Intentional Safety: A Reflection on Unsafe Flight

Copyright © 2018 by Max Collins.

Library of Congress Control Number:   2013907733

ISBN:            Hardcover                            978-1-4836-3236-0

                      Softcover                              978-1-4836-3235-3

                      eBook                                   978-1-4836-3237-7

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Any people depicted in stock imagery provided by Getty Images are models, and such images are being used for illustrative purposes only.

Certain stock imagery © Getty Images.

Rev. date: 10/31/2018

Xlibris

1-888-795-4274

www.Xlibris.com.au

514421

CONTENTS

Introduction

Chapter 1       Thoughts On Flight Safety

Chapter 2       What Is Intentional Safety?

Chapter 3       Situational Awareness

Chapter 4       Control Of Now

Chapter 5       Illusions

Chapter 6       Protections From Loss Of Flight Integrity

Chapter 7       Characteristics Of A Good Pilot / Captain

Chapter 8       The Big Picture

Chapter 9       The Three Times Convention

Chapter 10     The Weather

Chapter 11     The Last Five Minutes

Chapter 12     Protective Habits

Chapter 13     VMC / VFR; IMC / IFR

Chapter 14     What’s In A Name?

Chapter 15     Operational Decisions And Decision-Making.

Chapter 16     A Catastrophe Waiting To Happen

Chapter 17     Take-Offs And Landings

About the Author

INTRODUCTION

I never thought that I would write a book.

As I sit at home with my laptop I wonder when and where I will run out of inspiration.

With this in mind why am I doing it? Where is the inspiration and drive to do this?

Quite simply there is one reason and one reason only, and that is the desperate hope that in some way I can contribute to a reduction in the aircraft crash record.

One crash saved would be enough.

Two would be highly satisfying.

QUITE SIMPLY,

FLYING IS NOT SAFE

And to answer the above questions, probably never and no-where. There is always inspiration, unfortunately

CHAPTER 1

THOUGHTS ON FLIGHT SAFETY

D espite all the quoted statistics proving that flying is safe, it is not. It is not safe because aircraft still crash and lives are still lost. While this situation continues it cannot and should not be accepted that flying is safe.

Worth a thought too that there are many more safety breeches that do not result in a crash than those that do.

Forget the death rate per hours flown/passenger miles/ or whatever formula you use to prove that flying is much safer than, say, motoring.

Comparative rates of death is an abhorrent statement.

How can anyone gain comfort from saying that I am going flying as a passenger or crew and it is acceptable for me to do this because the risk of me losing my life is small?

It matters not whether the aircraft carries one or five-hundred there is not one person who boards an aircraft who expects that the flight will terminate unsuccessfully and that this will be their last day of life………………………. And this includes the crew.

There are no such things as aircraft accidents. I have no idea where the term came from but it should never be used.

The term accident allows one to generate the picture of a shrug of the shoulder, a submissive scowl of disappointment and the idea that nothing could be done about it, it was an accident.

AIRCRAFT ACCIDENTS DO NOT HAPPEN

MOTOR CAR ACCIDENTS DO NOT HAPPEN

There is always a cause. And if there is a cause, then there is always a point at which some action would have intervened and prevented the cause becoming an event that resulted in loss of life or machine … or both.

The aim of true flight safety is to identify the point of origin of the deviation from safe operation, stop its development and eradicate it.

As will be evident during the reading of this book, for some flights (car journeys, bicycle outings) the point of deviation from safe operation often takes place before the commencement of the activity. In other words at no stage has there been any real attempt to construct an activity in such a way that it is safety-protected from its inception.

As will also be evident later this is frequently because a number of similar activities have taken place without untoward events happening and so the pilot (driver) develops a habit of involving lessening preparation and concern for the result of what he/she is about to undertake.

Real safety can largely be achieved by thorough preparation for flight, an aspect which is missing from, and I fully expect that this statement will be challenged, most flights.

Most aviators will be familiar with the Five ’P’s.

That is, Proper Preparation Prevents Poor Performance.

I will be bold enough to suggest that the term virtually eradicates can be substituted for the third "P" though of course that spoils the mnemonic.

The same can be said of motoring crashes and in a lot of respects the word aircraft in this book can quite comfortably and correctly be replaced by the word car, or ship, or bicycle.

Further, it is even more appalling when you consider that the action that caused the crash is perpetrated by the pilot/driver/ rider of the vehicle.

Any analysis or criticism of the action or decision is carried out by the same person and is therefore subject to a less critical assessment.

Planning is commonly accepted as being what you do before a flight, ‘flight planning’, however as I will explain later, planning is a continuous responsibility which does not finish until the flight successfully and intentionally terminates safely.

Pilots are slow learners.

It is now over one hundred years since Kittyhawk.

Over that hundred years and despite the incredible advances in aircraft integrity and excellence, aircraft crashes still happen. Of course over that time the number of aircraft flying has increased beyond all imagination and along with that the number of crashes and deaths.

Don’t blame the aircraft. Or the manufacturer.

How often the newspaper headline indicates that (Aircraft manufacturer) (type) crashes casting a probably unintentional slur on the manufacturer or type to the extent that some sections of the travelling public will not fly on a ––––- because they are not safe.

What rubbish!!!!

The loss of integrity of an aircraft to the point that it is no longer flyable is such a microscopic percentage of the overall hull loss / death rate that it almost does not deserve consideration.

It was not always thus, however over the last eighty or so years it certainly has been the case. Over those same eighty years or so there have been thousands of aircraft crashes and a significantly higher number of lives lost.

I bring to mind here the tragic end to Air France flight 447, an Airbus A330 which was en-route from Rio de Janeiro to Paris. At night (of course! because that is when abnormalities become major events) the aircraft suffered a total loss of airspeed indications due to frozen airspeed sensors. This caused the aircraft’s flight management systems to malfunction as they were deprived of essential information.

Because of this abnormality the auto-pilot was unable to control the aircraft and therefore disengaged. For reasons unknown one of the pilots pulled back on the control side-stick causing the aircraft to stall and descend. Despite continuous stall warnings the nose of the aircraft was held very high probably in an attempt to arrest the descent.

Now I am not in any way pretending that this was a minor problem.

It certainly was not. It was a problem of major proportions, however…………….. The loss of the aircraft, crew and passengers was totally and absolutely avoidable.

(There has been much publicity that had the aircraft been manufactured by a different manufacturer and was fitted with a conventional control column, then the crash would not have occurred).

These proponents ignore the fact that in 1996 a BirgenAir Boeing 757 was lost in virtually identical circumstances when the pilot held the aircraft firmly in the stall with, not zero, but grossly over-reading airspeed indications on one side of the aircraft instruments only. The other pilot’s readings were absolutely normal.

What the A330 crew were deprived of was airspeed indications, a flight management system and auto-pilot. There was nothing wrong with the engines, flight controls or attitude indications or general aircraft integrity.

All pilots are taught in basic flying training that if a stall occurs then the control column, or side-stick, must be moved forward to reduce the angle of attack and un-stall the wings.

This did not occur and the side-stick was held fully back keeping the aircraft in a stalled condition. The resultant exaggerated nose-high attitude of the aircraft would have been plainly available to both pilots on their attitude indicators, yet nothing was done to correct that erroneous and fatal flight condition.

In either case, some consideration should be given to the fact that an inflight stall, unannounced and unpredicted, is a startling event and that the corrective action is counter-intuitive. However, that is what every pilot is taught.

Over-riding any of the previous paragraphs about the stall and the recovery therefrom, the basic fact is that if NOTHING had been done except for manually holding the aircraft in its original attitude, NOTHING untoward would have happened.

How is this possible?

Both pilots would have been taught back in basic flying school that power plus attitude equals performance. Nothing wrong with the engines so if normal flight attitude, usually about two degrees nose-up, was selected, then the aircraft would have resumed normal flight, albeit without airspeed indications or auto-pilot. Still undesirable, but normally flyable.

As it happened, this aircraft, and others in the fleet, had been fitted with a pitot heater system that subsequently was proven to be inadequate. That inadequacy would not have shown up if the pilots on this aircraft had been paying attention to the environment in which they were flying and had not permitted the aircraft to enter a towering cloud-form which contained heavy icing. Radar image would have made the hazard very clear.

All pilots of any aircraft have an obligation to avoid atmospheric conditions which are hazardous to flight.

I accept whole-heartedly that it was a serious and totally undesirable state of affairs but the aircraft was totally flyable and the crash and the attendant loss of aircraft and life need not have occurred.

The aircraft had not been degraded to the point that a crash was inevitable.

If the aircraft integrity is not to blame then what is?

In mentioning aircraft integrity I am not saying that aircraft systems are always one hundred percent fail-proof. What machine is, regardless of the cost, only that aircraft integrity is virtually never degraded to the