hits on the article containing his calculations, nobody has been able to blow a hole in them.

By 3 December Fugro Discovery expects to have completed the search of the area containing, according to Hardy’s calculations, the wreck of MH370 and the remains of those who went down with it.

Hardy says he says he is excited about the next month’s search, having invested more than a year of mental and emotional energy into working out where MH370 flew, and why. He wants it found.

He’s not alone.

Watch this space for more on MH370.

LATE NEWS: On 5 November Fugro Discovery had to suspend the search and return to Fremantle, Western Australia, according to Australia’s Joint Agency Coordination Centre, because one of the crew developed suspected appendicitis.

UPDATE: Fugro Discovery was due to arrive back in the search area on 3 December.

 

MH17 and the denial option

The Dutch-led international inquiry into the MH17 shootdown has clearly anticipated the organised denial that would follow its publication.

This is evident from the extraordinarily degree of thoroughness in its forensic examination of the wreckage of the Malaysia Airlines Boeing 777.

The inquiry was far more thorough than would have been required simply to confirm that an unidentified missile brought the aircraft down.

But as far as Russia and the eastern Ukrainian rebels are concerned this careful work is irrelevant. They can claim truthfully – although not with honest intent – that the wreckage was not secured, and that it could have been tampered with.

That makes them untouchable in law unless even more detailed evidence is uncovered that proves precisely where the missile was launched from.

Actually, there is a chance that evidence may be found.

But even if it’s not, the care to which the Dutch-led investigation has gone to identify the precise physical damage to the aircraft and chemical traces on the airframe is such that the report has real credibility: it makes clear that a Russian-built Buk missile did to the Malaysia 777 and its passengers and crew what Buk missiles are supposed to do.

The consequence of this report’s credibility is that the credibility of the deniers will be fatally damaged in the eyes of the global community as a whole.

So what else has the world learned as a result of MH17?

The day that MH17 happened the world’s airlines learned that intelligence about the safety of high level airspace is not guaranteed. Ukraine had closed its airspace below 32,000ft in the belief the rebels only had limited-performance weaponry. They were wrong.

ICAO has since set up a system for improving the communication of intelligence about conflict zones to airlines. But they could be wrong too.

So should airlines, from now on, avoid airspace over a zone in which – it is believed – small arms only are being used?…on the grounds that they might be misinformed about that too.

No easy answers here.

 

 

 

La Réunion, that wing flap, and MH370

The wing flap that has drifted ashore in La Réunion on the western side of the Indian Ocean may well have come from the Malaysia Airlines Boeing 777 that flew the ill-fated flight MH370.

But if it really was a part of that aircraft, does it help the search for the main wreckage?

Unfortunately no. It certainly does not mean the wreckage is near La Réunion.

This flap section has been afloat since the aircraft hit the sea on 8 March 2014, a year and four months ago. It has drifted a long way in that time, and tracing it back to its possible origin using a model of the prevailing sea currents and winds would provide such a massive approximation that it would indicate a larger search area than the one the Australian government has already searched, and which it continues to search right now.

The Indian Ocean’s main sea current system flows anti-clockwise, so if the aircraft did indeed crash in the area off the west coast of Australia where the search is taking place, the flap – and possibly other parts – would have been carried north, then westerly, then southerly, which makes La Réunion a plausible location for it to wash up. So the find certainly does not invalidate the present calculations.

Does it tell us anything new about how the aircraft was lost?

Again, unfortunately no. The experts reckon the aircraft had nothing wrong with it, and that it crashed into the sea when it ran out of fuel.

That is because an aircraft that sets off for one destination, makes a U-turn and then flies successfully for hours in the wrong direction while it could be seen on radar, and probably many more hours when it could no longer be seen, had nothing structurally wrong with it.

The favourite explanation from all the major players in the industry is that the disappearance of MH370 was a deliberate act by someone in control of the aircraft. In the light of the Germanwings crash earlier this year, deliberately carried out by the unbalanced copilot, that explanation now has additional credibility with the public.

If the flap is indeed from MH370, the discovery finally lays to rest two theories: sadly but inevitably, those who lost relatives on the flight and were still hoping that the aircraft had safely landed in a remote place, will now be confronted with the reality that the aircraft broke up, probably on impact with the sea; and finally those conspiracy theorists who reckon the CIA hijacked it to Diego Garcia – or anywhere else – are going to have to search their imaginations for an alternative explanation.