royal aeronautical society heathrow branch the sir richard ......in 2002 don bateman, father of...

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Royal Aeronautical Society Heathrow Branch The Sir Richard Fairey Lecture “Training to Avoid Loss of Control Accidents” RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 1 /165 “Training to Avoid Loss of Control Accidents” : Hugh DIBLEY FRAeS, FRIN, CMILT formerly BOAC/BA, AUH, AHK, MAU, Airbus Toulouse (Busy slides for reading without audio!)

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Page 1: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Royal Aeronautical Society Heathrow Branch

The Sir Richard Fairey Lecture

“Training to Avoid Loss of Control Accidents”

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 1 /165

“Training to Avoid Loss of Control Accidents”

:

Hugh DIBLEY FRAeS, FRIN, CMILT

formerly BOAC/BA, AUH, AHK, MAU, Airbus Toulouse

(Busy slides for reading without audio!)

Page 2: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 2 /165

Page 3: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Hugh Dibley’s Main Aviation Activities

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 3 /165

Page 4: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Training to Avoid to Loss Of Control Accidents

Main Accident Causes – CFIT (Controlled Flight in Terrain)LoC-I (Loss of Control In Flight)

CFIT now reduced – Read across to LoC-I preventionSymptoms and Causes

Examples of LOC-I - Instrument/system failure mis-handled

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 4 /165

Crew induced on serviceable aircraftExtreme weather – icing, windshearControl/system failure causing upset

Examples of Negative Training

Work across the Industry to Prevent LOC-I

Page 5: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 5 /165

Page 6: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 6 /165

Page 7: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 7 /165

Page 8: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 8 /165

Same number of accidents

Page 9: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 9 /165

Why did CFIT decrease? Could have been reduced sooner?

Page 10: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

What Have Been the Prime Causes of CFIT?What Have Been the Reasons for CFIT Reduction?

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 10 /165

Page 11: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

What Have Been the Prime Causes of CFIT?What Have Been the Reasons for CFIT Reduction?

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 11 /165

Page 12: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

What Have Been the Prime Causes of CFIT?What Have Been the Reasons for CFIT Reduction?

3°glidepath to runway

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 12 /165

Page 13: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

What Have Been the Prime Causes of CFIT?What Have Been the Reasons for CFIT Reduction?

Since 1970s with DME in line with the Runway,NO excuse for NOT following

Constant 3°path to runway threshold –Using DME – Altitude Display

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 13 /165

Using DME – Altitude Display

or by Altitude regularly calculated mentally -eg at 5 nm DME at Guam –

Approach Altitude = (5+3.3) x 300 + 310 = 2,800ft

Page 14: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

What Have Been the Prime Causes of CFIT?What Have Been the Reasons for CFIT Reduction?

Aids existed for crews not skilled in mentalarithmetic – like bookmakers’ clerks calculating betting odds

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 14 /165

Page 15: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

What Have Been the Prime Causes of CFIT?What Have Been the Reasons for CFIT Reduction?

Aids existed for crews not skilled in mentalarithmetic – like bookmakers’ clerks calculating betting odds

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 15 /165

Similar to using the improvedADF RMI (Radio Magnetic Indicator) versus an old

RBI (Relative Bearing Indicator)to which Magnetic Heading must be added to calculate the

Magnetic course to the beacon – no longer in use!

Page 16: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

What Have Been the Prime Causes of CFIT?What Have Been the Reasons for CFIT Reduction?

Aids existed for crews not skilled in mentalarithmetic – like bookmakers’ clerks calculating betting odds

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 16 /165

Similar to using the improvedADF RMI (Radio Magnetic Indicator) versus an old

RBI (Relative Bearing Indicator)to which Magnetic Heading must be added to calculate the

Magnetic course to the beacon – no longer in use!

RBI – Fixed Card Heading345° MagnetWhat is QDM(Direction M)to the NDB?

= 075+345=420-360 = 60°M

Page 17: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

What Have Been the Prime Causes of CFIT?What Have Been the Reasons for CFIT Reduction?

Aids existed for crews not skilled in mentalarithmetic – like bookmakers’ clerks calculating betting odds

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 17 /165

Similar to using the improvedADF RMI (Radio Magnetic Indicator) versus an old

RBI (Relative Bearing Indicator)to which Magnetic Heading must be added to calculate the

Magnetic course to the beacon – no longer in use!

RBI – Fixed Card RMI Heading Mag

Page 18: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

What Have Been the Prime Causes of CFIT?What Have Been the Reasons for CFIT Reduction?

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 18 /165

Page 19: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

What Have Been the Prime Causes of CFIT?What Have Been the Reasons for CFIT Reduction?

Published VOR-DME approach into Kuala Lumpurin 1976 was about 1.5°thus not sensible as drawn.

Circular slide rule defines a 3°final approachbased on the DME 12.5 nm from the runway.

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 19 /165

Page 20: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

What Have Been the Prime Causes of CFIT?What Have Been the Reasons for CFIT Reduction?

In1976 a BAOD 747-136 brushed treesduring a Go Around from a VOR-DME

approach to KUL 16 –The approach procedure started 2,000ft

below a 3°glide path with no DME-Altitudechecks. The approach was a “Black Hole”

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 20 /165

checks. The approach was a “Black Hole”over forest with no visual cues

The approach procedure was revised tofollow a 3°path with DME-Altitude checks,

which were being incorporated on all BAAerad charts and no similar NPA incidents

occurred afterwards in BA.

Page 21: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

BA/Aerad Provided DME-Altitude TablesPermitting Constant Angle NPAs starting in 1975

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 21 /165

Page 22: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

By the 1980s Most European Authorities providedDME-Altitude Information for Constant Angle NPAs,

But information not universally available.....

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 22 /165

Page 23: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

In 1989 Flying Tigers B747 Crashed with the FOflying a VOR-DME Approach in to Kuala Lumpur

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 23 /165

Final Approach Fix Altitude 2,400ftGPWS “Pull Up, Pull Up” ignored for 25 seconds

Page 24: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 24 /165

Page 25: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 25 /165

Page 26: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 26 /165

Page 27: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 27 /165

Page 28: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 28 /165

Page 29: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 29 /165

Page 30: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

CFIT NPAs Continued –In 2002 Don Bateman, father of GPWS/EGPW,

published 9 NPA CFIT accidents which could havebeen saved if EGPWS had been fitted

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 30 /165

But 5 had DME available but no DME-Altitude tableson the charts which could have avoided an accident.

Page 31: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

FMS navigation started in the 1970s andnavigation database integrity improved

during the 2000s to allow RNP(Required Navigation Performance) ILS

type approaches without need forground based navigation aids

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 31 /165

Page 32: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RNP Approaches particularly help Charter Operatorswith many NPAs – CFIT accidents should be reduced

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 32 /165

Capt Steve Solomon DFO Thompson Ltd 7 Oct 2010

Page 33: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

DME-Altitude Constant Angle NPAs remain a good backup

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 33 /165

Page 34: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Hazards of a “Dive & Drive” NPA Profile

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 34 /165

Page 35: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Approach Unstable – needing pitch, thrust & flap changes

Hazards of a “Dive & Drive” NPA Profile

Unstable profile

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 35 /165

Page 36: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Hazards of a “Dive & Drive” NPA Profile

Chance of hard landing or runway over-run

Approach Unstable – needing pitch, thrust & flap changes

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 36 /165

Experience shows that flying level at MDA while obtaining visual reference,especially in poor visibility, can lead to a late “dive” at the runway and chances

of a hard landing or deep landing with over-run off the end of the runway.

Page 37: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Hazards of a “Dive & Drive” NPA Profile

Missed step can cause terrain accident

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 37 /165

It is easy to misread the chart and miss a step possibly flying into an obstacle.

28 Sep 1992 PIA A300 accident VOR DME approach into Kathmandu.06 Aug 1997 KAL 747 accident LOC No Glidepath DME approach into Guam.

(During an old HKG Kai Tak IGS No Glidepath approach, a UA 747 missed astep and descended early towards the hill on the approach, but the error wasadvised by Hong Kong Approach Radar and the aircraft stopped the descent.)

Page 38: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Benefits of a Constant Angle NPA Profile

Stable Approach – established as many orders safer

Stable approach, landing configuration, no pitch/thrust changes

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 38 /165

NPA Minima may be reduced

6.5% 3.7° 393 f/nm

120 kts 140 kts 160 kts

790 fpm 920 fpm 1,050 fpm

Dist KLO Alt QNH (HAT)

D -7.4 4000' (2584')

D -7.0 3860' (2444')

D -6.0 3470' (2054')

D -5.0 3080' (1664')

D -4.0 2680' (1264')

D -3.3 2390' (974')

D -2.0 1900' (484')

D -1.0 1510' (94')

D -0.9 1470' (54')

DME-Altitude Tables can provide regular checks toconfirm aircraft on the correct profile to 30ft accuracy.Rather than checks at single points which might beinterrupted by ATC request, crew action etc.

Page 39: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

A final Comment about Use/Underuse of DME!

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 39 /165

Indicates Prevention of an event is Prime

Page 40: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Interesting that the recommendationsIn the FSF 1998-99 CFIT Task Force

made No mention of DME-Altitude TablesTo Fly

Constant Angle Non Precision Approaches

and One More!

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 40 /165

Constant Angle Non Precision Approachesalthough known to be a prime safety aid.

A proposal that “At night and IMC the FO shall fly theapproach and the captain shall land” was not included.

Page 41: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Don Bateman’s EGPWS is certainly a marvellous aidwhich has contributed incomparably to flight safety.

A B747-400 out ofMauritius which

turned North to flystraight over LionRock as cleared

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 41 /165

Rock as clearedby ATC was saved

by the EGPWSwarning

Page 42: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

CFIT remains an accident causeas frequent as LOC-I,

and remains a high priority of

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 42 /165

and remains a high priority ofauthorities such as ICAO

Page 43: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 43 /165

Page 44: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 44 /165

Page 45: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

During 3 recent accidents crews have ignored oreven cancelled EGPWS warnings

10 April 2010 Polish Air Force Tu-154 continuedafter Terrain Ahead & Pull Up warnings

20 Apr 2012 Bhoja Air Boeing 737 into Islamabad.Captain continued downwind despite

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 45 /165

Captain continued downwind despiteEGPWS warning and advice from FO.

10 May 2012 Sukhoi Superjet-100 descended belowMSA and into side of volcano

Behaviour can be read across to LOC-I events

Page 46: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Examples of LOC-IInstrument/system failure Mis-handled

Disorientation after Single/Simple Failure

21 Dec 1962 BEA Comet 4B Ankara. After rotation ontakeoff pitched up to 45°& stalled.Captain’s Flight Director was stuck.

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 46 /165

01 Jan 1978 Air India B747 Bombay. After takeoffcaptain rolled to the left into the seaafter his horizon “toppled” in right bank.

22 Dec 1999 Korean Air Cargo Stansted. Aftertakeoff captain rolled left into theground after his horizon failed.

Page 47: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Examples of LOC-IInstrument/system failure Mis-handled

Disorientation after Single/Simple Failure

Solved by improved training andCRM (Crew Resource Management)

(The co-pilot of the Korean B747 could have beenpreoccupied with trying to change to a radio frequency

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 47 /165

preoccupied with trying to change to a radio frequencywhich was not displayed as cleared.

The aircraft had an 833Mhz frequency selector required inEurope while the UK was still using/giving frequencies in the

older spacing.)

Page 48: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Examples of LOC-IInstrument/system failure Mis-handled

Disorientation after Single/Simple Failure

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 48 /165

Page 49: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Examples of LOC-IDisorientation with No apparent Failures

Confusion with AutomaticsManual Handling Skills

03 Jan 04 Flash Airlines B737-300 Sharm el-Sheikh. Aftertake off the aircraft rolled right instead of turningleft reaching 110°bank and crashing into thesea. The (ex military) captain was engaging anddisconnecting the autopilot in different modes.

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 49 /165

disconnecting the autopilot in different modes.

25 Jan 10 Ethiopian Airlines B737-800 Beirut. Aircraft tookoff out of trim which the captain did not correct& lost control of the aircraft reacting incorrectly toprolonged stall warning stick shakers. The captainand co-pilot were both relatively inexperienced.

Page 50: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Examples of LOC-IStalls due to Flap/Slat Mis-Handling?

27 Oct 1965 BEA Vanguard London Heathrow. During aGo Around after the 3rd approach the aircraftpitched up then crashed on the runway in asteep dive. Flaps had been retracted to zero.Flight’s comment: FDRs are Pilot’s Training aids.

18 Jun 1972 BEA Trident London Heathrow. Aircraft stalledafter the co-pilot retracted the droop/slats

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 50 /165

after the co-pilot retracted the droop/slatsprematurely.

12 Feb 2009 Colgan Air Bombardier DHC-8-400 Buffalo. Onapproach after flap selection with speeddecreasing the stall warning sounded. Theco-pilot retracted the flaps & the aircraft stalled.More about this later.

Page 51: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Examples of LOC-IStalls due Excess Thrust Causing Pitch Up at Low Level

26 Apr 1994 China Airlines A300-600 Nagoya. During theapproach the FO applied TOGA thrust in error &pushed forward on the control column while theautopilot trimmed back. The aircraft pitched up,stalled, pitched down & crashed on the runway.The captain tried to arrest the descent by pulling back.

11 Dec 1998 Thai Airways Int A310 Surat Thani. During 2 GoArounds the captain slowly applied TOGA thrust

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 51 /165

Arounds the captain slowly applied TOGA thrustand controlled the pitch up, but on the 3rd GAfor a diversion TOGA was applied rapidly by theautothrust, the aircraft pitched to 45°& crashed.

23 Sep 2007 Thomson Fly B737-300 Bournemouth. After the autothrustdisconnected without warning the autopilot trimmed backto maintain the glideslope. During Go Around theaircraft pitched up with full foward stick and stalled. Thecaptain recovered by reducing thrust & trimming forward.

Page 52: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Examples of LOC-IExtreme Weather – Turbulence Windshear, Icing,

5 Mar 1966 BOAC 707-436 near Mt Fuji. The aircraftencountered severe clear-air turbulence causinga sudden structural failure. Acceleration +9/-4G.

02 Aug 1985 Delta Air Lines L1011 Dallas. Crashed afterencountering a microburst-induced, severewindshear from a developing thunderstorm

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 52 /165

windshear from a developing thunderstormlocated on the final approach course. Windsheardetection/recovery systems were developed.

12 Feb 2009 American Eagle ATR 72 near Chicago. Controlwas lost when holding due to icing causingsudden aileron hinge moment reversal.

Page 53: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Icing – Aircraft may StallBefore the Stall Warning/Stick Pusher

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 53 /165

Page 54: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Examples of LOC-ILoss of Normal Pressure Instruments

6 Feb 1996 Birgenair B757 Puerto Plata. Continued takeoffwith captain’s pitot blocked, control was lostdue to confusion between flight instruments.

01 Oct 1996 AeroPerú B757 Lima. Took off with static ventscovered causing multiple warnings - rudderratio, mach trim, overspeed, underspeed and

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 54 /165

ratio, mach trim, overspeed, underspeed andflying too low. With no reliable barometricaltimeter and airspeed readings & experiencingseveral stalls the aircraft crashed into the sea.

This spurred manufacturers/operators to introduce unreliableairspeed procedures for all aircraft types.

.

Page 55: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 55 /165

Page 56: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Early aircraft –Input/sensor failures affected single systems

Current aircraft –Input/sensor failures affect multiple systems –With perhaps.....

Examples of LOC-IControl/System Failure Causing Upset

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 56 /165

With perhaps.....multiple consequences .....disconnections .....multiple warnings.....possibly startling –But if crews understand the systems and are prepared –Need not be quite so startling – hopefully!

Page 57: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Airbus A320 – Flight Control Laws Reconfiguration after failures

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 57 /165

Page 58: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Examples of LOC-IControl/System Failure Causing Upset

Table assumes failed systems are flagged invalidInputs/data can “fail” in different ways –

Erroneous/incorrect and flagged as Invalid –Inputs to systems switched off.Reconfigurations made as per design.

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 58 /165

Reconfigurations made as per design.

Erroneous/incorrect but not flagged as invalid –Bad information fed to systems, perhaps causing anomalies(Like 737 into AMS when Radio Altimeter fed 0 ft soautothrust reduced to idle as if landed.)

Unreliable – incorrect but may return to normal

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Examples of LOC-IFly By Wire Control/System Failure Causing Upset

1 Aug 2005 Malaysian 777-200 from Perth. When climbingthrough FL380 the airspeed indicated near theoverspeed and stall speed limits. The aircraftpitched up, climbed to FL410 with the airspeeddropping to 158 kt and the stall warning/stickshaker activated. The crew took control andreturned to Perth flying manually throughout.

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 59 /165

returned to Perth flying manually throughout.One of several accelerometers had failedanother accelerometer had failed in June 2001.

7 Oct 2008 Qantas A330 from Perth. ADIRU #1 fed veryhigh false AoA values to the flight controlcomputers commanding a nose-down aircraftpitch of about 8.5 degrees. The aircraft divertedto Learmonth.

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Examples of LOC-IClassic Aircraft Control/System Failure Causing Upset

03 Mar 1991 United Airlines 737-200 Colorado Springs.08 Sep 1994 USAir 737-300, near Pittsburgh.

Both aircraft crashed due rudder PCU jammingwhich could reverse the pilots inputs.

The FAA ordered that the servo valves be replaced and thatnew training protocol for pilots to handle unexpected

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 60 /165

new training protocol for pilots to handle unexpectedmovement of flight controls be developed.

Some airlines implemented upset training procedureswhich were not approved by the manufacturers therefore in1998 Airbus, Boeing and McDonnell Douglas published the

Airplane Upset Recovery Aidremains “bible” for Upset Prevention & Upset Training

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 61 /165

Page 62: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Bill Wainwright, Airbus Chief Test Pilot,one of the 3 signatories to the AURTA manual,

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 62 /165

one of the 3 signatories to the AURTA manual,gave more advice in an Upset Recovery article

in the June 1998 Airbus FAST magazine

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Bill Wainwright’s Advice

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 63 /165

Prevention is Prime

Page 64: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Bill Wainwright’s AdviceTogether with Boeing & McDonnell Douglas

Do NOT use Rudder in an Upset

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 64 /165

But AA persisted withtheir Upset Recoverypolicy of using rudder

Page 65: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

LOC Accidents –American 587 – Airbus A300-600

ex JFK October 2001

Copilot applied full rudder travel both ways after passingthrough B747 wake vortex, thus exceeding the designed loadsof the vertical stabiliser/fin which broke off.

Crews had been trained to use rudder in an upset and flightsimulators’ roll control response modified to require this –

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 65 /165

simulators’ roll control response modified to require this –against the advice of both major aircraft manufacturers.

Indicates the need for upset recovery training to be accordingto the manufacturer’s recommendations, otherwise negativetraining can result.

AA had modified the flightsimulator reaction in roll soonly rudder was effective

Page 66: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Recent LOC-I Accidents –14 Oct 2004 Pinnacle Bombardier CL-600-2B19

Ferry flight – only 2 pilots on boardFailed to monitor autopilot Vertical Speed Mode climbing to FL410,

Speed reduced to stall which was not recovered.Should have been prevented by improved knowledge of aerodynamics

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 66 /165

Should have been prevented by improved knowledge of aerodynamicsand thus use of automatics –(There is an official view that crews must not VS mode as the modenot understood. This indicates a failure in training.VS has to be used routinely when climbing fast in busy airspace toavoid unnecessary ACAS/collision avoidance warnings, etc.)Could have been recovered by better knowledge of aerodynamics and ifhad been given proper stall/stick pusher training..

Avoided by proper crew discipline.

Page 67: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Most Significant LOC-I Accident

Colgan Air - Bombardier DHC-8-40012th February 2009

Crew airspeed monitoring lapsed – due to fatigue?Speed reduced after flap selected & stick shaker activatedFO had discussed icing several times during flight –Had seen NASA tailplane icing video instructing flap retraction

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 67 /165

Had seen NASA tailplane icing video instructing flap retractionReacted as per training video to retract flaps & pull aft stick?Should have been prevented by type training on tailplane icingCould have been recovered by training/knowledge for type.

Page 68: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Most Significant LOC-I Accident

Colgan Air - Bombardier DHC-8-40012th February 2009

NASA Tailplane Icing Video

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 68 /165

Page 69: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Colgan Air Cockpit Voice Recorder

Captain pulled back on stick as per NASA video?

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 69 /165

FO Retracted the flaps

Page 70: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Video of Colgan Air Bombardier Accident into Buffalo

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 70 /165

Page 71: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Colgan Air Bombardier Accident into Buffalo

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 71 /165

Page 72: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Colgan Air Bombardier Accident into Buffalo

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 72 /165

Page 73: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

NASA Icing Video showed aircraft with a similar configurationto Colgan Air – High wing turboprop with high T tailplane

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 73 /165

Page 74: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Most Significant LOC-I AccidentFamilies of those lost formed a focus group & website

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 74 /165

Page 75: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Families of passengers killedIn the Colgan Airways Accident

into BuffaloLobbied congress to

Pass a Law

Most Significant LOC-I Accident

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 75 /165

Pass a LawRequiring Stall Training

For All Airline Pilotsand more hours’ experience.

(New president & administration)

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US Law

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 76 /165

Page 77: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

US Law

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 77 /165

Page 78: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Large Number ofLoss Of Control / Stall-Stick Pusher Related Groups

Set Up/Existing in the Industry

FAA Stall and Sticker Pusher GroupRAeS ICATEEICAO LOCART etc etc

Other activities:

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 78 /165

Other activities:ITQI (IATA Training & Quality Initiative) leading toEBT (Evidence Based Training)MPL (Multi-Crew Pilot’s Licence)ICAO NGAP (Next Group of Aviation Professionals)RAeS FSG IWG (International [Flt Sim Stds] Working Group)RAeS IPTC (International Pilot Training Consortium)EASA Rule Making Tasks

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FAA Advisory Circular 6th August 2012...to provide best practices and guidance

for training, testing, and checking forpilots, within existing regulations, to

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 79 /165

pilots, within existing regulations, toensure correct and consistent responses

to unexpected stall warnings and stickpusher activations

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FAA Stall Training ACRequirement for Instructors to HighlightFull Flight Simulator Motion Limitations

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 80 /165

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Development of Simulation

Angular motions are sensed in humans by canals in the inner ear

5. Motion Systems

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 81 /165

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Development of Simulation

Angular motions are sensed in humans by canals in the inner ear

5. Motion Systems

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 82 /165

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computeaerodynamic

computeaerodynamic convert axes

stability to body

and moment

forces compute linearaccelerations

compute a,b

a,b

P,Q,Rengine forces

r ,MXp,Zp

Xs,Ys,Zs

Xb,Yb,Zb U',V',W'

U,V,W

Ps,Qs,Rs

Vc

r

a,a ,b,b' '

and moments,M

Vc,

Vc,

Development of Simulation

The inputs to the motion platform are calculated by the Equations of Motion

5. Motion Systems

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 83 /165

coefficients

computeaerodynamic

and moment

moments

convert axesstability to body

compute angularaccelerations

computeEuler compute DCM

convert axesbody to Euler

convert axesbody to stability

atmosphericmodel

P',Q',R'

Ps,Qs,Rs

L,M,N

r, M

P,Q,Re0,e1,e2,e3

inceptorsLp,Mp,Np

r

inceptors

and moments

q,f,y

U,V,W

Vx,Vy,Vz

Pn,Pe,h

Ls,Ms,Ns

,M

parameters

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Development of Simulation

As movement is limited, platform motion must be washed out ready for next event

5. Motion Systems

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 84 /165

Centrifuges are needed for high G acceleration (seen only in civil aircraft rejected takeoffs)

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Development of Simulation

Acceleration sense available from motion platform

5. Motion Systems

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 85 /165

1g

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Development of Simulation

Acceleration sense available from motion platform

5. Motion Systems

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 86 /165

1g

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Development of Simulation

Acceleration sense available from motion platform

5. Motion Systems

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 87 /165

1g

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Development of Simulation

Acceleration sense available from motion platform

5. Motion Systems

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 88 /165

1g

Page 89: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

1g * Sin 20° = 0,34

Development of Simulation

Acceleration sense available from motion platform

5. Motion Systems

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 89 /165

1g

1g * Sin 20° = 0,34g

1g * Cos 20° =0,94g

20°

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Maintaining ControlThe ICATEE Approach

RAeS Flight Crew Training Conference27 September 2012Dr. Sunjoo Advani, Chairman of ICATEE

901Royal Aeronautical SocietyFlight Simulation Group

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ICATEE

• International Committee for Aviation Training inExtended Envelopes

• Initiated by RAeS Flight Simulation Group in June 2009

• MISSION: To deliver a comprehensive long-term strategyto reduce the rate of Loss of Control In-Flight accidents

91

to reduce the rate of Loss of Control In-Flight accidentsand incidents through enhanced UPRT

• Approach: Upset Prevention and Recovery Training

• Provide recommendations to ICAO, FAA and industry

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ICATEE Participants

Category Participants

Organization RAeS-FSG, ICAO

Airframe Manufacturer Boeing, Airbus, Bombardier

Regulator/Government FAA, NTSB, IATA (ITQI/EBT), Transport Canada, EASA, Russian CAA

Training Provider CAE, FlightSafety, Boeing Flight Training, APS, CALSPAN, Embry-Riddle

Simulation Provider CAE, FlightSafety, Thales, Opinicus, ETC, Bihrle

9292

45 organizations, over 80 individuals

Industry Body ALPA, IFALPA, ATA, BBGA

Airline KLM, Alaska, Flybe, FedEx, Air Canada, Lufthansa, several airlines

Research AIAA MSTC, NASA, UTIAS, NLR, TNO, IDT, DLR, U Liverpool, SOS, Volpe

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ICATEE Meetings to Date

1 11-09 London

2 03-10 Washington

3 04-10 Orlando

4 06-10 London

5 11-10 Oklahoma

6 03-11 Mesa

7 04-11 Daytona

9393

7 04-11 Daytona

8 04-11 Orlando

9 06-11 Amsterdam

10 08-11 Seattle

11 09-11 Montreal

12 11-11 London

13 04-12 Lutz

14 09-12 Cologne

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ICATEE Team

9494

ICAO, Montreal - September 2011

Page 95: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Loss-of-Control In-Flight

• Normal flight

• Upset

• Loss-of-Control

PreventionPrevention

RecoveryRecovery

9595

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Today’s Training Assumptions

1. Aircraft is within normal operational envelope and ina non-agitated flight condition

2. Situational awareness and information can beaccurately correlated by the pilot with respect toobserved flight condition

3. Airplane handling skills and strategies established by

96

3. Airplane handling skills and strategies established byregulatory licensing can directly resolve anescalating condition

4. Human psychophysical response is predictable andreliable.

96

Page 97: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

All-Attitude Daily Threat

All-Attitude Knowledge Deficiencies

Roll (Right)Roll (Left)

Pitch (+up)+ 90

o

+ 50o

+ 30o

+ 25o

+ 10o

- 10o

60o

90o 180o180o 135o135o

45o

100 % All-Attitude Training (180 AOB, +/- 90 Pitch)

97

11.1 % Max Licensing Limits (60 AOB, +/-30 Pitch)

4.9 %

Upset DefinitionUpset Definition

Airplane Upset RecoveryAirplane Upset RecoveryTraining AidTraining Aid

Upset Definition (45 AOB, +25 & -10 Pitch)

Pitch (-down)

- 50o

- 90o

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All-Attitude Daily Threat

All-Attitude Knowledge Deficiencies

Roll (Right)Roll (Left)

Pitch (+up)+ 90

o

+ 50o

+ 30o

+ 25o

+ 10o

- 10o

60o

90o 180o180o 135o135o

45o

100 % All-Attitude Training (180 AOB, +/- 90 Pitch)

98

11.1 % Max Licensing Limits (60 AOB, +/-30 Pitch)

4.9 %

Upset DefinitionUpset Definition

Airplane Upset RecoveryAirplane Upset RecoveryTraining AidTraining Aid

Upset Definition (45 AOB, +25 & -10 Pitch)

Pitch (-down)

- 50o

- 90o

Approximate limits, Colgan 3407

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All-envelope knowledge deficiencies

L/D MaxL/D Max

Stall WarningStall Warning

Full StallFull Stall

9999

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4-Psychophysical response is predictable & reliable

STARTLE

100100

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Training Assumptions

1. Aircraft is within normal operational envelope and ina non-agitated flight condition

2. Situational awareness and information can beaccurately correlated by the pilot with respect toobserved flight condition

3. Airplane handling skills and strategies established by

101Flight Simulation Group - Royal Aeronautical Society - London, UK

3. Airplane handling skills and strategies established byregulatory licensing can directly resolve anescalating condition

4. Human psychophysical response is predictable andreliable.

101

Page 102: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Upset Mitigation Levels

• Awareness

– Knowledge, Skills and Attitudes to prevent an Upset

• Recognition & Avoidance

– mitigation of a developing threat, as early as possible

• Recovery skills to regain control

P

R

102102

R

Prevent undesirable aircraft states

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Current Training

Loss-of-Control

Upsetincapacitation

103103

Normal flight

first recognition

recoveryawareness

Page 104: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Enhanced UPRT

Loss-of-Control

Upset

incapacitation

104104

Normal flight

first recognition recovery

awareness

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Learning Elements

Competency-based approachto UPRT

105105

to UPRT

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Developing Integrated UPRT Skills

FSTD

aircraft

UPRT RequiresIntegrated Training

Elements

UPRT RequiresIntegrated Training

Elements

106106

AcademicsElementsElements

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Element 1 - Academics

• Airplane Upset Recovery TrainingAid (1998) is the industry reference

• New ICATEE UPRT Manuals

– Pilot Academic Knowledge & SkillPreparation

– Instructor Guidance in UPRT

107107

– Instructor Guidance in UPRT

– Authorized Training Providers

– Regulatory Guidance

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Element 2 - Airplane

• Exposure to

– Psychological component

– Physiological component

– Accurate recovery environment

• Require

– qualified aircraft

108108

– qualified aircraft

– qualified instructors

CALSPANAPSTTCTCA

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• Upset Prevention & Recovery Training is NOTAerobatic Training

– Aerobatics focuses on precision maneuvers for aerobaticpilots

• UPRT focuses on recovery from dangeroussituations, and is designed for commercial pilots

Element 2 - Airplane

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situations, and is designed for commercial pilots

• UPRT includes significant surprise elements

• Management of startle

• Training of instructors

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Element 3: Appropriate Use of FSTD’s

• Better use of today’s devices

• Enhanced feedback in today’ssim’s

• Improved simulation fidelity inextended envelope

11010

– aero model

– pilot cueing (buffet, motion)

graduatedapproach

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UPRT learning objectives

FSTD A/CEITHER

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• FSTD + All-Envelope All-Attitude A/C skills needed

• Current pilot fleet possibly had adequate on-aircraftcomponent

• A/C exposure can be very small, if done properly

• Despite few training elements, UPRT a/c training is critical

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UPRT Instruction

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Page 113: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

UPRT Instruction

• Instructor Inputs• upset initiation

• surprise-inducing situations

• LOC training scenarios

• Instructor feedback

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• Did you stay reasonably within thevalidated flight envelope?

• Did you over stress the airframe?

• Did you apply incorrect/inappropriatecontrol inputs?

• Did you recover?

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Instructor Feedback

• UPRT is NOT about flying on the edge of theenvelope

• Bring the aircraft back to the heart of the envelope,THEN maneuver!

• Challenge: Provide the right tools for instructor andpilot

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pilot

114

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IOS Feedback

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Page 118: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

3

2

1

Lo

ad

Facto

r

Flapsdown

Flaps up

VS1 = flaps up 1-g stallspeed

VA = design maneuverspeed, flaps up

VC = design structured

Load Factor Envelope Showing Speeds and Load Factors

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0

-1

Airspeed

VS1 VA VC VD

Flaps up

VC = design structuredcruising speed

VD = design divespeed

-2

118

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Controls usage

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Page 120: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

AVOID NEGATIVETRAINING

AVOID NEGATIVETRAINING

12010Flight Simulation Group - Royal Aeronautical Society - London, UK

120

TRAININGTRAINING

Page 121: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

UPRT Simulation Requirements

• Simulation requirements specify

– Representative stall model characteristics

– Performance tests for high-altitude stalls

– Tighter objective performance standards inapproach-to-stall region

– Stall evaluations for additional flight conditions

121121

– Stall evaluations for additional flight conditions

– Objective stick pusher force tests

– Objective buffet tests for additional flightconditions

– Buffet onset requirements

– Improved icing model

– Wake vortex modelling

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Simulator-Based UPRT

• Learning Objective:

– Managing angle-of-attack / energy

– Recognizing and reacting to signs

• buffet

• reduced lateral control

• reduced stability

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• reduced stability

• Main objective: UNLOADING

– Maneuver-oriented familiarization: Experience a full stallunder standardized instruction

– Line-oriented training/checking: Recognize and applyrecovery at FIRST SIGNS

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Training media

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Training media

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Page 125: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Deliverables

• Recommendations to FAA:

– Stall/Stick-Pusher WG

– Stick Pusher Adverse Weather ARC

• ICAO

– Manual of Upset Prevention & Recovery Training

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• Regulatory framework for pilot, instructor, trainingprovider

– Simulator technical standards appendix (9625 or other)

• RAeS Report

– ICATEE UPRT Research and Technology Report

• IATA FSTD Data Document revisions

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Take-Away

• Loss of Control in Flight can be mitigated throughintegrated Upset Prevention and Recovery Training

– Academics

– In-Flight

– Simulator

• Simulator Standards Recommendations

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• Simulator Standards Recommendations– Improved simulator usage, scenarios, IOS, model

• ICATEE is working with industry to improve thetraining paradigm, effectively.

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www.icatee.org

[email protected]@idt-engineering.com

+31 655 737 345+31 655 737 345

Sunjoo AdvaniSunjoo Advani

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 128 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 129 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 130 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 131 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 132 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 133 /165

Page 134: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

2 pilots & Flight Engineer

2 pilots

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 134 /165

Page 135: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 135 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 136 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 137 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 138 /165

Page 139: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Dealing with Black Swans

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 139 /165

Page 140: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Some Black Swans?

Examples of Crew actions saving loss of life :

Eric Gennotte’s crewlanded a A300 B4 withno hydraulics usingdifferential engine thrustalone after hit by missileat Baghdad

Captain Peter Burkillretracted the 777 flaps to

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 140 /165

retracted the 777 flaps toreduce drag thus avoidingfences before the runwaywhen engines lost thruston final approach into LHR

Captain Sullenbergerstarted the APU out ofsequence to keep the A320powered normally whenditching in the Hudson

Page 141: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

Other Black Swans?

Examples of Failures requiring Considerable Crew Activity :

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 141 /165

After an A380 engine 2 uncontained failure, while the aircraft wasbeing flown manually, Richard de Crespigny’s crew had to action 53ECAM messages taking some 50 minutes to complete.It took the 5 man crew some 2 hours to prepare the aircraft forlanding. When on the ground they still had matters to resolve –engine 2 could not be shut down, wheels brakes reached 900°C.

Page 142: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 142 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 143 /165

Page 144: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

PRIORITIZATION OF TRAINING TOPICS

1.50

2.00

2.50

Gen1

Gen2

Gen3

Gen4

Factors in accidents / 1M TOs - Last 15 years

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 144 /165

0.00

0.50

1.00

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PRIORITIZATION OF TRAINING TOPICS

25%

30%

35%

40%

45% Gen1

Gen2

Gen3

Gen4

What % of accidents had each factor - Last 15 years

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 145 /165

0%

5%

10%

15%

20%

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 146 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 147 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 148 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 149 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 150 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 151 /165

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EASA’s Rule Making Tasks

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 152 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 153 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 154 /165

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 155 /165

Page 156: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 156 /165

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Training toAvoid to Loss Of Control Accidents

Prevention is Prime,Eliminate the Cause.

Everything is important

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 157 /165

Everything is importantRight from the start –

Pre-selection to...........retirement....

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Cruise – Crews Need to be Aware of Aircraft PerformanceTable of Airbus A320 All Engines and Engine Out information – easier to access than FMS.All Engines Max Altitude is always limited by Climb Thrust. Available after FMS failure.

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 158 /165

Paper type presentations can still be useful,giving essentials of aircraft performance

for background knowledge & gross error checks -Cruise Speeds, Thrust & Attitude,

Max/Optimum Altitudes - all engines & engine outTakeoff/Landing Speeds & distances

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Training toAvoid to Loss Of Control Accidents

Manual flying practiceversus rigid use of automatics -

Trident, 747, DC10, TriStar

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 159 /165

Trident, 747, DC10, TriStardifferent policies.

FDR event if flown manually?Whatever system we aim for:

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from Capt David Mason of Emirates

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 160 /165

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Remember

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 161 /165

Remember

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RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 162 /165

Page 163: Royal Aeronautical Society Heathrow Branch The Sir Richard ......In 2002 Don Bateman, father of GPWS/EGPW, published 9 NPA CFIT accidents which could have been saved if EGPWS had been

MCC Courses

All airline pilots must pass aMulti-Crew Cooperation Course

These concentrate on the fact that:We all make mistakes,

We should admit our mistakes/we were wrong

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 163 /165

We should admit our mistakes/we were wrong

We must help each other work together for thecommon good – of not having an accident.

MCC Courses should becompulsory for bankers!

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Thank you

RAeS Heathrow Branch Sir Richard Fairey Lecture Hugh DIBLEY : “Training to Avoid Loss of Control Accidents” 16oct 12 164 /165

Thank you