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A Simple System with Profound Consequences

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Among the many programs I have been watching on Amazon Prime and Netflix is a short series on airliner crashes over the years, with detailed explanations as to the causes. Actually in checking imdb, there have been many seasons but Amazon has just the first.

The accident investigators are interviewed, the controllers, and sometimes the passengers. I’ve seen 3 or 4 episodes, and it has been illuminating, not only for the causes but the pressures from the airline industry (which is understandable, given their investments). I’m thinking of the episode detailing the United Airlines 747, flight 811,  that had the cargo hold door explode from pressure over the Pacific.

It was eventually determined to be a faulty design in the latch, and the FAA mandated that it be updated. Parts were only $2,000 (amazing for the aircraft industry!), but the downtime just for that sidelining these jets (that are only making money when they are flying, making money so they can pay off the lease or loans), would run into many millions. So the airlines lobbied the FAA to allow them to wait until a major inspection when the planes would be offline anyway.

When a separate incident occurred, the FAA sped up the requirement. Not condoning the longer wait request, but can certainly understand it in the context of economics.

Although in the case of United 811, the flight crew, through superb flying (2 of the engines were out due to the debris) , brought it back to Honolulu although 9 passengers lost their lives being blown out of the damaged fuselage.

Take a look at the damage.

Anyway in the episode I just finished, they were talking about  Aero Peru 757 Flight 603 that, 5 minutes after takeoff, noticed a complete failure of all the primary flight instruments. They had no idea of their airspeed or altitude. And it was all traced to a stupid maintenance error.

Spoiler Alert 

When cleaning the airplane, the maintenance crew put duct tape over the static holes (part of the pitot-static system) while they washed the plane. But despite an institutional arrangement where 3 people (starting with the supervisor and ending with the captain doing a pre-flight), all missed the tape. Because duct tape is silver, and the holes on the wing were 15-17′ up – and it was night, all missed it.

And because in modern airliners so much computerization is dependent on this simple design, a design that has been around since at least the 1920s, there was pandemonium in the cockpit between the Captain and First Officer.

Imagine being over the ocean at night, with no visual references as to the horizon or the surface, and the computers are screaming to you that you are first going too fast then on the verge of stalling.  And for the final nail, the controller at Lima is verifying the altitude that their faulty altimeters are giving – not thinking that the plane’s transponder was simply transmitting that erroneous information. He was giving back the same bad information.

The 757 eventually flew into the dark Pacific.

Imagine being in that situation as at least 2 other flight crews faced.

In the case of the Birgenair, it was most likely a wasp nest in the pitot tube that the maintenance crew missed. In Air France 447, it was an iced over pitot tube.

Lex had a (naturally) good post on AF 447.

In the episode, a retired Canadian 757 Captain talks about what he would have done.

Easy, I suppose, to see “what they should have done” given the fact that we know what happened, but imagine the confusion when it is pitch black and multiple systems are blaring at you about critical failures.

Aviate – Navigate – Communicate – in that order.


 

05-28-20 In re-reading this, I was reminded of a book on survival I reviewed here some time ago. I found it fascinating, for the real-world examples the author gave of some – who with their experience and physical conditioning – should have survived their situations while others seemed to survive against improbable odds.

I’m thinking of a 16 year old girl who, in a dress, survived an airliner crash in the Peruvian jungle and for some days walked through that jungle until she saw a village. She was the sole survivor – the other survivors of the crash decided to wait for help.

She remembered something her father said about water – to “follow the streams – it will eventually lead you to people”.

The takeaway point from this book?

Stop for a moment – access the situation. Make a plan. 

In all three of these instances above – the flight crews were reacting to the false instrument readings and in essence – “bouncing off the walls”. 

What the Canadian pilot said in the program was the same as what Lex said about AF 447 – that you know the throttle lever position for cruise – put it there and with the engines running (you have good instruments telling you their state), you know that you are at cruising speed.

No matter what your airspeed indicator or altimeter tells you.


The Wright Brothers

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Like Joe Rosenthal’s iconic photo of Iwo Jima, this first flight was immortalized almost by accident .

I just finished David McCullough’s wonderful book on the Wright Brothers. He did some thorough research, including many notes by them on the study of bird flight, and letters.

One theme remained with me throughout the book.

Perseverance.

They had little money other than what they earned through their bicycle shop by their house.

They had a strong work ethic.

They persevered against all the naysayers.

Among the few persons who had faith in them to succeed were their father, a church bishop, and their sister.

They spent several summers traveling from Dayton, Ohio to Kitty Hawk, NC at their own expense to assemble their aircraft and perform test flights.

There, they not only tested their ideas but built a rudimentary cabin and hanger.

They battled hot, humid summers, storms, and in one year, swarms of mosquitos which made the place almost intolerable.

Then, when they had a demonstrable airplane, they continued testing in Ohio to an almost universal lack of interest.

The press, the US government, and the public had little interest in their activities.

In fact, one of the first periodicals to break the news of their powered flight in Ohio was not a newspaper or magazine, but a newsletter from a beekeeper.

None of this deterred them.

To generate sales, Wilber went to France where he did get a lot of interest. Over 200,000 people saw his demonstrations at LeMans.

And another amazing thing for me was that after a “critical mass” of interest in Europe (and by news, the United States) was reached, how explosive aviation development became. About a year later after those demonstrations, in 1910, was a grand air race at Reims, France.

…There were no participants from either Britain or the United States, but despite this, 76 machines were entered. They represented 14 different makes, but in the end no machines from Wright, Tellier or Maurice Farman would turn up. The most popular make was Henry Farman with 14 entrants, followed by Blériot (12), Sommer (9), Antoinette (8) and Voisin (8). Machines from Nieuport, Sanchez-Besa and Pischof (called “Werner” in the official program, after the manufacturers Werner & Pfleiderer) would appear for the first time at a French meeting.

Through those years, they never gave up. They were not motivated by wealth, but development.

Wilbur was feted in Paris and at a grand awards ceremony, he made a prediction for the future path of aviation.

At his acceptance speech on November 5th, 1908 at the Aero-Club de France’s banquet, he predicted the path of this new industry.

…I thank you for this. In the enthusiasm being shown around me, I see not merely an outburst intended to glorify a person, but a tribute to an idea that has always impassioned mankind. I sometimes think that the desire to fly after a fashion of birds is an ideal handed down to us by our ancestors who, in their grueling travels across trackless lands in prehistoric times, looked enviously at the birds soaring freely through space, at full speed, above all obstacles, on the infinite highway of the air. Scarcely ten years ago, all hope of flying had almost been abandoned; even the most convinced had become doubtful, and I confess that, in 1901, I said to my brother Orville that men would not fly for fifty years. Two years later, we ourselves were making flights. This demonstration of my inability as a prophet gave me such a shock that I have since distrusted myself and have refrained from all prediction—as my friends of the press, especially, well know. But it is not too necessary to look too far into the future; we see enough already to be certain that it will be magnificent. Only let us hurry and open the roads.

And to think just 39 years after that banquet, Chuck Yeager broke the sound barrier. And just 50 years after that banquet, the passenger jet age began and crossing continents in mere hours was a reality. And 66 years after that first flight, within a lifetime, Man was on the moon.

The book is highly recommended.

Cutaway Thursday: Lockheed F-104 Starfighter

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My all time favorite of the “Century Series” fighters, the first flight of the F-104 was this week, on 4 March 1954. Strangely, it had a relatively short career with the USAF but enjoyed far more success with NATO countries.

f104g_cutaway

You can learn more here at the International F-104 Society’s webpage.

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