The 2008 viral video of an unregistered plane supposedly losing a wing and the brave pilot landing it safely is making the rounds again, much to my disgust and the advertiser’s excitement. The video is completely faked but seems to have done the job of getting people’s attention. To compare, you can see this real video of a radio controlled aircraft landing with one wing – ignoring everthing else, the tilting plane on the runway is what’s clearly missing from the viral video. I find it a little bit bizarre that the advertising clip is continuing to fool so many people. And once they have found out the truth, do they really go and buy clothes?

The reality is not so pretty. The following are true accidents – including video – of the wings falling off during flight. Be warned, the results aren’t pretty. The first two videos are very hard to watch.

In 1983, this light twin (the Italian Partenavia P68C which is not an aerobatic aircraft) was being flown by the owner who had apparently imported the planes and showed them off at local airshows. He began a rapid pull-up at high speed (above the aircraft’s VNE). With an estimated load of 8.3 Gs, the wings separated from the plane. The NTSB determined the probable cause as the pilot in command’s overconfidence in the aircraft’s ability.

Accident Report

No engine sounds were heard during the spin & the prop was observed not rotating before impact. The engine was not equipped with an inverted fuel system. The aircraft was prohibited from aerobatic flight. There was no evidence that the pilot had ever received any aerobatic instruction.

In 2002, this Hercules was hired as fire-fighting plane to combat a 10,000-acre fire in California. The incident occurred on the sixth run of the day, delivering fire retardant. Examining the wreckage, the NTSB discovered fatigue cracks in the right wing’s lower surface skin, originating from the rivet holes. The cause of the accident was metal fatigue with a contributing factor of inadequate maintenance procedures to detect fatigue cracking. All three crew were killed on impact.

Accident Report

Tanker T130 flew down the east side of the drainage valley and proceeded to make a ½ salvo fire retardant drop. Just prior to the completion of the drop, the nose of the airplane appeared to rise and the airplane started to initially arrest its descent and to level out. The nose of the airplane then continued to rise towards a nose up attitude and almost at the completion of the ½ salvo fire retardant drop, the airplane’s wings folded upwards and detached from the fuselage at the center wing box beam-to-fuselage attachment location.

I’ve linked to this before but it is still the most amazing aviation story that I have ever read. Test pilot Bill Weaver tells the story of his SR-71 Blackbird disintegrating around him – and how he survived although he never had a chance to eject.

LiveLeak.com – SR-71 Disintegrates Around Pilot During Flight Test

Everything seemed to unfold in slow motion. I learned later the time from event onset to catastrophic departure from controlled flight was only 2-3 sec. Still trying to communicate with Jim, I blacked out, succumbing to extremely high g-forces. The SR-71 then literally disintegrated around us.

From that point, I was just along for the ride. My next recollection was a hazy thought that I was having a bad dream. Maybe I’ll wake up and get out of this mess, I mused. Gradually regaining consciousness, I realized this was no dream; it had really happened. That also was disturbing, because I could not have survived what had just happened. Therefore, I must be dead. Since I didn’t feel bad–just a detached sense of euphoria–I decided being dead wasn’t so bad after all.

AS FULL AWARENESS took hold, I realized I was not dead, but had somehow separated from the airplane. I had no idea how this could have happened; I hadn’t initiated an ejection. The sound of rushing air and what sounded like straps flapping in the wind confirmed I was falling, but I couldn’t see anything. My pressure suit’s face plate had frozen over and I was staring at a layer of ice.

For an incident with a happy ending, AVweb produced a video showing a wing come off of an aerobatic plane (a Rans S-9 Chaos) during an airshow in Argentina. In this instance, a full-plane parachute saved the pilot’s life.

Real Aircraft Loses Wing, Lands Safely (Under Canopy) – YouTube

Comparing a ballistic ‘chute to a normal parachute worn on the body in this case it seems the full-plane parachute was a good choice. Due to the rate of roll induced by the loss of one wing, it appears questionable that the pilot could have escaped the cockpit and saved himself wearing a conventional parachute on his back. Conventional parachutes are not aided by ballistic deployment and may require more altitude to properly open. Had the pilot been wearing a parachute and managed to escape the spinning aircraft without being hit by it, he may have simply have impacted the ground under a partially opened canopy. In this case, full-plane parachute FTW.

Meanwhile, the University of Cambridge has released a video to show that the common explanation of how wings create lift actually goes against the laws of physics.

How wings really work – Research – University of Cambridge

“A wing lifts when the air pressure above it is lowered. It’s often said that this happens because the airflow moving over the top, curved surface has a longer distance to travel and needs to go faster to have the same transit time as the air travelling along the lower, flat surface. But this is wrong,” he explained. “I don’t know when the explanation first surfaced but it’s been around for decades. You find it taught in textbooks, explained on television and even described in aircraft manuals for pilots. In the worst case, it can lead to a fundamental misunderstanding of some of the most important principles of aerodynamics.”

Mind, a little bit of physics would go a long way towards stopping that viral video from being passed around as real!

Class dismissed.

It happened just last week. Dr. Richard McGlaughlin and his daughter Elaine were flying his Cirrus SR22 to Haiti to do charity work, something Mr McGlaughlin has done regularly since the earthquake.

Dr. McG’s Haiti Chronicles – Cirrus Owners and Pilots Association

Dr. Dick “McG” McGlaughlin flew in with a Cirrus full of medical supplies because he “couldn’t stand to hear one more thing on the TV”. His first (short) report from ground zero said, “Everybody should come here- a great ameliorative for feeling put upon.” Interesting that McG ended up taking his own advice to heart. He has since flown his Cirrus to serve in Haiti more or less on a once-monthly basis.

They were a few miles out from Andros Island when they encountered engine trouble. The oil pressure dropped slightly and then within a few minutes it dropped to zero.

Elaine wrote about the experience in the COPA comments:

I’m writing this email from the Sheraton hotel in Nassau, after one of the most exhilarating days of my life. My dad and I took off from the smaller Tamiami-Executive Airport this morning, en route to Haiti after picking up his plane from a couple weeks of routine annual maintenance. I had bought a shiny new digital camera for the trip that morning, and was hungrily reading through the owner’s manual (something I never do) when I heard my dad speak into the headset, calling out to the nearest air traffic controllers that he planned to do an emergency descent because of an unexpected drop in oil pressure.

I thought that was kind of weird, but was mostly interested in organizing my granola bars and putting my travel sunscreen into MY backpack instead of his, and figured that if anything was really going on we would calmly make an unplanned landing on some dusty runway in the Bahamas, fix whatever was going on with the oil pressure, and be on our way. Then my dad’s voice became a little more pressured, and I noticed his hands were shaking.

They were at 9,500 feet. After the radio call, the engine seized and the propeller stopped. Dr. McGlaughlin configured the plane as best as he could and continued to speak to air traffic control. Elaine gradually became aware of the gravity of the situation.

My dad was obviously spooked, but mostly composed, adjusting whichever controls would respond at that point and continuing to communicate with air traffic controllers in various locations. They asked how many “souls” were on board, and I thought to myself that that particular word choice was decidedly morbid for a moment like this. As my dad’s voice became more gravelly, I sensed in him and began to feel myself what I now have the time and luxury to recognize as dread. Dread is sticky, humid; it fills the air and waits heavily, knowing and fearing, hating to have to know, but knowing all the same.

[...]

The air traffic controllers told us that the U.S. Coast Guard had been notified, and that we were four minutes from land. Four minutes was about three minutes too far, because we sank to 2200 feet at what looked to be a mile off shore, and my dad decided to pull the parachute. BOOM! We shot forward, I hit my head pretty hard on the dashboard– the energy of the parachute rocketing out the back of the plane caused us to pitch forward, and all of a sudden we were stopped still, dangling it seemed, looking straight down at so much flash-blue water. Just as quickly as it had careened over, the plane righted itself, the parachute slider doing its job, working the larger overarching parachute upright into the sky. Then we floated downwards, somewhat slowly, and hit the water HARD, a big firm collision right up your spine and down, but before I knew it water was rushing in EVERYwhere, and I couldn’t get my door open and whoa that water was pretty cold, aren’t we in the damn Caribbean here anyway?

Dr McGlaughlin stated separately that he was unsure of what would happen with a Cirrus Airframe Parachute System (CAPS) splash-down. He decided that he would pull at 2,000 feet above the ocean but then became impatient and deployed at 2,300 feet.

Early Reflections on CAPS Pull #32 by Dick McGlaughlin in the Bahamas – Pull early, pull often! – Cirrus Owners and Pilots Association

Dick vividly describes their splash down as a hard landing, harder than he expected. But both he and Elaine were uninjured. The cabin quickly began to fill with water through the fresh air vents, so they felt urgency to get out of the plane. While Elaine’s door would not open, the pilot door opened easily and both got onto the wing with their life vests and life raft.

As you can see, the plane did not break up on impact and they appear to be waiting relatively comfortably considering the 4-man raft looks about the size of a postage stamp.

Currrus have stated that this is the 28th save (making for a total of 53 survivors) since the Cirrus Airframe Parachute System was launched. Although having read the account, I’m sure Dr McGlaughlin could equally have handled a standard water ditching – he was perfectly in control and making decisions in what is for all of us a frightening possibility: engine failure during a water crossing.

Don’t you just love a happy ending?

The media is very focused on on fatigue at the moment and how it affects pilots. This 737 running off the runway, killing 158 people, is a reminder that fatigue is only one small piece in the puzzle.

Air India Express 812 was a quick-turnaround night flight, Mangalore to Dubai and back.

The captain, a 55-year-old Serbian national, had just returned from a few weeks spent at home. Air India Express employs a number of foreign captains, on a contract of eight weeks of flying duty followed by two weeks at home. The captain just had returned from two weeks in his hometown. This was his first flight since coming back on duty. He had over ten thousand hours flying experience as a Pilot in Command with 2,844 of those on the B-737-800.

The First Officer, a 40-year-old Indian national, was waiting for Command Training on the 737. He’d queried about the conversion six months before the accident but had received a generic response regarding company policy. He was a stickler for procedure and had previously complained about another foreign Captain who had not followed the company SOP. A note was made not to pair those two pilots together. It’s not hard to imagine his frustration at not being taken seriously.

The cockpit recorder has two hours of five minutes of the flight – the recording cycles over itself. I’m not sure why that might be, in this day and age of cheap storage. It would seem trivial to record twelve hours before recording over itself in order to give us a full picture of flight interactions. The result, in this instance, is that we do not know what interactions took place between the pilots that evening. We don’t know what conversation took place in the cockpit prior to the final descent.

The aircraft and crew departed Mangalore at 21:35 local time (Indian Standard Time, which I will use for all further times). No pre-flight medical check took place; however the crew interacted with engineering personnel at Mangalore who said both pilots seemed healthy and normal. It was a routine flight and they landed at Dubai on schedule at 01:14. They stopped at Dubai for just under an hour and a half and then at 02:36 they departed, on schedule for a 06:30 arrival in Mangalore. There were 160 passengers on board, including four infants. The take-off, climb and cruise appear to have been uneventful. There were many families in the cabin, quite a few first-time flyers. As the plane levelled off into the cruise, they probably dozed.

Certainly the captain did.

Our recording from the cockpit begins at 4am with the sound of the Captain snoring. He’s clearly deeply asleep for the first hour and forty minutes of the recording. He’s breathing deeply and is unaffected by the sounds of the First Officer making radio calls.

05:32:48 The first officer contacts Mangalore Area Control to say they are approaching reporting point IGAMA at flight level 370. He requests radar identification and is informed that the Mangalore Area Radar is out of service.

Mangalore Area Radar had been out of commission since the day before and a NOTAM had been issued. I would have expected the flight crew to have been made aware of this when they left Mangalore that evening.

05:33:20 The first officer reports position at IGAMA and asks regarding the approach. He requests descent clearance, which is denied to ensure safe separation with other aircraft.

Airlines that allow for controlled rest in the cockpit – that is to say, taking a quick nap while in the cruise – have specific regulations in place including this key point: a sleeping pilot must be woken at least 30 minutes prior to the beginning of the descent. This is to ensure that the pilot is properly awake before the critical phase of flight begins. Air India Express does not have a policy in place for controlled rest. It may not have occurred to the First Officer that he was obliged to wake the Captain with plenty of notice before the descent. There’s no evidence that he attempted to wake the Captain at all.

05:46:54 The first officer reports position and is cleared to descend to 7,000 feet. The aircraft begins the descent.

The cockpit recorder has some quiet mutterings from the Captain’s channel just prior to the descent. He’s woken up. There is no evidence of a descent and landing briefing.

From the accident report:

The crew had failed to plan the descent profile so as to arrive at correct altitude for positioning into ILS approach. The First Officer had said on the intercom to the Captain “RADAR NOT AVAILABLE, BUT I DO NOT KNOW WHAT TO DO.” This indicated that he was possibly not aware of procedure in case the radar was not available and in such a scenario, how to plan a descent and approach if not permitted by the Area Control to descend at the desired distance on DME.

Mangalore has a table top runway located at 337 feet above mean sea level. It is considered a challenging airport because of the surrounding terrain. Because of this, Air India Express standard operating procedure is such that only the Pilot in Command – that is to say the Captain – can carry out take-off and landings at Mangalore.

The Captain had done 16 landings at Mangalore. The First Officer had acted as co-pilot for 66 flights at Mangalore.

The flight is cleared to continue descent to 2,900 feet. The First Officer requests a direct route to radial 338 to join the 10 DME arc, which is approved.

The plane is high throughout this descent.

05:52:43 The aircraft is handed to ATC Tower at Mangalore. The tower is manned at this time of the morning specifically for the Dubai-Mangalore flight which is the first of the morning. ATC ask Air India Express to report established on the 10 DME arc for ILS runway 24. The First Officer acknowledges and yawns.

The airport reports the 10 DME arc and are asked to report established on the ILS.

The Captain selects Landing Gear DOWN at an altitude of approximately 8,500 feet, with speedbrakes still deployed in the Flight Detent position. This is clearly to increase the rate of descent. He’s too high and he knows it.

His configuration changes aren’t enough. The aircraft is still too high and fails to intercept the ILS glide path. In fact, it is at almost twice the altitude as it should be for a standard ILS approach.

06:03:14 The Captain selects the flaps at 40 degrees and completes the landing checklist.

06:03:35 At about 2.5 DME, the radio altimeter alerts the crew that their altitude is 2,500 feet.

06:03:33 The First Officer calls “it’s too high” and then “Runway straight down!” He’s just spotted the runway, coming up fast. They’re not on the approach path.

The Captain responds with “Oh my god” He disconnects the auto-pilot and increases the rate of descent.

06:03:53 The First Officer queries: “go around?”

They are in an unstabilised approach. The aircraft is too high and going too fast. It is absolutely correct that they should go around: break off the approach and circle around and try again.

06:03:56 The Captain responds with “Wrong Loc .. Localiser … glide path.”

So it is clear: the captain is not incapacitated. He is in control of the aircraft and comprehending at least some of the issues affecting the approach. However, he makes no move to go around. He’s still trying to get down to the runway in time.

The Extended Ground Proximity Warning System begins to sound an alarm: SINK RATE, SINK RATE. They are going down too fast.

06:04:02 The First Officer says “Go around Captain” and “Unstabilised!” but does not take any action to initiate a go-around.

There’s no question that they should go around. As a part of his training, the First Officer should have received very clear instructions as to when to take this decision. In most commercial airlines, the First Officer is expected to break off an unstabilised approach if the Captain is continuing despite a call to go around. This approach is clearly unstabilised. Assertiveness training is often offered in order to give the First Officer the confidence to override his captain in exactly this situation. A First Officer must have clear guidelines, confidence that his decision will not be held against him, and a good working environment within the cockpit. On Air India Express 812, the First Officer had none of the above.

The Captain does not go around. He makes visual contact with the runway and increases the rate of descent to almost 4,000 feet per minute.

This isn’t enough to cause screaming in the back. It’s unlikely that the passengers in the cabin even noticed that this is a more rapid descent than normal. They aren’t regular commuters and the rate of descent is not aggressive enough to feel like the plane is diving. Nevertheless, it is much greater than it should be for that approach.

The tower hasn’t heard from the flight and so they make contact: “Express India Eight One Two – confirm established.” Are you established on the ILS? Are you at the correct height going at the correct speed?

The First Officer doesn’t respond.

The Captain says “Affirmative” to him. When the First Officer doesn’t make the call, the captain barks it at him again: “Affirmative!”

The First Officer keys the radio. “Affirmative,” he says to the tower, even though he knows they are not established. They are too high and too fast.

Air India Express 812 is given landing clearance. Winds are calm.

For this flight, the target speed should have been 144 knots at 50 feet as they cross the threshold of the runway.

They cross the threshold at 200 feet with an indicated speed in excess of 160 knots.

06:04:38 Just before they touchdown, the Flight Officer calls out “Go around captain,” followed by “We don’t have runway left.”

From the accident report:

With the first Officer not showing any signs of assertiveness, the Captain had continued with the faulty approach and landing, possibly due to incorrect assessment of his own ability to pull off a safe landing. This violation of laid down SOP by the Captain can be attributed to fatigue, sleep inertia and the phenomenon of ‘GET OVER WITH IT’.

The captain continues the landing. Final touchdown is at 5,200 feet from the threshold of runway 24, leaving 2,800 feet of remaining paved surface.

Two thirds of the runway was behind them when the final mistake was made.

The captain selected the thrust reverser and commenced braking in order to stop as quickly as possible in the last third of the runway.

The full runway is 8,003 feet, more than enough for a 737 to land on. Boeing did tests simulating the conditions of the Air India Express 812 landing using the configuration of the aircraft. They came to the conclusion that if the Captain had applied maximum manual braking – that is, remained committed to the landing – the aircraft would have come to a halt at 7,600 feet beyond the threshold. The plane could and would have stopped before the end of the runway.

The only thing the Captain needed to do was continue braking.

But the Captain didn’t do that. He changed his mind. With two thirds of the runway behind him, having successfully landed and begun to slow the plane, he put full power on and attempted to take off again.

The last words recorded was one of the pilots saying, “Oh my God.” At this moment, 06:05:00 am on the 22nd of May 2010, the cockpit voice recorder went blank.

The 737 accelerated across the remainder of the runway and the overshoot. The right wing hit an ILS antenna mounting structure. The aircraft hit the fence and fell into a gorge.

INDIA Mangalore, survivor tells of air disaster – Asia News

Joel, a 24-year old native of Vamanjur, a town near Mangalore, was returning from a month spent in Dubai with his sister after completing a course of study on computer aided design in mechanical engineering. “I was in seat 23 – he tells AsiaNews – and we had barely touched the ground when it seemed that the pilot lost control of the aircraft.” He adds that “despite attempts by the pilot to stop the vehicle, it did not happen, the airplane crashed and the cabin was filled with a thick blanket of smoke. “Me and six others managed to escape – he confesses – and then we saw the plane break in two.”

The aircraft was destroyed in the impact and resulting fire. There were only eight survivors. All six crew members and 152 passengers lost their lives.

The DCGA cited the Captain’s persistence in landing as the direct cause, especially in light of the three calls from the First Officer to go around.

Even that was still survivable, if he’d just hit the brakes and done everything in his power to stop the plane. But there’s no question that continuing the approach was the primary factor.

Contributory factors:

1) Sleep inertia leading to impaired judgement. The Captain was in a prolonged sleep, waking at the top of the descent. The slowness of waking would be accentuated while flying in the Window of Circadian Low.

Quite honestly, I can’t see any other reason why he would make that bizarre choice to try to go around at the last minute, having successfully brought the plane to the ground. I can understand the desire to recover the approach. But having succeeded, and to the Captain’s credit, he had, it is beyond bizarre that he would then change his mind. This goes against all training and againt all standard operating procedures for the plane. It is crazy that an experienced Captain with over 10,000 hours in command would make such a reversal. I can only think that he was truly not quite awake and not actually understanding what was going on. Nothing else makes sense.

2) The aircraft was given a descent at a shorter distance than normal.

This should be a non-issue. However, it’s clear that the First Officer did not know how to deal with the last-minute change and the crew never planned the descent profile in order to correctly intercept.

3) The First Officer did not initiate a go around. Specifically: “the First Officer gave repeated calls to this effect, but did not take over the controls to actually discontinue the ill-fated approach.”

This strikes me as incredibly unfair. There is a clear training and cockpit resource management emphasis that needs to be in place at an airline in order to empower a First Officer to take control of the aircraft.

In this cockpit, the Captain expected the First Officer to do as he was told. This is clear from his insistence that the First Officer respond to ATC that they were established on the ILS when they most clearly were not. If ATC had been aware that the flight was not established, they would not have given the clearance to land.

But more importantly, the DGCA, even following this devastating report, has not clarified the issue in order to offer confidence to First Officers. In fact, going through their circulars, it seems clear that the Pilot Not Flying should not initiate a go around in a circumstance such as this.

The 15/2010 circular, still in effect now for Go-around following unstabilised approach is less than helpful:

Subtle incapacitation is associated with non-response to particular stimuli, as the crew is deeply involved in a particular maneuver. To assist in identifying subtle incapacitation, the PNF is expected to give two calls before taking any further action. In case the response is there from the PF towards the correction expected by the virtue of his action, it is taken as satisfactory. But the case where the response from the PF is absent or inadequate and the situation continues to deteriorate is something that needs to be addressed.

That is to say, it is up to the First Officer to decide that the response is “inadequate” and that the situation is continuing to deteriorate and to then consider addressing the situation. That’s not particularly inspiring for a First Officer who needs to be empowered to take control of the situation from an authority figure. But wait, it gets worse:

The action to take over controls by the PNF should only be in the case of total / subtle incapacitation. A situation of conflict in the cockpit is most undesirable for flight safety and would lead to a hazardous situation and needs to be avoided in all circumstances.

So rather than a straight-forward decision, such as “is my Captain continuing an unstabilised approach, yes or no?”, the Pilot Not Flying is told he shouldn’t take control unless the Captain is incapacitated, with a get-out clause of “subtle incapacitation”, in which case the PNF is expected to monitor to see if the situation continues to deteriorate.

Completely unreasonable to then allocate blame to the First Officer for not taking control, in my opinion, even as a contributing cause.

As the Ministry of Civil Aviation Court of Enquiry website appears to be timing out, I’ve included a PDF of the Report on Accident to Air India Express Boeing 737-800 Aircraft VT-AXV on 22nd May 2010 at Mangalore as a local file for your reference and convenience.

The pilot steps through the situation as he experienced it, with honest appraisals of the decisions he made and why. It’s just under ten minutes and should be recommended viewing for all pilots.

Most importantly, it has a happy ending: both the pilot and plane came out of an engine failure unscathed. That’s what really makes me like it.

One thing I find odd is that he declared an emergency but never called Mayday. Has this fallen out of fashion in the U.S. ?

I found this on a webpage called Funny air traffic controllers quotes and amusing aviation conversations and I just had to share. The story was submitted by an Air Traffic Controller named Jim.

In 1978 I was a trainee Air Traffic Controller under supervision at Collage Station Texas, Easterwood Tower. This is a true story of a radio discussion one afternoon:

Unknown Aircraft: “Hello…?”

Easterwood Tower (me): “Please say again.”

Unknown Aircraft: “What?”

Easterwood Tower: “Who is this?”

Unknown Aircraft: “This is Joe”

Easterwood Tower: “This is Easterwood Tower, where are you?”

Unknown Aircraft: “I’m in the plane!”

(I looked down the flight line, checking if someone was sitting in a parked plane playing with the radio. I didn’t see anything, and the senior controller was becoming more interested in my handling of the situation.)

Easterwood Tower: “Joe, where is the pilot?”

Unknown Aircraft: “He got out when the engine quit..”

(I could only imagine a bizarre scenario in which the pilot had jumped from the plane.)

Easterwood Tower: “Joe, what does your airspeed indicator read?”

Unknown Aircraft: (Long pause) “Zero?”

(So the plane was now in a stall, I thought.)

Easterwood Tower: “Joe, whatever you have in front of you – a stick or a steering wheel – push it forward – you need to get airspeed over your wings!”

Unknown Aircraft: “Are you sure?”

Easterwood Tower: “Yes Joe you need to push it forward… (pause)… What does your airspeed indicator read now?”

Unknown Aircraft: “It’s still zero.”

(I thought, oh my god, Joe’s plane was in a falling leaf spin. I couldn’t help him. Joe was going to die. I did not know what to do. I looked to the senior controller. He said, “Ask him where his plane is.”)

Easterwood Tower: “Joe, where is your plane?”

Unknown Aircraft: “We are parked down at the end of the runway, the pilot got out when the engine quit and walked back to the hanger..”

Easterwood Tower: “Joe, get off the radio.”

In 2007, they spent Easter weekend in Oban, flying every day along with wife and mother Angela in the back seat. A member of staff at Oban remembered them and posted to an online forum: “I spoke to the family shortly before they departed for home, and they came across as very nice people who were enjoying their flying in this part of the world.” But when it came time to return home, the weather was bad. They decided to depart Oban despite the clouds. The next morning, the wreckage was discovered in a farmer’s field in the west Highlands, just nine nautical miles from Oban Airport.

John Smith gained his UK PPL in March 1980 which was valid for life. He had 324 hours experience. His medical certificate expired on November 2006 and he had not submitted the annual exercise ECG required as a result of his heart condition. However, there is no evidence that he had any medical issues during the flight.

Jacqueline Smith’s was one of the first of the new-style JAR PPLs which only have a five year validity. In 2005, the CAA did not send any notifications that a renewal was required and numerous pilots were later found to be flying on expired licences. Jacqueline Smith did renew her Single Engine Piston (Land) rating and may well have overlooked the fact that her licence had expired.

Friday, 6 April 2007

The flight departs Andrewsfield Airfield in Essex with three on board. Father and daughter regularly flew together, with John Smith in the left seat and Jacqueline Smith in the right seat, regardless of who was the pilot in command. As such, it’s not possible to tell who flew the aircraft that day. Jacqueline Smith’s logbook shows that John Smith had flown the seven previous flight hours as commander and in the accident report, John Smith is referred to as the “commander” for simplicity’s sake. As he had more experience and was the one discussing the flight with airfield staff, it seems likely that he was, in fact, the pilot in command.

13:44 The family flight arrives at Blackpool Airport to refuel. John Smith is seemingly unaware that Blackpool required prior permission for all incoming flights. This was a temporary condition due to deal with heavy traffic over the bank holiday weekend so the Smiths would not have known this simply by looking at the plates. It’s not an uncommon mistake.

14:51 They departed Blackpool, arriving at Oban at 16:30. Oban Airport at the time required prior permission as standard and the Smiths were required to give at least three hours notice. John Smith expressed surprise when the Air/Ground Operator raised the matter with him after their landing.

The family toured around the local area every day in the aircraft. On Sunday the 8th, after returning from their flight, they refuelled to full ready for their flight home the following day. They went to a local hotel for dinner and drinks and arrived at the airfield the following morning.

Monday 9 April 2007

10:00 The family arrives at Oban airfield and loads the aircraft with their luggage. They report to the office and pick up the weather reports and forecasts.

The aftercast shows that between 10:00 and 12:00 hours, the cloud base was low with rain and drizzle around the mountains. Visibility at Oban varied between 4,000 metres and 10km and hill fog would have been extensive, with visibility less than 200 metres. Cloud was scattered or broken with a base varying from 400 feet to 1,500 feet and a top of 2,000 feet. But further broken or overcast clouds were above that laying starting at 2,000 to 3,000 feet with a top varying from 5,000 to 7,000 feet and further broken layers of cloud above that.

Later, a number of pilots around Scotland said that they had cancelled their flights on Monday owing to the rain and cloud. The Professional Pilots Rumour Network includes posts from pilots in the area in the days following the accident.

Light aircraft down near Oban – PPRuNe Forums:

“I know the area around Oban well and that afternoon I wouldn’t have been tempted to get airborne.”

“Ben Vorlich and the like were shrouded in mist, and the winds were very strong – you could certainly believe the weather guesser’s prediction of 28 knot+ gusts. I’ve never flown into Oban before (just overflys from my plank days), so all that, plus the surrounding terrain, was a big factor in my decision to go have lunch elsewhere and leave that for another day.”

However, John Smith hopes that he can get his family home. He comments that the weather is clearer in England and mentions as a part of conversation that he is not instrument rated. He decides that they will go up to have a look at the weather but, if it isn’t suitable, they will return to the airfield. The Air/Ground operator tells him that they won’t be charged for an additional landing if they have to come back. The family board the aircraft and do an engine check before heading for the runway.

10:35 The aircraft departs west and at approximately 1,000 feet above mean sea level it disappears into the cloud.

John Smith transmits that they are at 1,500 feet amsl and changing to the en-route frequency.

Oban Air/Ground give them the frequency for the appropriate Scottish ATC station and warns them that they’re unlikely to receive a reply until they are further south.

John Smith acknowledges this without reading back the frequency.

10:42 The aircraft is high enough to appear on radar tracking at Tiree in a climbing left-hand turn passing through 3,300 ft. It then does a complete circle to approximately 5,800 feet over the Isle of Kerrera, 8 nautical miles south-west of Oban. The aircraft turns were becoming tighter and its altitude seems to vary between 5,600 and 5,900 feet. The flight then appears to “wander” in a roughly south-easterly track.

From the Air Accident Investigation Branch official report Piper PA-28R-201T Turbo Cherokee Arrow III, G-JMTT:

The weather at takeoff and the forecast for the first part of the flight over south-western Scotland was not suitable for the intended Visual Flight Rules (VFR) flight. It is possible that the aircraft climbed in a hole in the cloud over the Isle of Kerrera. Once the aircraft had climbed to height the pilots would not have been able to keep in sight of the surface, as the privileges of their licences required them to do.

Neither pilot was trained in instrument flying other than the basic familiarisation training as a part of their initial training, which is meant to allow a pilot who accidentally flies into instrument conditions enough information to be able to fly back out. It is unlikely that either of the Smiths was experienced enough to maintain control of the aircraft in cloud.

10:48 The aircraft altitude reduces to approximately 5,300 feet and about thirty seconds later, the aircraft enters a left turn. During this turn, Tiree radar records that the altitude drops to 4,700 feet and then to 3,700 feet in under 16 seconds.

Lowther loses secondary radar tracking for 23 seconds. There’s no mechanical reason for this and it is likely that there was no line of sight between the radar and the aircraft transponder, which is consistent with the aircraft in a severe nose-down attitude.

In summary, the radar data shows the aircraft climbing to, and holding, a relatively stable cruise altitude but with no set direction. Turns were initiated, culminating in a relatively tight turn associated with a large descent rate and unusual aircraft attitudes. Electrical power was available at least until nearly the end of the last recorded turn, well after the tight descending turn was initiated. Given the location of the end of the radar track relative to the accident site location and disparity between the direction of the last recorded track and the estimated impact direction at the accident site, the aircraft carried out at least one further half turn between loss of the radar track and impact. It is also possible that it carried out further complete turns or other manoeuvres below radar coverage. The time between the loss of radar track information and impact is not known.

11:55 Oban’s Air/Ground Operator phones Scottish ATC to enquire whether G-JMTT has made contact with them. It has not.

There is no reason to file a flight plan for this flight, thus the Air/Ground Operator cannot know the route they are taking back to Andrewsfield. He thought they maybe planning to stop at Blackpool to refuel again, but the Smith’s have not contacted Blackpool for prior permission, which they were made aware was required on Friday’s flight. If ATC had been formally notified of the flight, overdue action would have been initiated within an hour of G-JMTT’s non-arrival. In practice, it would not have made a difference.

Tuesday 10 April 2007

One of the other pilots of the plane becomes concerned as he is unable to contact John Smith by phone. He contacts Oban and confirms that the flight departed the day before. He contacts John Smith’s office, who tell him that John Smith was expected in for 10am meeting but he has not arrived. He then contacts Andrewsfield who state that they have not heard from G-JMTT. He phones Distress and Diversion to inform them that G-JMTT is overdue. A full overdue action is instigated at 14:08.

13:40 Angus McFadyen, a farmer near Loch Scammadale, is out with his son, checking the sheep in the hills above Bragleenmore Farm. They discover the wreckage on a hillside at 963 feet above sea level and contact the Strathclyde police to report the crash.

Both wings were sheared off but McFadyen later tells the BBC that he recognised the fuselage as being from a plane. He finds the engine and the remnants of the cockpit 32 metres (104 feet) away.

The impact crater and other features are consistent with a high-speed nose-down impact at a speed of between 140 and 200 knots.

14:50 Distress and Diversion are contacted regarding the wreckage. The search is called off and the accident investigation begins.

So What Happened?

Post-mortems were carried out on all the occupants of the aircraft. All three died on impact. There were no obvious signs of disease and all the occupants tested negative for drugs. Although it is possible that a medical situation incapacitated one or both of the pilots in the flight, there was no evidence that this was the case.

However, both John and Jacquelyn Smith tested positive for alcohol. John’s result was the equivalent of a blood alcohol concentration of 99mg/100ml and Jacquelyn’s was 48mg/100ml. Angela Smith, in the backseat, tested negative, making it unlikely that the alcohol detected could have been produced post-mortem.

It is an offence to perform an aviation function where the proportion of alcohol in your blood is over 20mg/100ml. As a comparison, the legal limit for driving in the UK is 80mg/100ml. John Smith was legally too drunk to drive and yet appears to have been in command of the aircraft. Jacquelyn Smith had a lower result but still was not legal to fly.

Based on the weather reports, the flight took place in cloud (Instrument Meteorological Conditions or IMC), which meant that the pilots were unable to determine the attitude of the aircraft visually by looking at the horizon. They had to rely on instruments as they were not in sight of the ground.

The flight instruments in the plane consisted of electric Horizontal Situation Indicators and Turn Coordinators and a vacuum-driven Attitude Indicator (Artificial Horizon).

The vacuum pressure was supplied by a vacuum pump with no back-up. On the right side of the instrument panel was a gauge to show the level of suction and on the left side of the instrument panel was a warning light which illuminates if the suction drops too low.

The Century III autopilot on the plane relied on the vacuum-driven Attitude Indicator as its attitude reference source. The pressure from the altimeter is used to command the autopilot to maintain the set altitude. The autopilot is reliant on the pitch information as given by the Attitude Indicator, which is also the primary instrument for safe flight in IMC. Without the Attitude Indicator, the autopilot would not function correctly and would not be able to hold a heading or an attitude.

The GPS unit was damaged in the crash and so it is not possible to determine the aircraft’s last recorded position nor see what communication and navigation frequencies were set.

The flight was tracked externally by two radar installations. The radar tracking is not completely accurate and in fact, the tracks from Lowther don’t quite coincide with the tracks from Tiree. However, there’s certainly enough data to understand the “motion trends” and get a general feel for what the aircraft was doing.

The plane appears to have been “under reasonably precise control” until the final tight turn when the aircraft starts to descend rapidly. Lowther then loses secondary radar, indicative of the aircraft being in an unusual attitude. From the data, it appears that the Smiths had lost control of the aircraft and were plummeting nose first towards the ground.

The vacuum pump was severely damaged, the rotor and vane assembly had shattered. However, close examination showed rub marks on the fracture faces … which meant that that the engine-driven end of the pump must have still been rotating after the coupling fractured. That meant the engine was still running.

That means that the fracture must have occurred before the aircraft crashed into the ground.

The vacuum pump was eleven years old and had done approximately 994 hours. The pump manufacturer had sent out a Service Letter which limited its use to 6 years and 500 hours but the aircraft owners were not aware of this. The service manual was unclear and it could be understood that the pump needed to be replaced at the 1,000 hour inspection.

The vacuum pump had only one function on this aircraft: to supply vacuum pressure to operate the Attitude Indicator.

If there was no vacuum pressure, the gyro rotor within the Attitude Indicator would slow down and then start to topple. This takes quite some time and minutes could pass before the gyro was moving slow enough to become unbalanced.

The Attitude Indicator will give false information based on the movement of the gyro: it can’t tell the difference between the plane movements and the gyro toppling. If the autopilot were engaged, it would follow the false indications of pitching and rolling shown by the Attitude Indicator.

If the plane has lost vacuum pressure, the Attitude Indicator will not show it. The suction gauge should show a zero reading and the vacuum pressure failure light should illuminate.

As a result of the impact damage, it was impossible to determine whether the light was illuminated before the plane crashed. Nor is it possible to determine whether the autopilot was engaged at the time of the crash. But the faulty readings of the Attitude Indicator could confuse a pilot as easily as they do the autopilot. Flying in cloud, a pilot relies on the Attitude Indicator because his own responses cannot be trusted.

With the absence of outside visual references, physical sensations can produce compelling perceptions of the aircraft’s attitude and manoeuvres that differ markedly from those indicated by the flight instruments and spatial disorientation can occur. This tends to be more likely when recent and/or total instrument flying experience is low and in a high stress situation, or with alcohol in the pilot’s blood.

The flying conditions through cloud would have been stressful. Neither pilot had been trained in instrument flying. Both pilots had blood alcohol levels over the legal limit. Score three out of three for spatial disorientation.

Flying through clouds, the pilot would have suffered from “the leans”. A major breakthrough in aviation safety in the early 20th century was understanding this phenomenon and teaching pilots to use instruments for visual input, rather than trusting the false sensation of leaning. Instrument training teaches a pilot to use all the instruments in order to get a clear understanding of the aircraft’s attitude, including what to do under circumstances like this where a primary instrument has failed.

Without visual input, a pilot can inadvertently put the aircraft into a turn in order to try to straighten out a non-existent turn. This inadvertent turn then develops into a spiral dive and the plane accelerates nose-first into the ground, just as the radar tracking shows.

Although the Air Accidents Investigation Branch did not have records of accidents caused by vacuum system failures, their US counterpart, the National Transport Safety Board, had 62 accidents/incidents over the past twenty years which cited the vacuum system as one of the factors. Of those incidents, 40 were fatal. Reports showed that in many, the pilot was aware of the loss of vacuum pressure before losing control in IMC conditions – that is to say, flying through cloud.

It’s still possible that something else happened, that the pilot was incapacitated in such a way that did not leave medical evidence … and it is impossible to prove without a doubt that the vacuum pump failed completely; however the final spiral dive combined with high airspeed are standard symptoms of spatial disorientation and there is clear evidence that the pump must have broken before the impact.

The Air Accidents Investigation Branch concluded that the failed vacuum pump was the only failure discovered in the wreckage that could have caused the resulting loss of control of the aircraft. It is unclear when the vacuum pump failed but they estimate that the resulting erroneous readings probably started just before the aircraft entered the final left turn, approximately 24 seconds before the radar track was lost.

Conclusion

The aircraft crashed after control was lost while in IMC. The characteristics of the final flight path, particularly the high airspeed, the rapid descent and the rate of turn, were consistent with the effects of spatial disorientation. The pilots were not IMC or Instrument Rated, and alcohol was present in both pilots. It is likely that the accident resulted from loss of control as a result of the pilots following unreliable indications from the AI, whilst in IMC. The AAIB has made four Safety Recommendations relating to the maintenance of vacuum pumps.

The pilots were not IMC or Instrument rated. Had they been flying under VFR conditions, in sight of the surface, they would probably have been able to maintain control of the aircraft.

Four recommendations were made, focused on the correct maintenance of vacuum pumps. As for VFR pilots who fly in bad weather because they just really want to get home, well, there’s not much that the AAIB can recommend other than Don’t!

And if that hasn’t already got you wanting more, the accident also resulted in 19-year-old Betty Lou Oliver taking the Guinness World record for the longest survived elevator fall recorded.

So what happened?

Lieutenant Colonel William Franklin Smith Jr was the pilot of the B25 bomber.

750thSquad

Col Smith was with the original complement of officers as a 1st Lieutenant when the unit was formed and a Lt Col at the end of the war. He had a jaunty and devil-may-care attitude and was very popular with the men who flew with him. He witnessed all 236 missions of the 457th but fate caught up with him in 1945 after returning from England. He and several others were flying a B-25 bomber from Boston to his new assignment in the midwest.

The plane, a North American B-25 Mitchell medium bomber, was called the “Old John Feather Merchant”.

Lt. Colonel Smith was flying from Boston to Newark airport where he would pick up his superior officers. He travelled through steadily increasing fog and requested a weather report at 25 miles east of his destination. ATC at New York Municipal Airport (now La Guardia) reported that the ceiling was “near zero” and visibility forward limited to three miles.

The B-25 that Crashed Into the Empire State Building • Damn Interesting

Municipal tower reported extremely poor visibility over New York, and urged him to land, but Lt. Colonel Smith requested and received clearance from the military to continue his flight. “From where I’m sitting,” the tower operator warned, “I can’t see the top of the Empire State Building.” Despite the advice from the Municipal tower, Smith plunged into the soupy fog with his two crewmen, bound for Manhattan.

The Empire State Building, built in 1930, is 1,453 feet to the tip of the broadcast tower. It was built to take the impact of a 10-ton aircraft.

Gloria Pall was 18 and worked at the Empire State Building on the 56th floor, having been turned down by the Catholic War Relief Services group on the 79th floor because she was Jewish.

Eyewitnesses reported seeing the bomber overhead at about 500 feet and said that it just missed the Rockefeller center. The plane then climbed away back into the fog.

Historical Perspective: Plane hits Empire State Building

No one knows for sure, but investigators believe that Col. Smith looked down through a break in the cloud cover and saw a curved river and thought it to be the East River, when in fact it was the Hudson. Seeing this curve it is believed that he then descended for his approach at Newark airport. It is believed that the planes speed at this time was 225 mph.

Lt Colonel Smith appears to have seen the building at the last moment: the gear was moving up and the nose was pitched up but he was already too close to the building to evade it. The bomber crashed into the building at the 78th and 79th floor. The building was rocked by the impact which was heard for miles. A fire burst out immediately.

Gloria Pall was working that Saturday but she didn’t mind because the weather wasn’t good enough to go to the beach anyway. She remembers being disappointed that the “pea-soup fog” blocked her view when there was a loud explosion that threw her against the room.

The day a B-25 Bomber crashed into the Empire State Building

“It’s the German Buzz Bomb!” yelled Sarah, who was usually calm. “They tricked us. They didn’t really surrender!”

Another lady screamed that it was Martians. “We’re being invaded,” she yelled. “I just know it. We’re not getting out of here alive!”

Joan’s boss, Hazel, a short, rotund sweet-faced redhead, was calmly sitting in front of her Danish pastry and coffee. She was still on her break and had just returned from the first floor coffee shop.

The aircraft with a 67-foot wingspan created an 18 x 20 foot hole. The fuel tank exploded. Lt Colonel Smith and three others onboard died on impact and eleven office workers died immediately by the flying metal or in the fire.

Historical Perspective: Plane hits Empire State Building

The 102-foot building was rocked by the impact. Many people who were in the street at the time saw flames shooting from the point of impact, which was at the 913-foot level. The impact was heard as far as two miles away. Flames and dense smoke obscured the top of the structure. Later on a wing was found on Madison Avenue, one block away.

Nearby buildings were damaged by fragments of the impact and one of the planes engines was found on the South side of the building in the top of a twelve story building. The engine had flown over thirty-third St. and had crashed through a skylight in a penthouse. The engine started a $78,000.00 fire in the studio of sculptor Henry Hering.

Here’s a news reel from the time:

The plane crashed into the north side of the building. One wing was found on Madison Avenue. One of the engines was found on the south side of the building.The other engine fell down an elevator shaft and damaged the cables, including cutting the safety cables, as it fell.

Therese Fortier Willig was on the 79th floor, working for the Catholic Relief Services.
The Day A Bomber Hit The Empire State Building : NPR

“In the other side of the office, all I could see was flames,” Willig said. “Mr. Fountain was walking through the office when the plane hit the building and he was on fire — I mean, his clothes were on fire, his head was on fire. Six of us managed to get into this one office that seemed to be untouched by the fire and close the door before it engulfed us. There was no doubt that the other people must have been killed.”

Betty Lou Oliver, a 19-year-old elevator operator, was on the 80th floor. She was badly burned in the initial fire. Rescue workers placed her into the elevator to send her down an ambulance waiting at the bottom, with no idea that the cables had been damaged. There was a sound like a gunshot when the final cables snapped.

Our Local Correspondents: Up and Then Down : The New Yorker

By the time the car crashed into the buffer in the pit (a hydraulic truncheon designed to be a cushion of last resort), a thousand feet of cable had piled up beneath it, serving as a kind of spring. A pillow of air pressure, as the speeding car compressed the air in the shaft, may have helped ease the impact as well. Still, the landing was not soft. The car’s walls buckled, and steel debris tore up through the floor. It was the woman’s good fortune to be cowering in a corner when the car hit. She was severely injured but alive.

This remains the longest fall survived in an elevator according to the Guinness Book of World Records.

Gloria Pall and her friend Joan escaped the building using the stairwell, which had two long flights of steps between landing. One hundred and twelve flights later, they reached the ground floor and dashed out of the building.

The day a B-25 Bomber crashed into the Empire State Building

As Joan and I went over to look at the engine on 33rd Street, Mayor Fiorello LaGuardia came over to us to ask how we were, and congratulated us on our survival. As we turned to go, my boss pushed his way through the crowd and approached me.

“You ought to come in next Saturday because you didn’t even work two hours today,” he said, oblivious to my disheveled appearance, and the fact that I had my arm in a sling and traces of debris still on my clothes and face.

“What a grump,” I thought, “With all these people applauding us, he’s punishing me for surviving! How insensitive!” Joan and I turned, climbed over the rope that partitioned off the building, and limped our way down the street to the BMT subway so we could get back to Brooklyn.

Dozens of passengers leapt from the national carrier Garuda Airline plane's emergency exits into surrounding rice paddy fields to escape the inferno, which reduced the aircraft to a smoldering wreck of twisted metal. -Dwi Prasetyo on Reuters.com

The accident investigation report reference KNKT/07.06/07.02.35 is available online at the NTSC site as a PDF: Final Report.

Here’s my summary and analysis of the key information including excerpts from the Aircraft Accident Investigation Report by the NTSC. All images are from the report unless otherwise noted, in which case they link to the original source.

All times are given in UTC. Local time for Yogyakarta, Indonesia is UTC+7 hours.

On 7 March 2007, a Boeing Company 737-497 aircraft, registered PK-GZC, was being operated by Garuda Indonesia on an instrument flight rules (IFR), scheduled passenger service, as flight number GA200 from Soekarno-Hatta Airport, Jakarta to Adi Sucipto Airport, Yogyakarta. There were two pilots, five flight attendants, and 133 passengers on board.

ATC referred to the flight as “Indonesia 200″.

Here’s the timeline of the events:

21:30 Pilot in Command (PIC) and co-pilot commence duty at Jakarta.

Both pilots had over a day of rest time before the flight. There’s no evidence that either was unfit for duty.

The PIC had logged 13,421 hours flight time with 3,703 as pilot in command on type. He completed Controlled Flight into Terrain and Approach-and-Landing Reduction training recurrency just over a year before the accident.

The copilot had logged 1,528 hours of which 1,353 were on type.

Both crew members had attended an introductory seminar for the Enhanced Ground Proximity Warning System in 2005.

However, the accident report notes that there is no evidence that either pilot had been checked or received Boeing 373 similator training for appropriate vital actions and responses for alerts as warnings, such as TOO LOW TERRAIN and WHOOP, WHOOP, PULL UP. Note that the correct response to such a warning is to take control of the aircraft and aggressively apply maximum thrust, get the wings level and pitch up to 20 degrees. This will be important later.

23:17 Indonesia 200 departs Jakarta.

PIC was the pilot flying with the copilot offering monitoring and support. The initial flight was uneventful.

Up to the time of the top of descent briefing, the oral communication between the PIC and the copilot, air traffic control approach and tower controllers, and the company radio, were in normal tones and in an orderly manner. Subsequently, during the approach below 10,000 feet and prior to reaching 4,000 feet, the PIC was singing and there was some minor non-essential conversation, which was not in accordance with the Garuda Basic Operations Manual policy for a sterile cockpit below 10,000 feet.

23:43 PIC begins the crew briefing. The briefing is interrupted by Yogya Approach with clearance. After the radio call, the PIC continued with the crew briefing for an ILS approach.

23:54:10 Pressure altitude 6,560 feet, airspeed 269 knots
Yogya Approach asks the crew to confirm that they are visual.
The copilot responds with ‘affirm’.

At no time did the copilot inform ATC that they were flying the 09 ILS approach.

The Approach Controller cleared Indonesia 200 “for visual approach runway zero nine, proceed to long final, report runway in sight.”

The copilot read back the clearance and asked if they were cleared to descend to circuit altitude.

23:54:33 Pressure altitude 5,792 feet, airspeed 279 knots
The Approach controller clears Indonesia 200 to descend to 2,500 feet.

During this descent the PIC commented “Oops, strong wind”, showing a lack of observation of the strong wind they’d encountered during the flight. The wind at this stage had decreased from previous levels as they descended.

Eleven seconds after expressing concern about the wind, the PIC said ‘Target enam koma enam ILS, kagak dapat dong’ (the target is 6 point 6 ILS, we will not reach it). The PIC then attempted to trade off excess airspeed and lose height, but only succeeded in flying a flight path that was erratic in pitch, causing the airspeed and altitude to vary considerably. The PIC flew an unstabilized approach.

23:55:19 Pressure altitude 4,384 feet, airspeed 293 knots
The aircraft at this stage is at 3,419 feet above aerodrome elevation and flying much too fast.

The Garuda Aircraft Operation’s Manual specifies a maximum control speed in the terminal area below 10,000 feet as 250 knots. A speed over 250 knots requires air traffic control approval.

The airspeed increased from 288 knots to 293 knots then reduced to 243 knots.

Effectively, the PIC went into a steep descent to trade height for speed at a point in the approach when he should be losing height and speed. He lost 2,912 feet with his erratic flight path.

23:55:33 Aircraft is 10 miles out. Initial fix in the approach chart is 2,500. Aircraft was 1,427 feet above this and travelling at 283 knots.

The company Operations Manual required the aircraft to be configured for the landing, with the landing gear extended, flaps 15, and the airspeed 150 knots, when approaching the final approach point (FAP), one dot up on the glideslope instrument. When GA200 passed the FAP, the speed was 254 knots (groundspeed 286 knots), and it was in the clean configuration, meaning that the landing gear and flaps were not extended.

This is twenty seconds after he’d stated that they won’t reach the target.

23:56:35 Pressure altitude 3,456 feet, airspeed 239.5 knots
Wing flaps 1 degree position set.
Yogyakarta Tower: Surface wind calm, continue approach runway 09 report final

Runway 09 has a landing distance of 2,200 metres.

23:56:46 Pressure altitude 3,296 feet, speed 231 knots
PIC: gear down

They are now 2,596 feet above aerodrome elevation.

The gears are extended. The plane continues to descend. It is too high and too fast.

23:56:49 PIC: oh there is something not right

Between 23:56:49 and 23:57:20 the aircraft was in an unstabilized approach condition with the speed varying between 229 and 244 knots, pitch varying between 3.5 degrees up and 3.8 degrees down, and the rate of descent reached 3,520 feet per minute at 23:57:20.

[...]

The PIC said ‘The target is 6.6 ILS, we will not reach it’. The PIC flew an unstabilized approach. He also realized the abnormal situation when he commented ‘Wah, nggak beres nih!’ (‘Oh, there is something not right’). So, the PIC’s intention to continue to land the aircraft, from an excessively high and fast approach, was a sign that his attention was channelized during a stressful time.

23:57:13 PIC: check speed, flaps fifteen

23:57:15 Ground Proximity Warning System: SINK RATE SINK RATE
The terrain closure rate is 3,461 feet per minute. The aircraft is 1,369 feet above the runway.

23:57:17 Copilot: flaps five

The PIC requested fifteen as well as a speed check. The copilot did not offer a speed check nor did he make any attempt to explain why he intended to set the flaps to five instead of fifteen.

The reason was clear. The recorded airspeed of the aircraft at that point was was 238 knots. The maximum indicated airspeed for extension of flaps to the 15 position is 205 knots. So why didn’t he say so?

At interview the copilot stated that he did not extend the flaps to 15 degrees as instructed by the PIC, because the airspeed exceeded the maximum operating speed for flaps 15.

The PIC stated that he was unaware of the actual airspeed, and expected that the copilot would inform him of any speed concerns.

Quite right! On the other hand, he’s already ignored the Ground Proximity Warning System and he did not react to any of the other statements by the co-pilot, so it may not have made a difference. Still, there’s a critical failure here in terms of monitoring and support.

23:57:19 Tower Controller: Indonesia 200, wind calm, check gear down and lock clear to land runway 09
Ground Proximity Warning System: TOO LOW TERRAIN TOO LOW TERRAIN

23:57:23 The copilot selects wing flaps to the five degree position.
PIC: Clear to land Indonesia 200

Remember that as far as the tower controller is aware, they are doing a visual approach.

23:57:29 PIC: Check speed, flaps fifteen
PIC: Flaps fifteen
PIC: Flap fifteen
PIC: Check speed, flap fifteen

Their speed was around 252 knots at the first of these four times the PIC requested flaps fifteen. Maximum flaps operating speed for Flaps 5 is 250 knots. Flaps 15 maximum is 205 knots.

During this time, and until 1 second before the GPWS sounded ‘ten’, meaning 10 feet above the runway, the GPWS warning continued to sound loudly.

At interview, the PIC stated that he continued to call for flap fifteen because he was committed to land from the approach, and was aware that he would not be able to use flaps 40 as planned. He knew the risks, but believed that he could safely land using flaps 15, even with the higher airspeed required for a flap 15 approach.

23:57:34 Flaps reach the five degrees position
The aircraft is 569 feet above the runway. Airspeed is 254 knots, rate of descent is 1,600 feet per minute.

Garuda Indonesia Operations Manual states that any approach that becomes unstabilised below 500 feet above the aerodrome in VMC requires an immediate go around. The aircraft had never achieved a stabilised approach.

23:57:37 PIC: flight attendant, landing position

This was seventeen seconds before touchdown. The flight attendants should have been given enough time to sit and fasten their seat belts and “sit quietly for one minute to recall the emergency memory items.”

23:57:41 Ground Proximity Warning System: WHOOP, WHOOP, PULL UP

You’ll remember the correct response to this warning is to aggressively apply maximum thrust. That is, go around.

23:57:43 Copilot: Wah Captain, go around Captain

The aircraft is 217 feet above the runway. I don’t know about you but I was shouting “Go around!” at my screen long before this point.

23:57:45 Ground Proximity Warning System: WHOOP, WHOOP, PULL UP

There’s no justifiable reason not to go around at this point. This is pretty much the definition of an unstabilised approach. Almost every factor is wrong.

The copilot should have taken control and initiated a go around as the PIC hadn’t.

The PIC response to the situation is telling.

23:57:47 PIC: Landing checklist completed, right?

The PIC does not appear to have registered the warnings nor the copilot’s call to go around at all. The accident report describes his actions as fixated.

He intended to land the aircraft, so that the other tasks and warnings (GPWS ‘PULL UP’ and calls from the copilot) were either not heard or were disregarded. His attention was channelized and focused on landing the aircraft from the approach.

That is to say, his every priority was the landing and he simply disregarded all information that was not directly relevant to landing the plane. He never considered aborting the landing, so information relevant to not landing the plane was disregarded.

The copilot made no attempt to take control of the aircraft from the PIC.

Seven seconds before touchdown, the rate of descent was 1,400 feet per minute and decreasing. The aircraft crossed the runway 09 threshold at 89 feet above the ground (704 feet pressure altitude), at an airspeed of 234 knots (groundspeed of 236 knots).

The aircraft is travelling 98 knots too fast as it crosses the threshold.

The aircraft levelled off about ten feet above the runway for 4 seconds before touching down with a groundspeed of 235 knots.

The touchdown should have occurred around 300 metres from the landing threshold. The touchdown zone ends at 620 metres.

23:57:54 The aircraft touches down for the first time, 860 metres from the threshold, airspeed 221 knots.

The landing speed for 40 degrees flap is 134 knots. The maximum tyre speed is 195 knots groundspeed.

The plane’s touchdown speed was 221 knots. It landed 240 metres past the touchdown zone.

23:57:54 Copilot: go around

The aircraft bounces. Twice.

At the third (final) touchdown, the nose landing gear touches down heavily before the main landing gear.

The g force at the third (final) touchdown was about 2.9 g, and the aircraft’s pitch angle was about -1 degree (nose down), which caused the nose landing gear to touchdown heavily before the main landing gear. The left nose wheel tire failed due to high rotational forces applied during the initial landing roll. The subsequent bending load on the left nose wheel axle was above the material’s ultimate strength and caused the left axle to fail. Metal from the failed left nose wheel slashed the right nose wheel tire, causing deep cuts to the tire’s crown. The outer hub of the right nose wheel separated, leaving pieces on the runway. The inboard hub of the right nose wheel remained attached to the right axle and was scoring the runway during the high speed landing roll.

I have to give the PIC credit, that’s perfectly lined up on the centre-line, even after two bounces!

23:58:10 The aircraft overran the departure end of runway 09 at Yogyakarta Airport.

The Runway End Safety Area (RESA) is a paved area of 60 metres long. There is an additional 98 metres of grass thereafter which is not defined as part of the RESA. The ICAO standard requires a distance of at least 90 metres and recommends a RESA of 240 metres or more for a Category 3 airport such as Yogyakarta.

The PIC reported that as the aircraft was about to leave the runway, he shut down both engines. The aircraft crossed a road, and impacted an embankment before stopping in a rice paddy field 252 meters from the threshold of runway 27 (departure end of runway 09).

The fire fighting personnel noted the fast and high approach of the aircraft and the burst wheel on the runway. They mobilised two fire fighting vehicles to the perimeter fence immediately. But they couldn’t get past the embankment that the aircraft had barrelled through.

The fire fighters were unable to reach the wreckage due to the embankment and remained in position about 130 metres from the centre of the crash site. They sprayed the foam fire suppressant from the embankment but it was too far for the spray gun to reach. They attempted to deploy the flexible hose but it was punctured by vehicles driving over it and on the airport fencing. As a result of the lack of pressure, they were not able to cover the whole surface of the wreckage.

The fire was uncontrolled and consumed the aircraft.

The Airport Emergency Plan (AEP) required, the chief of fire fighting AP1 to lead the fire fighting operation, but at the time of the accident he was not able to lead the operation, due to too many people trying to act as leader and giving commands to fire fighting personnel. About 45 minutes after the accident, two city fire fighting vehicles arrived and were ordered by an un-qualified person to start hosing the fire. However, the city vehicles did not have foam; only water.

02:10 The fire is finally extinguished. The rescue operation continues.

Human factors are always an issue in any emergency situation and must be taken into account. But this Garuda Indonesia accident was so beset by problems, it is off the charts.

The co-pilot appears to have completely failed to offer basic monitoring and support to the pilot. He did not appear to notice the wind, he did not warn the PIC of excessive speed, he chose not to fulfil the PIC’s instructions but did not tell the PIC, and he did not respond at all to the repeated requests for a speed check. Once it was clear that the PIC planned to continue the landing from an unstabilised approach, he should have taken control of the aircraft and gone around.

The chaos of the rescue operations encompasses a further few pages of the report, which I have not covered in detail here. It took over two hours to extinguish the fire and although the report is not clear on the effects of this, it does say that this delay “may have significantly reduced survivability”.

But all of this pales into insignificance in the face of the pilot who continued the approach and landing despite all evidence available to him that this was an unsafe landing.

Garuda Indonesia’s policy is very clear: in case of an unstabilised approach, go around. Let’s see how many of the elements of a stabilised approach were in place?

Garuda Stabilised Approach Procedure
Recommended Elements of a Stabilized Approach
All approaches should be stabilized by 1000 feet HAA in instrument meteorological condition (IMC) and by 500 feet HAA in visual meteorological conditions (VMC). An approach is considered stabilized when all of the following criteria are met:

• the aircraft is on the correct flight path.
• only small changes in heading/pitch are required to maintain the correct flight path.
• the aircraft speed is not more than VREF +20 knots indicated airspeed and not less than VREF.
• the aircraft is in the correct landing configuration.
• sink rate is no greater than 1,000 fpm; if an approach require a sink rate greater than 1,000 fpm, a special briefing should be conducted.
• power setting is appropriate for the aircraft configuration.
• all briefing and checklist have been conducted.

These conditions should be maintained throughout the rest of the approach
for it to be considered a stabilized approach. If the above criteria cannot be
established and maintained at and below 500 HAA, initiate a go-around.

The PIC did not reduce the aircraft’s speed to the target airspeed of 141 knots for the approach. The actual speed was 245 knots. The aircraft was not in the landing configuration, and the actual sink rate of 3,520 fpm exceeded the Operations Manual requirement of not greater than 1,000 fpm. The landing checklist was not completed.

In fact, I’d say that out of the seven criteria, the approach might have fulfilled one: I presume the power setting was appropriate.

As the aircraft crosses the runway threshold it should be:

• Stabilized on target airspeed to within +10 knots until arresting the rate of flare.
• On a stabilized flight path using normal maneuvering.
• Positioned to make a normal landing in the touchdown zone (i.e., first 3,000 feet or first third of the runway, whichever is the less).

Initiate a go-around if the above criteria cannot be maintained.

Not any of these were in place.

The investigators asked the PIC what happened.

During interview he said to investigator that ‘his goal was to reach the runway and to avoid severe damage’. He ‘heard, but did not listen to the other voice (GPWS), and flaps 15 and speed 205 was enough to land’. The PIC experienced a heightened sense of urgency, and was motivated to escape from what he perceived to be a looming catastrophe, being too high to reach the runway (09 threshold). He fixated on an escape route, ‘which seem most obvious’, aiming to get the aircraft on the ground by making a steep descent. His decision was flawed, and in choosing the landing option rather than the go around, fixated on a dangerous option.

The NTSC Aircraft Accident Investigation Report concludes with the following primary causes:

1. Flight crew communication and coordination was less than effective after the aircraft passed 2,336 feet on descent after flap 1 was selected. Therefore the safety of the flight was compromized.
2. The PIC flew the aircraft at an excessively high airspeed and steep descent during the approach. The crew did not abort the approach when stabilized approach criteria were not met.
3. The pilot in command did not act on the 15 GPWS alerts and warnings, and the two calls from the copilot to go around.
4. The copilot did not follow company instructions and take control of the aircraft from the pilot in command when he saw that the pilot in command repeatedly ignored warnings to go around.
5. Garuda did not provide simulator training for its Boeing 737 flight crews covering vital actions and required responses to GPWS and EGPWS alerts and warnings such as ‘TOO LOW TERRAIN’ and ‘WHOOP, WHOOP PULL UP’.

For full details, read the final report from the NTSC.

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The spin was supposed to be a normal erect spin to the right, but for various unintentional reasons the spin went flat, up until that point I had never flat spun an aircraft. I eventualy mananged to get the aircraft into a normal erect spin from which I was able to recover. This aircraft is not fitted with an electric starter motor, so I was unable to restart the engine.

During the “flare” to land the main undercarriage caught the top wires of a barbed wire fence that was invisible to me.

After coming to rest inverted I waited 20mins for the rescue services to come and right the aircraft so I was able to exit via the outward opening canopy.

The aircraft rotated 26 times total, I was extremely disorientated after the recovery to straight and level flight, and was unable to read the instruments.

From the video I estimate I recovered at about 700ft from an entry altitude of 3500ft. If you listen carefully you will hear me say:”I think this is it”. At that stage I did not think I would be able to recover. However I continued to try various control inputs based on the aircraft attitude and rotational rate, which eventually effected a recovery.

My thanks go to the emergency services that found me and allowed my escape.

Here’s my original post from the time:

Fear of Landing » Tipsy Nipper feeling Dippy

Ever wondered what you’d do if you entered an unintentional spin? What about a flat spin, where the plane is horizontal and spinning like a top, all the while falling out of the sky.

Last autumn, there was a post to the Tipsy Nipper Owner’s Group Forum with this photograph and the following comment.

Whilst walking in the RSPB nature reserve in Tollesbury Essex I came across this Nipper after it had crash landed on Monday evening.

They were in the process of removing it on Tuesday morning when I went past, the pilot had a lucky escape as it had flipped over in the marsh, the pilot had to be freed by emergency crews.

The plane was immediately recognised as belonging to Neil Spooner but local news confirmed that he was unharmed. He posted on the message board within the week to let the members know what had happened:

A rather disturbing occurance, normal spin entry and the spin went flat. Having never done any flat spin training was rather at a loss as to what to do to recover (normal spin recovery techniques don’t work in a flat spin). However, a quick review of spin aerodynamics on the way down gave me a few ideas, one of which obviously worked. The engine stopped during the spin (22 rotations) which meant an outfield landing in a rather inhospitable area. The main wheels caught the two top wires of a barbed wire fence in the flare which both decelerated the aircraft and flipped it on its back. I spent 20mins waiting for the emergency services to turn up (pretty good I think) The police air support heli’ landed close by and 2 crew lifted the tail so I could open the canopy and step out. Absolutely no injuries except my pride.

Twenty-two rotations! No, he wasn’t counting, he had a webcam and laptop connected so that he could analyse his aerobatics later. You can read the full accident report as a PDF on the Air Accidents Investigation Branch website.

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The Citation, OY-JET, was coming into Atlantic City, New Jersey. He had the airport diagram attached to his control column which read “Arpt CLOSED to jet traffic”. The pilot flew a low pass over runway 29 and then climbed out to the right. He then came in to land on runway 11.

Somewhat telling is the commentary from the person who started filming: “We’ve got a nutball trying to land.” Even he didn’t expect to see the landing go so completely wrong, though. And then at the half-way mark of the video, just when I thought it was all over, things suddenly get exciting again. Take a look:

The pilot stated that he “lost the brakes”; however there as no fault found with the brake system nor the emergency brake system. However, examination of the runway shows that the treadmarks start about two-thirds down the runway.

OY-JET appears to have touched down about 800-1,000 feet beyond the approach end of runway 11. The video shows us the windsock with a tailwind which as been estimated at 10-15 knots. Runway 11 is a 2,948 foot asphalt runway.

NTSB Factual Report NYC05LA085

According to the Cessna 525A Landing Distance Chart, an airplane with a landing weight of 11,400 pounds required 3,000 feet of landing distance, in a no wind situation. With a 10 knot tailwind, the airplane required 3,570 feet of landing distance.

So if he’d landed on the numbers, he still would have not have been able to land safely. Touching down a third of the way down, he had no chance at all.

The same pilot has been in the news once before, as a result of this photograph taken into the cockpit of a Cessna 550 Citation II at Copenhagen five years previous. Maybe he’d planned to go skinny-dipping?

The NTSB have published Probable Cause on their website.

The pilot’s improper decision to plan a flight to a runway of insufficient length, his improper in-flight decision to land on that inadequate runway with a tailwind, and his failure to obtain the proper touchdown point.

Other than that, though, it was a lovely landing.

The owner of the aircraft appears to have one heck of a sense of humour. They’ve replaced the ruined aircraft with a Cessna 680:

Photos: Cessna 680 Citation Sovereign Aircraft Pictures | Airliners.net

The new registration? OY-WET

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