Modern Accident Theory,Investigations and Aviation


#1

All true, but note the modern approach to accident investigation had a lot of input from the pilots themselves. The industry at one time was happy enough to blame them for everything, seeing as how they were dead and weren’t going to complain in person.


“The Captains of Thor — What Really Caused the Loss of the SS El Faro” by Robert Frump
#2

I don’t recall seeing anything like this before, do you have an example? Accident investigation and flying seem like two separate areas of expertise.


#3

“The Go Team’s immediate boss is the Investigator-in-Charge (IIC), a senior investigator with years of NTSB and industry experience. Each investigator is a specialist responsible for a clearly defined portion of the accident investigation.”

“Under direction of the IIC, each of these NTSB investigators heads what is called a “working group” in one area of expertise. Each is, in effect, a subcommittee of the overall investigating team. The groups are staffed by representatives of the “parties” to the investigation (see the next section - The Party System) - the Federal Aviation Administration, the airline, the pilots’ and flight attendants’ unions, airframe and engine manufacturers, and the like. Pilots would assist the operations group …”

https://www.ntsb.gov/investigations/process/Pages/default.aspx


#4

Some stories of early accident investigation and pilot involvement appear in Ernest K. Gann’s “Fate is the Hunter,” arguably one of the best books about flying ever written.

Cheers,

Earl


#5

Hugh Patrick Ruffell Smith of “NASA Technical Memorandum #7848" was a physician and pilot.


#6

Gann was a sailor as well:


The American aviator, filmmaker and novelist Ernest K. Gann purchased the Albatross in 1954, re-rigged her as a brigantine, and she cruised the Pacific for three years. According to Charles Gieg (The Last Voyage of the Albatross), the Albatross survived a tsunami in Hawaii during this time. She was also used in the 1958 film Twilight for the Gods (starring Rock Hudson and Arthur Kennedy), whose script and the underlying novel by the same title were written by the Albatross’ owner Gann.

This ship was sold later on and operated as a school ship until she sank. This was made into a movie called White Squall.


#7

Pilot unions pushed very hard against “pilot error - case closed” investigations back in the day. Airplane manufacturers and airlines were both happy to blame the dead guy that wasn’t around to defend himself.
I’ll give one example: The then-new 727 was having landing accidents. What would happen was with full flaps and spoilers out along with the landing gear down, if airspeed was allowed to decay too far the engines could not spool up in time to save the airplane at low altitudes. This was new to pilots used to flying DC-3s and DC-6s, piston engines have instant full power available and jets do not. Sure it was the pilots fault, they shouldn’t have slowed down that much. But it also was a trap waiting for the next guy and the next guy after that. So eventually 727s were modified so that the engine idle speed was increased with full flaps.


#8

I misunderstood your post. I took it to mean that pilots had made significant contributions to modern accident theory, something I have not come across.

In order for the pilot unions to push for alternative explanations to simple pilot error those explanations, the framework to understand, have to have already been created by someone.


#9

That is a bit disingenuous. The cause of those crashes was due to pilots doing “chop and drop” approaches which the 727 excelled at due to Boeing’s amazing triple slotted flaps which made the 727 a winner in short haul routes to airports that were not available to larger and - faster landing - 4 engine aircraft.

The record is very clear on each of the accidents, they set up a 2000 foot per minute descent and started recovery too late. There was no mystery to anyone about the time to spool up the engines, jet engines were not new technology to 3-holer drivers, the awesome descent rate and lower landing speed was.

A review of the 727 accident history clearly shows what led to the rash of landing accidents.


#10

This article: Air Safety: The “Deadly” Boeing 727 doesn’t mention any input from pilot or the unions but from the public and congress.

This was the fix:

In response, the FAA required the airlines to make changes to their training procedures and their flight manuals to stress the importance of stabilized approaches.

The landing accidents ended.


#11

This thread about the NTSB and aviation is interesting. My impression is that the NTSB does a good job with aviation accidents and with equipment/engineering failures on ships, but they are weak on ship maneuvering issues.


#12

Summary of NTSB findings on the Jul 2017 incident at San Francisco, where an Air Canada flight almost landed on an occupied taxiway instead of the runway.

Aviation Herald

As is often the case in professional sites, some of the comments are interesting.

Official NTSB Report here.

Cheers,

Earl


#13

It appears that Boeing has now subscribed to the Airbus theory of flight control systems, which is that the robot is smarter than the pilot. The problem is that when the robot gets an erroneous sensor reading it acts without the pilot’s knowledge. In the case of the Lion Air 737 Max, this apparently resulted in an uncommanded pitch-down into the deck, and 189 people died. It is alleged that pilots were not notified of the existence of this feature:

https://arstechnica.com/information-technology/2018/11/indonesia-737-crash-caused-by-safety-feature-change-pilots-werent-told-of/

Detailed treatment here:

https://avherald.com/h?article=4bf90724&opt=0

Earl


#14

I should have saved the link, the article I read about this said the recommended action in this case is for the pilot to pull back as hard as he can. This while the stall alarm is sounding.


#15

This is going to make for a very interesting accident report:

Both Engines Shut Down on 787

Damn lucky they had 8K feet of runway to use when something that absolutely positively cannot happen … happens.

Earl


split this topic #16

17 posts were split to a new topic: Tall Ship Safety in Modern Times


#17

What wasn’t mentioned was how much fuel was onboard once they landed. Hope they weren’t flying on fumes.


#18

A subsequent inspection revealed no faults with the engines but the website says a service bulletin issued by Boeing warned that mishandling the thrust reverse controls can cause the Thrust Control Malfunction Accommodation system, which guards against inadvertent asymmetrical high thrust situations, to activate. The bulletin reportedly says problem can occur if the thrust reversers are deployed too soon after touchdown.

https://samchui.com/2019/01/19/ana-boeing-787-dual-engine-shutdown-upon-landing/#.XEz38s17mUm


#19

True, and yes I also read the bulletin but as no determination has yet to be made I figured they should start with the simple potential causes first. As they were not able to restart the engines, did anyone bother to check the levels in the fuel tanks.


#20

My first thought was the pilot had performed the weekly fire-test;

From CALLBACK = It could never happen to me. ASRS

■ Enroute … I started to perform my required “Weekly Checks” Checklist, going through item by item. The checklist calls for the weekly fire-test; the first item is to pull both fire handles. As I pulled them I noticed a sudden loss of performance on both engines. My gauges indicated that both of them flamed out. I pushed the handles back and started to troubleshoot. I determined that my right engine was still operational. Meanwhile, the aircraft was losing altitude but it was under control. I advised ATC about my situation and they told me there was an airport ten miles away along my route.… Being a new pilot on this airplane, under these circumstances I decided the best course of action was to secure the inoperative engine and land as soon as possible. Having my right engine operational, I was able to stabilize the airplane and started my VFR descent. I completed my Emergency Checklist and then performed a safe single engine landing.

I am a new pilot on this airplane, having just completed my upgrade training one week ago. During the flight training, this part of the checklist was never mentioned and the checklist was not available in the training aircraft. On the checklist, the fire test appears to be among the inflight test items. This situation was the result of me following the checklist that I believed I was supposed to perform. Had I received the proper training, I am sure this situation could have been avoided.