I was talking to someone about the Northwest Flight 188 – the one where both pilots somehow managed to get so distracted that they missed their destination and did not respond for over an hour. I expressed some indignation that the FAA had revoked the licences of both pilots without waiting for the NTSB report. She wondered what difference that might make – which I found somewhat difficult to explain.

The strength of accident investigations is that it is not simply a blame-allocation exercise. 2008 NTSB statistics for scheduled flights show one accident per million flight hours, no fatalities. One of the reasons that aviation is relatively safe is because every accident is treated seriously, rather than dismissed the moment someone is found who could be held accountable.

The focus over the last few decades has been on how to avoid the same scenario or sequence of events in the future, which is critical.

A very good example of how this works is Canada’s Transportation Safety Board of the Swissair Flight 111 in 1998.

BBC News | 8 September 1998 | Flight 111’s black hole

The first that air traffic controllers heard of the problem was 16 minutes before the crash.

The pilot announced: “Swissair 111 is declaring pan pan pan – we have smoke in the cockpit.”

“Pan pan pan” is the expression used when an emergency is less acute than a mayday signal, which indicates imminent disaster. But the situation rapidly deteriorated.

The pilot suggested landing at Boston, but was told Halifax was closer, so he began heading in that direction.

However, the plane was at an altitude of around 10,000 metres and needed to lose height.

Air traffic controllers also gave the pilot permission to dump at least 30 tons of fuel to land safely to help it land safely.

The pilot’s next words on the radio were that he was declaring an emergency.

“We have to land immediately,” the pilot said, the last words the controller heard from the plane.

Radar signals showed that the airliner began flying off course in a rapidly descending loop over the sea.

Six minutes later, it hit the water.

The easy assumption was that the flight crew were remiss in not declaring an emergency immediately, wasting valuable time.

The flight crew realised there was smoke in the cockpit. They presumed it was a problem with the air conditioning. They looked up the nearest airport with appropriate mechanics and asked for a diversion. The captain went through his checklists of how to respond to smoke in the cockpit. Long story short, by the time they declared an emergency, the captain was out of his seat trying to put out a raging fire, the First Officer was desperately trying to regain control of the aircraft with all the displays failed / failing and the plane crashed into the ocean.

Again, it would be easy to blame the Captain and his first officer: why didn’t they immediately declare an emergency? Why didn’t they immediately focus on getting the plane on the ground and *then* work out where the smoke was coming from?

The investigation cost millions and the Transportation Safety Board of Canada final report wasn’t released until five years later but it identified eleven “causes and contributing factors” which basically showed that the plane itself was unsafe – the initial problem (an unsafe in-flight entertainment system) didn’t trip circuit breakers and the insulation of the plane was flammable. The immediate effects of the investigation included removing flammable insulation material from aircraft.

The investigation concluded that, even if the crew had been immediately aware of the extent of the problem, they never had enough time to save the flight. A small electrical fire lit the insulation and the fire was out of control before the plane could have ever made it to the ground, even if the crew had diverted immediately.

Many changes were made, including better electrical systems and also usage of inflammable materials in planes. However, the report also isolated a specific issue with cockpit training, specifically challenging a presumption that pilots should operate from a best-case scenario.

Pilots live by their checklists which are meant to ensure that best procedures are followed both on the ground and in the air. The flight crew are trained to carry out checks and operations in a specific order, which should be both the safest and most efficient response to the situation. The concept of a checklist has been proven effective but there were some questionable assumptions made in some checklists, especially the standard checklists for Unidentified Smoke on Board.

Most instances of smoke in the plane are benign and it is rare to have an in-flight fire. The training was focused on finding the source and eliminating the problem, rather than treating the situation as a potential serious fire threat until you’ve identified the issue. In most instances, the situation is quickly dealt with in the air but it is incredibly dangerous to presume that will be the case.

Since this accident, the discovery of smoke is treated as a potential in-flight fire (that is, an emergency) until the source is found and the problem eliminated.

The knee-jerk response was “there was an electrical fault and the pilots failed to handle the emergency” whereas the drawn-out and expensive investigation effectively proved that there was a lot more to it than that.

As a result, specific changes were recommended (and taken up) which have helped us to avoid this sequence of events in the future. These changes in themselves would not have saved Swissair Flight 111 but their impact on aviation safety for the future is inestimable.

For more information, read the full accident report: Transportation Safety Board of Canada – AVIATION REPORTS – 1998 – A98H0003

Yesterday, the National Transportation Safety Board issued its final report on the Continental Flight 3407. On 12 February 2009, the plane lost control on approach to Buffalo, New York and crashed into a residential building, killing the crew and all of the passengers as well as a person on the ground.

You can read the full Aircraft Accident Report in PDF format.

In the hearing, the NTSB Chairman stated that the probable cause of the accident was the captain’s inappropriate response to an aerodynamic stall from which the airplane did not recover.

The report makes 25 new recommendations to the FAA and reiterates three previously issued recommendations. The NTSB’s 2010 Most Wanted List already lists two of these: Reduce Accidents and Incidents Caused by Human Fatigue in the Aviation Industry and Improve Crew Resource Management.

Executive Summary from the Report

On February 12, 2009, about 2217 eastern standard time, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121. Night visual meteorological conditions prevailed at the time of the accident.

The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the lowspeed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.

The safety issues discussed in this report focus on strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot training records, airspeed selection procedures, stall training, Federal Aviation Administration (FAA) oversight, flight operational quality assurance programs, use of personal portable electronic devices on the flight deck, the FAA’s use of safety alerts for operators to transmit safety-critical information, and weather information provided to pilots. Safety recommendations concerning these issues are addressed to the FAA.

Primary Issues: Fatigue and Training

Although legally the crew was within flight and duty time requirements, both the pilot and the first officer were likely fatigued.

The airport had a comfortable crew room with couches, recliners and a television but which was not considered adequate for rest before a trip. The EWR regional chief pilot stated that crewmembers were prohibited from using the crew room to sleep overnight.

Nevertheless, the Captain was seen in the crew room that evening and again at 0655 and records show that he logged into the CrewTrac system at 2151, 0310 and 0726.

The First Officer did not have accommodation either and stated to another pilot that one of the couches in the crew room “had her name on it.”

She sent a text message at 1305 stating she’d had a 6-hour nap on a recliner and felt good. Just over half an hour before take-off, however, she stated, “this is one of those times that if I felt like this when I was at home there’s no way I would have come all the way out here. … if I call in sick now I’ve got to put myself in a hotel until I feel better”.

Flight 3407’s communications with Buffalo was placed on YouTube courtesy of LiveATC.net.

The flight was uneventful (with the exception of a few recorded yawns) but as the pilots began to notice the ice forming on the windshield, they began “a discussion unrelated to their flying duties”. The full transcript of the Cockpit Voice Recorder is on the NTSB site as a PDF or you can read the final five minutes on WNYmedia.net.

14 CFR Part 121.542(a-c) states: “No flight crewmember may perform any duties during a critical phase of flight not required for the safe operation of the aircraft” where critical phases include flight operations below 10,000 feet.

At the time, Flight 3407 was descending to 4,000 feet.

The descent progressed as normal with the various duties and checklists used; however no one noticed as the airspeed dropped below safe levels.

At 2216:27.4, the CVR recorded a sound similar to the stick shaker. The CVR also recorded a sound similar to the autopilot disconnect horn, which repeated until the end of the recording. FDR data showed that, when the autopilot disengaged, the airplane was at an airspeed of 131 knots.

The plane has two stall protection systems: a stick shaker and a stick pusher. The stick shaker vibrates both control columns as “an aural and tactile warning of an impending stall.” An aircraft performance study done after the accident showed that the airplane’s airspeed was “below the minimum approach speed in icing conditions for about 8 seconds before stick shaker activation and below the lowspeed cue from the initial stick shaker activation to the end of the flight”.

FDR data also showed that, while engine power was increasing, the airplane pitched up; rolled to the left, reaching a roll angle of 45° left wing down; and then rolled to the right. As the airplane rolled to the right through wings level, the stick pusher activated (about 2216:34), and flaps 0 was selected.

The stick pusher system kicks in after the plane is already in an aerodynamic stall. It “positions the elevator to 2° nose down and provides a nose-down input to both control columns” in order to encourage the pilots to push forward on the control and regain airspeed to come out of the stall.

When the NTSB looked into stall training on the Q400, they found that there was no demonstration of the stick pusher system in the standard training syllabus at the time of the accident. One check airman stated that “most of the pilots who were shown the pusher in the simulator would try to recover by overriding the pusher”.

About 2216:37, the first officer told the captain that she had put the flaps up. FDR data confirmed that the flaps had begun to retract by 2216:38; at that time, the airplane’s airspeed was about 100 knots. FDR data also showed that the roll angle reached 105° right wing down before the airplane began to roll back to the left and the stick pusher activated a second time (about 2216:40). At the time, the airplane’s pitch angle was -1°.

About 2216:42, the CVR recorded the captain making a grunting sound. FDR data showed that the roll angle had reached about 35° left wing down before the airplane began to roll again to the right. Afterward, the first officer asked whether she should put the landing gear up, and the captain stated “gear up” and an expletive. The airplane’s pitch and roll angles had reached about 25° airplane nose down and 100° right wing down, respectively, when the airplane entered a steep descent. The stick pusher activated a third time (about 2216:50). FDR data showed that the flaps were fully retracted about 2216:52. About the same time, the CVR recorded the captain stating, “we’re down,” and a sound of a thump. The airplane impacted a single-family home (where the ground fatality occurred), and a postcrash fire ensued. The CVR recording ended about 2216:54.

The NTSB have produced an animated reconstruction of the last 2 minutes of the accident:

You can also see the video in context on the NTSB Public Hearing Update from May, 2009.

Analysis

The 68-page analysis section covers the following information:

• the accident sequence, including the minimal effect of icing on the airplane’s performance, the flight crew’s failure to monitor airspeed in relation to the rising position of the low-speed cue, and the captain’s incorrect actions in response to the stall warning;
• strategies to prevent flight crew monitoring failures, including explicit pilot training for monitoring and standard operating procedures that promote effective monitoring;
• pilot professionalism, including captain leadership skills and adherence to sterile cockpit and standard operating procedures
• fatigue, including commuting pilots’ use of company crew rooms as rest facilities and industry efforts to mitigate fatigue;
• remedial training for poor-performing pilots, the need for detailed documentation of pilot training and checking events and retention of such records, and the information to be included in an air carrier’s assessment of a pilot applicant;
• flight crew procedures and training to ensure that selected airspeeds are matched to the position of a ref speeds switch or similar device;

The NTSB chairman, Deborah A. P. Hersman, summarises as follows:

The final report includes 46 separate findings and a determination that the probable cause of the accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were the (1) flight crew’s failure to monitor airspeed in relation to the rising position of the low-speed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions. The final report also makes 25 new recommendations to the FAA and reiterates 3 previously issued recommendations. The recommendations cover a wide range of safety issues that were factors in this accident, including pilot training and fatigue.

And if you’ve made it this far, you probably should read the full Aircraft Accident Report on the NTSB website.

Yesterday morning, Joseph Andrew Stack flew his single-engine plane into the Echelon building in North Austin, Texas. He left Georgetown airfield and flew directly to the location – low and at full speed – before crashing into the building.

It was quickly confirmed that this was intentional, a controlled flight into a building which housed an IRS centre with almost 200 employees. The impact of the plane was described as an earthquake or an explosion. Thirteen employees were treated for injuries related to the resulting fire, with two admitted into hospital. The remains of three people have been found in the building.
Stack owned the plane, a Piper Cherokee Dakota, a single-engine, four-seater plane similar to the one pictured. The Dakota has four fuel tanks and holds 84 US gallons (318 litres) of fuel. He could have easily reached his destination with only one tank of AVgas, thus it is possible that the other three tanks could have held liquid accelerants in order to keep the fires burning.

Although Stack’s webpage has been removed, copies of his suicide manifesto which was posted to his company website that day, are available all over the Internet. At six pages, it is long and detailed – some say rambling – but makes it clear that the building he flew into was very carefully chosen.

Stack explains, in abstract terms, the issues he has had with the IRS over the years. Yahoo! News offers some detail. “According to California state records, Stack had a troubled business history, twice starting software companies in California that ultimately were suspended by the state’s tax board, one in 2000, the other in 2004. Also, his first wife filed for bankruptcy in 1999, listing a debt to the IRS of nearly $126,000.”

Certainly it is clear that Stack felt he had been treated unfairly and in his manifesto he comes to the conclusion that “violence not only is the answer, it is the only answer.”

The Manifesto Of Austin Texas Crash Pilot Joseph Andrew Stack

I saw it written once that the definition of insanity is repeating the same process over and over and expecting the outcome to suddenly be different. I am finally ready to stop this insanity. Well, Mr. Big Brother IRS man, let’s try something different; take my pound of flesh and sleep well.

Earlier that day, Stack appears to have set his house on fire. Austin paper the Statesman reports:

Neighbors said they heard a loud noise that sounded like a car crash at about 9:15 a.m. and soon saw flames coming from house.

Neighbor Elbert Hutchins said he ran to the house while calling 911 and saw flames coming out of an upstairs window. Soon he saw a woman and a girl drive up in a car.

Neighbors believe that was Stack’s wife and daughter, who is about 12 years old.

His neighbour, Chuck Watkins, filmed the flames:

Stack then went to Georgetown airfield to his plane. Many news reports have cited that he did not have a flight plan – I’m not sure why you would want to notify the FAA of your intentions to fly into a building or quite how that flight plan would look. However, it’s worth understanding that there is no reason to fly a flightplan for a local VFR flight – it would have been more surprising if he had filed one.

12160.ORG state that this recording is the final transmissions to Georgetown Tower from N2889D, in MP3 format. The pilot was cleared for take-off and then stated he was heading southbound from Georgetown. The controller approved a frequency change and the pilot signed off. There’s been no information that he spoke to Austin control after this point.

Local news station KXAN have put footage of the scene on YouTube for viewing.

The National Transportation Safety Board are expected to announce a press briefing today.

One question I didn’t deal with in my Frequently Asked Questions was whether the Saratoga has oxygen. The plane does have an oxygen tank and you can plug masks in on the ceiling to take it in directly. We’ve never used the supplemental oxygen other than to test to make sure it’s really there. The plane is not pressurised and we very rarely fly high enough that it is an issue.

What is the issue? Hypoxia: oxygen deficiency. The altitude at which pilots can be affected varies based on a number of issues including health, age and training.

Hypoxia (medical) – Wikipedia, the free encyclopedia

Symptoms of generalized hypoxia depend on its severity and acceleration of onset. In the case of altitude sickness, where hypoxia develops gradually, the symptoms include headaches, fatigue, shortness of breath, a feeling of euphoria and nausea.

The onset of hypoxia is often masked by the euphoria – you have a general sense of well-being and can be apathetic to the fact that something has gone wrong. You will feel confused and disoriented. Your time of useful consciousness is limited – the time in which you remain capable of making sensible decisions and correcting the issue.

A recent and well-known hypoxia incident was the crash of Helios Flight 522, in which the flight crew were incapacitated due to hypoxia. The plane flew into a holding pattern over Athen’s International Airport and after the sixth loop, two Hellenic Air Force F16s flew to intercept. One of the F16 pilots was able to see into the cockpit: the Captain’s seat was vacant and someone was slumped over the controls in the First Officer’s seat.

You can read the full details on the Final Accident Report (in English). There were, as always, a series of factors that led to the final crisis and the detailed analysis makes for interesting, albeit chilling, reading.

However, hypoxia is not just an issue for high-level jets. As a part of my UK PPL, I was told to start considering hypoxia symptoms whenever I flew over 8,000 feet and to actively be monitoring the risk at all times over 10,000 feet. The FAA has a specific regulations for flights over 12,500 feet. The flight crew must have supplemental oxygen available and use it when the flight is at a cabin altitude pressure of 12,500 to 14,000 feet for more than 30 minutes. Above 14,000 feet the flight crew must use supplemental oxygen for the entire duration of the flight at that altitude.

The passengers aren’t required to have their own oxygen supply until the cabin pressure altitude is above 15,000 feet as they hopefully are not making critical decisions. Personally, I’d ask for my fair share on any flight over 12,000.

A tragic VFR case in 2003 involved a PA-28 flying over the Rockies. You can read the full accident report from the NTSB – again a number of issues came into play. The pilot was delayed due to bad weather and changed her planned routing to avoid further weather. She requested an altitude of 15,500 feet. The PA-28 was unpressurised and did not carry supplementary oxygen. Radar data indicates that the pilot flew above 12,500 feet for 2 hours, 17 minutes, above 14,000 feet for 1 hour, 49 minutes, and at approximately 16,000 feet for an estimated 45 minutes.

While flying above 14,000 feet, from 18:42 to 20:31, the pilot received numerous heading corrections from ARTCC, some of them by as much as 70 degrees. On one occasion, the pilot reported that she was over Montrose, Colorado, and the ARTCC informed her that she was over Telluride, Colorado. The pilot responded with “roger that, I appreciate it, can’t see a darn thing out here.” The radio communication between the pilot and ARTCC became increasing difficult and erratic. Many other aircraft assisted in relaying information between the two.

The radar data showed that she began to descend rapidly (1,077 feet per minute) and five minutes later made a mayday call – possibly the result of the increased air pressure as she returned to below 10,000 feet. She had come to her senses too late.

At 20:35, the pilot transmitted the following: “Denver radio, mayday, mayday, I’ve got myself in (unintelligible).” At 20:37, a Federal Express flight 1290, flying in the area, said “yeah, we just picked up a strong Emergency Locator Transmitter (ELT) signal on 121.5, it’s gone now.” The ELT signal was not received again. On the morning of January 25, 2003, at approximately 09:30, a rancher observed a column of smoke on his land. Upon investigation, he discovered the downed airplane.

Her flight plan was never viable. She shouldn’t have been at that altitude without supplementary oxygen but also she’d planned a 4-hour flight based on having 8-hours of fuel in the plane. In all actuality, with the most efficient fuel burn, the flight required 5 hours and 25 minutes – in an aircraft with 5 hours maximum endurance.

In addition, she had a strong headwind. She lost total engine power due to fuel starvation and she was not in a mental state even to realise the issue until the plane was rushing towards the ground.

Gradual hypoxia is insidious as it is difficult to realise that there is an issue, clearly she flew for hours without ever realising that she was beginning to suffer from oxygen deprivation. However, at least there is a chance of noticing. A sudden change of air pressure resulting in reduced oxygen has much more dramatic effects, even at levels where we’d be able to survive a short amount of time under other circumstances.

The AOPA article Luck Saves the Day, describes an instance of sudden onset of hypoxia, miraculously with no fatalities.

The pilot and two passengers were in a Cessna 421B, a pressurized cabin-class twin. They were warned of isolated, severe thunderstorms in the area but it seemed trivial to route around them. However, the pilot relied on the radar and spotted a gap, 15-20 miles wide, that would allow direct route that was “clear on the scope”. Clouds were visible ahead but due to the position of the sun, they appeared white.

The pilot very quickly found himself in a hailstorm, which can be masked on radar, painting “a far more benign picture than what is actually in front of the aircraft”.

Then, a piece of ice the size of a golf ball broke the windshield.

The only possible procedure at this point is to use supplementary oxygen immediately (presuming you have it) and descend. The time of useful consciousness at 19,000 feet is severely limited. The sudden onset due to the broken windshield is much more severe than generalised hypoxia.

The pilot was still reacting to the windshield, ducking into his seat and the passenger (a VFR pilot) took control to attempt to keep the wings level. And then their time was up.

The passenger stated that he “never felt dizzy or lightheaded.” Nevertheless, the 421 crash-landed in a field with all occupants unconscious. The passenger in the backseat did not remember the crash. “When I came around, all was quiet.”

You can read the full article on AOPA Online.

May we all be so lucky on the day the flight goes wrong…

I found this on an aviation forum and I just can’t stop staring at the photographs.

N9368D is a Piper Supercub registered in Anchorage.

Apparently, the owner went on a fishing trip and left the catch in the plane.

A bear smelled the food and tore the plane apart to get to it. I suppose a Piper is easier to open than a tin can…

Take a look at the horizontal stabilizer. Wow.

So, the story goes that the Alaskan pilot had 2 new tires, three cases of speed tape and several rolls of cellophane delivered to the site and promptly repaired his plane so that he could fly it home.

If you look closely, you can just about see that he wrote the registration on the side with a ball-point pen.

Would you get in?

Update: Alaska Dispatch say they got the whole story from the pilot’s father: An appetite for revenge

This Press Advisory just in. The bold text is my addition.

NTSB Advisory
National Transportation Safety Board
Washington, DC 20594
August 17, 2009

NTSB RELIEVES AIR TRAFFIC CONTROLLERS GROUP OF PARTY STATUS IN HUDSON RIVER MIDAIR COLLISION INVESTIGATION

The National Transportation Safety Board today removed the National Air Traffic Controllers Association as a party to its investigation into the August 8 midair collision of two aircraft over the Hudson River that killed all 9 persons aboard.

Under the Safety Board’s procedures, organizations and agencies are invited to participate in NTSB investigations if they can provide technical expertise. At the outset of the investigation, the organizations sign an agreement to abide by NTSB party rules. Among the rules parties agree to is that they will not reveal investigative information being learned through that process, nor publicly comment on it. Parties agree that only the NTSB will release factual information on the progress of the investigation and discuss the progress of the investigation with the public, including the news media.

On Friday, August 14, NATCA convened a press conference to discuss information released earlier that day by the NTSB. The organization was subsequently reminded of its responsibilities as a party to the investigation. This morning, NATCA issued a press release again discussing the information released, and conducted another press conference this afternoon.

Patrick Forrey, NATCA President, was informed today that his organization has been removed as a party to the investigation.

In light of conflicting interpretations of factual information released by the NTSB on Friday, the Board takes this opportunity to address the issue of the Teterboro controller’s interaction with the accident airplane in the minutes before the collision:

According to preliminary data provided to the Safety Board by the Federal Aviation Administration, the controller cleared the accident airplane for departure at 11:48:30. The first radar target for the airplane was detected at 11:49:55, at about 300 feet. The controller initiated a non-business-related telephone conversation at 11:50:31. Prior to the Teterboro controller instructing the pilot to contact Newark Tower at 1152:20, there were several aircraft in the Hudson River Class B Exclusion Area in the vicinity of the airplane, some of which were potential traffic conflicts. These were detected by radar and displayed on the controller’s scope in Teterboro tower. The Teterboro controller did not alert the airplane pilot to this traffic prior to instructing him to change his radio frequency and contact Newark. The accident helicopter was not visible on the Teterboro controller’s radar scope at 1152:20; it did appear on radar 7 seconds later – at approximately 400 feet.

At 1152:54, 20 seconds prior to the collision, the radar data processing system detected a conflict between the accident airplane and the accident helicopter, which set off aural alarms and caused a “conflict alert” indication to appear on the radar displays at both Teterboro and Newark towers. The controller terminated his non-business-related telephone call at 11:53:13. The collision occurred at 11:53:14.

As the Safety Board stated in its media release on Friday, the role that air traffic control might have played in this accident will be determined by the NTSB as the investigation progresses. The Board is waiting for more detailed air traffic control-related data from the Federal Aviation Administration. Any opinions rendered at this time are speculative and premature.

“Although we appreciate the technical expertise our parties provide during the course of an investigation,” NTSB Chairman Deborah A.P. Hersman said, “it is counterproductive when an organization breaches the party agreement and publicly interprets or comments on factual information generated by that investigation. Our rules are set up precisely to avoid the prospect of each party offering their slant on the information. I regret that we have had to remove NATCA from the investigation.”

###

NTSB Press Contact:

Ted Lopatkiewicz
(202) 314-6100
lopatt@ntsb.gov

No details from the NTSB yet but here is the media information available at the moment.

9 Dead After Copter and Plane Collide Over Hudson – NYTimes.com

The cause of the accident was under investigation. But what perhaps thousands of people out on a crystalline summer day saw from both sides of the Hudson was a stunning, low-altitude accident in which the plane rolled up and into the helicopter, striking with a crack like thunder as the helicopter’s blades and one of the plane’s wings flew off, and then both aircraft fell and vanished into the river.

Fatal midair crash over Hudson raises questions – USATODAY.com

At an afternoon briefing Monday, Hersman said an eight-day NTSB survey of the river corridor before the collision had counted about 225 aircraft flying within a 3-mile radius of the collision site each day.

The airspace where many of these tour craft fly is below 1,100 feet, where pilots are largely free to choose their own routes, radioing their positions periodically but not communicating regularly with air traffic controllers.

Hersman said air traffic controllers at Teterboro (New Jersey) Airport told the pilot of the small plane to switch radio frequencies so controllers at Newark (New Jersey) Airport could communicate with him. She said Newark controllers never made contact with the pilot before the crash.

Hudson Crash Bares Friction Between Safety Board and F.A.A. – NYTimes.com

She said the agency was considering an immediate reaction to the Hudson crash: making it mandatory for pilots in the uncontrolled air corridor to announce their location and intentions on a common radio frequency whose use is now voluntary.

“We welcome their taking some action, but we certainly don’t feel it goes far enough, said Robert M. Gottheim, district manager for Congressman Jerrold L. Nadler, a Democrat who represents the West Side of Manhattan.

Pilots caution against tighter rules in wake of tragedy – The Connecticut Post Online

“We would not support closing the corridor because there are less onerous ways to address safety concerns,” Chris Dancy said.

Dancy speaks for the Aircraft Owners and Pilots Association, an industry group that represents the general aviation industry. General aviation refers to private pilots.

Among those measures could be to separate helicopters and fixed-wing aircraft, Dancy said. But the AOPA will wait until the National Transportation Safety Board completes its work and will then analyze its report.

“In this particular case what needs to be done is to give the NTSB the time to investigate,” Dancy said. “Then we as an organization are ready to look at all the alternatives to improve safety.”

The Associated Press: Plane pilot in Hudson collision had clean record

Altman had a clean record and was instrument-rated, meaning he was trained to fly in poor weather if necessary, according to the Federal Aviation Administration. His medical clearance was up to date, the only restriction being he needed glasses for nearsightedness.

“He was perfectly legal and qualified to fly that aircraft,” FAA spokesman Jim Peters said Monday.

FAA suspends 2 air traffic controllers over Hudson crash – CNN.com

A source with knowledge of the investigation said the controller was on the phone with his girlfriend “after he cleared the pilot for takeoff; he was still on the phone at the time of the crash.”

In addition, “the supervisor was not present in the building as required,” Brown said.

“While we have no reason to believe at this time that these actions contributed to the accident, this kind of conduct is unacceptable, and we have placed the employees on administrative leave and have begun disciplinary proceedings,” she said.

Engine Failure After Take-Off, commonly referred to as EFATO, is one of the most frightening events that can happen to a pilot. A recent incident hit International headlines when US Airways flight 1549 landed in the Hudson after a sudden loss of engine power. Every pilot has been trained to deal with EFATO but the reality of the situation has little in common with the practice runs when you have a competent instructor at your side with his hand on the throttle.

I don’t actually want to have to experience that particular reality but I do want to be as prepared as I possibly can should I have to deal with an engine problem close to the ground. One way of doing this is to read the details of real failures and how the pilots dealt with getting their planes onto the ground.

Manny Peralta, a commercial pilot in Australia, wrote about his experience for AirCentre Australia with useful detail and a summary of lessons learnt. I found it particularly interesting to read about how he ended up fighting his own instincts.
Low Level Engine Failure After Takeoff:

For me, the most frightening thought just after an EFATO, is the overpowering urge to turn back despite the high risk of a stall and spin. It seems that fear and self-preservation, can overcome logical thinking and training. I only just managed to fight off the urge to turn back, by shouting to myself repeatedly over the intercom: “don’t turn back! For a split second, I also remembered a friend, who died when he apparently tried to turn back after an EFATO, from the same runway that I took off from that day. Being a young family man, a fiery death for me was definitely not an option!

The FLYER forums had a recent post about this emergency landing in which the pilot gives an emotional and honest description of writing off a plane and his recollections of the sequence of events.
A recount of my EFATO 4th November 2008:

The noise reverberates through every inch of my body; not a bang as such, but a metallic noise that I can most liken to a flak burst from a world war two movie: the chilling sound of an engine that has just died. Time seems to stop and yet accelerate tremendously all at once. The heavy whine as the engine drops from full power to nothing, the propeller windmilling uselessly in the airflow… No, no, bloody hell no! This cannot be happening! I glance in disbelief at the throttle and mixture levers, which I know that I am both holding fully forward anyway. Sheer terror grips me; my God we’re only at 200ft and we’re going to crash! I feel panic overwhelming me, then: Get a f*cking grip man!!!

This blog post about an EFATO in South Africa is not from the pilot’s perspective but nevertheless it is full of detail of the successful landing of a twin missing an engine.
Soaring: EFATO:

He then spoke to Nationwide who said to him we have an emergency. We have lost hydraulics and partial disintegration of our right engine. The traffic controller said it is not part disintegration. The whole engine is lying on the runway.

This article for dealing with an engine failure is aimed at twins but as a single engine pilot I still found it full of interesting details and important advice.
Pelican’s Perch #4:Engine Failure!:

Many GA pilots are confused over just how to handle an engine failure. What is most important? What to do first? What should the step-by-step procedure be? Every book written that I’ve seen is different, every CFI has her own variation, and when the unfortunate Applicant goes up for the Multi-Engine check ride, the Inspector/Examiner is very likely to say “No, no, no, that’s all wrong, here’s what I want to see,” and the poor Applicant learns yet another way to do it during the check ride. There are variations between instructors and check pilots within the same organizations, and very large differences between different companies, even when operating the same type of equipment.

Even highly-experienced pilots will get into heated arguments over this one. My two favorite ways to start a barfight are to ask “What makes lift?” and “What are the best memory items for an engine failure?” Then I sit back, listen quietly, and leave when it gets bloody. Of course, pilots no longer hang out in bars, so this is much less fun these days.

I also enjoyed reading this argument turned discussion of turning back after an EFATO and why it is so easy to get it wrong.
The Pilot’s Lounge #121: The Big Silence After Takeoff:

The horizon seems higher. The ground is nearer — dramatically so. In a turn, the ground is a powerfully close blur of color that is a stunningly integral part of your peripheral vision: It’s right there, bigger than life and, by gawd, it’s going by fast. That’s something one doesn’t experience in normal flight, even when maneuvering steeply at altitude. Up there, the ground is a more remote, abstract concept and it seems to be moving slowly. Down low, with the ground moving fast, and with the groundspeed increasing while the airplane holds a constant speed near the stall and turns from upwind to downwind, even a pilot with low-altitude experience feels the very powerful sensation of the groundspeed increase and tends to unconsciously pull back on the yoke to keep the speed under control (and, sadly, despite all training, to try to keep from going down). What makes it even worse is that, when the nose must be pushed down hard to accelerate to get speed for the flare, all the pilot sees is a windshield full of ground. It takes a lot of training to accept that visual picture long enough to get enough speed to avoid a stall. When experienced for the first time under the massive stress of an engine failure, it is no surprise that the end is almost preordained even for high-time pilots: a stall, with the future existence of the pilot and passengers telescoped to mere seconds.

This Airbum article includes sensible points about making the decision whether to abort a take-off to avoid that low-level engine failure altogether.
Aborts, Go-Arounds And Other Common Sense:

Unfortunately, there are no hard and fast rules here because every situation is going to be different. However, a couple of concepts do apply. For instance, it’s better to run off the end of the runway with brakes locked and the tires smoking at 20 mph or slide off the end with a curled prop and the gear up than it is to stagger off the end at 100 feet and have the engine quite completely. Yeah, it’s expensive to land and run off the end of the runway but it is almost never fatal. Come down from even 100 feet and chances are, at the very least, you’ll be injured. If you abort and run off the end there will always be the nagging question, “would it have kept running?” If it quits at 100 feet, the question may be “will I ever walk again and did my passengers survive?”

And if that fails, then I’ll be glad if I can remember the points in their article about controlling an unplanned collision with the ground.
Crash Survivability:

Many injuries are the result of getting the airplane too slow while still too far off the ground. The airplane didn’t stall, but the nose was brought up while the airplane was too high and the vertical rate of descent had plenty of time to skyrocket. There is a lot of structure in an airplane to absorb forward impact, but very little that works in the vertical direction.

Rule one in crashing: Fight the urge to pull. Maintain best glide speed until flaring just before impact. Try to make the landing as nearly normal as possible.

And finally, a short clip showing a Tigermoth landing in a field directly after take-off and running into a common field hazard:

Shortly after takeoff, when at approximately 200 ft above ground level, the engine speed dropped to idle. The pilot lowered the nose of the aircraft to maintain flying speed and turned right to land in a suitable field. The aircraft cleared a sturdy barbed wire fence but, as the aircraft touched down, a cow ran under and struck the left wing. The cow was apparently uninjured. Investigation of the aircraft by a local engineer found corrosion debris in the carburettor

Everyone’s heard about the A320 that successfully landed in the Hudson and almost everyone seems to have an opinion. Finding the insightful points of view can take a little bit more time. Here’s my collection of the most interesting pieces on the Web that deal with the flight and its aftermath.

Yesterday, new footage of the plane in the river was released:
1010 WINS New York’s #1 source for local news, traffic and weather – Security Cam. Shows Plane’s Hudson River Crash Landing

The Con Ed tape, which company spokesman Chris Olert said was recorded by a security camera at a steam plant on Manhattan’s west side, begins with the plane hitting the river and skidding to a halt in a spray of water and steam at 3:25 p.m.

Within a minute, an emergency slide folds from the plane’s right side, and the first passengers and crew members appear on the wings where dozens gathered to await rescue. One or two people are visible in the water, which authorities said was a dangerous 41 degrees at the time.

Photographs of the airplane recovery:
AOPA Pilot Blog: Reporting Points » Blog Archive » Fishing for an A320

Flight Sim view of landing in the Hudson:
BBC NEWS | Special Reports | A pilot’s eye view of NY crash flight

The achievement of Captain Chesley Sullenberger in getting his plane down safely has astonished pilots and aviation experts.

US Airways letter to the passengers:
What US Airways is Doing for The Passengers of Flight 1549 >> The Cranky Flier – Airlines|Airports|Air Travel Blog

On behalf of all of us at US Airways, we hope that you have returned home and are resting and recovering following the evacuation of Flight 1549 on January 15, 2009. We are extremely grateful that our crew used their combined experience and training to safely land and evacuate all of the passengers onboard this flight. We also thank you, as many of you also played a role in ensuring a quick and safe exit.

Some pertinent points regarding the media coverage:
Ditching of US Air 1549 – Few clarification | Plastic Pilot

It is interesting to see that the co-pilot, Jeff Skiles, was the flying pilot on this leg, but Captain Sullenberger decided to take over after the bird strike. Taking this decision and its acceptation by the co-pilot reveals excellent CRM. Swapping the flying pilot and non-flying pilot roles under such circumstances requires in-depth training and conviction that the CRM principles are good.

Aviatrix objects to the terminology:
Cockpit Conversation: Safety Is Not a Miracle

And then, having interviewed everyone available and panned around everyone’s cellphone photographs, for lack of anything else to say about it, the networks and headline writers started calling it ‘a miracle,’ and making me yell at the TV. Don’t get me wrong: this landing wasn’t a routine occurrence. It’s a stunning, inspiring event. It’s good that no one died. It’s also good that no one died on the hundreds of flights US Airways conducted that day without incident. But I think it’s somewhat insulting to attribute any of that safe flying to divine intervention.

A pilot steps through the sequence of events:
Flight Level 390: Dual Engine Flame Out, continued…

The crew sees the geese, then feels the impact forces. Flight deck alarms are going off, one after the other. You can feel the aircraft decelerating. Get the nose down, fast! Maintain airspeed!What is happening here? A sick feeling washes over you from head to toe.

A bit of a light-hearted view:
Do birds fly in clouds ? – PPRuNe Forums

Owls are night rated and equipped (and oh so silent) In fact night aerobatic. One passed me walking dogs half an hour ago at head height pulled up and virtually stall turned onto a branch. Very skilful!

A more serious answer:
Flight Without Horizon References in European Starlings

Radar studies (Griffin 1972) suggest that some birds can maintain straight and level flight under completely overcast conditions, but birds flying within clouds may produce erratic tracks, suggesting disorientation in the absence of visual cues.

August is a busy time in general aviation so I suppose it’s not surprising that it is also a time of many accidents. However, the amount of small planes in the news this past week has seemed excessive. These three stories made the international press: the first resulted in five fatalities and thankfully the other two only in minor injuries. I’ll be watching for the accident reports on all of them.

17 August, England: The mid-air collision in Warwickshire has garnered the most attention. A Cessna twin on final appears to have flown directly into a home-built two-seater light aircraft, which disintegrated on the spot. The twin-engine appears to have limped on a bit before crashing into a field about a mile away. The four occupants of the twin and the pilot of the light aircraft were fatally injured. Both pilots were very experienced and were in contact with air traffic control. Both aircraft were coming in to land at Coventry Airport when the crash happened so it would seem the radio transcripts could shed some light on the accident.

Further references:
BBC News
AAIB Press Statement

17 August, Germany: A couple flying a single engine plane clipped high-tension power lines on take-off from Kempten-Durach and ended up hanging upside down in the plane, some 20 metres above the ground, for two hours before they were able to be rescued. The rescue team brought a hydraulic lift to remove the pilot and his wife from the aircraft before using a car crane to lift the plane out of the wires. Preliminary reports are pointing towards pilot error.

As it happens, this is an airfield I know well, as it is local to my cousin’s Bavarian farm. I only have one photograph that shows the power lines:

I recommend watching the Liveleak video of this, just for the incredible view of the plane dangling upside down. It put shivers up my spine.

Further references:
Welt Online (German news)
Liveleak with video

19 August, Japan: A Cessna crashed into a city street in Yao, a suburb of Osaka, crumpling the plane into a scary looking piece of metal. The two occupants sustained only light injuries and no one on the ground was injured. The plane had taken off from the local airfield and then, according to news reports, the pilot stated his intention to turn back due to engine trouble. Apparently, fuel to the engine stopped when the pilot made a turn although there was plenty in the tanks.

Looking at the photograph, it’s amazing the amount of damage the plane sustained without causing any major injuries to either the occupants or pedestrians.

Further references:
Flightglobal photograph
http://www.japantoday.com/category/national/view/small-plane-crashes-on-city-street-in-japan

After landing on Jersey, my attention was immediately taken by a plane parked near the flying school, half a wing missing. A laminated sheet was attached. Ever the voyeur for accident reports, I couldn’t resist.

The pilot had noticed a slight thump shortly after taking off. He checked for anything visibly wrong inside the cockpit and noticed no issue. A passenger thought he’d seen something black on the left side of the plane. The pilot decided it was likely a bird strike, no damage appeared to have been done, so he continued his planned flight across the English Channel (from Ireland to Portugal). As they carried on, he noticed that the port-side fuel gauge showed as empty. The starboard fuel showed as full. I’m guessing he tapped on the gauge a few times and cursed before informing his passengers that it was likely just a display error, nevertheless they were going divert to Jersey in order to check the issue on the ground. It was an uneventful landing until he climbed out of the cockpit and saw the ripped remains of his wing.

He’d knocked off the entire wingtip tank and a large portion of his port wing and aileron. Pine needles were found within the fuselage.

The preliminary accident investigation found a 50 foot pine tree near the starting airfield with 6 foot severed off the top and fragments of wing in the branches. The fuel tank was found around 75 yards farther along the route.

I put my fingers to the jagged edges of the wing remains and stood there for a while. I’m constantly amazed at the resilience that small planes show, how they are able to keep flying in the direst of circumstances. I learned enough physics and aerodynamics to pass my aviation exams but deep down I still believe it’s magic that holds the things up in the air. If I’m honest, I suspect that (like Tinkerbell) if I stop believing in the plane’s ability to fly, it will crash with a thunk into the reality of gravity.

I continued to the terminal with a final backwards glance at the Cessna Centurion, grounded.

Sam Cross was just another PPL student – he needed one more birthday before he could complete his licence but he wasn’t in a rush. He was 16 years old and had flown 15 hours and, in his previous session, he’d gone solo for the first time. His instructor considered him an accomplished pilot.

Aircraft Type: Cessna F150L
Registration: G-BABB
Injuries: Crew – 1 (Fatal)
Nature of Damage: Aircraft destroyed

A summary from the Air Accidents Investigations Branch bulletin:

During his second solo flight the student was instructed to carry out an unfamiliar and non-standard manoeuvre. Presented with a situation beyond his experience, he failed to reconfigure the aircraft for level flight. The aircraft continued to fly level at a power setting which the available evidence indicates would have been insufficient to maintain flying speed, and eventually the aircraft stalled at a height from which recovery was impossible.

This tragic accident happened at Southend-on-Sea in July, 2006. The inquest was completed last week and the death of Sam Cross was designated as accidental; however the CAA have implemented a number of safety recommendations in order to avoid a similar build-up of stress on an inexperienced pilot.

What happened? The bulletin says:

The student, who was training at Southend Airport towards the issue of a Private Pilot’s Licence, was on his second solo flight. Having established the aircraft on final approach, the student was instructed to go around so that a faster aircraft approaching to land behind his aircraft would not catch up with it. Both the controller’s instruction and the student pilot’s acknowledgement involved non-standard RTF phrases. In order to avoid any possibility of conflict between the two aircraft the student was then instructed to turn away from the final approach track. During this manoeuvre, the student flew level at low altitude and it is likely that the aircraft remained in the approach configuration with insufficient power applied to maintain flying speed. In level flight, the aircraft stalled at a height from which recovery was impossible and it struck the ground in a public park approximately 1 nm from the airport. The student pilot was fatally injured.

Initial solo flights are straight-forward. You fly in a pattern around the airfield, called a circuit. First you’ll simply take off and follow the circuit and land again. The next stage is to start coming down as if to land but as the wheels touch the runway you clean up the plane and take off again – a touch and go – to save time.

Before going allowed to go solo, you need to be landing competently and – more importantly – you need to be willing to go around if everything isn’t just right. Going around means aborting the landing: you put full power on and get the plane up to speed and then bring up the flaps and climb away, ready to rejoin the circuit and try again. The emphasis at this stage of your training is to recognise a less-than-perfect approach and be willing to throw it away and try again. Only once the instructor is convinced that you can and will go around safely will he let you fly alone.

Sam Cross understood about going around.

His instructor notified ATC that they had two flights planned, the instructor would take his student up for a few circuits and then leave him alone in the plane. Persons on board was omitted from the Flight Progress Slip as it “could not be done without ambiguity” but the radio controller was informed that “at some stage the student pilot would be sent solo.” This was confirmed by the instructor when he vacated the plane and again by Sam Cross as a part of his radio call. Two minutes later there was a shift change.

The controller who took over stated that he was not made aware that Sam Cross was a student flying solo.

Then the approach controller received details of a Piper Meridian coming in from the south. Flight priorities are such that a “normal” flight such as the Piper gets a higher priority than the Cessna which is a training flight. It is standard practice to make way for faster traffic when possible – bearing in mind Sam Cross is in a slow-moving plane going around the circuit – he’s pottering along and he doesn’t mind. The Piper just wants to get straight in and down and parked. The cost of a go-around to the student is negligible – one more circuit out of dozens. Unexpected circuits on commercial flights quickly add up. The Cessna would have been going around 60 knots on approach; the Piper 120 knots.

That’s not to say only students go around: every pilot is always ready to go around . However, it’s sensible to avoid it, if possible under normal circumstances, without risk. That was the initial decision: Sam Cross called final and was told to maintain runway centreline but go around at circuit height (one thousand feet).

However, the Piper was so much faster than Sam Cross’s little Cessna that the controller changed his mind: he was concerned that if the Piper had to go around, he’d end up passing the Cessna from underneath it, a potentially dangerous situation. He made a new call:

“ER GOLF BRAVO BRAVO DISREGARD THAT JUST TAKE A LEFT TURN AND FLY NORTH I’LL CALL YOU BACK IN VERY SHORTLY.”

Focus changed to the incoming Piper and it was confirmed that the Cessna would get out of the way and the Piper could come straight in to Southend. Meanwhile, the controller has realised he did not receive a response from his previous call to the Cessna. He called him again, just to confirm, and told him turn northbound now. After the third call, Sam Cross responded:

“BRAVO BRAVO TURN NORTH”

The controller thanked him for being helpful and cleared the Piper to land. Then he called Sam Cross back and told him to make a left-turn and orbit back onto final approach. Sam Cross repeated back:

“MAKE LEFT HAND TURN ONTO FINAL APPROACH.”

Meanwhile, his instructor was getting nervous. He was listening in on the radio and aware that Sam Cross was being given instructions to do things he was unfamiliar with. Visibility was dropping. He watched for Sam Cross to come onto final so that he could ask the tower to tell him to make a “full stop” landing rather than continue with the circuits. The student would need a break after this.

Using binoculars he watched the aircraft fly away from the final approach track in what appeared to be the opposite direction to base leg, at lower than normal circuit height with what he considered to be a nose-up attitude and low airspeed. He then saw the aircraft reverse direction with a high rate of turn before entering a spiral dive, from which he considered there was no possibility of recovery.

Sam Cross and the plane crashed into Eastwood Park, still spinning. Bystanders ran straight to the scene of the accident, despite the smell of fuel and the risk of an explosion. Sam Cross was dead.

His instructor confirmed that Sam had not been taught to do orbits in the approach configuration – nor would he have expected to, at that stage of his training.

If instructed to go around, the student had been taught to apply full power, position the aircraft slightly to the right of the centreline , maintaining a positive climb, fly straight ahead and select the flap up in stages.

However, Sam Cross was told to go north to get out of the way at a point when cockpit workload is already high. He turned off of his final approach, expecting to join it again after the Piper had flown past.The request to go around had specifically been rescinded. It must have seemed logical to leave the plane in the approach configuration: leave the power alone and keep the flaps extended. The difference is that the plane is flying straight and level now, rather than descending down to a runway to land. He’s not been taught how to deal with this.

Sam Cross has a lot on his mind. He’s been taught a very specific sequence of events and everything is suddenly contrary to what he’s been taught. He’s going the wrong way around the circuit. He’s probably concerned about this FAST TRAFFIC BEHIND that he can’t see. The controller is busy and there’s no one else to turn to. It’s a safe bet that Sam Cross was not at full capacity and in fact was starting to panic. Certainly, he didn’t appear to have understood the loss of speed nor react to the stall warner siren which would have sounded directly before the stall.

As a part of the investigation, a test pilot flew another Cessna F150L to recreate the conditions that Sam Cross found himself in:

The aircraft decelerated and eventually stalled with a nose high attitude. As it stalled, the example aircraft rolled quickly to the left, adopting a bank angle of approximately 60º within one second. Simultaneously, the nose dropped approximately 45º below the horizon and a high rate of descent developed.

Sam Cross’s Cessna went straight into a spiral dive, just like the example plane. The experienced test pilot recovered from the dive but lost 400 feet in the process. Sam Cross was flying at a height of between 200 to 300 feet when he went into the dive. He never had a chance.

The controller stated to the press that he would never have given those instructions to Sam Cross if he had known it was an inexperienced student. The AAIB bulletin says:

By turning G-BABB to the north he intended to place G-BABB safely out of the way, focus attention on N347DW until it had landed and then re-direct his attention to G-BABB. However, it is likely that of the two pilots immediately involved, the pilot of N347DW, who was bound to be more experienced, would have been better equipped to deal with demanding or unusual instructions.

The Southend Manual of Air Traffic Services offers no advice to controllers in regards to dealing with training flights. The AAIB’s initial safety recommendation in the bulletin was to fix that specific issue:

Safety Recommendation 2007-036
It is recommended that London Southend Airport includes information relating to the notification and handling of flights by inexperienced solo pilots in its Part 2 of the Manual of Air Traffic Services.

As a part of the accident analysis, the CAA stated that they’d like to see students identify themselves to traffic controllers which resulted in the following two recommendations from the AAIB:

Safety Recommendation 2007-050
The Civil Aviation Authority should instigate the use of a suitable prefix, for use in civil radiotelephony, to signify a student pilot, flying solo.

Safety Recommendation 2007-051
The Civil Aviation Authority should amend the Manual of Air Traffic Services Part 1 and the Radio Telephony Manual (CAP413) to emphasise to controllers that pilots identifying themselves as students have limited ability, which must be taken into consideration when issuing instructions.

These changes are all focused on ensuring that the controllers are aware of who they are dealing with and what the expected level of experience is. No one expects a student on his second solo to understand what the controller at Southend meant for Sam Cross to do.

…although the use of non-standard phraseology probably exacerbated the student’s difficulties, even a clear instruction to orbit in the approach configuration would have been problematic. Under existing provisions, air traffic controllers are not expressly prohibited from instructing this manoeuvre.

Thus, there is an argument that Sam Cross should have been given precedence due to his inexperience. Also, although it was a training flight, the fact that he was on final should have given him precedence over a plane still coming in. Sam had been told he was number one to land and had called final in full confidence that he would be cleared. A sudden flurry of activity at this point is not what any pilot is expecting.

The further recommendation from the AAIB makes it clear that they did not feel the manoeuvre was necessary under the circumstances:

Safety Recommendation 2007-037
The Civil Aviation Authority should amend MATS Part 1 so that, with the exception of issuing instructions to go-around, controllers shall not issue instructions that would require an aircraft in the final stages of approaching to land to deviate from its expected flight path unless exceptional overriding safety considerations apply.

None of this can help Sam Cross now. As a mother, my heart bleeds for the young boy in the cockpit, at a loss as to what to do and without the guidance to fix it. As a pilot, I know that the circumstances that culminated in his death are not common and that the accident could not have been predicted. If we can learn to help inexperienced pilots in difficult situations rather than adding to their workload, it has to count for something.

What else can we do?

Further reference:

• Air Accidents Investigations Branch bulletin
• BBC News report of the inquest, with links to previous stories.