June 3, 2002
Vol. 16 Iss. 22

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Table of Contents


'Awesome Effects' of Chinese Jet Crash Anticipated

Structural Failure, Fuel Tank Explosion, Possible Scenarios

Flammable vapors in the center wing tank of an airliner flying at 35,000 feet can be ignited if an errant ignition source is strong enough, experts say. The scenario may be relevant to the May 25 crash of China Airlines flight CI-611 while flying six and a half miles high over the waters of Taiwan Strait on a routine 90-minute flight from Taipei to Hong Kong. The B747-200 exploded into four major pieces, killing all 225 passengers and crew aboard.

To be sure, at this preliminary stage in what is sure to be a comprehensive investigation by Taiwan's Aviation Safety Council (ASC), other scenarios apply: the sudden structural failure and explosive decompression of an aging jetliner, a terrorist bomb, a failed cargo door locking mechanism, and possibly others. A mid-air collision may be ruled out, as the extensive radar coverage of the Taiwan Strait does not show the track of another airplane, military or civilian, intersecting the flight path of the accident aircraft. Nor does the accident airplane appear to be the victim of a surface-to-air missile launched in the heavily militarized area of confrontation between Taiwan and mainland China. A missile capable of downing an aircraft at 35,000 feet would be large enough to be picked up on radar.

While some aviation authorities have declared the air is too rarified at 35,000 feet for vapors in the center wing tank of a B747 to explode, scientists who have studied the hazard say the potential exists. The B747 features a large center wing tank (CWT), about the size of a two-car garage to a height of six feet. Three air conditioning packs are located immediately beneath the tank. Whether the packs provide cooling or heated air to the passenger cabin, they generate heat. That heat can migrate into the CWT, contributing to the creation of flammable vapors in the space between the liquid fuel and the tank walls. The term "ullage" often is used to describe the vapors in this space.

"At 30,000 feet the ullage is flammable in a temperature range of 15?C to 50?C [60?F-126?F]. At 35,000 ft. the nominal range is 12?C to 47?C (54?F to 116?F)," said Dr. Joseph Shepherd, Ph.D., an expert in the field at the California Institute of Technology's (Caltech) Explosion Dynamics Laboratory (EDL). With respect to the ignition energy, Shepherd said, "The ignition energy requirement increases rapidly with decreasing temperature, and the tank contents cool rapidly at 35,000 feet." In various experiments in which Shepherd participated, simulated fuel tank explosions occurred at ambient pressures of 4.4 psi and with ullage temperatures as low as 26?C (79?F). "We never did experiments at temperatures and pressures lower than this condition since our work was focused on the TWA scenario," Shepherd added. At 35,000 feet, the altitude at which the China Airlines B747 exploded, the ambient pressure is about 3.5 psi. Nevertheless, experiments conducted many years ago showed that flammable ullage can explode at altitudes as high as 40,000 feet if there is a sufficiently energetic ignition source.

Given the paucity of data presently available, it is premature to predict the final outcome of the ASC's investigation. The physical evidence will reveal a catastrophic structural failure, as it was in the explosive decompression of a high-time Aloha Airlines B737 in 1988. Microscopic pitting and "gas wash" in the metal remains will provide telltale evidence if a terrorist bomb destroyed the aircraft. Gouged metal, frayed wires, blackening and charring from arcing, will reveal if a cargo door blew off.

A CWT explosion also would leave unique evidence of the type that led U.S. National Transportation Safety Board (NTSB) investigators to conclude that such a blast destroyed TWA Flight 800 in 1996. Witness marks left on the structure as it collapsed under the force of the explosion, fire damage and sooting all pointed to a CWT explosion. The TWA tragedy was followed by the March 2001 CWT explosion in a Thai Airways International B737 - another Boeing [BA] design with air conditioning packs located under the CWT. The 1990 CWT explosion of a Philippine Airlines B737 on the ground at Manila also should be mentioned. In each of these three cases, the ambient conditions were hot, the air conditioning packs were running and the CWTs were empty, carrying only a small amount of residual fuel sloshing on the bottom of the tank.

Similarities with TWA Flight 800

Indeed, experts see a number of similarities between the loss of the China Airlines B747 and the 1996 explosion that destroyed the TWA B747:

  • Both were old jets. The TWA jetliner was 25 years old; the China Airlines B747 was another "Classic" model, some 23 years old.
  • Both jets were built with general purpose wiring known to crack with age. Cracking of the Poly-X wiring installed in early-model B747s was recorded with as little as 6,000 hours of service, which equates to about four years of flying. Cracked, chafed, frayed and otherwise damaged wire insulation can create an opening for electrical arcing. In the case of TWA 800, the NTSB concluded that a power surge from one wire in the same bundle was transmitted via a low-power fuel-quantity indication system circuit into the CWT. This was deemed the most plausible ignition source of the fatal explosion.
  • Both the China Airlines and the TWA jets were operating with empty CWTs.

    CWT explosions in 1990, 1996 and 2001 all occurred in conditions of high ambient temperature, in the 90°F range. The temperature at Taipei, where the China Airlines jet departed, also was in the 90°F range.

  • The TWA jet blew up 16 minutes into its flight. The China Airlines jet exploded 19 minutes after takeoff. The tank is inside the outer skin of the airplane, and with the air conditioning packs operating continuously during flight, they will continue to generate heat that will migrate into the tank. "Using the same rate of temperature decrease and TWA 800 type initial conditions, I estimate that after 20 minutes the ullage temperature would drop to about 110?F ... The temperature will continue to drop during the flight. Since these temperatures are well inside the known flammable range, the tank will most likely be flammable 20 minutes into the flight," Shepherd explained.
  • There were no reported difficulties. No final message or distress call was heard from the TWA crew. No message was heard from the China Airlines jet, radio call sign Dynasty Six One One.
  • The TWA jet exploded at 14,000 feet. At only twice that altitude, the China Airlines jet exploded.

As has often been observed, the art of prophecy can very difficult, especially with respect to the future" No conclusions dare be drawn as to the probable cause. Indeed, there is one bit of evidence that contradicts an exploded fuel tank scenario - nothing brought out of the water yet shows evidence of fire damage. The absence of fire damage points a tentative finger to catastrophic structural failure of a high-time jet. However, if a fuel tank explosion destroyed China Airlines Flight CI-611, the implications go beyond significant. "The effects are going to be awesome," predicted Bill Kauffman, an explosives expert in the Department of Aerospace Engineering at the University of Michigan. Kauffman ticked off at least four effects:

  1. Depressed demand for air travel, with passengers refusing to board "flying bombs."
  2. A major mobilization to inert the ullage in all heated CWTs. To date, the industry has resisted this effort as not cost-effective.
  3. An acceleration of the fuel system safety deadlines mandated by the Special Federal Aviation Regulation (SFAR 88) issued May 7, 2001, by the Federal Aviation Administration (FAA). The three-year program outlined in SFAR 88 may have to be compressed considerably (see ASW, May 14, 2001).
  4. Whether a CWT explosion or catastrophic structural failure from cracking, corrosion fatigue (or a combination), Kauffman predicted "more grief" regarding the so- called "geriatric jets."

"There may be an effort to 'hard time' them for mandatory retirement at 20 years," Kauffman said. >> Shepherd, e-mail jeshep@galcit.caltech.edu; Kauffman, e-mail cwkauff@engin.umich.edu <<


'Spoiler Not Armed' Alert Needed for Correct Landing Configuration

'Proper warning for landing does not exist,' Swedish Report Concludes

A runway overrun in Sweden illustrates the universal nature of aviation hazards and at the same time the different emphasis investigating bodies can place on corrective actions. The case involves a Scandinavian Airlines System (SAS) DC-9-82 that landed on a wet runway at Kronoberg Airport (VXO) in Vaxjo, Sweden, after a flight from Stockholm. The pilots had failed to arm the spoilers and were unable to stop the airplane before running out of concrete.

The airplane came to a halt with its tail some 135 feet (41 meters) beyond the paved edge of the runway. The airplane was undamaged, and none of the 125 passengers and crew was injured.

The case features amazing coincidences with the crash of an American Airlines [AMR] MD-82 at Little Rock, Ark. The pilots of American Flight 1420 landed on a wet runway and, not having armed the spoilers, were doomed to overrun. In this case, the outcome was grievous - the airplane roared off the far end of the runway at approximately 100 mph., struck a steel light stanchion in the Arkansas River flood plain, and the aircraft was destroyed. Capt. Richard Buschmann and ten passengers were killed by the impact and subsequent fire (see ASW, Feb. 14, 2000). The crash at Little Rock occurred June 1, 1999; the SAS incident followed on June 23, 1999, 22 days after the fatal overrun in the United States. Two cases, half a world apart, involving wet runways, the same series of aircraft, and spoilers not armed.

In the case of the Flight 1420 crash, the U.S. National Transportation Safety Board (NTSB) concluded its exhaustive investigation with an admonition that cockpit procedures simply must be in place to ensure that the spoilers are armed (see ASW, Oct. 29, 2001).

Design deficiency

The Swedish Board of Accident Investigation (Statens haverikommission, SHK) concluded that, yes, as in the Little Rock crash, there were problems of crew resource management, but the SHK report went a step further. It pointed to a design flaw:

"SHK maintains that the aircraft's design, with a spoiler warning system for takeoff, but not for landings, is not logical. No proper explanation has been provided as to why a proper warning system for landing does not exist. It is SHK's opinion that the installation of a proper system to warn the pilots that the spoilers are not properly armed for landing is sufficiently motivated [ASW note: 'justified' might be a better word, but this is a translation from Swedish]. The absence of a proper system in this case has been compensated by the introduction of a pilot procedure."

Rune Lundin, SHK chief investigator for this case, explained that the spoilers are armed for takeoff, as a precaution should the pilots need to abort the takeoff run. The spoilers dump lift (hence the British term for them, "lift dumpers"), thereby allowing the brakes to perform with maximum effectiveness. If the pilots fail to arm the spoilers, an aural warning will sound when they advance the throttles to takeoff power.

Only partial warnings are provided for landing. For example, if the landing gear is not down. But for the spoilers, no warning comparable to that for takeoff will sound if they are not armed for landing.

Lundin said Boeing [BA] was contacted about this design deficiency. "Our recommendation was to improve the warning system to warn [of spoilers not armed] even when landing. Boeing's opinion was that it would be very expensive and demanded quite new sensors installed in aircraft," he recounted.

At the time of the Little Rock crash, American Airlines was practicing a "silent cockpit" doctrine in which only two of ten items on the before-landing checklist required a positive challenge and response between the pilot not flying (PNF), executing the checklist, and the pilot flying (PF). Those items involved the altimeter setting and the flight instruments/bugs. For items dealing with landing gear, flaps and slats, autobrake settings, and such, the PNF basically confirmed the settings himself as he worked through the switches of the carrier's mechanical checklist. On the night of the Flight 1420 accident, near midnight with both pilots fatigued after a long day, the spoilers were not armed. Nor at the time of the accident did American Airlines require a "no spoilers" callout from the PNF, which would alert the PF to manually deploy spoilers. Both policies combined to place Capt. Buschmann on a wet runway without spoilers - making a safe landing problematic. Buschmann tried to slow the airplane by applying 1.6 EPR (engine pressure ratio) reverse thrust, about 20 percent more than the manufacturer's recommended limit of 1.3 EPR for reverse thrust (above which the "blanking" effect on the rudder could cause the crew to lose directional control).

Six months later, another American Airlines MD-82 overran the runway at Palm Springs, Calif. With patches of water from recent rain on the runway, this landing, too, went badly. In the post-incident interview with investigators, the first officer said the landing felt normal until the captain (PF) activated the thrust reversers, at which point "everything got screwy." The airplane veered off the centerline, with the left main gear plowing through gravel before the crew was able to maneuver the wheels back onto the hard surface. Flying gravel inflicted minor damage on the airplane.

The first officer was heard declaring "spoiler levers armed" in the playback of the cockpit voice recorder (CVR). But they hadn't been armed, and the captain said he hadn't armed them and hadn't looked to confirm that the spoilers had been armed.

Two cases, two changes

Within a week of this Feb. 16, 2000, incident, and six months after the crash at Little Rock, American Airlines changed the DC-9/MD-80 operations manual, requiring callout and response for arming spoilers, and a PNF call after touchdown confirming deployment of spoilers or, as the case may be, a call of "no spoilers" so the PF can operate them manually.

Now consider some of the related details of the SAS overrun:

  • The captain was sure the spoilers had been armed before touchdown (spoilers must be armed in order for the autobrakes to work).
  • Initial rollout felt normal, but even with 1.4 EPR reverse thrust the airplane just didn't seem to be decelerating as expected. The reported 5-knot tailwind might have been stronger, the PF suspected.
  • Reverse thrust was increased to 1.8 EPR.
  • Still rolling at 60 knots, and with the end of the runway fast approaching, reverse thrust was increased to 2.1 EPR (some 60 percent above the manufacturer's recommended limit).
  • The PF checked that the autobrake system switch was in the correct position. It was. However, with the spoilers not armed, the autobrakes are not activated.
  • The spoilers did not extend after touchdown and no wheel braking took place, according to the flight data recorder (FDR).
  • The aircraft, as the saying goes, "departed" the far end of Runway 19's 6,890 foot length (2,103 meters) at a speed estimated between 11 mph and-23 mph. (10 knots and 20 knots).
  • SAS landing checklist procedures in effect at the time only required a challenge and response for the first 10 items on the checklist. Checklist items 11-15 were done from memory, without an individual challenge and response. After touchdown, SAS procedures called for the PNF to observe and call out whether or not the spoilers deployed. The flight crew told investigators that the pre- and post-touchdown procedures were part of their routine, and they hadn't deviated from habitual practice. However, they left the CVR running after the incident, which meant the period of time for approach and landing was not captured on the 30-minute loop tape. Contrary to procedure following an accident or incident, the crew had not immediately shut off the CVR by pulling the applicable circuit breaker.

SAS reaction

Just as American changed its procedures promptly after the no-spoilers overrun at Palm Springs, SAS initiated changes in the month after publication of the SHK incident report. Capt. Per Ytting-Knudsen, MD-80 chief pilot for SAS, explained the previous and post-incident practice. It had always been the pilot in the left seat who armed the spoilers. "When the left pilot is PF, this procedure seem to have been working just fine, as there is an 'informal' check by the right pilot that the arming is in fact done."

"But," he went on to say, "when the right pilot is PF, this check may not be so effective, as it is the left pilot who reads the checklist and performs this item. We therefore changed our checklist to read: SPOILERS - ARMED and CHECKED. The left pilot still arms the spoilers, and the other pilot checks that this has been performed."

"We have of course maintained our call out after landing regarding SPOILERS or NO SPOILERS if they do not deploy," he added. With respect to the 1.3 EPR limit for reverse thrust, Capt. Ytting-Knudsen said, "We are aware of this value and it is our standard setting."

Procedures have been tightened, but the design deficiency highlighted by the SHK - the absence of an alert that spoilers are not armed for landing - remains. In fact, SHK's perceived design shortcoming has been carried into the latest version of the DC-9/MD-80 series, the B717. A Boeing official said for this airplane, too, "There is no alert associated with failure to arm the spoilers."

"The arming is part of the landing checklist," he said. This procedure, of course, is the whole bone of contention raised by the SHK. In the course of the NTSB's investigation into the Flight 1420 crash, the Allied Pilots Association (APA), the union of American Airline pilots, weighed in with the same concern expressed by the SHK. In its extensive comments on the case to the NTSB, the APA cited as an ancillary failure in the Little Rock crash, "The failure of the aircraft manufacturer to equip this model aircraft with active warnings related to critical systems."

There may be a halfway solution - not during final descent, but an oral alert upon touchdown. According to the technical data for DC-9/MD-80/90 series aircraft, an electric solenoid unlocks the speed brake lever when the right main landing gear strut is compressed two inches by the weight of the airplane upon touchdown. This feature allows the pilots to manually deploy the spoilers. This same solenoid could activate an aural warning for manual deployment should touchdown occur without the spoilers having been armed to extend automatically. Even if manual spoiler deployment wasn't possible (i.e., lever won't move), there would still be ample time to convert the landing to a "touch and go," sources say. Capt. Buschmann's problem was that he didn't realize the missing element from the stop equation - spoilers not armed.

There can be no more dismaying feeling than to be sliding rapidly toward the end of a wet runway - up the proverbial creek, as it were - without the spoiler paddle. (The full report of the SAS incident may be read on the SHK website, http://www.havkom.se/) >> Lundin, e-mail lundir@telia.com; Ytting-Knudsen e-mail Per.Ytting-Knudsen@sas.se <<

'Not Logical'

"The commander felt certain that the spoilers had been armed for automatic deployment upon landing, which would enable the ABS (automatic braking system) to function correctly. The data on the flight recorder [FDR], however, does not indicate that this was the case. The statements given by both pilots to SHK support all the data on the flight recorder except [for] ... activation of the spoilers for automatic deployment and the confirmation of this must have been forgotten. If this mistake had been discovered during the landing rollout, then the commander should have instead used normal manual braking and the aircraft would ... [have] most probably stayed on the runway. The non-flying pilot must have also forgotten to verbally confirm automatic spoiler deployment after touchdown.

"SHK considers that the present aircraft design that warns the pilot against failure to activate the automatic spoiler deployment before takeoff but not for landing is not logical. A pilot performed procedure has instead compensated for this design fault."

Source: SHK Report RL 2000:38e, p. 5


Accidents and Incidents

DATE/SITE & INVEST. ID#
AIRCRAFT & REGISTRATION
CIRCUMSTANCES
DEATHS & INJURIES
PRELIMINARY ANALYSIS2
29 Aug 01 Malaga, Spain Casa CN-235 of Binter Awys F/O inadvertently shut down both engines following fire-warning. Crashed 50 meters short of runway threshold. 4 fatal and 26 injured of 47 on board National broadcast of cockpit voice recorder (CVR) CVR contents last week has greatly disturbed pilots' unions globally.
22 Apr 02 NTSB ID# CHI02IA116 Enroute Holman to Outagame Beech 200 reg: N26SJ of Flying Dollar Air, Inc. Airstair entrance door departed in cruise at flight level 190, near Hillsdale, Wisconsin. A/C landed at the Chippewa Valley Regional Airport Nil/9 on board Airstair entrance door was found in a field 30 nm northwest of Eau Claire. Inspection revealed it to be locked.
08 May 02 1600L NTSB ID# MIA02IA094 Montego Bay to Chicago O'Hare B737-448 reg: EI-BXI of Ryanair Severe inflight vibration until flaps five was selected. Diverted to Miami. Nil/160 on board 24-inch section of the right elevator trim tab was missing.
08 May 02 NTSB ID# NYC02IA097 All flts ex Covington A/P 3 x CL600-2B19 regional jets (CRJ), Comair flight 5883 Comair flight 5296 Comair flight 5261 After lengthy pre-takeoff holding in heavy rain, all 3 a/c experienced aileron restriction in cruise at FL280 to FL310. Nil Trapped water freezing at height - despite 2000 AD fitting splash-shields.
11 May 02 CHI02LA128 Chicago-Midway 757-33N, reg: N552TZ ATA211 Transair 757 struck SWA 737 during pushback. Nil/151 total on board Honeycomb damage to both right elevators on both aircraft.
13 May 02 1737L Vancouver-Toronto 767-300 of Air Canada (Flt 116) Aft cargo bay fire warning and smoke smell at 10 mile final Pearson A/P Nil/185 on board Intense electrical fire in insulation blankets was extinguished by Halon. Significant structural damage.
17 May 02 Orlando Fla to Manchester UK 767 of Air 2000 Tire blew on takeoff, threw tread, badly damaging (and holing) port wing spoiler Nil/318 on board Warning given by alert pax; crew dumped fuel, landed Sandford A/P, closing runway (2 hours).
22 May 02 LAX Mazatlan - LAX MD-80 of Alaskan Airlines [AS212] The aircraft made a safe emergency landing at LAX after a flight control problem occurred on descent. Nil/102 on board Unk
22 May 02 Gibraltar Gatwick UK to Gibraltar 757-2T7 of Monarch G-MONC CN: 22781 Nosewheel severely damaged in heavy landing (brake problem caused rapid de-rotation onto the nose gear) Nil Highest cycle 757 in the world (may be not be economically repairable due to low residual value) -wrinkles, ripples and skin tears.
23 May 02 Hong Kong (Fukuoka -HK) DC-10 of JAL [flt 753] Another pilot and ATC warned JAL crew of proximity closure to HK's highest mountain in stormy conditions (supposedly <2nm and approx 500ft above) Nil/216 on board JAL crew reqsted to fly around a thunderstorm over eastern Kowloon and then re-join the ILS path, but being then virtually perpendicular to the ILS course, they overshot ILS finals towards Mt Tai Mo Shan
25 May 02 30m N of Nabire Indon Nabir-Enarotali DHC-6 of Trigana Reg: PK-YPZ Crashed into 7,800ft high terrain enroute in heavy rain. Located after two day search. 6 fatal/6 on board Controlled flight into terrain; attempting visual [VFR] flight in IMC conditions.
25 May 02 20mls NE of Penghu Taiwan Chang Kai Shek - Hong Kong 747-209B of China Airlines reg: B-18255 CN 21843 /386 [flt 611] 23 y.o. a/c broke up on radar climbing through approx 35,000ft - no prior indication of any emergency condition in CAVOK weather. 225 fatal/225 on board Unknown (water depth in Taiwan Straits 135 to 160ft will readily permit debris recovery). Last comms passing 18,700ft in climb. On final CA Flight (sold).
28 May 02 Port Gentile 737-200 of Air Gabon Runway overrun Unk Damage unknown
30 May 02 Antigua 777 of British Airways Became bogged in newly laid tarmac while turning on runway. 0 of 140 on board Heavy aircraft operating at high LCN possibly exceeded runway PDF (pavement depth factor).
1 Air carrier incidents or accidents, or other accidents involving serious failures or fatal injuries, investigated by National Transportation Safety Boards. 2 DISCLAIMER: The information obtained from these National Reports is preliminary, possibly incomplete, and may be supplemented by new findings of fact as the inquiry progresses. These assessments, based on a reading of initial reports, are not intended to assert probable cause or liability, but rather are intended to provide insight pending publication of a final report of investigation. 3A/P=Airport. - Data compiled from National Aviation Authority's documents. Preliminary analysis by John Sampson, director of aircraft, engineering & technical operations, International Aviation Safety Association.(IASA)

No wiring to cockpit

Concerning electrical system safety, LanChile has installed new interactive in-flight entertainment systems (IFE) in its long-haul fleet of Boeing [BA] 767s and Airbus A340s. The installation avoids problems associated with the IFE systems installed in Swissair MD-11s, which were connected to a flight essential bus and could only be depowered by pulling circuit breakers (see ASW, Sept. 13, 1999).

LanChile's IFE system can be controlled from the cockpit without having to pull circuit breakers. A LanChile official explained that the IFE can be depowered in the cockpit by turning off the utility bus. In the video control center located in the cabin, a cutout switch also enables the IFE to be depowered.

No wires to the IFE system are routed to the cockpit. Rather, the IFE is connected to the left utility bus. This low priority bus, which does not handle critical systems, can be shedded. The IFE system is being retrofitted to the B767s and comes fitted from the factory for the Airbus A340 with the same installation arrangement (i.e., a low-priority bus that can be shedded).


Ground support

The concept of free flight may require more not less ground support, according to Per Olof Skold, a retired Scandinavian Airlines System (SAS) captain. Capt. Skold offered this observation at the recent annual meeting in Norway of the International Federation of Air Line Pilots Associations (IFALPA). "The rationale for free flight is capacity enhancement," Capt. Skold explained. If more of the task of separating airplanes is transferred from the ground to the cockpit, pilots will need more sophisticated tools. "I haven't seen those tools," Capt. Skold said. If the tools for safe separation aren't in the cockpit, by exclusion his argument holds that they're going to have to be on the ground. >> Skold e-mail per-olof.skold@swipnet.se <<


To blame or not to blame - that is the question

Dr. Paul Blanchon was a passenger who survived the October 2000 nighttime crash of Singapore Airlines Flight SQ006 on takeoff at Taipei (see ASW, May 6). Often, survivors bring to these horrendous events a different perspective, motivation and impetus than the authorities. Blanchon has a few biting thoughts about fault and, from a survivor's point of view, some suggested recommendations:

"Are the pilots to blame for the SQ006 crash or did the weather and the environment at Chiang Kai-Shek airport conspire to force their mistake? Let me try and clarify the issue.

"To err is human. Everyone makes mistakes. But when your mistake costs the lives of 83 men, women and children, not to mention horrific burns to 40 survivors, then something is going to hit the fan [emphasis in original]. People will blame you for making that mistake because you were in full control and made all the decisions.

"The fact is that blame for this accident lies squarely at the feet of Capt. Foong, and his crew, because they failed the basic test of navigation - to ensure that the aircraft ended up on the correct runway. The fact that Runway 05R looked 'normal' or that the taxiway and runway markings were bad is irrelevant because if Capt. Foong had employed good navigation skills and not dead reckoning, the crash would not have happened. At no point did the taxi require a continuous 180-degree turn. By knowing this simple fact, they would have passed Runway 05R, and perhaps been surprised that it was lit up, but carried on to Runway 05L nonetheless. The bad runway lights and lack of markings would have made no difference whatsoever. Indeed, the fact that another plane took off 16 minutes prior to SQ006 under identical conditions indicates that the other crew employed good navigation and they were not drawn onto 05R. But for all those pilots who got into the bad habit of navigating on runways using dead reckoning, the visual trap provided by 05R constituted an accident waiting to happen 'one dark and stormy night.'

"A word of warning to pilots who use dead reckoning in poor visibility conditions - there is a reason they call it dead reckoning.

"The fundamental objective of any investigation is to identify who made the mistake and then ask why it was made, and how to prevent it being made again. Taiwan's Aviation Safety Council (ASC) identified the who, it was blurry on the why and completely missed the how. To rectify this failing, I recommend some simple common-sense solutions to prevent similar accidents:

1. All pilots require certification in low visibility navigation and need regular testing of those skills to prevent development of bad habits that lead to ground accidents. Until such a certification scheme is in place, all airports without ground radar should use follow-me cars for taxiing under low-visibility conditions.

2. Designation of runways as 'wet' or 'contaminated' should be assessed using common sense. Heavy rain during approaching tropical storms clearly produces a contaminated runway. The emphasis should switch from actual measurements on the runway to measuring the rate at which precipitation is falling. Such measurements could be taken both by crew during preflight aircraft inspection and by airport staff.

3. Flying during extreme weather conditions has to stop. The practice of waiting for brief crosswind takeoff windows during extreme weather conditions is ridiculous, given that crosswinds are just as likely to exceed the limits during the takeoff roll. If airlines continue to violate these limits and show no common-sense approach to safety, then we advocate that passengers exercise their own rights to safety and refuse to fly during extreme weather."

Various additional articles, and recommendations to improve emergency evacuation, may be read at the SQ006 survivors website: http://www.anycities.com/sq006/survivors.html. >> Blanchon, e-mail blanchon@mar.icmyl.unam.mx <<

Systemic Failings Across a Broad Spectrum

It's convenient to blame the captain when it was really the support structure that failed him. Some of those factors involved the inattention of Singapore Airlines (SIA) to low visibility procedures (and para-visual device training), slackness of the Chiang Kai-Sheck airport authority, the urgency predicated by an approaching typhoon, the decision to use Runway 05L instead of the more familiar Runway 06, and damning discrepancies such as the crosswind threatening to exceed contaminated runway limits. Nothing was "broken," just systemic failings across a broad spectrum. Capt. Foong was simply sitting at the apex of that rickety pyramid.

Source: IASA


And smoke hoods, too

The SQ006 survivors' website includes a gripping essay about the harsh life-or-death choices faced in the crash by flightcrew and passengers (see http://www.anycities.com/sq006/reconstruction.html). Herewith, three samples:

  • "There was mass confusion as passengers met the crew from the lower deck coming up. No one could see anything or knew what to do in the choking smoke. A few passengers who were stuck in the aisles ...started to climb over the seats back toward the blocked exit doors."
  • "Steward Tay stated: 'I ran back to the front [of the plane] and saw a Caucasian man with his clothes burnt off, just like that famous Vietnam war photo of the naked girl screaming from napalm burns.' "
  • Passenger Diaz, at the front of first class, recalled that: "As the plane was sliding to a halt, the flames were springing up everywhere. My video screen monitor melted in front of me ... the entire cabin was filled with a thick acrid black smoke and I could barely see. I breathed, out of necessity, a lot of smoke as I stumbled blindly to the door."

To mitigate mortality, among other improvements (e.g., better emergency procedures training for flight attendants), the surviving SQ006 passengers noted that the thick smoke caused widespread panic. Among their recommendations:

  1. "Smoke hoods (such as the EVAC-U8 from Brookdale International Systems) should be mandatory emergency equipment for passengers and crew and would have reduced mortality in this crash probably by as much as 50-70 percent."
  2. "In the event that Recommendation 1 is not implemented, airlines should issue smoke hoods to all crew so that they are better equipped to coordinate evacuation of passengers and do not panic in the face of adverse smoke conditions."
  3. "At the very least, passengers and crew should be advised to carry their own smoke hoods and international airports should provide space to vendors of smoke hoods."

Apropos of these recommendations, Canada-based Brookdale has under development a combined emergency oxygen/smoke hood. Dubbed the DIX-EVAC, the unit stores in the passenger service unit. Should a loss of pressurization occur in flight, the unit drops down, just like the "little yellow cups" with which passengers already are familiar, and provides an emergency oxygen supply. Should the cabin fill with smoke, the unit serves also as a smoke hood, and can be detached from its umbilical, enabling the passenger to evacuate the cabin while being protected by the smoke hood from the heat and choking agents from an in-cabin conflagration.

One of the virtues of this dual-use unit is that it stores out of sight, thereby overcoming one of the airlines' major objections - that if they provided smoke hoods (say, in underseat pockets), many passengers would steal them. (For more on the DIX-EVAC, contact Brookdale's Tony Smithbower) >> Smithbower, e-mail smithbower@evac-u8.com <<


Suing for space

A businessman who flew economy class on a Trans-Atlantic flight from the UK to Canada sued JMC Airlines over the "intolerable" 29-inch seat pitch. UK Judge Gareth Edwards of Chester Country, UK, recently ruled in favor, awarding plaintiff £500 ($800), according to AVMARK, an aviation consulting company with offices in the United Stakes, England and Singapore. The judge suggested a minimum pitch of 34-inches "to provide for people in the normal range of adult height." The $800 penalty, by the way, is about the price of an economy-class round trip ticket across the Atlantic.

The case, presently on appeal, bears directly on a recent study of seat size and spacing. The 2001 report by ICE Ergonomics, Ltd., a UK-based consulting firm specializing in vehicle safety research, concluded that a minimum seat pitch of 35 inches would better accommodate taller people and would allow for an "optimum safe brace position." The study was conducted for the UK's Civil Aviation Authority (CAA) and for Europe's Joint Aviation Authorities (JAA). Although the study's recommendations were not intended to improve passengers' comfort, they were intended to ameliorate the problem of deep vein thrombosis (DVT) on long flights and, more particularly, to expedite emergency evacuation (see ASW, Nov. 5, 2001).


Experience the reality

With respect to cramped seating for the humblest passenger, Harold Caplan has a modest suggestion. Caplan, a long-time observer on the industry whose published writings on accident investigations, air safety and such date back to at least 1953, suggests that airline officials themselves should occasionally fly economy class. In a speech Feb. 27, 2001, at the "Aircraft Interiors Expo 2001," Caplan suggested a voluntary program with the following features:

  • Once each year, each airline board member and each line manager or chief pilot, each chief aircraft and engine designer, and each senior government safety regulator, should take a trip around the world seated in the cheapest part of the cabin.
  • The individual should, whenever and wherever possible, be accompanied by spouse, partner, and children.
  • The individual should participate in all procedures, to which the ordinary passenger peasantry is exposed (including the use of public transport to and from airports, queuing for check-in, queuing for security, immigration, customs and baggage retrieval)
  • Use of executive or VIP lounges would be prohibited. The individual and partner/family would be treated throughout as ordinary passengers.

"No good purpose would be served by requiring staff at lower levels to accept [this] voluntary commitment," Caplan said. "They already know how it is."

Caplan predicts should any chief designer, regulator or airline board member be bold enough to accept this challenge, it would not take very long before things improved for all passengers and new designs began to be drawn on the backside of airsickness bags.

Caplan related that he is not the only one propounding this experience. He recalled the opening remarks at an "Air Passenger Rights' symposium May 10, 2001, in Lisbon, Portugal, by Claudio Costa Pereira, secretary general of the International Civil Aviation Organization (ICASO). Pereira opined, "I would guess that most of us travel primarily in business class or first class. We might be wise to travel more often in economy class and reacquaint ourselves with conditions in the back of the aeroplane. We might even feel a bit of air rage ourselves at times."

Caplan related, "So far as I know, there has not been any follow up to his remarks, [which were] aimed mainly at government officials and regulators in Europe." >> Caplan, tel. +44 (0) 1932 781 200 <<


Thought for the week

"Experience is a hard lady. She makes you take the test first and then teaches you the lesson."

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