Why Are We Here? (The Accident Loss of Control Record) ICAO Loss of Control Symposium May 20-22, 2014
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Dennis A. Crider Chief Technical Advisor, Vehicle Simulation National Transportation Safety Board
LOC Accident / Incident Data Set
• NTSB LOC data collection • Dick Newman (Crew Systems) and
Tony Lambregts • 2008 paper • Frequently quoted
• NASA • Wouldn’t it be nice to work together? • Broader LOC dataset
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LOC Accident / Incident Data Set • Data Sources
• Aircraft Accident Reports on DVD (R. Dorsett, 2006) • Australian Transport Safety Bureau (ATSB) • Aviation Safety Network (ASN) • Canadian Transportation Safety Board (TSB) • Flightglobal (Ascend Database) • French Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (BEA) • German Bundesstelle für Flugunfalluntersuchung (BFU) • International Civil Aviation Organization (ICAO) • Irish Air Accident Investigation Unit (AAIU) • National Transportation Safety Board (NTSB)
• Search Criteria • “loss-of-control” • “upset” • “unusual attitude” • “stall” • “uncontrolled”
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Take
off
Initi
al C
limb
Clim
bC
ruis
eD
esce
ntH
oldi
ngAp
proa
chVF
R P
atte
rnC
irclin
gFi
nal A
ppro
ach
Land
ing
Go-
arou
ndM
isse
d Ap
proa
chM
aneu
verin
g
0
20
40
60
80Ev
ents
Events
0
500
1000
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2500
On-Board Fatalities
On-
Boar
d Fa
talit
ies
LOC by Flight Regime
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LOC by Event Factors
Stall Examples
• Pinnacle Airlines, Flight 3701 • Bombardier CL-600-2B19 • Aircraft stalled at high altitude
• Colgan Air Flight 3407
• Bombardier DHC-8-400 • Stalled on approach to Buffalo
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02:54:30 02:54:40 02:54:50 02:55:00 02:55:10 02:55:20-80
-60
-40
-20
0
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40
60
80
-40
-30
-20
-10
0
10
20
30
40Right
Bank
Ang
le (d
eg)
Time (Hr:Min:Sec)
Roll - left system Roll - right system
Right
Left
Whe
el (d
eg)
Left Wheel Right Wheel
Left
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95520 95530 95540 95550 95560 95570-50-40-30-20-10
0102030405060708090
100110
-100
-80
-60
-40
-20
0
20
40
60
80
100Buffalo Colgan DHC-8-400
Roll (
deg)
FDR Time (sec)
Roll
Upse
tLeft
Right Right
Whe
el (d
eg)
Captain's Wheel
Left
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02:54:30 02:54:40 02:54:50 02:55:00 02:55:10 02:55:20-15
-10
-5
0
5
10
15
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25
30
25
20
15
10
5
0
-5
-10
-15
-20
-25
Angl
e of
Atta
ck (d
eg)
Time (Hr:Min:Sec)
FDR Angle of Attack
Nose Up
Ele
vato
r (de
g)
FDR elevator
Nose down
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95520 95530 95540 95550 95560 95570-5
0
5
10
15
0
5
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25
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35
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Cont
rol C
olum
n (d
eg)
FDR Time (sec)
Left Column Right Column
Upse
t
Left Angle of Attack Right Angle of Attack
Ang
le o
f Atta
ck (d
eg)
Breaking The Accident Chain
• Addressing elements in the sequence
• Train cue recognition • Account for human nature
• Train crews for all cues
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13 13
Precursor Sequence
Loss of Energy State
Awareness / Inappropriate
Energy Management
Stall / Departure
Improper / Ineffective Recovery
Normal Flight LOC Crew
Fatigue / Impairment
Colgan Air 3407 (2/12/2009)
Loss of Energy State
Awareness / Inappropriate
Energy Management
Stall / Departure
Improper / Ineffective Recovery
Normal Flight Ground
Impact
Engine failure
Pinnacle 3701 (10/14/2004)
Stall Cues
• Stick Shaker • Ignored
• Stick Pusher • Fought • Stick pusher dynamics not
recognized • Un-commanded Roll
• Not recognized
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Icing and Contaminated Airfoils
National Transportation Safety Board
Upsets from Stalls due to Icing • Saab 340: Eildon Weir, Australia,
• November 1998 • 2300-foot altitude loss
• Saab 340: Albury, Australia, • June 2004 • 40-foot altitude loss
• Saab 340: San Luis Obispo, CA, USA • January 2006 • 5000-foot altitude loss
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0 5 10 15 20
Lift C
oeffic
ient -
C L
Angle of Attack - α (deg)
Albury Eildon Weir American Eagle 3008 No ice lift curve
Saab 340Icing Event Comparison
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0 5 10 15 20 25
CRJ Icing Event Comparison
C L
Angle of attack
Fredericton no ice (sim sweep) Baotou no ice (sim sweep) Fredericton Baotou
Fredericton
Baotou
19 19
Precursor Sequence Ice Contamination
Stall / Departure
Improper / Ineffective Recovery
Normal Flight LOC
Icing
Stall Cues with Ice
• Stick Shaker • May be after departure
• Stick Pusher • May be after departure
• Natural stall cues • Un-commanded Roll • Buffet • Stall break
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Summary • Elements of LOC
sequences have been identified
• Stall leading element
• Need to address multiple points in accident chain for best affect.
• New training we are outlining this week addresses most LOC factors
• Some elements may be better addressed by technologies
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Spatial Distortion
• In pitch • Typical go-around in IMC • Acceleration produces illusion of pitch up
• Pilot pitches down flies into ground
• In Roll • Slow roll develops pilot doesn’t feel • Then confused when bank angle warning
or g’s alert to roll but feel level
Atmospheric Disturbance
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Sch
edul
ed A
irlin
es
Non
-Sch
edul
ed
Non
-Rev
enue
Ope
ratio
ns
Exe
cutiv
e Tr
ansp
orta
tion
0102030405060708090
100110120130140150
Even
ts
Events
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
5500
6000
On-Board Fatalities
On-
Boar
d Fa
talit
ies
LOC by Operation
Recommendation A-10-22
Require 14 Code of Federal Regulations Part 121, 135 and 91K operators and 14 Code of Federal Regulations Part 142 training centers to develop and conduct training that incorporates stalls that are fully developed; are unexpected; involve autopilot disengagement; and include airplane-specific features such as a reference speeds switch
Recommendation A-10-23
• Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators of stick pusher-equipped aircraft to provide their pilots with pusher familiarization simulator training.
Recommendation A-10-24
Define and codify minimum simulator model fidelity requirements to support an expanded set of stall recovery training requirements, including recovery from stalls that are fully developed. These simulator fidelity requirements should address areas such as required angle-of-attack and sideslip angle ranges, motion cueing, proof-of-match with post-stall flight test data, and warnings to indicate when the simulator flight envelope has been exceeded.
Public Law 11-216 (sec 208)
The Administrator of the Federal Aviation Administration shall conduct a rulemaking proceeding to require part 121 air carriers to provide flight crewmembers with ground training and flight training or flight simulator training – A. To recognize and avoid a stall upset of an
aircraft or, if not avoided, to recover from the stall;
Recommendation A-11-46
Define and codify minimum simulator model fidelity requirements for aerodynamic degradations resulting from airframe ice accumulation. These requirements should be consistent with performance degradations that the National Transportation Safety Board and other agencies have extracted during the investigations of icing accidents and incidents.
Recommendation A-11-47 Once the simulator model fidelity requirements requested in Safety Recommendation A-11-46 are implemented, require that flight crews of all aircraft certificated for flight in icing conditions be trained in flight training simulators that meet these fidelity requirements. Such simulation training should emphasize the following: (1) cues for recognizing changes in the aircraft’s flight characteristics as airframe icing develops; (2) procedures for monitoring and maintaining appropriate airspeeds in icing conditions, including the use of icing airspeed reference indices; and (3) procedures for responding to decaying airspeed situations, stall protection system activation, and early stalls that can occur without stall protection system activation.
Stall Upsets (no icing) Accident
Shaker
Pusher
Break
Airborne Express DC-8-63 December 22, 1996 IO IO NR
China Airlines Flight 676, A300-622, February 16, 1998 UK UK UK Thai Airways Flight 261, Airbus A310-300, December 11, 1998 UK UK UK Pinnacle Airlines Flight 3701 Bombardier CL-600-2B19, October 14, 2004
NR NR NR
United Express Flight 6291 Jetstream 4101, January 7, 1994 NR NR UK Pulkova Flight 612, TU-154M, August 22, 2006 UK UK UK West Caribbean airlines MD-82 near Machiques, Venezuela, August 16, 2005
NR UK NR
Continental Connection Flight 3407 Bombardier DHC-8-400, February 12, 2009
NR NR NR
IO = Inoperative UK = Unknown NR = Not responded to
Stall Upsets (icing) Accident/Incident
Shaker
Pusher
Break
Saab 340A, VH-LPI, Eilden Weir, Victoria, November 11, 1998 ES ES NR
Saab 340A, VH-KEQ, Albury, New South Wales Australia, June 18, 2004
ES ES PR
Saab 340B, VH-OLM, Bathurst, New South Wales Australia, June 28 2002
ES ES NR
American Eagle Flight 3008, Saab 340B+, San Luis Obispo, January 2, 2006
ES ES NR
Air Canada Flight 646, Canadair CL-600-2B219, December 16, 1997 -- -- -- Cessna Citation 560, Pueblo, Colorado, February 16, 2005 UK UK UK Comair Flight 3272, Embraer EMB-120RT, January 9, 1997 ES -- NR Skywest Flight 3855, Bombardier CL-600-2B19, January 17, 2004 -- -- -- ComAir Flight 5054, EMB-120, March 19, 2001 NR NR NR
Empire Airlines Flight 8284, ATR-42, Lubbock TX, January27, 2009 NR ES NR IO = Inoperative UK = Unknown PR = Proper response
NR = Not responded to ES = Early stall
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