Why Are We Here? (The Accident Loss of Control Record) ICAO Loss of Control Symposium May 20-22, 2014 Dennis A. Crider Chief Technical Advisor, Vehicle Simulation National Transportation Safety Board 1
2 LOC Accident / Incident Data Set NTSB LOC data collection Dick Newman (Crew Systems) and Tony Lambregts 2008 paper Frequently quoted NASA Wouldn t it be nice to work together? Broader LOC dataset
3 LOC Accident / Incident Data Set Data Sources Aircraft Accident Reports on DVD (R. Dorsett, 2006) Australian Transport Safety Bureau (ATSB) Aviation Safety Network (ASN) Canadian Transportation Safety Board (TSB) Flightglobal (Ascend Database) French Bureau d'enquêtes et d'analyses pour la sécurité de l'aviation civile (BEA) German Bundesstelle für Flugunfalluntersuchung (BFU) International Civil Aviation Organization (ICAO) Irish Air Accident Investigation Unit (AAIU) National Transportation Safety Board (NTSB) Search Criteria loss-of-control upset unusual attitude stall uncontrolled
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80 LOC by Flight Regime 2500 On-Board Fatalities Events 60 40 20 0 Takeoff Initial Climb Climb Cruise Descent Holding Approach VFR Pattern Events Circling Final Approach Landing Go-around Missed Approach Maneuvering 2000 1500 1000 500 0 On-Board Fatalities 5
6 LOC by Event Factors
Stall Examples Pinnacle Airlines, Flight 3701 Bombardier CL-600-2B19 Aircraft stalled at high altitude Colgan Air Flight 3407 Bombardier DHC-8-400 Stalled on approach to Buffalo
Bank Angle (deg) 80 60 40 20 0-20 -40 Right Left Wheel Right Wheel Roll - left system Roll - right system Right 40 30 20 10 0-10 -20 Wheel (deg) -60-30 Left -80-40 02:54:30 02:54:40 02:54:50 02:55:00 02:55:10 02:55:20 Time (Hr:Min:Sec) Left 8
9 Roll (deg) Buffalo Colgan DHC-8-400 110 100 Right Right 100 90 80 Captain's Wheel 80 Roll 60 70 60 40 50 40 20 30 0 20 10-20 0-40 -10-20 -60-30 -80-40 Left Left -50-100 95520 95530 95540 95550 95560 95570 Upset FDR Time (sec) Wheel (deg)
30 25 FDR Angle of Attack FDR elevator Nose Up -25-20 Angle of Attack (deg) 20 15 10 5 0-5 -15-10 -5 0 5 10 15 Elevator (deg) -10-15 25 02:54:30 02:54:40 02:54:50 02:55:00 02:55:10 02:55:20 Time (Hr:Min:Sec) Nose down 20 10
Control Column (deg) 15 10 5 0 Left Column Right Column Left Angle of Attack Right Angle of Attack Upset 50 45 40 35 30 25 20 15 10 5 Angle of Attack (deg) -5 0 95520 95530 95540 95550 95560 95570 FDR Time (sec) 11
Breaking The Accident Chain Addressing elements in the sequence Train cue recognition Account for human nature Train crews for all cues 12
Precursor Sequence Colgan Air 3407 (2/12/2009) Normal Flight Crew Fatigue / Impairment Loss of Energy State Awareness / Inappropriate Energy Management Stall / Departure Improper / Ineffective Recovery LOC Pinnacle 3701 (10/14/2004) Normal Flight Loss of Energy State Awareness / Inappropriate Energy Management Stall / Departure Improper / Ineffective Recovery Engine failure Ground Impact 13 13
Stall Cues Stick Shaker Ignored Stick Pusher Fought Stick pusher dynamics not recognized Un-commanded Roll Not recognized 14
Icing and Contaminated Airfoils
National Transportation Safety Board Upsets from Stalls due to Icing Saab 340: Eildon Weir, Australia, November 1998 2300-foot altitude loss Saab 340: Albury, Australia, June 2004 40-foot altitude loss Saab 340: San Luis Obispo, CA, USA January 2006 5000-foot altitude loss
Saab 340 Icing Event Comparison Lift Coefficient - C L Albury Eildon Weir American Eagle 3008 No ice lift curve 0 5 10 15 20 Angle of Attack - α (deg) 17
CRJ Icing Event Comparison Fredericton no ice (sim sweep) Baotou no ice (sim sweep) Fredericton Baotou Fredericton Baotou C L 0 5 10 15 20 25 Angle of attack 18
Precursor Sequence Ice Contamination Normal Flight Icing Stall / Departure Improper / Ineffective Recovery LOC 19 19
Stall Cues with Ice Stick Shaker May be after departure Stick Pusher May be after departure Natural stall cues Un-commanded Roll Buffet Stall break 20
Summary Elements of LOC sequences have been identified Stall leading element Need to address multiple points in accident chain for best affect. New training we are outlining this week addresses most LOC factors Some elements may be better addressed by technologies 21
Spatial Distortion In pitch Typical go-around in IMC Acceleration produces illusion of pitch up Pilot pitches down flies into ground In Roll Slow roll develops pilot doesn t feel Then confused when bank angle warning or g s alert to roll but feel level
Atmospheric Disturbance
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LOC by Operation 150 6000 Events 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 Scheduled Airlines Non-Scheduled On-Board Fatalities Events Non-Revenue Operations Executive Transportation 5500 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 On-Board Fatalities 26
Recommendation A-10-22 Require 14 Code of Federal Regulations Part 121, 135 and 91K operators and 14 Code of Federal Regulations Part 142 training centers to develop and conduct training that incorporates stalls that are fully developed; are unexpected; involve autopilot disengagement; and include airplane-specific features such as a reference speeds switch
Recommendation A-10-23 Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators of stick pusherequipped aircraft to provide their pilots with pusher familiarization simulator training.
Recommendation A-10-24 Define and codify minimum simulator model fidelity requirements to support an expanded set of stall recovery training requirements, including recovery from stalls that are fully developed. These simulator fidelity requirements should address areas such as required angle-of-attack and sideslip angle ranges, motion cueing, proof-of-match with post-stall flight test data, and warnings to indicate when the simulator flight envelope has been exceeded.
Public Law 11-216 (sec 208) The Administrator of the Federal Aviation Administration shall conduct a rulemaking proceeding to require part 121 air carriers to provide flight crewmembers with ground training and flight training or flight simulator training A. To recognize and avoid a stall upset of an aircraft or, if not avoided, to recover from the stall;
Recommendation A-11-46 Define and codify minimum simulator model fidelity requirements for aerodynamic degradations resulting from airframe ice accumulation. These requirements should be consistent with performance degradations that the National Transportation Safety Board and other agencies have extracted during the investigations of icing accidents and incidents.
Recommendation A-11-47 Once the simulator model fidelity requirements requested in Safety Recommendation A-11-46 are implemented, require that flight crews of all aircraft certificated for flight in icing conditions be trained in flight training simulators that meet these fidelity requirements. Such simulation training should emphasize the following: (1) cues for recognizing changes in the aircraft s flight characteristics as airframe icing develops; (2) procedures for monitoring and maintaining appropriate airspeeds in icing conditions, including the use of icing airspeed reference indices; and (3) procedures for responding to decaying airspeed situations, stall protection system activation, and early stalls that can occur without stall protection system activation.
Stall Upsets (no icing) Accident Shaker Pusher Break Airborne Express DC-8-63 December 22, 1996 IO IO NR China Airlines Flight 676, A300-622, February 16, 1998 Thai Airways Flight 261, Airbus A310-300, December 11, 1998 Pinnacle Airlines Flight 3701 Bombardier CL-600-2B19, October 14, 2004 United Express Flight 6291 Jetstream 4101, January 7, 1994 Pulkova Flight 612, TU-154M, August 22, 2006 West Caribbean airlines MD-82 near Machiques, Venezuela, August 16, 2005 Continental Connection Flight 3407 Bombardier DHC-8-400, February 12, 2009 IO = Inoperative UK = Unknown NR = Not responded to UK UK UK UK UK UK NR NR NR NR NR UK UK UK UK NR UK NR NR NR NR
Stall Upsets (icing) Accident/Incident Shaker Pusher Break Saab 340A, VH-LPI, Eilden Weir, Victoria, November 11, 1998 ES ES NR Saab 340A, VH-KEQ, Albury, New South Wales Australia, June 18, 2004 Saab 340B, VH-OLM, Bathurst, New South Wales Australia, June 28 2002 American Eagle Flight 3008, Saab 340B+, San Luis Obispo, January 2, 2006 ES ES PR ES ES NR ES ES NR Air Canada Flight 646, Canadair CL-600-2B219, December 16, 1997 -- -- -- Cessna Citation 560, Pueblo, Colorado, February 16, 2005 UK UK UK Comair Flight 3272, Embraer EMB-120RT, January 9, 1997 ES -- NR Skywest Flight 3855, Bombardier CL-600-2B19, January 17, 2004 -- -- -- ComAir Flight 5054, EMB-120, March 19, 2001 NR NR NR Empire Airlines Flight 8284, ATR-42, Lubbock TX, January27, 2009 NR ES NR IO = Inoperative UK = Unknown PR = Proper response NR = Not responded to ES = Early stall